Emergency Medical Services At the Crossroads (2007) / Chapter Skim
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3 Building a 21st-Century Emergency and Trauma Care System
3 Building a 21st-Century Emergency and Trauma Care System
Pages 73-118
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From page 73... ...
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.
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From page 74... ...
. 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)
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From page 75... ...
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)
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From page 76... ...
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,
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From page 77... ...
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. SUPPORTING REGIONALIZATION 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.
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From page 78... ...
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)
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From page 79... ...
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)
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From page 80... ...
. In cases of out-of-hospital cardiac arrest, properly trained and equipped EMS personnel can provide all needed interventions at the scene.
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From page 81... ...
report Emergency Medical Serices for Children, which stated that "categorization and regionalization are essential for full and effective operation of systems" (IOM, 1993, p.
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From page 82... ...
EMERGENCY MEDICAL SERVICES AT THE CROSSROADS County B County A Community Hospital/ Stroke Center Community Hospital Urgent Care Center Scene Treat & Release Community Hospital Children's Hospital/Terti ary Hospital/ Trauma I FIGURE 3-1 Service configuration in a regionalized system. The figure illustrates some potential transport options within a regionalized system.
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From page 83... ...
. 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.
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From page 84... ...
", 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)
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From page 85... ...
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.
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From page 86... ...
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.
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From page 87... ...
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.
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From page 88... ...
. 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.
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From page 89... ...
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.
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From page 90... ...
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. Coordination A key component of the effective operational coordination of the emergency care system in Maryland is the statewide EMS communications system.
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From page 91... ...
Regionalization 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.
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From page 92... ...
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.
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From page 93... ...
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.
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From page 94... ...
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.
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From page 95... ...
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.
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From page 96... ...
. 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)
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From page 97... ...
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)
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From page 98... ...
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)
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From page 99... ...
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.
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From page 100... ...
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 Serices Agenda for the Future, as well as a number of other important EMS reports.
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From page 101... ...
. 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.
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From page 102... ...
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.
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From page 103... ...
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.
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From page 104... ...
Option : 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.
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From page 105... ...
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.
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From page 106... ...
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.
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From page 107... ...
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)
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From page 108... ...
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
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From page 109... ...
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.
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From page 110... ...
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. 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.
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From page 111... ...
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.
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From page 112... ...
EMTALA and HIPAA are discussed below. Emergency Medical Treatment and Actie Labor Act of EMTALA was enacted to prevent hospitals from refusing to serve uninsured patients and "dumping" them on other hospitals.
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From page 113... ...
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
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From page 114... ...
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)
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From page 115... ...
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 medi cal services (both ground and air)
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From page 116... ...
Department of Health and Human Serices, From the Emergency Medical Treatment and Labor Act Technical Adisory Group. Washington, DC: CMS.
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From page 117... ...
1993. Impact of first responder defibrillation in an urban emergency medical services system.
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From page 118... ...
1996. Emergency Medical Serices Agenda for the Future.
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