Building a 21st-Century Emergency and Trauma Care System
While today’s emergency and trauma care system offers significantly more medical capability than was available in years past, it continues to suffer from severe fragmentation, an absence of systemwide coordination, and a lack of accountability. These shortcomings diminish the care provided to emergency patients and often result in worsened medical outcomes (Davis, 2003). To address these challenges and chart a new direction for emergency and trauma care, the committee envisions a system in which all communities will be served by well-planned and highly coordinated emergency and trauma care systems that are accountable for performance and serve the needs of patients of all ages within the system.
In this new system, 9-1-1 dispatchers, emergency medical services (EMS) personnel, medical providers, public safety officers, and public health officials will be fully interconnected and united in an effort to ensure that each patient receives the most appropriate care, at the optimal location, with the minimum delay. From the patient’s point of view, delivery of services for every type of emergency will be seamless. All service delivery will also be evidence-based, and innovations will be rapidly adopted and adapted to each community’s needs. Hospital emergency department (ED) closures and ambulance diversions will never occur, except in the most extreme situations, such as a hospital fire or a communitywide mass casualty event. Standby capacity appropriate to each community based on its disaster risks will be embedded in the system. The performance of the system will be transparent, and the public will be actively engaged in its operation through prevention, bystander training, and monitoring of system performance.
While these objectives will require substantial, systemwide change, they
are achievable. Early progress toward the goal of more integrated, coordinated, and regionalized emergency and trauma care systems became derailed over the last two decades (see Chapter 2). Efforts stalled because of deeply entrenched interests and cultural attitudes, as well as funding cutbacks and practical impediments to change. These obstacles remain today and represent the primary challenges to achieving the committee’s vision. However, the problems are becoming more apparent, and this provides a catalyst for change. The committee calls for concerted, cooperative efforts at multiple levels of government and the private sector to finally break through and achieve these goals.
This chapter describes the committee’s vision for a 21st-century emergency and trauma care system. This vision rests on the broad goals of improved coordination, expanded regionalization, and increased transparency and accountability, each of which is discussed in turn. The chapter then profiles current approaches of states and local regions that exhibit these features. Finally, the chapter details the committee’s recommendation for a federal demonstration program to support additional state and local efforts aimed at attaining the vision of a more coordinated and effective emergency and trauma care system.
Today’s emergency and trauma care system suffers from fragmentation along a number of different dimensions. As described in Chapter 2, EMS occupies a space that overlaps three major silos: health care, public health, and public safety. In most cases, these three systems are not aligned, and their means of communicating or coordinating with one another are highly limited. Within health care, there is considerable fragmentation along a number of dimensions relating to EMS. For example, coordination among 9-1-1 dispatch, prehospital EMS, air medical providers, and hospital and trauma centers is often lacking (NHTSA, 1996). EMS personnel arriving at the scene of an incident often do not know what to expect regarding the number of injured or their condition (McGinnis, 2005). They also are frequently unaware of which hospitals are on diversion status and which are ready to receive the type of patient they are transporting. Lack of coordination between EMS and hospitals can result in delays that compromise care. In addition, deployment of air medical services is often not well coordinated. While air medical providers are not permitted to self-dispatch, a lack of coordination at the ground EMS and dispatch level sometimes results in multiple air ambulances arriving at the scene of a crash even when all are not needed. Similarly, police, fire, and EMS personnel and equipment often overcrowd a crash scene because of insufficient coordination regarding the appropriate response.
In addition, in many communities there is little interaction between emergency care services and community safety net providers, even though the two share a common base of patients, and their actions may affect one another substantially. The absence of coordination represents missed opportunities for enhanced access, improved diagnosis, patient follow-up and compliance, and enhanced quality of care and patient satisfaction.
Coordination between EMS and public health agencies could also be improved. Through their regular activities, EMS providers have information that could serve as a barometer for both illness and injury trends within the community, potentially assisting state and local public health departments. However, communication links between these agencies are often not well established. Moreover, although prevention activities are generally limited in the emergency care setting, utilization of emergency services represents an important opportunity for imparting information on injury prevention to patients. Emergency care providers could benefit from the resources and experiences of public health agencies and experts in establishing injury prevention activities.
Finally, perhaps now more than ever, with the threat of bioterrorism and outbreaks of diseases such as avian influenza, it is essential that EMS, EDs, trauma centers, and state and local public health agencies partner to conduct surveillance for disease prevalence and outbreaks and other health risks. Emergency responders can recognize the diagnostic clues that may indicate an unusual infectious disease outbreak so that public health authorities can respond quickly (GAO, 2003c). However, a partnership that allows for improved communication of information between emergency care providers and public health officials must first be in place.
Movement Toward Greater Coordination
The value of integrating and coordinating emergency and trauma care has long been recognized. For example, the 1966 National Academy of Sciences/National Research Council (NAS/NRC) report Accidental Death and Disability: The Neglected Disease of Modern Society called for better coordination of emergency and trauma care through community councils on emergency medical services, which would bring together physicians, medical facilities, EMS, public health agencies, and others to procure equipment, construct facilities, and ensure optimal emergency care on a day-to-day basis, as well as in a disaster or national emergency (NAS and NRC, 1966).
Although the drive toward system development waned when federal funding of EMS was folded into state block grants in 1981, the goal of system planning and coordination has remained paramount within the emergency and trauma care community. In 1996, the National Highway Traffic
Safety Administration’s (NHTSA) Emergency Medical Services Agenda for the Future also emphasized the goal of system integration:
EMS of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring…. [P]atients are assured that their care is considered part of a complete health care program, connected to sources for continuous and/or follow-up care, and linked to potentially beneficial health resources…. EMS maintains liaisons, including systems for communication with other community resources, such as other public safety agencies, departments of public health, social service agencies and organizations, health care provider networks, community health educators, and others…. EMS is a community resource, able to initiate important follow-up care for patients, whether or not they are transported to a health care facility. (NHTSA, 1996, pp. 7, 10)
While the concept of a highly integrated emergency and trauma care system as articulated by NHTSA was not new, progress toward its realization has been slow. Nevertheless, there have been important successes in the coordination of emergency and trauma care services that point the way toward solutions to the problem of fragmentation. The most important example of such successes is the trauma system, which has developed a comprehensive and coordinated approach to the care of injured patients. Children’s hospitals have been successful in effecting regional coordination to ensure transport and appropriate care for children with specialized needs. The pediatric intensive care system is a leading example of regional coordination among hospitals, community physicians, and EMS providers (Gausche-Hill and Wiebe, 2001). These examples demonstrate the possibilities for enhanced coordination across the system as a whole.
Importance of Communication
Communication is critical to establishing systemwide coordination. An effective communications system is the glue that can hold together effective, integrated emergency and trauma care services. It provides the key link between 9-1-1 dispatch and EMS responders and is necessary to ensure that on-line medical direction is available when needed. It enables dispatchers to offer prearrival instructions to callers requesting an ambulance. An effective communications system also enables ambulance dispatchers to assist EMS personnel in directing patients to the most appropriate facilities based on the nature of their injuries and the facilities’ fluctuating capacity. Good communication is necessary to link EMS personnel with other public safety providers, such as police, fire and emergency management,
and public health, and can facilitate coordination and incident command in disaster situations. Effective communication also facilitates medical and operational oversight and quality control within the system. In Chapter 5, the committee stresses the importance of fully integrated communications systems to link EMS with hospital, public safety, public health, and emergency management personnel.
The objective of regionalization is to improve patient outcomes by directing patients to facilities with experience in and optimal capabilities for any given type of illness or injury. Substantial evidence demonstrates that doing so improves outcomes and reduces costs across a range of high-risk conditions and procedures, including cardiac arrest and stroke (Grumbach et al., 1995; Imperato et al., 1996; Nallamothu et al., 2001; Chang and Klitzner, 2002; Bardach et al., 2004). The literature also supports the benefits of regionalization of treatment for severely injured trauma patients in improving patient outcomes of care, reducing mortality from traumatic injury, and lowering costs (Jurkovich and Mock, 1999; MacKenzie, 1999; Mann et al., 1999; Mullins, 1999; Mullins and Mann, 1999; Nathens et al., 2000; Chiara and Cimbanassi, 2003; Bravata et al., 2004; MacKenzie et al., 2006), although the evidence here is not uniformly positive (Glance et al., 2004). Formal protocols within a region for prehospital and hospital care contribute to improved patient outcomes as well (Bravata et al., 2004). In addition, organized trauma systems have been shown to add value in facilitating performance measurement and promoting research.
While regionalization of trauma services to high-volume centers is optimal when feasible, Nathens and Maier (2001) argued for an inclusive trauma system in which smaller facilities have been verified and designated as lower-level trauma centers. They suggested that the quality of care may be substantially better in such facilities than in those outside the system, and comparable to national norms. Inclusive trauma systems are designed to cover the entire continuum of care of the injured patient, from the site of injury through acute care and, when appropriate, rehabilitation. Such a system requires the committed involvement of all qualified medical facilities in the region. An efficient triage system, coupled with established transfer agreements, is required to ensure that patients receive the right care in the right place at the right time. In addition, all facilities caring for injured patients must be evaluated for standards of care and must contribute at least a minimal dataset to support systemwide quality/performance improvement programs.
Regionalization may also be a cost-effective strategy for developing and training teams of response personnel. Regionalization benefits triage,
medical care, outbreak investigations, security management, and emergency management. Indeed, both the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) have made regional planning a condition for preparedness funding (GAO, 2003a).
