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Appendix C Federal Response to 2006 IOM Recommendations TABLE C-1â Federal Response to 2006 IOM Recommendations Rec # (Report) IOM Recommendation Federal Response 2.1 Congress should establish Congress has taken up a number of (ED) dedicated funding, separate from related bills in the last two years, three Disproportionate Share Hospital of which were passed, but they targeted (DSH) payments, to reimburse only two states (Tennessee and Hawaii). hospitals that provide significant Overall this recommendation has gone amounts of uncompensated emergency unanswered. (Handrigan) and trauma care for the financial losses incurred by providing those services. a. Congress should initially appropriate $50 million for the purpose, to be administered by the CMS. b. CMS should establish a working group to determine the allocation of these funds, which should be targeted to providers and localities at greatest risk; the working group should then determine funding needs for subsequent years. continued 101
102 NATIONAL EMERGENCY CARE ENTERPRISE TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 3.1 HHS and NHTSA, in partnership Some states (CA, IL, OK, TN) have (All) with professional organizations, voluntary designations that hospitals can should convene a panel of individuals seek. Illinois and California designate with multidisciplinary expertise emergency departments approved for to develop an evidence-based pediatrics; Oklahoma and Tennessee categorization system for emergency give pediatric medical recognition. This medical services, emergency may signify the presence of a pediatric departments, and trauma centers emergency coordinator, for example. based on adult and pediatric service (Kavanaugh) capabilities. 3.2 NHTSA, in partnership with NHTSA, with FICEMS and NEMSAC, (All) professional organizations, should is creating an evidence-based guideline convene a panel of individuals with development process that will be multidisciplinary expertise to develop dynamic rather than static and will evidence-based model prehospital care keep pace with the changing nature of protocols for the treatment, triage, EMS best practices. (See Chapter 1.) and transport of patients, including (Dawson) children. 3.3 HHS should convene a panel of The ECCC has convened a new entity (All) individuals with emergency and called the Council on Emergency Care trauma care expertise to develop which brings together partners from evidence-based indicators of throughout government at all levels, emergency and trauma care system with diverse subject matter expertise, to performance. coordinate the entire federal emergency care agenda, but also to examine indicators of performance. (Handrigan) NHTSA has partnered with the EMS community in conducting the Performance Measurement Project, which will recommend indicators of quality emergency medical services and system performance. This project will soon be final. (Dawson) 3.4 HHS should adopt regulatory changes CMS convened a technical advisory (ED) to EMTALA and HIPAA so that the group in 2006. They issued a series original goals of the laws will be of recommendations which have preserved, but integrated systems can contributed to the progress of legislation be further developed. that is now in committee. (Handrigan)
APPENDIX C 103 TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 3.4 Congress should establish Congress has not yet provided the $88 (EMS) a demonstration program, million needed to fund the trauma (Peds) administered by the HRSA, to system. However, there is now a bill promote coordinated, regionalized, in Congress that would help stabilize and accountable emergency care the trauma system. In addition, in May systems throughout the country, and 2009 the ECCC, in conjunction with appropriate $88 million over 5 years FICEMS and other federal partners, held to this program. a town hall meeting at the Society for Academic Emergency Medicine. IOM will also be conducting a workshop on regionalization in September 2009. ECCC also plans to create several demonstration projects focused specifically on regionalization in 2010. So this is moving forward. (Handrigan) NHTSA and NEMSAC have produced model legislation focusing on regional EMS systems. This will be reflected in DOTâs revised highway safety standards that serve as a basis for assessing state EMS systems. (Dawson) 3.5 Same as 3.4 (EMS) above (ED) Regional demonstrations ($88 million) 3.5 Same as 3.6 (ED) below (EMS) Federal lead agency 3.5 Same as 3.4 (ED) above (Peds) EMTALA and HIPAA continued
104 NATIONAL EMERGENCY CARE ENTERPRISE TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 3.6 Congress should establish a lead The Emergency Care Coordination (ED) agency for emergency and trauma Center (ECCC) charter was signed (Peds) care within two years of the release in January 2009. ECCC is an infant of this report. The lead agency organization, but this is the federal should be housed in HHS, and answer to the IOM recommendation. should have primary programmatic The primary mission of the ECCC is responsibility for the full continuum to support the USGâs coordination of of emergency medical services in-hospital emergency medical care and emergency and trauma care activities and to promote programs and for adults and children, including resources that improve the delivery of medical 9-1-1 and emergency medical our nationâs daily emergency medical dispatch, prehospital emergency care and emergency behavioral health medical services (both ground and care. (Handrigan) 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 develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care. 3.6 Same as 3.4 (ED) above (EMS) EMTALA and HIPAA 3.7 CMS should convene an ad hoc This recommendation is directed (EMS) working group with expertise to CMS. However, NEMSAC has in emergency care, trauma, and requested, through FICEMS, that CMS emergency medical services systems establish this working group. Also, to evaluate the reimbursement of NEMSAC is completing a white paper emergency medical services, and that addresses EMS financing. (Dawson) make recommendations with regard to including readiness costs and permitting payment without transport. 3.7 Congress should appropriate $37.5 Recommendation not directed to the (Peds) million per year for the next 5 years federal partners. to the EMS-C program. 4.1 CMS should remove the current This issue has not been addressed, but (ED) restrictions on the medical conditions is worthy of consideration by CMS. that are eligible for separate clinical (Handrigan) decision unit (CDU) payment.
