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3 Building a 21st-Century Emergency and Trauma Care System
Pages 101-150

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From page 101...
... , emergency department (ED) providers, trauma care, public safety, and public health 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 102...
... This chapter is dedicated to describing the three goals of the committee's vision for the emergency care system of the future, with a special focus on pediatric emergency care. In some areas of the country, states and regions are already developing coordinated, regionalized systems that incorporate elements of accountability; some of these efforts are described as well.
From page 103...
... . For example, public safety and EMS agencies often lack common communications frequencies and protocols for communicating with each other during disasters.
From page 104...
... . In her analysis of heavy users of ED services, Malone argued that "emergency departments remain today a ‘window' on wider social issues critical to health care reforms" (p.
From page 105...
... 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 care through Community Councils on Emergency Medical Services, which would bring together physicians, medical facilities, EMS, public health, and others "to procure equipment, construct facilities and ensure optimal emergency care on a day to day basis as well as in disaster or national
From page 106...
... to take an administrative and leadership role in federal EMS activities. The Emergency Medical Services Systems Act of 1973 (P.L.
From page 107...
... An effective communications system also enables ambulance dispatchers to assist EMS personnel in directing patients to the most appropriate facility based on the nature of their illness or injury and the capacity of receiving facilities. It links the emergency medical system with other public safety providers -- such as police and fire departments, emergency management services, and public health agencies -- and facilitates coordination between the medical response system and incident command in both routine and disaster situations.
From page 108...
... . Steps to regionalize certain pediatric services were supported by the American College of Critical Care Medicine and the Society of Critical Care Medicine in their 2000 Consensus Report for Regionalization of Serices for Critically Ill or Injured Children (Committee on Pediatric Emergency Medicine Pediatric Section and Task Force on Regionalization of Pediatric Critical Care, 2000)
From page 109...
... . Many states and/or communities have taken steps toward regionalizing pediatric emergency care by designating hospitals that meet certain requirements as "stand-by emergency departments approved for pediatrics" (SEDPs)
From page 110...
... Concerns About Regionalization One concern about the regionalization of pediatric emergency and trauma care is that moving too many children to regional centers would further dilute the pediatric experience of community hospitals. But all hospitals must have some baseline of pediatric readiness.
From page 111...
... Under the ACS approach, every hospital in the community can play a role in the trauma system by undergoing 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 the relative travel times to each center.
From page 112...
... . EMS responders who provide stabilization before the patient arrives at a critical care unit are sometimes subject to criticism because of a strongly held bias among some physicians that out-of-hospital stabilization only delays definitive treatment without adding value; however there is little evidence
From page 113...
... This effort need not start from scratch. The Model Pediatric Protocols developed by the National Association of EMS Physicians and supported by the Emergency Medical Services for Children (ESM-C)
From page 114...
... Over time, based on evidence on the effectiveness of alternative delivery models, some pediatric patients may be transported to a nearby urgent care center for stabilization or treated and released at the scene. Whichever pathway the patient follows, communications are enhanced, data collected, and the performance of the system evaluated and reported so that future improvements can be made.
From page 115...
... 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 how well 9-1-1, dispatch, prehospital EMS, hospital emergency and trauma care, and other components of the system perform and how their performance compares with that in other regions and the rest of the nation.
From page 116...
... 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, ambulance services are accredited by the Commission on Accreditation of Ambulance Services, and air medical services are voluntarily accredited by the Commission on
From page 117...
... . The committee concludes that a standard national approach to the development of performance indicators is essential and 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, including the performance of pediatric emergency care (3.3)
From page 118...
... Naturally, measures should also be appropriate for assessing the performance of pediatric emergency care. To this end, it may be necessary to include additional, pediatric-specific measures in data collection efforts.
From page 119...
... 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 can take various forms, including public report cards, annual reports, and state public health reports.
From page 120...
... The Maryland EMS for children program develops state guidelines and resources for care, reviews pediatric emergency care and facility regulations, and coordinates pediatric education programs. Additionally, the program works with organizations, including the Safe Kids Coalition, the National Study Center for Trauma and Emergency Medical Systems, the Maryland Highway Safety Office, and the American Trauma Society, to foster and support education and injury prevention programs.
From page 121...
... Regionalization is also used to direct adult patients to trauma, stroke, burn, eye, perinatal, and hand referral centers. The control of air medical services by the state facilitates the regionalization of care through the active operation of dispatch.
From page 122...
... Regionalization The unified system supports the regional emergency and trauma care 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.
From page 123...
... Regionalization 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.
From page 124...
... In spring 2004, physician leaders, hospital executives, and public health officials formed the Emergency Department Management Group to address this problem. One approach being explored is to attack the rising cost of malpractice insurance for emergency care providers, which discourages specialists from serving on on-call panels.
From page 125...
... 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.
From page 126...
... . 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 (3.4)
From page 127...
... 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. 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 128...
... . If, as recommended below, a lead agency is established to consolidate funding and provide leadership for these multiple activities, it would be the appropriate agency to lead this proposed effort.
From page 129...
... EMTALA was passed in 1986 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 properly stabilize patients or transfer them to an appropriate facility if an emergency medical condition exists (GAO, 2001)
From page 130...
... 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.
From page 131...
... 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, 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.
From page 132...
... DHS also plays an important role in emergency and trauma care. The Federal Emergency Management Agency (FEMA)
From page 133...
... For example, the Interagency Committee on Emergency Medical Services for Children 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.
From page 134...
... • 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, as having a significant role in relation to the purposes of the interagency committee • A state EMS director appointed by the Secretary adults and children, trauma care, hospital-based care) individually have not received sufficient attention, stature, and funding within the federal government.
From page 135...
... 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.
From page 136...
... emergency and trauma care providers over time. • Lead agency could consolidate constituencies and engender stronger political representation.
From page 137...
... Option 2: 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 Serices 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.
From page 138...
... , 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: • Provide federal leadership on important policy issues that cut cross agency boundaries.
From page 139...
... The committee therefore recommends that Congress establish a lead agency for emergency and trauma care within 2 years of the release 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 140...
... 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 141...
... Programs included in 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.
From page 142...
... 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, it would be critical for each program office to have equal status and reporting relationships within the agency's organizational structure. The committee lacks the expertise to specify the organizational structure in further detail.
From page 143...
... 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 imperative that support for emergency and trauma care programs already in place in the various federal agencies be sustained.
From page 144...
... This additional funding would better enable a state representative to initiate improvements, which could include organizing pediatric disaster drills, increasing the level of available pediatric emergency care training, participating in and organizing statewide pediatric emergency care planning, and meeting with provider organizations to encourage and facilitate improvements in pediatric preparedness.
From page 145...
... . Support for pediatric emergency care will always remain a vital aspect of that federal leadership, but it may not be in the form of a separate program.
From page 146...
... 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 medi cal services (both ground and air) , hospital-based emergency and trauma care, and medical-related disaster preparedness.
From page 147...
... . Committee on Pediatric Emergency Medicine Pediatric Section and Task Force on Regionaliza tion of Pediatric Critical Care.
From page 148...
... 1993. Efficacy of pediatric trauma care: Results of a population-based study.
From page 149...
... Academic Emergency Medicine 9(11)
From page 150...
... 1996. Ambulatory visits to hospital emergency departments.


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