Concerns About Regionalization
The case for regionalization of emergency services is strong, but not absolute. Regionalization can adversely impact the overall availability of clinical services in a community if directing a large number of patients to a regional program leads to elimination of needed services at other facilities. For example, the loss of a profitable set of patients, such as those with suspected acute myocardial infarction (AMI), could result in the closure of a smaller hospital’s cardiac unit or even the entire hospital. The survival of small rural facilities may require the identification and treatment of patients who do not require the capacities and capabilities of larger facilities, as well as repatriation to a local facility for long-term care and follow-up after stabilization at a tertiary center. It is important to take a systems approach that considers the full effects of regionalization on a community.
Determining the appropriate metrics for this type of analysis and defining the process for applying those metrics within each region raise significant research and practical issues. Nonetheless, in the absence of rigorous evidence to guide the process, planning authorities should take the above factors into account in developing regionalized systems of emergency and trauma care. Also, the committee is wary of regionalization that results in directing patients to specialty hospitals that do not provide comprehensive emergency services, as these facilities can drain financial resources from those hospitals that do provide such care (GAO, 2003b; Dummit, 2005).
Configuration of Services
The design of the emergency and trauma care system envisioned by the committee bears similarities to the inclusive trauma system originally conceived and first proposed and developed by CDC, and adapted and disseminated by the American College of Surgeons (ACS). Under this approach, every hospital in a community can play a role in the trauma system by undergoing state verification and designation as a level I to level IV/V trauma center based on its capabilities. Trauma care is optimized in the region through protocols and transfer agreements that are designed to direct trauma patients to the most appropriate level of care available given the type of injury and relative travel times to each center.
In addition to trauma center verification, ACS, along with the American
College of Emergency Physicians (ACEP), state EMS directors, NHTSA, HRSA, trauma nurses, and others, has developed the nascent Trauma Systems Consultation program. Under this program, on-site consultation is provided when requested by the lead agency of a region. The consultation is performed by a multidisciplinary team, which evaluates all components of the system and offers specific recommendations for raising the system to the next level, regardless of how embryonic or mature the system may be. An important feature of these consultations is that they cover the entire continuum of care. A number of regions have sought and received such a consultation.
The committee’s vision expands the concept of an inclusive trauma system to encompass all illnesses and injuries, as well as the entire continuum of emergency care—including 9-1-1 dispatch, prehospital EMS, and clinics and urgent care providers that may take part in emergency care. All providers can play a role in supplying emergency care in their community according to their capabilities. Under the committee’s vision, providers would undergo a process by which their capabilities would be identified and categorized in a manner not unlike trauma verification and designation; the result would be a complete inventory of emergency and trauma care providers within a community. Initially, this categorization might simply be based on the existence of a service—for example, the availability of a cardiac catheterization laboratory or coverage by a neurosurgeon. Eventually, the categorization process might evolve to include more detailed information—for example, the availability of specific emergency procedures and on-call specialty care and indicators of quality, including both service-specific outcomes and general indicators, such as time to treatment, frequency of diversion, and ED boarding. Prehospital EMS could be similarly categorized according to ambulance capacity, availability, credentials of EMS personnel, advanced life support (ALS) and pediatric ALS, treat and release and search and rescue capabilities, disaster readiness (e.g., personal protective equipment), and outcomes (e.g., survival rate from witnessed cardiac arrest due to ventricular fibrillation).
A standard national approach to the categorization of emergency and trauma care providers is needed. Categories should reflect meaningful differences in the types of emergency and trauma care available, yet be simple enough to be understood easily by the provider community and the public. The use of national definitions would ensure that the categories would be understood by providers and by the public across states or regions of the country and would promote benchmarking of performance. Therefore, the committee recommends that the Department of Health and Human Services and the National Highway Traffic Safety Administration, in partnership with professional organizations, convene a panel of individuals with multidisciplinary expertise to develop evidence-based categorization systems for
emergency medical services, emergency departments, and trauma centers based on adult and pediatric service capabilities (3.1). The results of this process would be a complete inventory of emergency and trauma care assets for each community, which should be updated regularly to reflect the rapid changes in delivery systems nationwide. The development of the initial categorization system should be completed within 18 months of the release of this report.
Treatment, Triage, and Transport
Once understood, the basic classification system proposed above could be used to determine the optimal destination for patients based on their condition and location. However, more research and discussion are needed to determine the circumstances under which patients should be brought to the closest hospital for stabilization and transfer as opposed to being transported directly to the facility offering the highest level of care, even if that facility is farther away. Debate continues over whether EMS personnel should perform ALS procedures in the field, or rapid transport to definitive care is best (Wright and Klein, 2001). The answer to this question likely depends, at least in part, on the type of emergency condition. It is evident, for example, that whether a patient will survive out-of-hospital cardiac arrest depends almost entirely on actions taken at the scene, including rapid defibrillation, provision of cardiopulmonary resuscitation (CPR), and perhaps other ALS interventions. Delaying these actions until the unit reaches a hospital results in dismal rates of survival and poor neurological outcomes. Conversely, there is little that prehospital personnel can do to stop internal bleeding from major trauma. In this instance, rapid transport to definitive care in an operating room offers the victim the best odds of survival.
EMS responders who provide stabilization before the patient arrives at a critical care unit are sometimes subject to criticism because of a strongly held belief among many physicians that out-of-hospital stabilization only delays definitive treatment without adding value; however, there is little evidence that the prevailing “scoop and run” paradigm of EMS is always optimal (Orr et al., 2006). In cases of out-of-hospital cardiac arrest, properly trained and equipped EMS personnel can provide all needed interventions at the scene. In fact, research has shown that failure to reestablish a pulse on the scene virtually ensures that the patient will not survive, regardless of what is done at the hospital (Kellermann et al., 1993). On the other hand, the scoop and run approach makes sense when a critical intervention needed by the patient can be provided only at the hospital.
Decisions regarding the appropriate steps to take should be resolved using the best available evidence. Therefore, the committee recommends that the National Highway Traffic Safety Administration, in partnership
with professional organizations, convene a panel of individuals with multidisciplinary expertise to develop evidence-based model prehospital care protocols for the treatment, triage, and transport of patients (3.2). The transport protocols should also reflect the state of readiness of given facilities within a region at a particular point in time. Real-time, concurrent information on the availability of hospital resources and specialists should be furnished to EMS personnel to support transport decisions. Development of an initial set of model protocols should be completed within 18 months of the release of this report. These protocols would facilitate much more uniform treatment of injuries and illnesses nationwide so that all patients would receive the current standard of care at the most appropriate location. The protocols might require modification to reflect local resources, capabilities, and transport times; however, they would acknowledge the fact that the basic pathophysiology of human illness is the same in all areas of the country. Once in place, the national protocols could be tailored to local assets and needs. The process for updating the protocols will also be important because it will dictate how rapidly patients will receive the current standard of care.
The 1966 NAS/NRC report Accidental Death and Disability anticipated the need to categorize care facilities and improve transport decisions:
The patient must be transported to the emergency department best prepared for his particular problem…. Hospital emergency departments should be surveyed … to determine the numbers and types of emergency facilities necessary to provide optimal emergency treatment for the occupants of each region…. Once the required numbers and types of treatment facilities have been determined, it may be necessary to lessen the requirements at some institutions, increase them in others, and even redistribute resources to support space, equipment, and personnel in the major emergency facilities. Until patient, ambulance driver, and hospital staff are in accord as to what the patient might reasonably expect and what the staff of an emergency facility can logically be expected to administer, and until effective transportation and adequate communication are provided to deliver casualties to proper facilities, our present levels of knowledge cannot be applied to optimal care and little reduction in mortality and/or lasting disability can be expected. (NAS and NRC, 1966, p. 20)
These views were echoed in the 1993 Institute of Medicine (IOM) report Emergency Medical Services for Children, which stated that “categorization and regionalization are essential for full and effective operation of systems” (IOM, 1993, p. 171).
Once the decision has been made to transport a patient, the responding ambulance unit should be instructed—either by written protocol or by on-line medical direction—which hospital should receive the patient (see Figure 3-1). This instruction should be based on developed transport
protocols to ensure that the patient is taken to the optimal facility given the severity and nature of the illness or injury, the status of the various care facilities, and the travel times involved. Ideally, this decision should take into account a number of complex and fluctuating factors, such as hospital ED closures and diversions and traffic congestion that hinders transport times for the EMS unit (The SAFECOM Project, 2004).
In addition to using ambulance units and the EMS system to direct patients to the optimum location for emergency and trauma care, hospital emergency and trauma care designations should be posted prominently to improve patients’ self-triage decisions. Such postings can educate the public about the types of emergency services available in their community and enable patients who are not using EMS to direct themselves to the optimal facility.
Fostering accountability is perhaps the most important of the committee’s three goals because it is necessary to achieve the other two. Lack of accountability has contributed to the failure of the emergency and trauma care system to adopt needed changes in the past. Without accountability, participants in the system need not accept responsibility for their failures and can avoid making changes necessary to avoid them in the future.
