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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary 7 Federal Partners Roundtable Arthur Kellermann, workshop chair, moderated the concluding session. It brought together the chairs of the four crosscutting panel discussions, and the three federal partner representatives. Kellermann reminded the participants of the original charge of the workshop, which was to examine where the emergency medical services (EMS) community is 3 years after the release of the Institute of Medicine (IOM) reports, and to suggest concrete ideas and thoughts regarding how the federal emergency care enterprise can most immediately and significantly advance emergency care in the United States. The session chairs began by describing what they considered to be the high points of their sessions. SESSION CHAIR SUMMARIES Michael Rapp, who chaired the first panel on quality and patient safety, said that crowding had been the key point in his panel’s discussion. A number of participants called crowding a major issue that adversely impacts quality and safety in the emergency care system. One participant argued that the state of hospital-based emergency care should be viewed as the “vital signs” for the functioning of the health care system overall. Rapp noted that workshop participants considered 40 percent of health care costs wasteful and unnecessary. He asked how the emergency care system could be more efficient in terms of delivery of care. He noted that the panel’s discussion of regionalization highlighted the competitive issues that may arise among facilities operating in a regionalized system. Although regionalization has benefits, it can also have adverse impacts on community hospitals.
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary Tom Scalea, chair of the research panel, spoke next. He observed that the two issues that repeatedly emerged in all four sessions were money and workforce challenges. Among the four panel topics, he said emergency care research is probably the area where the least progress has been made in the past 3 years. He summarized the three major points of the research panel discussion. First, the field needs a team of investigators who can be funded and sustained through their entire career (much of the research conducted now, he said, is done on the backs of faculty practice plans). Second, research questions that cross traditional academic boundaries need to be defined, and people need to cooperate in order to be able to execute research plans. The corollary to this, he said, is identifying a way to fund that research. Little clinical research on trauma care is funded, he noted, other than perhaps by the Department of Defense. Finally, people need to grapple with regulatory issues that hinder emergency care research. Jon Krohmer, chair of the workforce panel, spoke third. He said the top take-home message from his panel was how pessimistic the discussion had been. The overall theme was that there are critical issues at the physician level, not just among the emergency physicians and trauma surgeons, but also the on-call specialists, critical care specialists, and other disciplines that are needed to support the emergency care system. The emergency nursing workforce also has significant challenges, particularly in recruiting and retaining sufficient numbers of nurses to care for patients appropriately. In addition, there are ongoing concerns with EMS personnel, particularly in terms of how they should fit into the broader emergency care system. Overall, he said, the system today is very stressed. Krohmer noted that his panel had discussed alternative models of care that involve mid-level providers, physician assistants, and nurse practitioners. However, he said that right now health profession students are not offered enough education in emergency health care. This problem needs to be addressed. Certification or some other type of recognition should be established, he said. Guy Clifton, chair of the fourth and final panel discussion oneconomics, said the combination of underpayment of public programs and growing numbers of the uninsured has produced a chronically underfunded system. He recalled trauma surgeon William Schwab’s statement that in Pennsylvania, the percentage of patients on which trauma hospitals lose money varies between 20 percent and 65 percent. Some hospitals are “operating on air.” Clifton said his panel’s discussion highlighted longstanding distortions in the Medicare Resource-Based Relative Value Scale (RBRVS) system. This discussion raised interesting questions regarding where the money would come from to rebalance the system. In a zero-sum situation, would transfer payments have to come from other specialties such as neurosurgery and
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary cardiac surgery and be brought over to emergency care? Clifton does not believe it has to be a zero-sum game. Given widespread variability in care and obvious inefficiencies in the system, eliminating waste would free up plenty of money to strengthen the system. Clifton said the panel’s conclusion seemed to be that nationally accepted standards of care are needed to reduce wasteful variability of practice. A powerful idea, he said, is to tie malpractice protection to physician compliance with clinical standards. FEDERAL PARTNER OBSERVATIONS The three federal partners then highlighted some of the key messages they heard over the course of the 2-day workshop. Mike Handrigan, from the Office of the Assistant Secretary for Preparedness and Response in the U.S. Department of Health and Human Services, said he thought this had been a tremendously successful meeting. Looking around the room, he said, “we have EMS personnel