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3 Building a 21st-Century Emergency Care System
Pages 81-128

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From page 81...
... To address these challenges and chart a new direction for emergency care, the committee envisions a system in which all communities will be served by well-planned and highly coordinated emergency care services 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, 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 page 82...
... report Accidental Death and Disability called for better coordination of emergency care through Community Councils on Emergency Medical Services that 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, p.
From page 83...
... Limited Progress While the concept of a highly integrated emergency care system as articulated in NHTSA's Emergency Medical Serices Agenda for the Future is not new, progress toward its realization has been slow. Prehospital EMS, hospital-based emergency and trauma care, and public health have traditionally worked in silos (NHTSA, 1996)
From page 84...
... We now know that increased use of seat belts reduces the number of seriously injured car crash victims in the ED -- the ED served as a proving ground for documenting the results of seat belt enforcement initiatives. Although prevention activities have been limited in the emergency care setting, that
From page 85...
... Unfortunately, in many communities there is little interaction between emergency care services and community safety net providers -- this even though they 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 adherence to treatment; and enhanced quality of care and patient satisfaction.
From page 86...
... The Importance of Communications Communications are a critical factor in establishing systemwide coordination. An effective communications system is the glue that can hold together effective, integrated emergency care services.
From page 87...
... argued for an inclusive trauma system in which smaller facilities have been verified and designated as lower-level trauma centers. They suggested that care may be substantially better in such facilities than in those outside the system, and comparable to national norms (Nathens and Maier, 2001)
From page 88...
... The committee believes communities will best be served by emergency care systems in which services are organized so as to provide the optimal care based on the patient's location and condition. To the extent that the movement toward specialty hospitals impacts the configuration of services and therefore the ability of the system to optimize emergency services, it is an appropriate subject for the committee to address.
From page 89...
... The committee's vision expands this concept beyond trauma care to include all serious illnesses and injuries, and extends beyond hospitals to include the entire continuum of emergency care -- including 9-1-1 and dispatch and prehospital EMS, as well as clinics and urgent care providers. In this model, every provider organization can potentially play a role in providing emergency care services according to its capabilities.
From page 90...
... 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)
From page 91...
... The committee concludes that there should be a national approach to the development of prehospital protocols. It therefore 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)
From page 92...
... In addition to the use of ambulance units and the EMS system to direct patients to the optimum location for emergency care, hospital emergency care designations should be posted prominently to improve patients' selftriage 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.
From page 93...
... Over time, based on evidence reports all 3 on the effectiveness of alternative delivery models, some patients may be transported to a nearby urgent care center for stabilization or treated on the R00789 street and released. Whichever pathway the patient follows, communications are enhanced, data are collected, and the performance of the system is evaluated and E #2 reported so that future improvements can be made.
From page 94...
... Further, public awareness is hindered by the lack of nationally defined indicators of system performance. Few localities can answer basic questions about their emergency care services, such as "What is the overall performance of the emergency care system?
From page 95...
... 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 care system within each community, as well as the ability to benchmark that performance against statewide and national performance metrics.
From page 96...
... Currently it is difficult to piece together a complete picture of an episode of emergency care. To address this need, states should develop guidelines for the sharing of patient-level data from dispatch through post–hospital release.
From page 97...
... Public Dissemination of Information on System Performance Public dissemination of performance data is crucial to drive the needed changes in the delivery of emergency care services. Dissemination could take various forms, including public report cards, annual reports, and state public health reports, which could be viewed either in hard copy format or on line.
From page 98...
... 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; CMS's reports on home health and nursing home care -- the Home Health Compare and Nursing Home Compare websites, respectively (CMS, 2005a)
From page 99...
... These include payment systems and the legal framework that defines much of the structure of emergency care delivery. Aligning Payments with Incenties No major change in health care can take place without strong financial incentives.
From page 100...
... 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, could also develop contracts that would penalize hospitals for chronic delays in treatment, ED crowding, and EMS diversions.
From page 101...
... While the recent CMS guidance and deliberations of the EMTALA advisory group are positive steps, the committee envisions a more fundamental rethinking of the act 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.
From page 102...
... . CURRENT APPROACHES A number of current efforts to establish emergency care systems achieve some or all of the committee's goals of coordination, regionalization, and accountability.
From page 103...
... The control of air medical services by the state facilitates the regionalization of care through the active operation of dispatch.
From page 104...
... 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.
From page 105...
... Palm Beach County, Florida An initiative currently under way in Palm Beach County, Florida, is more limited in scope than the Maryland and Austin/Travis County 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.
From page 106...
... 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.
From page 107...
... A PROPOSAL FOR FEDERAL, STATE, AND LOCAL COLLABORATION THROUGH DEMONSTRATION PROJECTS States and regions face a variety of situations, and no one approach to building EMS 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.
From page 108...
... . 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 care systems throughout the country, and appropriate $88 million over 5 years to this program (3.5)
From page 109...
... 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 EMS providers or the purchase of EMS equipment. Funds could also be used to enhance linkages between rural and urban emergency services within broadly defined regions so as to improve rural emergency care through communications, telemedicine, training, and coordination activities.
From page 110...
... • Total program funding: $88 million (over 5 years) Granting Agency No single federal agency has responsibility for the various components of the nation's emergency care system.
From page 111...
... Operationally, this means that all of the key players in a given region -- hospital EDs, EMS 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 care.
From page 112...
... , 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.
From page 113...
... Problems with the Current Structure Despite recent efforts at improved federal collaboration, there is widespread agreement that the various components of emergency care (EMS for adults and children, trauma, care, hospital-based care) individually have not received sufficient attention, stature, and funding within the federal
From page 114...
... • Wireless Telecommunications Bureau, Federal Communications Commission • A representative of any other federal agency appointed by the Secretary of Transportation or the Secretary of Homeland Secu rity through the Under Secretary for Emergency Preparedness and Response, in consultation with the Secretary of Health and Human Services, having a significant role in relation to the pur poses of the interagency committee government. The scattered nature of federal responsibility for emergency care limits the visibility necessary to secure and maintain funding within the federal government.
From page 115...
... The problems associated with fragmented federal leadership of emergency care, documented above, include variable funding, periodic program cuts, programmatic duplication, 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 federal lead agency has diminished.
From page 116...
... Authority • FICEMS has the authority • Lead agency would have planning to convene meetings, but no and budgetary authority over authority to enforce planning, the majority of emergency care evaluation, and coordination of activities at the federal level. programs and funding.
From page 117...
... costs. • Consolidated funding would allow for better allocation of federal dollars across the various emergency care needs (e.g., would eliminate overlapping programs)
From page 118...
... Specifically, a federal lead agency could: • Provide consistent federal leadership on policy issues that cut cross agency boundaries. • Create unified accountability for the performance of the emergency and trauma care system.
From page 119...
... The committee therefore recommends that Congress establish a lead agency for emergency and trauma care within 2 years of this report. The 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)
From page 120...
... 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.
From page 121...
... 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. Working Group 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.
From page 122...
... 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 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 • Trauma systems • Pediatric emergency and trauma care • Rural emergency and trauma care • Disaster preparedness 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.
From page 123...
... 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 those costs would be substantial.
From page 124...
... 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 ser vice capabilities. 3.2: The National Highway Traffic Safety Administration, in part nership 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.
From page 125...
... The lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full con tinuum 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.
From page 126...
... 2001. Emergency Care.
From page 127...
... 2002. The development of indicators to mea sure the quality of clinical care in emergency departments following a modified-delphi approach.
From page 128...
... 1996. Ambulatory visits to hospital emergency departments.


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