Accountability has failed to take hold in EMS systems because responsibility is dispersed across many different components of the system; thus it is difficult for policy makers to determine when a system breakdown occurs, much less where it is located or how it can be adequately addressed. EMS diversion is a good example. When a city recognizes it has an unacceptably high frequency of diversions, the locus of responsibility for the problem remains unclear. EMS can blame the ED for crowded conditions and excessively long off-loading times; EDs can blame their hospital for not transporting admitted patients to inpatient units promptly; hospitals can blame on-call specialists or the discharging physician, as well as long-term care facilities that are unwilling to take additional referrals; and all players in the system can blame the state public health department for inadequate funding of community-based alternatives or community physicians for failing to manage their patients adequately so as to keep them out of the ED.
The unpredictable and infrequent nature of emergency and trauma care contributes to the lack of accountability. Most people have limited exposure to the emergency and trauma care system and consider it unlikely that they will ever require an ambulance transport. Consequently, public awareness of specific problem areas in the system is limited. In fact, however, Americans visit EDs more than 114 million times a year, and more than 16 million of these visits involve transport by ambulance (Burt et al., 2006).
Public awareness is also hindered by the lack of nationally defined indicators of system performance. Few localities can answer basic questions about their emergency and trauma care services, such as “What is the overall performance of the emergency care system?”; “How well do 9-1-1, dispatch, prehospital EMS, hospital emergency and trauma care, and other components of the system perform?”; “What is the system’s success rate for resuscitating victims of out-of-hospital cardiac arrest compared with other cities of similar size?”; and “How does the system’s performance compare with that in other regions and the rest of the nation?” By and large, the public assumes that the system functions better than it actually does (Harris Interactive, 2004), and awareness of the problems plaguing the system is very limited.
The committee believes several steps are required to bring accountability into the emergency and trauma care system. These include the development of national performance indicators, the measurement of system performance, and public dissemination of performance information.
Development of National Performance Indicators
There is currently no shortage of performance measurement and standards-setting projects. For example, ED performance measures have been developed by Qualis Health and Lindsay (Lindsay et al., 2002). In addition, the Data Elements for Emergency Department Systems (DEEDS) project and Health Level Seven (HL7) are working to develop uniform specifications for ED performance data (Pollock et al., 1998; CDC and NCICP, 2001; HL7, 2005).
The EMS Performance Measures Project is coordinated by the National Association of State EMS Officials in partnership with the National Association of EMS Physicians, and is supported by NHTSA and HRSA. The project is working to develop consensus measures of EMS system performance that will assist in demonstrating the system’s value and defining an adequate level of EMS capacity and preparedness for a given community (measureEMS.org, 2005). The consensus process of the project has sought to unify disparate efforts to measure performance previously undertaken nationwide that have lacked consistency in definitions, indicators, and data sources. Work undertaken under the project in 2004 resulted in the development of 138 indicators of EMS performance. This list was pared down to 25 indicators in 2005. The list included system measures, such as “What are the time intervals in a call?” and “What percentage of transports is conducted with red lights and sirens?”, and clinical measures, such as “How well was my pain relieved?” The questions were defined using data elements from the National EMS Information System (NEMSIS) dataset so that results could be compared with validity across EMS systems (see Chapter 5).
In addition, statewide trauma and EMS systems are evaluated by ACS, NHTSA’s Office of EMS, and (in the past) HRSA’s Division of Trauma and EMS. There are also various components of the system with independent accrediting bodies. Hospitals, for example, are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); ambulance services are accredited by the Commission on Accreditation of Ambulance Services (CAAS); and air medical services are voluntarily accredited by the Commission on Accreditation of Medical Transport Systems (CAMTS). Each of these organizations collects performance information.
What is missing is a standard set of measures that can be used to assess the performance of the full emergency and trauma care system within each community, as well as the ability to benchmark that performance against statewide and national performance metrics. A credible entity to develop such measures would not be strongly tied to any one component of the emergency care continuum.
One approach would be to form a collaborative entity that would include representation from all of the system components, including hospitals, trauma centers, EMS agencies, physicians, nurses, and others. Another approach would be to work with an existing organization, such as the National Quality Forum (NQF), to develop a set of emergency care–specific measures. NQF grew out of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry in 1998. It operates as a not-for-profit membership organization made up of national, state, regional, and local groups representing consumers, public and private purchasers, employers, health care professionals, provider organizations, health plans, accrediting bodies, labor unions, supporting industries, and organizations involved in health care research or quality improvement. NQF has reviewed and endorsed measure sets applicable to several health care settings and clinical areas and services, including hospital care, home health care, nursing-sensitive care, nursing home care, cardiac surgery, and diabetes care (NQF, 2002, 2003, 2004a,b, 2005).
The committee recommends that the Department of Health and Human Services convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency and trauma care system performance (3.3). Because of the need for an independent, national process that involves the broad participation of every component of emergency and trauma care, the federal government should play a lead role in promoting and funding the process. The development of the initial set of performance indicators should be completed within 18 months of the release of this report.
The measures developed should include structure and process measures, but evolve toward outcome measures over time. They should be nationally standardized so that statewide and national comparisons can be made.
Measures should evaluate the performance of individual providers within the system, as well as that of the system as a whole. Measures should also be sensitive to the interdependence among the components of the system; for example, EMS response times may be adversely affected by ED diversions.
Furthermore, because an episode of emergency and trauma care can span multiple settings, each of which can have a significant impact on the final outcome, it is important that patient-level data from each setting be captured and combined. Currently it is difficult to piece together an episode of emergency and trauma care. To address this need, states should develop guidelines for the sharing of patient-level data from dispatch through post–hospital release. The federal government should support such efforts by sponsoring the development of model procedures that can be adopted by states to minimize their administrative costs and liability exposure as a result of sharing these data.
Measurement of Performance
Performance data should be collected on a regular basis from all of the emergency and trauma care providers in a community. Over time, emerging technologies may support more simplified and streamlined data collection methods, such as wireless transmission of clinical data and direct links to patient electronic health records. However, these types of technical upgrades would likely require federal financial support, and EMS personnel would have to be persuaded to transition from paper-based run records, which are less amenable to efficient performance measurement. The collected data should be tabulated in ways that can be used to measure, report on, and benchmark system performance, generating information useful for ongoing feedback and process improvement. Using their regulatory authority over health care services, states should play a lead role in collecting and analyzing these performance data.
While a full-blown data collection and performance measurement and reporting system is the desired ultimate outcome, the committee believes a handful of key indicators of regional system performance should be collected and promulgated as soon as possible. These could include, for example, indicators of 9-1-1 call processing times, EMS response times for critical calls, and ambulance diversions. In addition, consensus measurement of EMS outcomes could be applied to two to three sentinel conditions. For example, emergency and trauma care systems across the country might be tasked with providing data on such conditions as cardiac arrest (see Box 3-1), pediatric respiratory arrest, and major blunt trauma with shock. Data from the different system components would allow researchers to measure how well the system performs at each level of care (9-1-1, first response, EMS, and ED).
Cardiac Arrest Registry to Enhance Survival
A new 18-month initiative funded by the Centers for Disease Control and Prevention (CDC) is under way in Fulton County, Georgia. Cardiac Arrest Registry to Enhance Survival (CARES) is intended to develop a prototype national registry to help local EMS administrators and medical directors identify when and where cardiac arrest occurs, which elements of their EMS system are functioning properly in dealing with these cases, and what changes can be made to improve outcomes. The initiative is engaging Atlanta-area 9-1-1, EMS and first-responder services, and EDs in systematically collecting minimum data essential to improving survival in cases of cardiac arrest and submitting these data to the registry. Area hospitals log on to a simple, Health Insurance Portability and Accountability Act (HIPAA)–compliant website to report each patient’s outcome. Data compilation and analysis are conducted by researchers at Emory University. Using information gathered from the CARES registry, a community consortium organized by the American Heart Association (AHA) will orchestrate various community interventions to reduce disparities and improve outcomes among victims of cardiac arrest. CARES is designed to enable cities across the country to collect similar data quickly and easily, and use these data to improve cardiac arrest treatment and outcomes.
Sudden cardiac arrest results from an abrupt loss of heart function and is the leading cause of death among adults in the United States. Its onset is unexpected, and death occurs minutes after symptoms develop (AHA, 2005). Survival rates in the event of sudden cardiac arrest are low, but vary as much as 10-fold across communities. Victims’ chances of survival increase with early activation of 9-1-1 and prompt handling of the call, early provision of bystander cardiopulmonary resuscitation (CPR), rapid defibrillation, and early access to definitive care. CARES is designed to allow communities to measure each link in their “chain of survival” quickly and easily and use this information to save more lives.
Public Dissemination of Information on System Performance
Public dissemination of performance data is crucial to drive the needed changes in the delivery of emergency and trauma care services. Dissemination can take various forms, including public report cards, annual reports, and state public health reports, which can be viewed either in hard copy format or online. A key to success is ensuring that important information
regarding the performance of the community’s emergency and trauma care system can be retrieved by the public with a minimum of effort in a format that is highly organized and visually compelling.
Public dissemination of health care information is still in a state of development, despite the proliferation of such initiatives over the past two decades. Problems include the costs associated with data collection, the sensitivity of individual provider information, concerns about interpretation of data by the public, and lack of public interest. There are many examples from which to learn—the Health Plan Employer Data and Information Set (HEDIS), which reports on managed care plans to purchasers and consumers; the Centers for Medicare and Medicaid Services’ (CMS) reports on home health and nursing home care—the Home Health Compare and Nursing Home Compare websites, respectively (CMS, 2005a); and Hospital Compare from the Hospital Quality Alliance, which reports comparative quality data on hospitals (CMS, 2005b). A number of states and regional business coalitions have also developed report cards on managed care plans and hospitals (State of California Office of the Patient Advocate, 2005). Because of the unique status of the emergency and trauma care system as an essential public service and the public’s limited awareness of the significant problems facing the system, the public is likely to take an active interest in this information. The committee believes dissemination of these data will have an important impact on public awareness and the development of integrated regional systems.