APPENDIX C 105 TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 4.1 State governments should adopt The National EMS Scope of Practice (EMS) a common scope of practice for Model was completed several years ago. emergency medical services personnel, It now serves as the basis for the National with state licensing reciprocity. EMS Education Standards. The National Association of State EMS Officials (NASEMSO), through a cooperative agreement with NHTSA, is assisting in promoting implementation. Currently, 39 states have adopted or plan to adopt the scope of practice model. (Dawson) 4.1 Every pediatric- and emergency Recommendation not directed to the (Peds) care-related health professional federal partners. credentialing and certification body should define pediatric emergency care competencies and require practitioners to receive the level of initial and continuing education necessary to achieve and maintain those competencies. 4.2 Hospital CEOs should adopt Recommendation not directed to the (ED) enterprisewide operations federal partners. management and related strategies to improve the quality and efficiency of emergency care. 4.2 States should require national Although progress has been slow, (EMS) accreditation of paramedic education the National Registry of Emergency programs. Medical Technicians (NREMT) has made a decision to require paramedic students to graduate from an accredited paramedic educational program by the year 2013. The National Association of State EMS Officials is working with the Committee on Accreditation of EMS Programs (CoAEMSP) to ensure that this will happen. Twelve states currently require paramedic education program accreditation. (Dawson) continued
106 NATIONAL EMERGENCY CARE ENTERPRISE TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 4.2 HHS should collaborate with As the IOM report noted, unless there (Peds) professional organizations to is a commitment to funding pediatric convene a panel of individuals with emergency medicine research, there wonât multidisciplinary expertise to develop, be an adequate evidence base from which evaluate, and update clinical practice to derive the practice guidelines. Recently, guidelines and standards of care for EMS-C funding has been directed more pediatric emergency care. toward activities that would improve the evidence base rather than guideline development specifically. However, EMS-C has provided some funds toward NHTSAâs evidence-based guidelines development process. (Kavanaugh) 4.3 Training in operations management Recommendation not directed to the (ED) and related approaches should federal partners. be promoted by professional associations; accrediting organizations, such as the JCAHO and the NCQA; and educational institutions that provide training in clinical, health care management, and public health disciplines. 4.3 States should accept national NASEMSO is tracking progress on this (EMS) certification as a prerequisite for state recommendation. As of May 2008, licensure and local credentialing of 45 states use NREMT certification for emergency medical services providers. licensure of at least one level of EMS provider. However, state requirements still vary considerably. (Dawson) 4.4 ABEM should create a subspecialty Recommendation not directed to the (EMS) certification in emergency services. federal partners. 4.5 Hospitals should end the practices of The first part of this recommendation (ED) boarding patients in the emergency is directed to hospitals. However, the department and ambulance diversion, second part, relating to the working except in the most extreme cases, such group, is now being considered by as a community mass casualty event. Congress. The Access to Emergency CMS should convene a working group Medical Services Act would convene that includes experts in emergency a bipartisan commission to evaluate care, inpatient critical care, hospital and recommend a path forward. operations management, nursing, and (Handrigan) other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures and incentives for implementation, monitoring, and enforcement of these standards.
