Overview

In June 2006, the Institute of Medicine (IOM) concurrently released three reports on the Future of Emergency Care in the United States Health System. The reports focused on hospital-based emergency care, prehospital emergency care, and pediatric emergency care. Although considerable progress has been made in emergency care since the release of a National Academy of Sciences report in 1966 that galvanized national attention to strengthen the emergency care system, numerous challenges remain. These include widespread emergency department crowding, frequent boarding of admitted patients in emergency department hallways, diversion of inbound ambulances due to lack of capacity, a serious and worsening shortage of on-call specialty coverage, and persistent financial challenges. All of these problems are exacerbated by a fragmented delivery system and lack of clear lines of responsibility for oversight and policymaking.

One of the central recommendations of the IOM’s Committee on the Future of Emergency Care was that the nation should develop a “regionalized, coordinated, and accountable” system of emergency care. Regionalized systems would help to promote cooperation among competing local providers and ensure that emergency patients receive “the right care at the right place at the right time.” Historically, regionalization has entailed categorizing the capabilities of each local hospital facility and instructing ambulances to bypass nearby hospitals when necessary to ensure that patients receive optimal care. Early trauma systems were built on this model.

The 2006 IOM reports recommended that the federal government fund demonstration programs to promote the development of regionalized, coordinated, and accountable emergency care systems across the country.



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Overview In June 2006, the Institute of Medicine (IOM) concurrently released three reports on the Future of Emergency Care in the United States Health System. The reports focused on hospital-based emergency care, prehospital emergency care, and pediatric emergency care. Although considerable progress has been made in emergency care since the release of a National Academy of Sciences report in 1966 that galvanized national attention to strengthen the emergency care system, numerous challenges remain. These include widespread emergency department crowding, frequent boarding of admitted patients in emergency department hallways, diversion of inbound ambulances due to lack of capacity, a serious and worsening shortage of on-call specialty coverage, and persistent financial challenges. All of these problems are exacerbated by a fragmented delivery system and lack of clear lines of responsibility for oversight and policymaking. One of the central recommendations of the IOM’s Committee on the Future of Emergency Care was that the nation should develop a “regional- ized, coordinated, and accountable” system of emergency care. Regionalized systems would help to promote cooperation among competing local pro- viders and ensure that emergency patients receive “the right care at the right place at the right time.” Historically, regionalization has entailed categoriz- ing the capabilities of each local hospital facility and instructing ambulances to bypass nearby hospitals when necessary to ensure that patients receive optimal care. Early trauma systems were built on this model. The 2006 IOM reports recommended that the federal government fund demonstration programs to promote the development of regionalized, coordinated, and accountable emergency care systems across the country. 

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 REGIONALIZING EMERGENCY CARE Legislative language to provide funding for this effort has been included as part of the health reform bills debated during 2009-2010. The proposed demonstration program would be broad in scope but would focus on learn- ing more about the development, day-to-day operation, and maintenance of regionalized emergency care systems. A nationwide effort to establish regional systems of emergency care was also undertaken in the 1970s. Two federal departments, the Department of Transportation (DOT) and the Department of Health, Education, and Welfare (DHEW, now Department of Health and Human Services [HHS]) administered grant programs that provided assistance to states and regional systems. The DHEW program established 303 contiguous emergency care regions across the country. Some of the regionalized systems established by this program survive to this day; others withered when federal funding was folded into state block grants in 1980. As a result, fragmentation of care remains a persistent problem in many parts of the country. One of the key Committee recommendations in the 2006 reports was the establishment of a “lead federal agency” within the Department of Health and Human Services to provide overall coordination of federal activities to strengthen emergency care. While regionalization often centers on the important role of states, patient transports frequently involve cross- ing state lines and these can highlight deficiencies in areas such as commu- nication, coordination, and performance measurement. Some argue that accountability at the regional system level may require leadership from the federal level, while others see this as a state responsibility. The concept of a federal lead agency in emergency care was advanced by Homeland Security Presidential Directive-21 (HSPD-21), which was issued in October 2007 and directed that an office dedicated to emergency care be created within HHS. In January 2009, Secretary Michael Leavitt signed the charter establishing the Emergency Care Coordination Center (ECCC) in the Office of Assistant Secretary for Preparedness and Response, within HHS. When the Obama Administration took office, it affirmed its support of the nascent ECCC. Since that time, the Center has engaged a variety of federal agencies in joint problem solving through the creation of a federal Council on Emergency Medical Care (CEMC). This interagency working group has focused on strengthening hospital-based emergency care and has also worked in conjunction with the Federal Interagency Committee on Emergency Medical Services (FICEMS), which serves a similar role in strengthening prehospital EMS care. During 2009, the newly formed ECCC sponsored three IOM workshops to examine the U.S. emergency care system and assess the progress made since the release of the 2006 reports. The first workshop, held in May 2009 in Washington, DC, focused on the Emergency Care Enterprise, the joint effort between FICEMS and ECCC to improve prehospital and hospital-