Public reporting can be at a detailed or aggregate level. Because of the potential sensitivity of performance data, they should initially be reported in the aggregate at the national, state, and regional levels, rather than at the level of the individual provider organization. Prematurely reporting organizational performance data may inhibit participation and divert providers’ resources to public relations rather than corrective efforts. At the same time, however, individual provider organizations should have full access to their own data so they can understand and improve their individual performance, as well as their contribution to the overall system. Over time, information on individual provider organizations should become an important part of the public information on the system. Eventually, the data may be used to drive performance-based payment for emergency and trauma care.
Aligning Payments with Incentives
In addition to public data reporting, financial incentives can play a major role in improving health care service and performance (Bailit Health Purchasing, 2001). The way emergency and trauma care services are currently reimbursed reinforces certain modes of delivery that are inefficient and stand in the way of achieving the committee’s vision. Historically, pay-
ment for EMS has been based on transport of a sick or injured person to the hospital. This approach has created a financial incentive to transport patients to the hospital even when doing so may not be required or when out-of-hospital “treat and release” may be more appropriate.
It has been estimated that anywhere from 11 to 61 percent of ambulance transports to EDs are not medically necessary (Gratton et al., 2003). Current financial incentives are suspected of adding unnecessary costs to the health care system and burdening already overburdened hospital-based providers. Under the current system, a patient with a sprained ankle may be transported by ambulance and treated at the ED, incurring substantial costs from both providers, when a simple splint by an EMT and a car or taxi ride to a primary care provider would achieve essentially the same outcome at a much lower cost. On the opposite end of the spectrum, allowing paramedics to terminate an unsuccessful cardiac resuscitation in the field could reduce costs by preventing futile care in the hospital and might also reduce the danger to EMS personnel and the public by limiting the number of high-speed transports. However, current financial incentives discourage EMS agencies from making determinations regarding the need for transport to a hospital.
To determine whether incentives are properly aligned, CMS should investigate whether Medicare and Medicaid payment methodologies ought to be revised to support payment for emergency care services in the most appropriate setting (including treat and release), perhaps encompassing payments for medical directors who assume responsibility for release decisions. The committee believes CMS should consider using demonstration projects to test various options, to ensure that the models are safe, and to assess whether downstream savings may result.
Another example of misaligned incentives is that many hospitals do not have a strong economic motivation to address the problems of ED crowding, boarding, and ambulance diversion. In fact, hospitals may benefit financially from these practices. Several payment approaches could eliminate this perverse incentive. One would be to eliminate or compensate for the differential in payment between scheduled and ED admissions. Another would be to assess direct financial rewards or penalties for hospitals based on their management of patient throughput. Through its purchaser and regulatory power, CMS has the ability to drive hospitals to address and manage patient flow and ensure timely access to quality care for its clients. All payers, including Medicare, Medicaid, and private insurers, should also develop contracts that reward hospitals for timely and efficient emergency care and penalize those in which chronic delays in treatment, crowding, and EMS diversions occur. CMS should lead the way in the development of innovative payment approaches that can accomplish these objectives; all payers should be encouraged to do the same.
MODEL SYSTEMS CURRENTLY IN OPERATION
A number of current efforts to establish emergency and trauma care systems achieve some or all of the committee’s goals of coordination, regionalization, and accountability. Some are purely voluntary, while others have the force of state regulation. Some are local and regional in scope, while others are statewide or national. This section highlights several such efforts that provide insights for future initiatives.
The Maryland EMS and Trauma System
Maryland has a unique statewide system that coordinates emergency care, including prehospital care, EDs, and trauma and specialty centers. The Maryland Institute for EMS Systems (MIEMSS) is the administrative lead agency for the system. MIEMSS is an independent state agency governed by an 11-member multidisciplinary board that is appointed by the governor. The system is funded through a surcharge on vehicle registrations that provides support for a broad range of statewide services, including the Maryland State Police medevac program, training and licensure of EMS personnel, medical oversight, prehospital care and triage protocols, trauma and specialty center designation, data management, quality improvement, and an EMS communications system.
A key component of the effective operational coordination of the emergency care system in Maryland is the statewide EMS communications system. This system includes a communications center in Baltimore that dispatches the Maryland State Police medevac helicopters and provides communications and coordination among all components of the state EMS system, including EMS, hospitals, trauma and specialty centers, and 9-1-1 dispatch facilities. For example, a paramedic in western Maryland can talk directly with a local ED physician or obtain on-line consultation with a specialty center in Baltimore. While local 9-1-1 centers initiate dispatch, they typically are too busy to follow patients through the continuum of care and to coordinate health care facilities and major incidents. The EMS communications system provides these critical linkages that enable medical direction, coordination of patient distribution, and continuity of care on a day-to-day basis. The communications center also has direct links to incident command to facilitate the coordination of EMS and health care resources during major incidents. Over the past decade, the state has enhanced the communications system through the development of a digital microwave network, which now connects EMS with other public safety (police, fire, emergency management) and public health entities throughout the state.
In addition, the state has developed a County Hospital Alert Tracking System (CHATS) that monitors the status of hospitals so that ambulances can be directed to less crowded facilities. The system can also be used for individual services—for example, patients with acute coronary syndrome can be directed to facilities according to the current availability of reperfusion suites. The Facility Resource Emergency Database (FRED) system was designed to gather electronically detailed information from hospitals on bed availability, staffing, medications, and other critical capacity issues during disasters, but is also used to communicate information to and from hospitals on a day-to-day basis.
The state ensures coordination and compliance with protocols through a system of EMS operational programs that are required to undertake credentialing, medical oversight, and quality improvement activities.
While EMS and 9-1-1 are operated locally, EMS providers use statewide treatment and triage protocols that promote regionalization of care at state-designated facilities. In addition to trauma centers, these facilities currently include neurotrauma, hyperbaric, burn, eye, perinatal, and hand centers. Regulations have recently been promulgated to designate stroke centers, and the relatively new prehospital stroke protocol will triage acute stroke patients to these designated stroke centers. The state is divided into five regions, each with an advisory council that includes representatives from EMS, hospitals, and trauma and specialty centers. Each region has a representative on the 29-member State EMS Advisory Council.
The Maryland system monitors the performance of providers, as well as that of the system itself. Providers are monitored through their affiliated EMS operational programs, and when necessary, quality assurance issues are referred to the state-level Provider Review Panel. EMS operational programs are required to submit performance data, and as a state agency, MIEMSS reports on system performance. The CHATS system enables EMS programs, participating hospitals, and the public to view the status of hospitals, including availability of ICU beds, ED beds, and trauma beds, at all times through its website. CHATS also collects and reports historical information on trends in hospital diversion, which are reviewed on a regular basis. A statewide web-based EMS patient care report is replacing paper ambulance run sheets so that data can be collected and analyzed more quickly and accurately, thereby facilitating real-time performance improvement.
While Maryland is relatively advanced in achieving the goals of coordination, regionalization, and accountability, it is not clear how easily its system could be replicated in other states. Over the years, the system has benefited from stable leadership, strong support of government leaders and the public, a steady and reliable source of funding, a high concentration of career and volunteer EMS personnel and health care resources, and limited geography—features that many states do not currently enjoy.
Austin/Travis County, Texas
Austin/Travis County and four surrounding counties in Texas agreed to form a single EMS and trauma system to provide seamless care to emergency and trauma patients throughout the region. The initiative, which required a decade of planning, started with a fragmented delivery system consisting of the Austin EMS system, 13 separate fire departments, and a 9-1-1 service run through the sheriff’s office that lacked unified protocols. These different entities agreed to come together to form a unified system that would coordinate all emergency care within the region. The system operates through a Combined Clinical Council that includes representatives of the different agencies and providers within the geographic area, including fire departments, 9-1-1, EMS, air medical services, and corporate employers. This is a “third service” system—it is separate from fire and other public safety entities. The system is supported financially by the individual entities.
Coordination of care is achieved through several means. A unified set of clinical guidelines was developed and is maintained by the system in accordance with current clinical evidence. These guidelines provide a common framework for the care and transport of patients throughout the system. Any changes to the guidelines must be evaluated and approved by the Combined Clinical Council.
All providers in the region have a common set of credentials and are given badges that identify them as certified providers within the system, substantially reducing the multijurisdictional fragmentation that is common across metropolitan areas. In addition, there is no distinction within the system between volunteer and career providers. The integrated structure facilitates both incident command and disaster planning.
The unified system supports the regional emergency and trauma system through clinical operating guidelines that determine the care and transport of all emergency and trauma patients. But the system is focused more on coordination and medical direction of EMS than on regionalization of care.
A Healthcare Quality Committee is charged with reviewing the performance of the system and recommending specific actions to improve quality.
Palm Beach County, Florida
An initiative currently under way in Palm Beach County, Florida, is more limited in scope than the Maryland and Austin systems. The goal of the initiative is to find regional solutions to the limited availability of physician specialists who provide on-call emergency care services. In spring 2004, physician leaders, hospital executives, and public health officials formed the Emergency Department Management Group to address this problem. The initiative is in the early stages of development, and approaches are evolving. One approach is to attack the rising cost of malpractice insurance for emergency care providers, which discourages specialists from serving on on-call panels. The organization is developing a group captive insurance company to offer liability coverage for physicians providing care in county EDs.