APPENDIX C 107 TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 5.1 Hospitals should adopt robust This recommendation is directed to (ED) information and communications the hospitals; however, the federal systems to improve the safety and government has provided significant quality of emergency care and momentum through the stimulus funds enhance hospital efficiency. and the overall health IT strategy. (Handrigan) 5.1 States should assume regulatory There are several bills in Congressional (EMS) oversight of the medical aspects committees that would provide states of air medical services, including with additional oversight responsibilities communications, dispatch, and for air medical services. The National transport protocols. Transportation Safety Board (NTSB) also held a 4-day hearing on the topic in early 2009 and was scheduled to present a status report to FICEMS in June 2009. (Dawson) 5.1 HHS should fund studies on A number of studies are currently (Peds) the efficacy, safety, and health under way. For example, PECARN is outcomes of medications used for conducting a study examining the safety infants, children, and adolescents in and efficacy of Lorazepam and diazapem emergency care settings in order to in treating pediatric status epilepticus. improve patient safety. Also, in April 2009, NICHD updated its priority list of needs and pediatric therapeutics. Some of what is currently under study or proposed for study include ketamine for sedation and hydroxyurea for sickle cell disease. (Kavanaugh) 5.2 Hospitals, trauma centers, emergency DOT has completed the Next (EMS) medical services agencies, public Generation 9-1-1 (NG-9-1-1) project, safety departments, emergency and has a national systems architecture management offices, and public health for looking at more digital based agencies should develop integrated communication systems able to transmit and interoperable communications digital data (e.g., telematics) from the and data systems. caller to first responders. (Dawson) See also Recommendation 5.3 (EMS) below. continued
108 NATIONAL EMERGENCY CARE ENTERPRISE TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 5.2 HHS and the NHTSA should fund HHS and NHTSA are funding the (Peds) the development of medication dosage development of medication dosage guidelines, formulations, labeling, guidelines, formulations, labeling and and administration techniques administration techniques for the for the emergency care setting to emergency care setting, and federal maximize effectiveness and safety for agencies and private industry are infants, children, and adolescents. funding research on pediatric style Emergency medical services agencies technologies and equipment used by and hospitals should incorporate emergency care and trauma personnel. these guidelines, formulations, and techniques into practice. Also, the EMS-C National Resource Center, Duke University, and the American Academy of Pediatrics sponsored a meeting to discuss and prioritize ways to safely administer pediatric medication in emergency settings. (Kavanaugh) 5.3 HHS should be fully involved The National EMS Information System (EMS) in prehospital EMS leadership (NEMSIS) and the national common in discussions about the design, data standard are now going through deployment, and financing of the HL-7 standardization development the National Health Information process so they will be in sync with Infrastructure. health information technology and electronic health records. Information on NEMSIS is available at www.nemsis. org. (Dawson) 5.3 Hospitals and EMS agencies should Recommendation not directed to the (Peds) implement evidence-based approaches federal partners. to reducing errors in emergency and trauma care for children.
APPENDIX C 109 TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 5.4 Federal agencies and private industry In February 2009, the National Center (Peds) should fund research on pediatric- for Research Resources at NIH held specific technologies and equipment a meeting on pediatric drug and used by emergency and trauma care medical device development. The personnel. meeting highlighted the insufficient and fragmented infrastructure for pediatric clinical drug trials and device development. Discussions surrounded use of clinical research infrastructure, provided through CTSAs, to develop effective partnerships to develop drugs and medical devices that meet the needs of children, including those that are most likely to be used by emergency care personnel. (Kavanaugh) 6.1 Hospitals, physician organizations, This is a contentious issue. CMS has (ED) and public health agencies should initiated a community on-call system to collaborate to regionalize critical allow communities to develop on-call specialty care on-call services. lists. This allows hospitals to continue to function within target guidelines, but it is arguable whether it is an adequate solution to the problem. (Handrigan) 6.1 HHS, NHTSA, and DHS, and states Since the IOM report, there has been (EMS) should elevate emergency and trauma considerably increased activity with care to a position of parity with respect to EMS at the Federal level. other public safety entities in disaster The Office of Health Affairs (OHA) planning and operations. was created in DHS; the Emergency Care Coordination Center (ECCC) was established in HHS; and FICEMS also has a Preparedness Committee. (Dawson) continued
110 NATIONAL EMERGENCY CARE ENTERPRISE TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 6.1 Federal agencies (HHS, NHTSA, The Federal Emergency Management (Peds) and DHS), in partnership with state Agency (FEMA) operates the national and regional planning bodies and emergency family registry and locator emergency care providers, should system to facilitate reunification of convene a panel with multidisciplinary families separated after a major disaster. expertise to develop strategies for HHS has this information in the locations addressing pediatric needs in the it provides disaster response services. event of a disaster. This effort should The EMS-C program is also funding a encompass the following: system to capture and process digital images of disaster victims who enter â¢ Development of strategies to disaster response facilities. This will minimize parentâchild separation enable parents to view retrieved images to and improved methods for identify their missing children. reuniting separated children with their families. Other federal activities and capacity â¢ Development of strategies to include the Integrated Medical Public improve the level of pediatric Health Preparedness and Response expertise on disaster medical Training Summit; AHRQâs âPediatric assistance teams and other Hospital Surge Capacity and Public organized disaster response teams. Health Emergenciesâ report; the â¢ Development of disaster plans that FEMA Crisis Counseling and address pediatric surge capacity Training and Assistance Program; the for both injured and non-injured EMS-C National Resource Centerâs children. informational toolbox on pediatric â¢ Development of and improved disaster preparedness, the National access to specific medical and Commission on Children and Disasters; mental health therapies, as well as the Pediatric Disaster Resource and social services, for children in the Training Center in Los Angeles; The event of a disaster. Substance Abuse and Mental Health â¢ Development of policies to ensure Services Administrationâs (SAMHSAâs) that disaster drills include a National Child Traumatic Stress pediatric mass casualty incident at Network, and the HHS National least once every 2 years. Disaster Pediatric Medical Team. (Kavanaugh) 6.2 Congress should appoint a This is the intent of the Access to (ED) commission to examine the impact Emergency Medical Services Act. of medical malpractice lawsuits on (Handrigan) the declining availability of providers in high-risk emergency and trauma care specialties, and to recommend appropriate state and federal actions to mitigate the adverse impact of these lawsuits and ensure quality of care.
