National Emergency Care Enterprise: Advancing Care Through Collaboration: Workshop Summary (2009)

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NATIONAL EMERGENCY CARE ENTERPRISE ADVANCING CARE THROUGH COLLABORATION Workshop Summary Ben Wheatley, Rapporteur Board on Health Care Services 

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, N.W.  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This study was supported by Contract No. HHSP233200800008T, Task Order #21 between the National Academy of Sciences and the Emergency Care Coordination Center, part of the Office of the Assistant Secretary for Preparedness and Response in the Department of Health and Human Services; other contributors include the American College of Emergency ­Physicians and the Society of Academic Emergency Medicine. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the workshop participants and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-14161-1 International Standard Book Number-10: 0-309-14161-3 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2009. National Emergency Care ­ nterprise: Advancing Care Through Collaboration: Workshop Summary. Washing- E ton, DC: The National Academies Press. 

“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health. 

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engi­ neers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org 

PLANNING COMMITTEE ON THE NATIONAL EMERGENCY CARE ENTERPRISE WORKSHOP ARTHUR KELLERMANN (Chair), Professor and Associate Dean for Health Policy, Emory University School of Medicine DREW DAWSON, Director, Office of Emergency Medical Services, National Highway Traffic Safety Administration, Department of Transportation MICHAEL HANDRIGAN, Acting Director, Emergency Care Coordination Center, Office of the Assistant Secretary for Emergency Preparedness and Response, Department of Health and Human Services MARY JAGIM, Client Engagement Manager, Intelligent InSites JON KROHMER, Principal Deputy Assistant Secretary for Health Affairs and Deputy Chief Medical Officer, Department of Homeland Security MICHAEL T. RAPP, Director of the Quality Measurement and Health Assessment Group, Office of Clinical Standards and Quality, Centers for Medicare and Medicaid Services THOMAS M. SCALEA, Physician-in-Chief in the Shock Trauma Center, University of Maryland School of Medicine ROSLYNE SCHULMAN, Senior Associate Director, American Hospital Association Study Staff BEN WHEATLEY, Program Officer Ashley mcwilliams, Senior Program Assistant Roger Herdman, Board Director  



Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: Robert R. Bass, Executive Director, Maryland Institute for Emergency Medical Services Systems Gary Fleisher, Egan Family Foundation Professor; Pediatrician- in-Chief; Chair of Department of Medicine, Children’s Hospital of Boston Lewis Goldfrank, Director of Emergency Medicine, New York University School of Medicine Ricardo Martinez, Executive President of Medical Affairs, The Schumacher Group Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Megan McHugh, Health Research and Educational Trust. Appointed vii 

viii REVIEWERS by the Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the author and the institution. 

Contents OVERVIEW 1 1 FEDERAL PROGRESS REPORTS: ADVANCING EMERGENCY AND TRAUMA CARE 5 Workshop Overview, 5 Keynote Address, 6 Federal Progress Reports, 8 Audience Discussion, 11 Reference, 13 2 HOW FEDERAL POLICY AFFECTS EMERGENCY CARE AT THE COMMUNITY LEVEL 15 General Audience Discussion, 16 The Role of Governments and Local Providers, 17 International Approaches to ED Crowding, 20 Trauma System Support, 22 3 QUALITY AND PATIENT SAFETY 25 Improving ED Crowding and Patient Flow, 25 Regionalization and Quality Health Care, 26 Trauma System Evaluations, 27 Standardizing Quality in EMS, 28 Emergency Care as a Health System Barometer, 29 What Is Quality?, 30 Finding Quality by Connecting the Links of the Chain, 30 ix 

 CONTENTS Legislating Quality, 31 Bundling Payments to Improve Provider Linkages, 32 Patchwork Regulatory Systems, 32 Recommendations to Federal Partners, 33 4 ENHANCING EMERGENCY CARE RESEARCH 37 Research Capability and Productivity, 37 Barriers to Emergency Care Research, 38 Opportunities for Emergency Care Research Funding, 39 Unfulfilled Research Agendas, 40 AHRQ’s Role in Emergency Care Research, 41 Audience Discussion, 41 Private Research Dollars, 42 Bolstering the Research Workforce, 43 Enrollment in Clinical Trials Through EDs, 44 Translating Research to Everyday Practice, 45 Suggestions for Advancing Emergency Care Research, 45 Increasing the Perceived Value of Emergency Care Research, 46 5 HEALTH PROFESSIONS TRAINING 49 A Shortage of Emergency Physicians, 50 A Shortage of Trauma Surgeons, 50 A Shortage of Emergency Nurses, 51 Reforming EMS Education, 52 New Roles for EMS Personnel, 53 Audience Discussion, 53 Addressing Workforce Shortages, 54 Disaster Preparedness, 55 Improving EMS Education, 56 Workforce Integration and Collaboration, 56 Performance Improvement, 57 Improving Nurse and Medical Education, 58 Regionalization, 59 Establishing a Critical Care Certification, 59 Reference, 60 6 EMERGENCY CARE ECONOMICS 61 Impact of the Economic Downturn on Emergency Care, 61 Medicare Payments, 63 The Hospital’s View of the ED, 63 Financing Trauma Care, 64 Reimbursing EMS, 66 A Vignette, 67 

CONTENTS xi Distortions in the Medicare Payment Schedule, 68 Audience Discussion, 68 Finding New Revenue, 70 Covering Hospitals Costs, 71 References, 72 7 FEDERAL PARTNERS ROUNDTABLE 73 Session Chair Summaries, 73 Federal Partner Observations, 75 Suggested Federal Priorities, 76 Closing Remarks, 80 APPENDIXES A Workshop Agenda 83 B Workshop Participants 93 C Federal Response to 2006 IOM Recommendations 101 



Figures 5-1 The EMS Education Agenda for the Future: A systems approach, 52 6-1 Payment distribution for routine medical emergency, 68 xiii