The Emergency Department Management Group is developing a web-based, electronic ED call schedule so the EMS system can track which specialists are available at all hospitals throughout the county. This will enable the system to direct transport to the most appropriate facility based on a patient’s type of injury or illness.
The Emergency Department Management Group is exploring the regionalization of certain high-demand specialties, such as hand surgery and neurosurgery, so that the high costs of maintaining full on-call coverage can be concentrated in a few high-volume hospitals, where the volume of cases makes it feasible to maintain such coverage. Hospitals throughout the county would pay a “subscription fee” to support the cost of on-call
coverage at designated hospitals. The fee would be set at a level below what it would cost to have hospitals manage their on-call coverage problems individually.
The initiative includes the development of a countywide quality assurance program under which all hospitals would submit certain data elements for assessment. It is unclear at this time how far this system would go toward public disclosure of system performance.
San Diego County, California
San Diego County has a regionalized trauma system that is characterized by a strong public–private partnership between the county and its five adult and one children’s trauma centers. Public health, assessment, policy development, and quality assurance are core components of the system, which operates under the auspices of the state EMS Authority.
A countywide electronic system (QA Net) provides the real-time status of every trauma center and ED in the county, including the reason for diversion status, ICU bed availability, and trauma resuscitation capacity. The system has been in place for over 10 years and is a critical part of the coordination of emergency and trauma care in the county.
A regional communications system serves as the backbone of the emergency and trauma care system for both day-to-day operations and disasters. It includes an enhanced 9-1-1 system and a countywide network that allows all ambulance providers and hospitals to communicate. The network is used to coordinate decisions on EMS destinations and bypass information, and allows each hospital and EMS provider to know the status of every other hospital and provider on a real-time basis. Because the system’s authority comes from the state to the local level, all prehospital and emergency hospital services are coordinated through one lead agency. This arrangement provides continuity of services, standardized triage, treatment and transport protocols, and an opportunity to improve the system as issues are identified.
The county is divided into five service areas, each of which has at least a level II trauma center. Adult trauma patients are triaged and transported to
the appropriate trauma center, while the children’s hospital provides trauma care to all seriously injured children below the age of 14. Serious burn cases are taken to the University of California-San Diego Burn Center. The county is considering regionalization for other conditions, such as stroke and heart attack, based on the trauma model. The system includes the designation of regional trauma centers, designation of base hospitals to provide medical direction to EMS personnel, establishment of regional medical policies and procedures, and licensure of EMS.
Accountability is driven by a quality improvement program in which a medical audit committee meets monthly to review systemwide patient deaths and complications. The committee includes trauma directors; trauma nurse managers; the county medical examiner; the chief of EMS; and representatives of key specialty organizations, including orthopedic surgeons and neurosurgeons, as well as a representative for nondesignated facilities. A separate prehospital audit committee that includes ED physicians and prehospital providers also meets monthly and discusses any relevant prehospital issues.
DEMONSTRATING FUTURE MODELS
States and regions face a variety of situations, and no one approach to building emergency and trauma care systems will achieve the goals discussed in this chapter. There is, for example, substantial variation across states and regions in the level of development of trauma systems; the effectiveness of state EMS offices and regional EMS councils; and the degree of coordination and integration among fire departments, EMS, hospitals, trauma centers, and emergency management. The baseline conditions and needs also vary. For example, rural areas face very different problems from those of urban areas, and an approach that works for one may be counterproductive for the other.
In addition to these varying needs and conditions, the problems involved are too complex for the committee to prescribe an a priori solution. A number of different avenues should be explored and evaluated to determine what does and does not work. Over time and over a number of controlled initiatives, such a process should yield important insights about what works and under what conditions. These insights can provide best-practice models that can be widely adopted to advance the nation toward the committee’s vision.
The process described here is one that can be supported effectively through federal demonstration projects. Such an approach can provide
funding critical to project success; guidance for design and implementation; waivers from federal laws that might otherwise impede the process; and standardized, independent evaluations of projects and overall national assessment of the program. At the same time, the demonstration approach allows for significant variations according to state and regional needs and conditions within a set of clearly defined parameters. The IOM report Fostering Rapid Advances in Health Care: Learning from System Demonstrations articulated the benefits of the demonstration approach: “There is no accepted blueprint for redesigning the health care sector, although there is widespread recognition that fundamental changes are needed…. For many important issues, we have little experience with alternatives to the status quo…. [T]he committee sees the launching of a carefully crafted set of demonstrations as a way to initiate a ‘building block’ approach” (IOM, 2002).
The committee therefore recommends that Congress establish a demonstration program, administered by the Health Resources and Services Administration, to promote coordinated, regionalized, and accountable emergency and trauma care systems throughout the country, and appropriate $88 million over 5 years to this program (3.4). The essential features of the program are described below.
Grants would be targeted at states, which could develop projects at the state, regional, or local level; cross-state collaborative proposals would be encouraged. Grantees would be selected through a competitive process based on the quality of proposals and an assessment of the likelihood of success in achieving the stated goal(s). Grantees could propose approaches that would address one, two, or all three of the goals of coordination, regionalization, and accountability.
Purpose of the Grants
Each proposal would be required to describe the proposed approach in detail, explain how it would achieve the stated goal(s), identify who would carry out the responsibilities associated with the initiative, identify the costs associated with its implementation, and describe how success would be measured. Proposals should describe the state’s current stage of development and sophistication with regard to the stated goal(s) and explain how the grant would be used to enhance system performance in that regard.
Grants could be used in a number of different ways. Grant funds could be used to enhance communications so as to improve coordination of services; of particular interest would be the development of centralized
communications centers at the regional or state level. Grants could be used to establish convening and planning functions, such as the creation of a regional or state advisory group of stakeholders for the purposes of building collaboration and designing and executing plans to improve coordination. Grant funds could be used to hire consultants and staff to manage the planning and coordination functions, as well as to pay for data collection, analysis, and public reporting. In very limited circumstances, the funds could also be used to implement information systems for the purpose of improving coordination of services. Grant funds should not, however, be used for routine functions that would be performed in the absence of the demonstration project, such as the hiring or training of pediatric specialists or the purchase of pediatric equipment.
The central objective of the grants would be to promote the coordination of emergency and trauma care assets within selected regional areas and to drive improvements in performance. This objective might be achieved in any number of ways, and one basis for awarding the grants would be the level of innovation shown by the applicants. In many urban and suburban areas of the country, for example, emergency care resources are often allocated inefficiently. Multiple EMS agencies of different types (including ground and air ambulances) may all be called to a scene, duplicating care capacity and creating unnecessary confusion. An applicant might devise a method of dispatch that would improve the allocation of resources, avoid redundancy, and improve care. An applicant might propose investing in technology that would promote better positioning of ambulances to reflect the most frequent “hot spots.” Or an applicant might propose establishing a creative means of tracking the performance of the EMS system, such as a direct feedback loop in which EMS personnel could ascertain (e.g., through a web-based program) the outcomes of the patients they treated. A region might elect to keep this information confidential to support voluntary improvements or supply it to medical directors to support improvements in specific performance measures. Such a system might seek to improve data flow through each point along the care continuum, including 9-1-1 dispatch, EMS, hospital EDs and trauma centers, and subsequent care, allowing for a better understanding of systemwide performance. These data might also be used to assess the cost-effectiveness of prehospital care.
In addition, regional emergency and trauma care systems might examine patient outcomes to inform EMS treatment and transport decisions and to make local modifications to the national protocols proposed in this report. The system might also track workforce safety issues, such as injuries, exposures, and stress-related conditions of paramedics and emergency medical technicians (EMTs).
The above are just a few of the many uses for the proposed grants that might be devised by states and regions.
The committee proposes a two-phase program. In phase I, the program would fund up to 10 projects at up to $6 million each over 3 years. The committee recommends support for this number of projects for two reasons. First, the committee hopes that the recommendations presented in this report will stimulate a desire among states and communities to undertake efforts aimed at achieving the committee’s vision. Resources should be available to encourage and support these efforts. Second, there is likely to be considerable variation in the types of projects proposed. A certain number of projects will be needed to generate appropriate lessons learned.
Based on successful results that appeared to be replicable and sustainable in other states, the program would launch phase II, in which smaller, 2-year demonstration grants—up to $2 million each—would be made available to up to 10 additional states. This phase of the program would also include a technical assistance program designed to disseminate results and practical guidance to all states. Program administration would encompass evaluation of the program throughout its 5 years, including reports and public comments at 2.5 and 5 years after project initiation. The committee estimates funding for the program as follows:
Phase I grants: $60 million (over 3 years)
Phase II grants: $20 million (over 2 years)
Phase II technical assistance: $4 million (over 2 years)
Overall program administration: $4 million (over 5 years)
Total program funding: $88 million (over 5 years)
No single agency has responsibility for the multiple components of the nation’s emergency and trauma care system. As noted earlier, this responsibility is currently shared among multiple agencies—principally NHTSA, HRSA, CDC, and the Department of Homeland Security (DHS). If, as recommended below, a lead federal agency is established to consolidate funding and provide leadership for these multiple activities, it would be the appropriate agency to lead this proposed effort. Until that consolidation occurs, however, the committee believes this demonstration program should be placed within HRSA. HRSA has directed a successful related demonstration program—Emergency Medical Services for Children (EMS-C)—and sponsors the Trauma-EMS Systems Program, both of which share many of the broad goals of the proposed demonstration program (although both have been targeted for elimination in recent federal budgets). HRSA has already demonstrated a willingness and ability to collaborate effectively with other
relevant federal agencies, including NHTSA, CDC, and, increasingly, DHS, and should be encouraged to consider them as partners in this enterprise.