APPENDIX C 111 TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 6.2 Congress should substantially increase N/A (EMS) funding for EMS-related disaster preparedness through dedicated funding streams. 6.3 The American Board of Medical Recommendation not directed to the (ED) Specialties and its constituent federal partners. boards should extend eligibility for certification in critical care medicine to all acute care and primary care physicians who complete an accredited critical care fellowship program. 6.4 Professional training, continuing Disaster preparedness is included in the (ED) education, and credentialing and National EMS Education Standards. certification programs for all the These have also been synchronized with relevant professional categories of NIMS through the national emergency EMS personnel should incorporate responder credentialing process. So the disaster preparedness into their entire EMS Education Agenda for the curricula and require the maintenance Future and NIMS are linked together. of competency in these skills. (Dawson) 6.5 HHS, DOT, and DHS should jointly A detailed assessment of the emergency (ED) undertake a detailed assessment of and trauma workforce has not yet been emergency and trauma workforce done, however the ECCC and FICEMS capacity, trends, and future needs, and are now in an ideal position to take this develop strategies to meet these needs on. (Handrigan) in the future. In June 2008, NHTSA, in partnership with HRSA, published EMS Workforce for the 21st Century: A National Assessment. The assessment describes the national EMS workforce, while also elucidating the absence of consistent, nationwide EMS workforce data. The assessment is being used to guide development of the EMS Workforce Agenda for the Future. (Dawson) continued
112 NATIONAL EMERGENCY CARE ENTERPRISE TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 6.6 HHS, in partnership with professional Multiple stakeholders are required to (ED) organizations, should develop national execute this broad recommendation. standards for core competencies HHS established the Federal Education applicable to physicians, nurses, and and Training Interagency Group other key emergency and trauma (FETIG), which acts as the board of professionals, using a national, directors for the new National Center evidence-based, multidisciplinary for Disaster Medicine at Uniformed process. Services University of the Health Sciences (USUHS) and will help define a core curriculum relating to disaster preparedness. Using quality measures, the group is developing and improving core competencies. More work remains to be done. (Handrigan) 6.6 States should link rural hospitals This issue relates to regionalization. (ED) with academic health centers to There is great interest in this topic at the enhance opportunities for professional federal level and we intend to partner consultation, telemedicine, patient with our non-federal stakeholders on referral and transport, and continuing it. The recommendation was directed professional education. at the states and we will leave it to the states and the hospitals to address it specifically. (Handrigan) 7.1 DHS, HHS, DOT, and the states Through Homeland Security Presidential (ED) should collaborate with the Veterans Directive (HSPD)-21, the Department Health Administration to integrate the of Veterans Affairs (VA) has been VHA into civilian disaster planning substantially and increasingly engaged and management. in preparedness activities both at the federal and local levels. There has been great progress on this recommendation. (Handrigan) 7.1 Federal agencies that fund research PECARN is developing research (EMS) and trauma care research should partnerships with two EMS agencies. target additional funding at They have completed a descriptive prehospital EMS research, with an study of the EMS pediatric population emphasis on systems and outcomes within PECARN, and they encourage research. the involvement of prehospital EMS in the Research Network. NEMSIS will aid researchers tremendously by making standardized data available. (Dawson) 7.1 See 8.2 (ED) below (Peds) Research gaps and opportunities
APPENDIX C 113 TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 7.2 All institutions responsible for the The Federal Education and Training (ED) training, continuing education, Interagency Group (FETIG) and the credentialing and certification of national center have taken this on and professionals involved in emergency we are moving forward. (Handrigan) care (including medicine, nursing, emergency medical services, allied health, public health, and hospital administration) should incorporate disaster preparedness training into their curricula and competency criteria. 