here with allied health, nursing, emergency physicians, surgical staff, and in-house physicians all converging and coalescing around the concept of the emergency care enterprise…. [I]t is absolutely amazing to see this coalition developing around the emergency care enterprise with such a great deal of momentum, both inside and outside the federal government.” Drew Dawson, director of the Office of EMS at the National Highway Traffic Safety Administration, said the key messages he would highlight have to do with the importance of collaboration and coordination, and how important both are in exercising leadership. He said we certainly need extra finances in many parts of the system, but he agreed with Dr. Runge’s observation that “you can’t grant your way out of a problem.” In Dawson’s view, one of the most critical issues raised in the workshop was to determine how “regionalized, accountable, and coordinated” systems of care should best be structured. “We need to examine the structure and function of existing systems—how they work, where they work, where they don’t work, and what factors contribute to their success,” he asserted. Dan Kavanaugh, of the Maternal and Child Health Bureau at the Health Resources and Services Administration, said there had been discussion on Day 1 regarding who the champions on Capitol Hill are, but less focus on the consumer constituencies that need to serve as champions for emergency care resources and research. For example, where is emergency care’s Michael J. Fox—a strong advocate for Parkinson’s disease research? Perhaps one reason advocates are not out there is because frontline providers do such a good job, so people think everything is okay, Kavanaugh noted. With regard to research, he believes there is a need to improve linkages among academic institutions, community hospitals (where 90 percent of children
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary receive care), and EMS agencies. He endorses the notion of a moratorium on creating emergency care research agendas. Roger Lewis, an emergency physician from Los Angeles, recently identified 19 emergency care research agendas that had been produced over the past 10 years. Many priorities detailed in these agendas have yet to be addressed. With respect to collaboration, Kavanaugh noted that even before the Federal Interagency Committee on Emergency Medical Services (FICEMS) and the Emergency Care Coordination Center (ECCC) existed, there was a lot of collaboration between NHTSA and the Emergency Medical Services for Children (EMSC), a part of HRSA. He believes it is important to institutionalize these relationships, rather than basing them on individuals. For example, each year the EMSC program sends a small amount of money to help support the NEMSIS effort, even though NEMSIS is not specifically directed to children. SUGGESTED FEDERAL PRIORITIES Ryan Mutter from the Agency for Healthcare Research and Quality (AHRQ) responded to Dawson’s question by observing that we have data on what happens to patients before they come into an emergency department (ED) and on what happens after they arrive, but these two datasets do not talk to each other. There needs to be a push to link these datasets to capture what is going on across the entire emergency care enterprise. He also noted several important gaps in our knowledge. For example, two unknowns are how many ED beds our country has and how many staff members work in EDs. Improving data capture and linkage would be very helpful. Dia Gainor of Idaho called for demonstration programs or grants aimed at supporting regionalized, accountable systems of emergency care. These will need to be geographically diverse and include rural areas. Although the IOM reports were great in describing regionalization in overarching terms, they lacked specificity with regard to what regionalized systems should look like and how they would work. Jerry Jurkovich asked for more federal dollars for comparative effectiveness research in trauma and emergency care. This type of research would help to define which systems of care are cost effective, minimize variability, and maximize safety and quality. Rapp asked what aspects of these systems would be compared. Jurkovich replied that the two types of trauma systems, inclusive and exclusive, should be compared. For example, how many hospitals within a region should be part of the trauma program? Is 70 percent appropriate? Also, he asked, what transport distances provide the most cost-effective care? How many ambulances are needed in a system? How many helicopters are needed? Should helicopters transport patients from
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary 100 miles away? If the federal government puts out a Request for Proposals, it will receive hundreds, he remarked. Handrigan responded that his previous job was in the comparative effectiveness field, as a program officer in the Center of Outcomes and Evidence at AHRQ. Handrigan sees an opportunity to develop the argument that emergency care, systems of care, and disease-oriented questions should be evaluated in context of comparative effectiveness. “We stand ready to partner with you to make that argument,” he said. Dean Wilkerson, executive director of the American College of Emergency Physicians (ACEP), said many good ideas had been generated at this conference, but the reality is that money and staff—and time to find both—are limited. In response to Dawson’s question, Wilkerson said he would encourage federal agencies to figure out where their efforts are most likely to result in immediate discernible progress. Wilkerson believes that figuring out how to address the boarding problem has the potential to have a huge impact on quality and patient safety in the