NEED FOR SYSTEM INTEGRATION AND A FEDERAL LEAD AGENCY
The committee’s vision of a coordinated, regionalized, and accountable emergency and trauma care system is impeded by the structure of federal programs that currently support emergency and trauma care. To function effectively, the components of the emergency and trauma care system must be highly integrated. Operationally, this means that all of the key players in a given region—hospital emergency and trauma departments, 9-1-1 dispatchers, state public health officials, trauma surgeons, EMS agencies, ED nurses, hospital administrators, firefighters, police, community safety net providers, and others—must work together to make decisions, deploy resources, and monitor and adjust system operations based on performance feedback.
As documented throughout this report, however, fragmentation, silos, and entrenched interests prevail throughout emergency and trauma care. The organization of federal government programs that support and regulate emergency and trauma care services reflects to a large degree the fragmentation of those services at the local level. Responsibility for emergency and trauma care is widely dispersed among multiple federal agencies within the Department of Health and Human Services (DHHS), the U.S. Department of Transportation (DOT), and DHS. This situation reflects the history and inherent nature of emergency and trauma care—essential public services that operate at the intersection of medical care, public health, and public safety (police and fire departments and emergency management agencies). In the 1960s, the mounting toll of highway deaths led NHTSA to become the first government home for EMS, and it has remained the informal lead agency for EMS ever since. Thus although EMS is first and foremost a medical discipline, federal responsibility for EMS rests with DOT. This responsibility was recently reinforced by the elevation of NHTSA’s EMS program to the status of the Office of EMS within the agency. Today, NHTSA actively supports a number of workforce and research initiatives, the development of NEMSIS, and a major nationwide initiative to promote the development of next-generation 9-1-1 service.
DHHS has played an important supporting role in the development of EMS and has taken the lead role with respect to hospital-based emergency and trauma care. It has housed the Division of Emergency Medical Services and the Division of Trauma and EMS for many years and, most recently, the Trauma/EMS Systems Program. All of these programs have since been eliminated; the latter was zeroed out in the fiscal year 2006 federal budget. DHHS continues to support CDC’s National Center for Injury Prevention
and Control, the EMS-C program, and the National Bioterrorism Hospital Preparedness Program. These programs have made important contributions to emergency and trauma care despite inconsistent funding and the frequent threat of elimination. The Agency for Healthcare Research and Quality (AHRQ), another DHHS agency, has historically been the principal federal agency funding research in emergency care delivery, including much of the early research on management of out-of-hospital cardiac arrest. Recently, AHRQ has funded important studies of ED crowding, operations management, and patient safety issues. It is active as well in funding research on preparedness, bioterrorism planning, and response.
DHS also plays an important role in emergency and trauma care. The Federal Emergency Management Agency (FEMA), once an independent cabinet-level agency now housed in DHS, provides limited amounts of grant funding to local EMS agencies through the U.S. Fire Administration. DHS also houses the Metropolitan Medical Response System (MMRS), a grant program designed to enhance emergency and trauma preparedness in major population centers. This program moved from DHHS to DHS in 2003. In addition, DHS houses the Disaster Medical Assistance Team (DMAT) program, through which health professionals volunteer and train as locally organized units so they can be deployed rapidly, under federal direction, in response to disasters nationwide.
Efforts have been made to improve interagency collaboration at the federal level, especially in recent years. Over the last decade, federal agencies have worked collaboratively to provide leadership to the emergency and trauma care field, to minimize gaps and overlaps across programs, and to pool resources to jointly fund promising research and demonstration programs. For example, NHTSA and HRSA jointly supported the development of the Emergency Medical Services Agenda for the Future, as well as a number of other important EMS reports. This degree of collaboration has not been universal among federal agencies, however. Moreover, collaborative efforts are limited by the constraints of agency authorization and funding. At some point, agencies must pursue their own programmatic goals at the expense of joint initiatives. Furthermore, to the degree that successful collaboration has occurred, it has generally depended on the good will of key individuals in positions of leadership, which may limit the sustainability of these efforts when personnel changes occur.
In an effort to enhance the sustainability of collaborative initiatives, a number of agencies have participated in informal planning groups. For example, the Interagency Committee on EMSC Research (ICER), which is sponsored by HRSA, brings together representatives from a number of federal programs for the purposes of sharing information and improving research in emergency and trauma care for children.
A broader initiative is the Federal Interagency Committee on EMS
(FICEMS), a planning group designed to coordinate the efforts of the various federal agencies involved in emergency and trauma care (see Box 3-2). FICEMS was originally established in the late 1970s. The organization had no statutory authority until 2005, when it was given formal status by the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU), DOT’s reauthorization legislation (P.L. 109-59). While the focus of FICEMS is EMS, the group has in practice reached beyond the strict boundaries of prehospital care to facilitate coordination and collaboration with agencies involved in other aspects of hospital-based emergency and trauma care. NHTSA is charged with providing administrative support for FICEMS, which must submit a report to Congress annually. The central aims of the group are as follows:
To ensure coordination among the federal agencies involved with state, local, or regional EMS and 9-1-1 systems.
To identify state, local, or regional needs in EMS and 9-1-1 services.
The 2005 Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users designated the following agencies as members of FICEMS. Each year, members elect a representative from one of these member organizations as the FICEMS chairperson:
To recommend new or expanded programs, including grant programs, for improving state, local, or regional EMS and implementing improved EMS communications technologies, including wireless 9-1-1.
To identify ways of streamlining the process through which federal agencies support state, local, or regional EMS.
To assist state, local, or regional EMS in setting priorities based on identified needs.
To advise, consult, and make recommendations on matters relating to the implementation of coordinated state EMS programs.
Problems with the Current Structure
Despite recent efforts at improved federal collaboration, there is widespread agreement that the various components of emergency and trauma care (EMS for adults and children, trauma care, hospital-based care) have not received sufficient attention, stature, and funding within the federal government. The scattered nature of federal responsibility for emergency and trauma care limits the visibility necessary to secure and maintain funding within the federal government. The result has been marked fluctuations in budgetary support and the constant risk that key programs will be dramatically downsized or eliminated. The lack of a clear point of contact for the public and for stakeholders makes it difficult to build a unified constituent base that can advocate effectively for funding and provide feedback to the government on system performance. The lack of a unified budget has created overlaps, gaps, and idiosyncratic funding of various programs (for example, separate hospital surge capacity initiatives are currently taking place in AHRQ, CDC, HRSA, and DHS). Finally, lack of unified accountability disperses responsibility for system failures and perpetuates divisions between public safety and medical-based emergency and trauma care professionals. The degree to which the scattered responsibility for emergency and trauma care at the federal level has contributed to this disappointing performance is unclear. Regardless, the committee believes a new approach is warranted.
Strong federal leadership for emergency and trauma care is at the heart of the committee’s vision for the future, and continued fragmentation of responsibility at the federal level is not consistent with these goals. Consequently, the committee considered two options for remedying the situation: (1) maintain the status quo, giving the FICEMS approach time to strengthen and mature, or (2) designate or create a new lead agency within the federal government for emergency and trauma care. Some of the key differences between these two approaches are summarized in Table 3-1.
TABLE 3-1 Comparison of the Current FICEMS Approach and the Committee’s Lead Agency Proposal
Maintain the Status Quo, Allowing FICEMS to Gain Strength
Designate or Create a New Lead Agency
Maintain the Status Quo, Allowing FICEMS to Gain Strength
Designate or Create a New Lead Agency
Maintain the Status Quo and Allow FICEMS to Strengthen
The committee considered the ramifications of maintaining the status quo. The problems associated with fragmented federal leadership of emergency care, documented above, include variable funding, periodic program cuts, programmatic duplications and critical program gaps. With the recent enactment of a statutory framework for FICEMS, however, the committee considered the possibility that the need for a lead federal agency has diminished. The committee carefully examined the rationale for delaying the move toward a lead federal agency and allowing FICEMS time to gain strength. The central argument in support of this strategy is that there have been a number of recent improvements in the level of collaboration at the federal level, and these efforts should be given a chance to work before an unproven and politically risky approach is pursued. A number of recent developments support this view: the enactment of a statutory framework for FICEMS; the increasing level of collaboration among some federal agencies; the substantial new NHTSA funding for a next-generation 9-1-1 initiative; and the elevation of the NHTSA EMS program to the Office of EMS, which has
the potential to improve visibility and funding for EMS, and perhaps other aspects of emergency and trauma care, within the federal government.
While the committee applauds these positive developments, setbacks have occurred as well. As noted above, DHHS’s Division of Emergency Medical Services, its Division of Trauma and EMS, and most recently its Trauma/EMS Systems Program have been zeroed out of the federal budget. Federal funding for AHRQ, nonbioterrorism programs at CDC, and other federal programs related to emergency and trauma care at the federal level have been cut. These developments suggest that a fragmented organizational structure at the federal level would significantly hinder the creation of a coordinated, regionalized, accountable emergency and trauma care system. FICEMS can be a valuable body, but it is a poor substitute for formal agency consolidation. FICEMS is expressly focused on EMS, and ultimately has limited power even within this sphere. It is not a federal agency and therefore cannot regulate, spend, or withhold funding. It cannot even hold its own member agencies accountable for their actions—or lack of action.