7.2 See 8.4 (ED) below (EMS) Federalwide Assurance (FWA) Program 7.2 Administrators of state and national The EMS-C program supports the (Peds) trauma registries should include National EMS-C Data Analysis standard pediatric-specific data Resource Center (NEDARC), which elements and provide the data to helps EMS-C grantees and state EMS the National Trauma Data Bank. offices refine their capabilities to Additionally, the American College perform EMS research and optimize of Surgeons should establish a the delivery of emergency and trauma multidisciplinary pediatric specialty care. Specifically, the staff at NEDARC committee to continuously evaluate provides guidance on formatting, pediatric-specific data elements for interpreting, and displaying data. the National Trauma Data Bank and (Kavanaugh) identify areas for pediatric research. 7.3 Congress should significantly increase The trend is toward decreased, not (ED) total preparedness funding in fiscal increased, funding. The federal budget year 2007 for hospital emergency picture between now and 2019 is truly preparedness in the following areas: terrible. (Handrigan) strengthening and sustaining trauma care systems; enhancing emergency department, trauma center, and inpatient surge capacity; improving emergency medical servicesâ response to explosives; designing evidence- based training programs; enhancing the availability of decontamination showers, standby intensive care unit capacity, negative pressure rooms, and appropriate personal protective equipment; and conducting international collaborative research on the civilian consequences of conventional weapons of terrorism. continued
114 NATIONAL EMERGENCY CARE ENTERPRISE TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 7.3 See 8.2 (ED) below (EMS) Research gaps and opportunities 8.1 Academic medical centers should Recommendation not directed to the (ED) support emergency and trauma federal partners. care research by providing research time and adequate facilities for promising emergency care and trauma investigators, and by strongly considering the establishment of autonomous departments of emergency medicine. 8.2 The Secretary of HHS should The NIH has moved forward (ED) conduct a study to examine the gaps substantially on this, for example by and opportunities in emergency convening a Roundtable on Emergency care research, including pediatric Care that examined issues in the emergency care, and recommend a conduct of emergency care research. strategy for the optimal organization The other federal partners need to move and funding of the research forward on this as well, and coordinate effort. This study should include their efforts. (Handrigan) consideration of the training of new investigators, involvement The EMS-C program provided FICEMS of emergency and trauma care with gap analysis of prehospital researchers in grant review and research. This analysis is inclusive of all advisory processes, and improved ages, not just pediatric. The report noted research coordination through a that the literature in the prehospital dedicated center or institute. Congress setting continues to be largely non- and federal agencies involved in randomized control trials conducted emergency and trauma care research as retrospective observational studies. (including DOT, HHS, DHS, and The majority of the recommendations DOD) should implement the studyâs of the research agendas continue to be recommendations. unmet. Particularly lacking is research in optimal methods of education and competency assessment, quality and patient safety, and trauma management. (Kavanaugh) 8.3 States should ease their restrictions Recommendation not directed to the (ED) on informed consent to match federal federal partners. law.
APPENDIX C 115 TABLE C-1â Continued Rec # (Report) IOM Recommendation Federal Response 8.4 Congress should modify Federalwide While no recent legislation addressing (ED) Assurance (FWA) Program regulations Federalwide Assurance could be located, to allow the acquisition of limited, it is no recommendation that deserves linked, patient outcome data attention (Handrigan). without the existence of Federalwide Assurance Program. SOURCES: Dawson (2009); Handrigan (2009); Kavanaugh (2009); IOM (2006a,b,c). References Dawson, D. 2009. Emergency Medical Services at a Crossroads Implementation Update. PowerPoint slides presented at the National Emergency Care Enterprise Workshop, Washington, DC. Handrigan, M. 2009. Hospital-Based Emergency Care: At the Breaking Point. May 2009. PowerPoint slides presented at the National Emergency Care Enterprise Workshop, Washington, DC. Kavanaugh, D. 2009. PowerPoint slides presented at the National Emergency Care Enterprise Workshop, Washington, DC. Institute of Medicine, 2006a. Emergency Care for Children: Growing Pains. Washington, DC: The National Academies Press. Institute of Medicine, 2006b. Emergency Medical Services at a Crossroads. Washington, DC: The National Academies Press. Institute of Medicine, 2006c. Hospital-Based Emergency Care: At the Breaking Point. Wash- ington, DC: The National Academies Press.