Regionalizing Emergency Care Workshop Summary (2010) / Chapter Skim
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4 Regionalization: Potential and Pitfalls
4 Regionalization: Potential and Pitfalls
Pages 51-64
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From page 51... ...
He noted the landmark National Academy of Sciences publication Accidental Death and Disability: The Neglected Disease of Modern Society, published in September 1966, and cited the following quote: "The patient must be transported to the emergency department best prepared for his particular problem. Hospital emergency departments should be surveyed to determine the number and types of emergency facilities necessary to provide optimal emergency treatment for the occupants of each region.
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From page 52... ...
This is partly due to "huge holes" that exist in current Emergency Medical Treatment and Active Labor Act (EMTALA) rules, which allows providers not to take call in their subspecialty (although they can decide to come in for paying patients)
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From page 53... ...
In rural America, Emergency Medical Services (EMS) is often subsidized through the tax base, but the largest subsidy, Sanddal noted, comes from volunteer labor.
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From page 54... ...
DILUTING PARAMEDIC EXPERIENCE Michael Sayre, associate professor of emergency medicine at Ohio State University and chair of the American Hospital Association Emergency Cardiovascular Care Committee, said that the various systems of critical care we have heard about today -- percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI)
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From page 55... ...
We should track whether the EMS system is delivering care by providers who have enough experience, making sure the paramedics are kept relatively few, and the tradeoff that may occur with slightly longer response times. ADDRESSING SUBURBAN ACCESS CHALLENGES Dennis Andrulis, associate dean for research and director of the Center for Health Equality at Drexel University in Philadelphia, discussed regionalization in the context of the demographic and sociological trends affecting suburban America.
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From page 56... ...
DISTRIBUTION OF SERVICES TO OUTLYING AREAS Stephen Epstein, a practicing emergency physician at Beth Israel Deaconess Medical Center in Boston, talked about geographic access and some of the distribution issues involved in regionalization. He said that in Boston there are now five Level I trauma centers -- more than there are in many states -- and the city is truly a medical Mecca.
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From page 57... ...
What the Level I trauma centers did was develop partnerships with some of the local community hospitals that were farther out. These are tightly controlled partnerships and backup catheterization is often only a half-hour away.
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From page 58... ...
"Yet that is what often happens." He said that in a perfect world that patient would show up at an outside emergency department, a CT scan could be viewed through telemedicine, there would be a discussion with the physician, and the patient would stay in the original location. If the patient were one of the few whose condition does deteriorate, he or she would be immediately transferred to the larger tertiary care center.
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From page 59... ...
But, he said, "A lot of the stuff that is being sent is not really very appropriate." AUDIENCE DISCUSSION Session chair Jon Krohmer began the discussion period by asking the panelists to assess why it seems that regionalization has worked in some cases but not in others. Anderson noted that at the time Parkland became the first Level I trauma center in the area, many other hospitals "did not want certification or verification, they did not want to be a number two or a number three, and they didn't see a financial reason" for participating in a system.
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From page 60... ...
Krohmer asked the panel whether the regional boundaries established by a state for its trauma system will necessarily be the same as the regional boundaries for cardiac, stroke, and pediatric care systems. He asked whether a state could potentially have six trauma regions, five cardiac regions (that cannot be superimposed)
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From page 61... ...
Joseph Waeckerle, editor emeritus of Annals of Emergency Medicine, asked, "When you are talking about regionalization, what are you going to regionalize? " He said he presumes that the list includes trauma, cardiovascular disease, and pediatric disease, but what about neurosurgical disease, or ear, nose, and throat (ENT)
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From page 62... ...
We need to find a way to regionalize emergency care services, Handrigan continued, without disturbing the existing safety net. In part, that means reaching out to the specialists and surgical subspecialists, but it also means reaching out to the primary care providers, because many people are utilizing emergency care services for primary care issues.
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From page 63... ...
He pointed to the National Highway Traffic Safety Administration's effort to develop best-practice strategies in the EMS environment and declared that if EMS are following those best-practice guidelines within a systemized regional approach to emergency care, "I think our immunity is much greater than it is if we're just doing whatever the doctor on the phone tells us to do today or tomorrow or the next day. Bass agreed, saying that for inter-facility transports for patients with time-critical conditions, EMS personnel are exposed to liability unless they make transport decisions based on clear, published guidelines for the region-wide system.
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From page 64... ...
Wild said that CMS regularly reviews these issues. For example, to follow the point that Anderson raised, when CMS finds out that a surgeon is coming in to see their own patients in the emergency department but is not available for emergency call, that can present a problem.
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