Designate or Create a New Federal Lead Agency
The possibility of a lead agency for emergency and trauma care has been discussed for years and was highlighted in the 1996 report Emergency Medical Services Agenda for the Future. While the concept of a lead agency promoted in that report was focused on prehospital EMS, the committee believes a lead agency should encompass all components involved in the provision of emergency and trauma care. This federal lead agency would unify federal policy development related to emergency and trauma care, provide a central point of contact for the various constituencies in the field, serve as a federal advocate for emergency and trauma care within the government, and coordinate grants so that federal dollars would be allocated efficiently and effectively.
A lead federal agency could better move the emergency and trauma care system toward improved integration; unify funding and other decisions; and represent all emergency and trauma care patients, providers, and settings, including prehospital EMS (both ground and air), hospital-based emergency and trauma care, pediatric emergency and trauma care, rural emergency and trauma care, and medical disaster preparedness. Specifically, a federal lead agency could:
Create unified accountability for the performance of the emergency and trauma care system.
Rationalize funding across the various aspects of emergency and trauma care to optimize the allocation of resources in achieving system outcomes.
Coordinate programs to eliminate overlaps and gaps in current and future funding.
Provide consistent federal leadership on policy issues that cut across agency boundaries.
Create a large combined federal presence, increasing the visibility of emergency and trauma care within the government and among the public.
Provide a recognizable entity that would serve as a single point of contact for stakeholders and the public, resulting in consolidated and efficient data collection and dissemination and coordinated program information.
Enhance the professional identity and stature of emergency and trauma care practitioners.
Bring together multiple professional groups and cultures, creating cross-cultural and interdisciplinary interaction and collaboration that would model and reinforce the integration of services envisioned by the committee.
Although creating a lead agency could yield many benefits, such a move would also involve significant challenges. Numerous questions must be addressed regarding the location of such an agency in the federal government, its structure and functions, and the possible risk of weakening or losing current programs. HRSA’s rural EMS and EMS/Trauma System programs have already been defunded, and the EMS-C program is under the constant threat of elimination. There is real concern that proposing an expensive and uncertain agency consolidation could jeopardize programs already at risk, such as EMS-C, as well as cripple new programs just getting started, such as NHTSA’s enhanced 9-1-1 program. This is particularly likely if there is resistance to the consolidation from within the current agency homes for these programs.
A related concern is that the priority currently given to certain programs could shift, resulting in less support for existing programs. EMS advocates have expressed concern that hospital-based emergency and trauma care issues would dominate the agenda of a new unified agency. The pediatric community is worried about getting lost in a new agency and has fought hard to establish and maintain strong categorical programs supported by historically steady funding streams. There is concern that under the proposed new structure, the EMS-C program could become diminished or simply lose visibility amid the multitude of programs addressed by the new agency.
There is also the potential for administrative and funding disruptions. Combining similar agencies, particularly those that reside within the same department, may be straightforward. But combining agencies with different missions across departments with different cultures may prove highly difficult. The problems experienced during the consolidation of programs in DHS increase anxiety about this proposal.
Another concern is that removing medical-related functions from DHS and DOT could exacerbate rather than reduce fragmentation. Operationally, nearly half of EMS operations are fire department–based. Thus, there is concern that separating EMS and fire responsibilities at the federal level could splinter rather than strengthen relationships.
The Committee’s Recommendation
Despite the concerns outlined above, the committee believes the potential benefits of consolidation outweigh the potential risks. A lead federal agency is required to fully realize the committee’s vision of a coordinated, regionalized, and accountable emergency and trauma care system. The committee recognizes that a number of challenges are associated with the establishment of a new lead agency, though it believes these concerns can be mitigated through appropriate planning. The committee therefore recommends that Congress establish a lead agency for emergency and trauma care within 2 years of the release of this report. This lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of emergency medical services and emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital emergency medical services (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and design and monitor the transition to its assumption of the responsibilities outlined above. The working group should include representatives from federal and state agencies and professional disciplines involved in emergency care (3.5).
Objectives of the Lead Agency
The lead agency’s mission would be to enhance the performance of the emergency and trauma care system as a whole, as well as to improve the performance of the various components of the system, such as prehospital EMS, hospital-based emergency care, trauma systems, pediatric emergency and trauma care, prevention, rural emergency and trauma care, and disaster preparedness. The lead agency would set the overall direction for emergency and trauma care planning and funding; would be the primary collector and repository of data in the field; and would be the key source of information about emergency and trauma care for the public, the federal government, and practitioners themselves. It would be responsible for allocating federal resources across all of emergency and trauma care to achieve
systemwide goals, and should be held accountable for the performance of the system and its components.
Location of the Lead Agency
The lead agency would be housed within DHHS. The committee considered many factors in selecting DHHS over DOT and DHS. The factor that drove this decision above all others was the need to unify emergency and trauma care within a medical care/public health framework. Emergency and trauma care is by its very nature involved in multiple arenas—medical care, public safety, public health, and emergency management. The multiple identities that result from this multifaceted involvement reinforce the fragmentation that is endemic to the emergency and trauma care system. For too long, the gulf between EMS and hospital care has hindered efforts at communication, continuity of care, patient safety and quality of care, data collection and sharing, collaborative research, performance measurement, and accountability. It will be difficult for emergency and trauma care to achieve seamless and high-quality performance across the system until the entire system is organized within a medical care/public health framework, while also retaining its operational linkages with public safety and emergency management.
Only DHHS, as the department responsible for medical care and public health in the United States, can encompass all of these functions effectively. Although DOT has played an important role in both EMS and acute trauma care and has collaborated effectively with other agencies, its EMS and highway safety focus is too narrow to represent all of emergency and trauma care. DHS houses the Fire Service, which is closely allied with EMS, particularly at the field operations level. But the focus of DHS on disaster preparedness and bioterrorism is also too narrow to encompass the broad scope of emergency and trauma care.
Because emergency and trauma care functions would be consolidated in a department oriented toward medical care and public health, there is a risk that public safety and emergency management components could receive less attention, stature, or funding. Therefore, the committee considers it important that the mission of the new agency be understood and clearly established by statute so that the public safety and emergency management aspects of emergency and trauma care will not be neglected.
Programs Included Under the Lead Agency
The committee envisions that the lead agency would have primary programmatic responsibility for the full continuum of EMS; emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch; prehospital EMS (both ground and air); hospital-based
emergency and trauma care; and medical-related disaster preparedness. The agency’s focus would be on program development and strategic funding to improve the delivery of emergency and trauma care nationwide. It would not be primarily a research funding agency, with the exception of existing grant programs mentioned above. Funding for basic, clinical, and health services research in emergency and trauma care would remain the primary responsibility of existing research agencies, including the National Institutes of Health (NIH), AHRQ, and CDC. Because of the limited research focus of the lead agency, it would be important for existing research agencies, NIH in particular, to work closely with the new agency and strengthen their commitment to emergency and trauma care research. On the other hand, it may be appropriate to keep certain clinical and health services research initiatives with the programs in which they are housed, and therefore bring them into the new agency. For example, the Pediatric Emergency Care Applied Research Network could be moved into the new agency along with the rest of the EMS-C program.
In addition to existing functions, the lead agency would become the home for future programs related to emergency and trauma care, including new programs that would be dedicated to the development of inclusive systems of emergency and trauma care.
While the committee envisions consolidation of most of the emergency care–related functions currently residing in other agencies and departments, it recognizes that many complex issues are involved in determining which programs should be combined and which left in their current agency homes. A deliberate process should be established to determine the exact composition of the new agency and to coordinate an effective transition. For these reasons, the committee is recommending the establishment of an independent working group to make recommendations regarding the structure, funding, and responsibilities of the new agency and to coordinate and monitor the transition process. The working group would include representatives from federal and state agencies and professional disciplines involved in emergency care. The committee considered whether FICEMS would be an appropriate entity to assume this advisory and oversight role and concluded that, as currently constituted, it lacks the scope and independence to carry out this role effectively.
Role of FICEMS
FICEMS is a highly promising entity that is complementary to the proposed new lead agency. FICEMS would play a vital role during the proposed
interim 2-year period by continuing to enhance coordination and collaboration among agencies and providing a forum for public input. In addition, it could play an important advisory role to the independent working group. Once the lead agency had been established, FICEMS would continue to coordinate work between the lead agency and other agencies, such as NIH, CMS, and the Department of Defense (DoD), that would remain closely involved in various emergency and trauma care issues.
Structure of the Lead Agency
While the principle of integration across the multiple components of emergency and trauma care should drive the structure, operation, and funding of the new lead agency, the committee envisions distinct program offices to provide focused attention and programmatic funding for key areas, such as the following:
Prehospital EMS, including 9-1-1, dispatch, and both ground and air medical services
Hospital-based emergency and trauma care
Pediatric emergency and trauma care
Rural emergency and trauma care
To ensure that current programs would not lose visibility and stature within the new agency, each program office should have equal status and reporting relationships within the agency’s organizational structure. The committee envisions a national dialogue over the coming year—coordinated by the proposed independent working group, aided by input from FICEMS, and with the involvement of the Office of Management and Budget and the congressional committees with jurisdiction—to specify the organizational structure in further detail and implement the committee’s recommendation.