United States. All five federal agencies are impacted by this problem, through disaster preparedness, metrics, young people, traffic crash victims, or other ways. These agencies should determine how to work within their spheres to improve this problem. Bob Bass, director of the Maryland Institute of EMS Services and a member of the original 2006 IOM committee, rose to reiterate the point about boarding and overcrowding. He recalled that the committee spent a lot of time on this issue and came up with some well-thought-out recommendations. Some were directed to the Centers for Medicare & Medicaid Services (CMS), such as convening experts to develop standards and create financial incentives and disincentives to address the issue. Some hospitals have made improvements, he said, but it is not happening on a widespread basis. If CMS addressed some of these recommendations, it would result in tangible progress. He also believes the Joint Commission and professional organizations should take another serious look at the IOM recommendations. Kellermann outlined three ways to solve the boarding and crowding issue. One is public shame. That requires publishing hospital-specific data. Second, regulatory or congressional action is needed, but that has not been forthcoming. The third is to cover the uninsured. That is the best way to change the financial incentives so that fixing crowding becomes a good business decision. Jurkovich said comparative effectiveness research could focus on identifying the best approaches to reducing ED overcrowding. Handrigan noted that there is a natural experiment happening right now in Massachusetts with respect to the state’s ban on ambulance diversions. This state’s experi-
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary ence could be compared with others to find out if the ban has decreased crowding and improved service. ACEP Vice President Sandra Schneider said the positive outcomes in Massachusetts have been tied to the ability to move ED patients to hallways upstairs, rather than hold every admission in the emergency department. Data have shown that when patients go upstairs, Schneider said, they get better care and get into a bed faster. Putting patients on the floor works, she said, because then the floor staff needs to find a bed for the patient, who is no longer invisible in the emergency department. Angela Gardener from ACEP asserted that if a moratorium were placed on elective surgery when patients are being boarded in the emergency department, boarding would end tomorrow. David Marcozzi, of the White House Homeland Security Council, said there are concerns that in fall 2009, the United States will experience a major public health and medical event with the H1N1 virus. The virus has the potential to significantly affect how acute care is delivered nationwide. He noted that many of the nation’s leaders in acute care are present in the room. He acknowledged the value of broad and strategic goals, but said we also must focus on a short-term goal—the impending pandemic. He put it this way: This Hurricane Katrina (the H1N1 pandemic) is approaching, and we do not know whether it will be a Category 1 or a Category 5 storm, but we know it is coming. How can we express as one voice what we need to do to effect change by this fall? Kellermann suggested that a Presidential order be communicated that every hospital that receives Medicare funding adopt and begin gaining experience with the use of a “full-capacity protocol”—a recommendation recently tendered by ACEP. It requires each inpatient unit to temporarily hold one or more admitted patients in their hallways whenever the ED reaches a critical level of crowding. This is a safer strategy than holding all admissions in the ED. Adopting this policy now, Kellermann argued, would give hospitals vital experience with the logistics required to operate at 120–150 percent of their normal occupancy. Emergency departments have been rehearsing this for 20 years; now is the time for inpatient units to do the same. Asking hospitals to begin placing additional patients on the inpatient floors now will communicate the level of gravity of and concern about the current situation and invest the entire hospital in planning for the challenge. Lewis said the first question from the California hospital administration about H1N1 will be whether such a federal mandate will override state regulations on nursing ratios. If it does not, it is a nonstarter. Pennsylvania trauma surgeon Schwab said we need one government agency that speaks for all of emergency care. He said the Federal Aviation Administration sets regulations for nearly all things having to do with avia-
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary tion. If our nation had 50 airports that were run by 6 or 7 different federal agencies, the amount of crashes in aviation would increase exponentially. He said the IOM report acknowledges that the federal partners need to have good working relationships, but it concludes a single agency needs to speak for emergency care. This lead agency structure needs to be inclusive because emergency care involves many different provider types, including cardiologists, neurologists, toxicologists, surgeons, high-risk obstetrician/gynecologists, and others, and to end boarding, “We have to make sure the back end of the house works well.” But in his view the biggest crisis will come not from swine flu, but from the fact that “we just won’t have a workforce in about 3 or 4 years.” John Fildes, chief of the Division of Trauma & Critical Care at the University of Nevada School of Medicine and chair of the Committee on Trauma (COT),agreed that in order to effect the kinds of changes detailed at this workshop, strong central leadership