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 OVERVIEW based emergency care in the United States. The second workshop, held in June 2009 in Washington, DC, addressed medical surge capacity with particular emphasis on the emergency care system’s capacity to respond to catastrophic health events, including disasters and large-scale acts of terrorism. This report summarizes the final workshop, which was held on September 10-11, 2009, in Washington, DC, and which focused specifically on emergency care regionalization. The final workshop was convened to bring stakeholders and policymak- ers together to discuss the concept of regionalization from a wide range of perspectives, to review past efforts to promote regionalization, and to iden- tify future challenges that must be addressed to achieve the IOM’s vision. The workshop had three primary objectives: 1. Foster information exchange among federal and state officials, key stakeholder groups, and experts from around the country who are involved in developing, managing, or evaluating regionalized systems of care. 2. Learn from past experiences and current efforts. 3. Hold discussions with federal partners regarding policy options to inform future federal action. Attendees included national thought leaders, as well as policymakers from the various federal, state, and local agencies involved in emergency care. A concerted effort was made to identify and involve key stakehold- ers from the health care community. These included experts from a wide range of disciplines, including nursing, Emergency Medical Services (EMS), specialty physicians and surgeons, public health officers, and hospital and health system administrators. As is expected in an IOM workshop, the participants expressed a wide array of perspectives and opinions, sometimes differing sharply from each other. Various philosophical perspectives were expressed as well, ranging from strong support for market driven solutions to equally strong support for highly regulated systems with substantial government oversight. Some advocated models organized around major academic medical centers, others envisioned more decentralized approaches knitted together by informa - tion technology. IOM workshops are designed to elicit discussion and give voice to divergent points of view. Although readers of this summary may encounter statements and positions that are at odds with each other, this is not a weakness of the process, but a strength. An IOM workshop has a different purpose than an IOM consensus committee. Consensus committees are expected to draw conclusions and make recommendations about the issues raised by the study’s statement of task. Committee members are carefully vetted in order to balance oppos-

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 REGIONALIZING EMERGENCY CARE ing views and screen out potential conflicts of interest. None of these rules apply in the case of an IOM workshop. Members of the audience who attend the workshop have not been screened for bias or conflicts, have not been charged with making any formal recommendations, and do not con- stitute an official IOM consensus committee. Consequently, the views they have expressed in this workshop summary do not represent the views of the IOM. This particular workshop was structured to emphasize interactive discussion among panelists and participants. Instead of long introductory lectures, each panelist was limited to a 5-minute opening statement and a single PowerPoint slide. Following these introductory statements, the ses- sion chair opened the floor for discussion. This process ensured that every attendee was actively engaged in deliberations throughout the two-day workshop. It also stimulated rich interactive exchanges. The purpose of this report is to summarize the proceedings of the workshop. The first four chapters summarize the speaker presentations and participant discussions from day one. Chapter 1 describes the trauma system model, which is the archetype for regionalized emergency care systems and has been in operation for decades. Chapter 2 examines emerging models that have extended the concept of regionalized care to other time-sensitive conditions, including acute stroke, out-of-hospital cardiac arrest, acute ST-elevation myocardial infarction (STEMI), and the care of critically ill and injured children. Chapter 3 examines three large integrated delivery systems—the Veterans Administration health system, the military’s Joint Theater Trauma System, and the Kaiser Permanente health system. These case studies illustrate how regionalization can be achieved within integrated health care delivery sys- tems. Chapter 4 examines the potential advantages and possible pitfalls of regionalization. Workshop participants recognized that although there are likely to be many benefits of regionalization, it may also produce unintended consequences. Panelists and participants were challenged to identify and consider these in detail. Chapters 5-9 capture presentations and discussions from the second day of the workshop. These chapters focus on the “nuts and bolts” of regional- ization, and how it plays out at the local level. Chapter 5 addresses gover- nance and accountability. It explores strategies to bring competing providers together to pursue shared objectives. Chapter 6 examines the many financial issues that regionalization raises, including the implications of bypassing one hospital in favor of another and the problems associated with transferring costly patients who are unable to pay for their care. Chapter 7 focuses on data and communications. As one panelist said, “Unless the pieces of the system are able to communicate with one another, it’s not possible to be a system.” Chapter 8 focuses on disaster preparedness (fitting, since the sec-

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 OVERVIEW ond day of the workshop was the eighth anniversary of the September 11, 2001, terrorist attacks). Discussants considered how day-to-day emergency care fits (or does not fit) within disaster response scenarios. Chapter 9 summarizes the responses of the workshop’s federal partners—officials from the Department of Transportation’s National Highway Traffic Safety Administration (NHTSA) Office of EMS, the Department of Homeland Security (DHS) Office of Health Affairs, and the ECCC, located within the Department of Health and Human Services. Each discussed what they would take away from the 2-day workshop and how it would inform their upcoming initiatives.

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