Appendix C
The Future of Emergency Care: Key Findings and Recommendations from 2006 Study

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Appendix C The Future of Emergency Care: Key Findings and Recommendations from 2006 Study 

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0 REGIONALIZING EMERGENCY CARE INSTITUTE OF MEDICINE FACT SHEET • JUNE 2006 OF THE NATIONAL ACADEMIES The Future of Emergency Care: Key Findings and Recommendations KEY FINDINGS Critical specialists are often unavailable to provide emergency and trauma care. [Drawn from Hospital- Based Emergency Care: At the Breaking Point] Many EDs and trauma centers are overcrowded. • Three quarters of hospitals report difficulty finding [Drawn from Hospital-Based Emergency Care: At the specialists to take emergency and trauma calls. Breaking Point] • Key specialties are in short supply. For example, the • Demand for emergency care has been growing fast— number of neurosurgeons declined between 1990 and emergency department (ED) visits grew by 26 percent 2002, while the number of trauma visits increased. between 1993 and 2003. • On-call specialists often treat emergency patients • But over the same period, the number of EDs declined without compensation due to high levels of by 425, and the number of hospital beds declined by uninsurance. 198,000. • These specialists also face higher medical liability • ED crowding is a hospital-wide problem—patients exposure than those who do not provide on-call back up in the ED because they can not get admitted to coverage. inpatient beds. • As a result, patients are often “boarded”—held in the The emergency care system is ill-prepared to handle ED until an inpatient bed becomes available—for 48 a major disaster. [Drawn from all three reports] hours or more. • With many EDs at or over capacity, there is little surge • Also, ambulances are frequently diverted from capacity for a major event, whether it takes the form of overcrowded EDs to other hospitals that may be a natural disaster, disease outbreak, or terrorist attack. farther away and may not have the optimal services. • EMS received only 4 percent of Department of In 2003, ambulances were diverted 501,000 times—an Homeland Security first responder funding in 2002 average of once every minute. and 2003. • Emergency Medical Technicians in non-fire based Emergency care is highly fragmented. [Drawn from services have received an average of less than one Emergency Medical Services At the Crossroads] hour of training in disaster response. • Cities and regions are often served by multiple 9-1-1 • Both hospital and EMS personnel lack personal call centers. protective equipment needed to effectively respond to • Emergency Medical Services (EMS) agencies do not chemical, biological, or nuclear threats. effectively coordinate EMS services with EDs and trauma centers. As a result, the regional flow of EMS and EDs are not well equipped to handle patients is poorly managed, leaving some EDs empty pediatric care. [Drawn from Emergency Care for and others overcrowded. Children: Growing Pains.] • EMS does not communicate effectively with public • Most children receive emergency care in general (not safety agencies and public health departments—they children’s) hospitals, which are less likely to have often operate on different radio frequencies and lack pediatric expertise, equipment, and policies in place common procedures for emergencies. for the care of children. • There are no nationwide standards for the training and • Children make up 27 percent of all ED visits, but only certification of EMS personnel. 6 percent of EDs in the U.S. have all of the necessary • Federal responsibility for oversight of the emergency supplies for pediatric emergencies. and trauma care system is scattered across multiple • Many drugs and medical devices have not been agencies. adequately tested on, or dosed properly for, children. • While children have increased vulnerability to disasters—for example, children have less fluid reserve, which leads to rapid dehydration—disaster planning has largely overlooked their needs. Drawn from the Future of Emergency Care report series, 2 006 • Institute of Medicine •

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 APPENDIX C RECOMMENDATIONS Enhance emergency care research. [Drawn from all three reports] • Federal agencies should target additional research Create a coordinated, regionalized, accountable funding to prehospital emergency care services and system. [Drawn from all three reports] pediatric emergency care. • The emergency care system of the future should be one • DHHS should conduct a study of the research needs in which all participants (from 9-1-1 to ambulances to and gaps in emergency care, and determine the best EDs) fully coordinate their activities and integrate strategy for closing the gaps, which may include a communications to ensure seamless emergency and center or institute for emergency care research. trauma services for the patient. • Congress should enact a demonstration program Promote EMS workforce standards. ($88 million over 5 years) to encourage states to [Drawn from Emergency Medical Services At the identify and test alternative strategies for achieving Crossroads] the vision. • States should strengthen the EMS workforce by: • The federal government should support the requiring national accreditation of paramedic development of national standards for: emergency education programs, accepting national certification care performance measurement; categorization of all for state licensure, and adopting common EMS emergency care facilities; and protocols for the certification levels. treatment, triage, and transport of prehospital patients. Enhance pediatric presence throughout emergency Create a lead agency. [Drawn from all three reports] care. [Drawn from Emergency Care for Children: • The federal government should consolidate functions Growing Pains.] related to emergency care that are currently scattered • EDs and EMS agencies should have pediatric among multiple agencies into a single agency in the coordinators to ensure appropriate equipment, Department of Health and Human Services (DHHS). training, and services for children. • Pediatric concerns should be explicit in disaster End ED boarding and diversion. [Drawn from Hospital- planning. Based Emergency Care: At the Breaking Point] • More research is needed to determine the • Hospitals should reduce crowding by improving appropriateness of many medical treatments, hospital efficiency and patient flow, and using medications, and medical technologies for the care operational management methods and information of children. technologies. • Congress should increase funding for the federal • The Joint Commission on the Accreditation of Emergency Medical Services for Children Program Healthcare Organizations should reinstate strong to $37.5 million per year for 5 years. standards for ED boarding and diversion. • The Centers for Medicare and Medicaid Services should develop payment and other incentives to discourage boarding and diversion. Increase funding for emergency care. [Drawn from Hospital-Based Emergency Care: At the Breaking Point and Emergency Medical Services At the Crossroads] • Congress should appropriate $50 million for hospitals that provide large amounts of uncompensated emergency and trauma care. • Funding should be increased for the emergency medical component of preparedness—both EMS and hospital-based—especially for personal protective equipment, training, and planning. Drawn from the Future of Emergency Care report series, 2 006 • Institute of Medicine •

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