is needed. Otherwise, we will not be able to standardize care, reduce variation, implement an effective monitoring system, or enforce the metrics. We need a strong top-down leadership in order to standardize and integrate all the areas discussed. “The only difference between a pile of wool and a sweater is organization, and really we are like a pile of wool,” he said. Emergency physician Lewis suggested that the ECCC use the participants attending this workshop as an advisory group. Handrigan responded that the emergency care enterprise covers the entire spectrum of emergency care activities and agreed that the federal government should not act in a vacuum. He said the ECCC was created in part to be a “touch point” for nonfederal stakeholder partners, but also so officials in the federal government will have a touch point inside government to get a handle on emergency care issues. “I look forward to the nonfederal stakeholder input and I need it,” Handrigan said. However, he noted that the Council on Emergency Medical Care (CEMC) is explicitly designed as a federal council. Creating a nongovernmental advisory council that complies with Federal Advisory Committee Act (FACA) is a multimillion dollar process that can take several years to establish. “The vetting process for that,” he said, “is beyond something we can accomplish tomorrow.” In the meanwhile, the CEMC will be reaching out to individual nonfederal stakeholders to get the expertise and guidance it needs. Dawson mentioned that, with respect to the prehospital component of the emergency care enterprise, there is now the National Emergency Medical Services Advisory Council. It is compliant with the FACA and provides a significant amount of input to the national emergency care enterprise, predominantly from a prehospital perspective. ECCC Paramedic Andrew Roszak, who recently worked for Congress, applauded the discussions about coming together and making a lobbying
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary effort on behalf of emergency care. Having said that, though, he cautioned against making enemies right off the bat by saying the attorneys and malpractice costs are to blame for the problems of emergency care. He noted that Capitol Hill is made up of attorneys. Ron Anderson, president and chief executive officer at Parkland Health & Hospital System in Dallas, pointed out that there are limited resources to pay for health care in this country. In the allocation of limited resources, some services will be deemed essential and others nonessential. We should make it clear that emergency medical care is an essential public service and should therefore be protected and funded as an essential public service. CLOSING REMARKS Clifton said that problems in emergency care appear to be deep, structural, and financial. They are inextricably tied to the overall health care system. But he said you can’t get attention to a problem if you can’t measure it and you can’t report it. As an example, the problem of diversion is under-reported and consequently many are unaware of it. The first job should be to report publicly and continually the measures of distress of emergency care services. Krohmer recalled Gainor’s question on the first day of the workshop, “Why is the federal government requiring us to plan for taking care of 500 people in a catastrophic event, when we cannot take care of a regular patient load of 50 people on a day-to-day basis?” Krohmer completely agrees with that perspective. Having said that, he noted that some of the threats we face are real and significant. The H1N1 threat has very severe potential for harm. There are some real issues that our nation must address. It is vital to ensure that the preparedness activities enhance what happen on a day-to-day basis because enhanced day-to-day capabilities allow communities to respond more appropriately to catastrophic events. Scalea noted that near the end of the meeting, much of the discussion had been focused on priorities for immediate action—what are we going to do first? He cautioned that we need a durable plan as well. Over the long haul, the ability to collect data, to ask and answer questions, will be hugely important. Rapp cautioned that presidential directives sound appealing, but there are not too many areas in health care where even the President has complete authority. There are more than 4,000 hospitals in the United States, and most are run by various private entities. In highlighting the challenge of organizing a federal response, Rapp cited his own area of expertise—measurement. There, changes cannot just be directed; a lot of consensus making must take place first. Measures that CMS uses must go through the National Quality Forum, which has to endorse them. Pretty much anything CMS does
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National Emergency Care Enterprise: Advancing Care through Collaboration - Workshop Summary involves rule making and mandatory public comment periods. CMS must consider all public comments before coming up with a final ruling. Rapp noted that the same considerations would apply to any modification in the Medicare payment system. Getting anything accomplished will require long-term engagement and will likely face resistance from interest groups. If overcrowding and boarding are issues this group wants the federal government to tackle, he said, it will be important to maintain continued engagement in the process. “When you try to push things one way,” he said, “somebody will think it’s great, but somebody else is going to think it’s terrible. I urge you to continue your engagement with your federal partners as we try to tackle these issues through the ECCC.”
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