Funding for the Lead Agency
Existing programs transferring to the new agency would bring with them their full current and projected funding, although this may not be possible for some funds, such as the Highway Trust Funds, which contribute to the operational funding for the Office of EMS. Congress should also establish additional funding to cover the costs associated with the transition to and the new administrative overhead associated with the lead agency. In addition, Congress should add new funding for the offices of hospital-based
emergency and trauma care, rural emergency and trauma care, and trauma systems. In light of the pressing challenges confronting emergency care providers and the American public, this would be money well spent. While the committee is unable to estimate the costs associated with establishing a unified lead agency, it recognizes that these costs would be substantial. At the same time, however, the committee believes that countervailing cost savings would result from reduced duplication and lower overhead. Consequently, new funding that flowed into the agency would result in new programming, rather than an increase in existing overhead.
Mitigation of Concerns Regarding the Establishment of a Lead Federal Agency
The committee recognizes that transitioning to a single lead agency would be a difficult challenge under any circumstances, but would be especially difficult for an emergency and trauma care system that is already under duress from funding cutbacks, elimination of programs, growing public demand on the system, and pressure to enhance disaster preparedness. During this critical period, it is important that support for emergency and trauma care programs already in place in the various federal agencies be sustained. In particular, the Office of EMS within NHTSA has ongoing programs that are critical to the EMS system. Similarly, existing emergency care–related federal programs, such as those in HRSA’s EMS-C program and Office of Rural Health Policy and at CDC, should be supported during the transition period. If the committee’s proposal is to be successful, the constituencies associated with established programs must not perceive that they are being politically weakened during the transition period.
The committee believes the proposed consolidation of agencies would enhance support for emergency and trauma care across the board, benefiting all current programs. But it also believes avoiding disruptions that could adversely affect established programs is critically important. Therefore, the committee believes legislation creating the new agency should protect current levels of funding and visibility for existing programs. The new agency should balance its funding priorities by adding to existing funding levels, not by diverting funds away from existing programs.
The committee acknowledges the concern that removing medical-related emergency and trauma functions from DHS and DOT would create additional fragmentation. The committee believes the public safety aspects of emergency and trauma care must continue to be addressed as a core element of the emergency and trauma care system. But the primary focus of the system should be medical care and public health if the recognition, stature, and outcomes that are critical to the system’s success are to be achieved.
Adapting the Legal and Regulatory Framework
The way hospitals and EMS agencies deliver emergency care is shaped largely by federal and state laws—in particular, the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986, the Health Insurance Portability and Accountability Act (HIPAA), and medical malpractice laws. The application of these laws to the actual provision of care is guided by sometimes baffling regulatory rules and advisories, enforcement decisions, and court decisions, as well as by providers’ understanding of the laws. EMTALA and HIPAA are discussed below.
Emergency Medical Treatment and Active Labor Act of 1986
EMTALA was enacted to prevent hospitals from refusing to serve uninsured patients and “dumping” them on other hospitals. The act established a mandate for hospitals and physicians who provide emergency and trauma care to provide a medical screening exam to all patients and appropriately stabilize patients or transfer them to an appropriate facility if an emergency medical condition exists (GAO, 2001).
EMTALA has implications for the regional coordination of care. The act was written to provide individual patient protections—it focuses on the obligations of an individual hospital to an individual patient (Rosenbaum and Kamoie, 2003). While it serves an important purpose, the statute is not clearly adaptable to a highly integrated regional emergency care system in which the optimal care of patients may diverge from conventional patterns of emergency treatment and transport.
Until recently, EMTALA appeared to hinder the regional coordination of services in several specific ways—for example, requiring a hospital-owned ambulance to transport a patient to the parent hospital even if it is not the optimal destination for that patient, requiring a hospital to interrupt the transfer to administer a medical screening exam for a patient being transferred from ground transport to helicopter using the hospital’s helipad, and limiting the ability of hospitals to direct nonemergent patients who enter the ED to an appropriate and readily available ambulatory care setting or clinic. Interim guidance published by CMS in 2003 appeared to mitigate these problems (DHHS, 2003). This guidance established, for example, that a patient visiting an off-campus hospital site that does not normally provide emergency care does not create an EMTALA obligation, that a hospital-owned ambulance need not return the patient to the parent hospital if it is operating under the authority of a communitywide EMS protocol, and that hospitals are not obligated to provide treatment for clearly nonemergency situations as determined by qualified medical personnel. Further, hospitals involved in disasters need not adhere strictly to EMTALA if operating under a community disaster plan. Despite these changes, however, uncertainty sur-
rounding the interpretation and enforcement of EMTALA remains a damper on the development of coordinated, integrated emergency care systems.
In 2005, CMS convened a technical advisory group to study EMTALA and address additional needed changes (CMS, 2005a,b,c). To date, the advisory group has focused on incremental modifications to the act.
While the recent CMS guidance and deliberations of the EMTALA advisory group are positive steps, the committee envisions a more fundamental rethinking of EMTALA that would support and facilitate the development of regionalized emergency systems, rather than simply addressing each obstacle on a piecemeal basis. The new EMTALA would continue to protect patients from discrimination in treatment while enabling and encouraging communities to test innovations in the design of emergency care systems, such as direct transport of patients to non–acute care facilities—dialysis centers and ambulatory care clinics, for example—when appropriate.
Health Insurance Portability and Accountability Act
HIPAA was enacted to facilitate electronic transmission of data between providers and payers while protecting the privacy of patient health information. In protecting patient confidentiality, HIPAA can present certain challenges for providers, such as making it more complicated for a physician to send information about a patient to another physician for a consultation. Regional coordination is based on the seamless delivery of care across multiple provider settings. Patient-specific information must flow freely between these settings—from dispatch to emergency response to hospital care—to ensure that appropriate information will be available for clinical decision making and coordination of services in emergency situations. In addition, retrospective patient-level data are needed to measure the performance of the system and to develop protocols based on outcomes of care across providers. Current interpretations of HIPAA would make it difficult to achieve the required degree of information fluidity.
Both EMTALA and HIPAA protect patients from potential abuses and serve invaluable purposes. As written and frequently interpreted, however, they can impede the exchange of lifesaving information and hinder the development of regional systems. The committee believes appropriate modifications can be made to both acts that would preserve their original purpose while reducing their adverse impact on the development of regional systems. The committee recommends that the Department of Health and Human Services adopt regulatory changes to the Emergency Medical Treatment and Active Labor Act and the Health Insurance Portability and Accountability
Act so that the original goals of the laws will be preserved, but integrated systems can be further developed (3.6).
Financing System Costs
In addition to the above and other regulatory issues that should be addressed by the federal government, there are outstanding issues related to the financing of the emergency care system. While the establishment of the proposed federal lead agency would help rationalize the federal grant payments allocated to EMS and the emergency care system more broadly, these grants represent a small share of total payments to EMS providers. Payments for EMS are made primarily through public and private insurance reimbursements and local subsidies. A large percentage of EMS transports are for elderly patients, making the federal Medicare program a particularly important payer.
EMS costs include the direct costs of each emergency response, as well as the readiness costs associated with maintaining the capability to respond quickly, 24 hours a day, 7 days a week—costs that are not adequately reimbursed by Medicare. In addition, by paying only when a patient is transported, Medicare limits the flexibility of EMS in providing the most appropriate care for each patient. Therefore, the committee recommends that the Centers for Medicare and Medicaid Services convene an ad hoc working group with expertise in emergency care, trauma, and emergency medical services systems to evaluate the reimbursement of emergency medical services and make recommendations with regard to including readiness costs and permitting payment without transport (3.7). A key objective of this working group would be to develop a strategy and a mechanism to ensure that federal, state, and local governments each would pay a fair share toward maintaining EMS readiness capacity. The working group would examine the role played by the Medicare and Medicaid programs in establishing a basic level of EMS readiness across the country and assess the extent to which local self-determination should be the basis for deciding whether to extend service beyond this level. In addition, the working group would consider whether pay-for-performance principles should be applied to EMS. Finally, the group would examine the costs and burden sharing required for local EMS systems to make needed upgrades in communications and information technology.
SUMMARY OF RECOMMENDATIONS
3.1: The Department of Health and Human Services and the National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of indi-
viduals with multidisciplinary expertise to develop evidence-based categorization systems for emergency medical services, emergency departments, and trauma centers based on adult and pediatric service capabilities.
3.2: The National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidence-based model prehospital care protocols for the treatment, triage, and transport of patients.
3.3: The Department of Health and Human Services should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency and trauma care system performance.
3.4: Congress should establish a demonstration program, administered by the Health Resources and Services Administration, to promote coordinated, regionalized, and accountable emergency and trauma care systems throughout the country, and appropriate $88 million over 5 years to this program.
3.5: Congress should establish a lead agency for emergency and trauma care within 2 years of the release of this report. This lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of emergency medical services and emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital emergency medical services (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and design and monitor the transition to its assumption of the responsibilities outlined above. The working group should include representatives from federal and state agencies and professional disciplines involved in emergency and trauma care.
3.6: The Department of Health and Human Services should adopt regulatory changes to the Emergency Medical Treatment and Active Labor Act and the Health Insurance Portability and Accountability Act so that the original goals of the laws will be preserved, but integrated systems can be further developed.
3.7: The Centers for Medicare and Medicaid Services should convene an ad hoc working group with expertise in emergency care, trauma, and emergency medical services systems to evaluate the reimbursement of emergency medical services and make recommendations with regard to including readiness costs and permitting payment without transport.
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