FUTURE OF EMERGENCY CARE

HOSPITAL-BASED EMERGENCY CARE

AT THE BREAKING POINT

Committee on the Future of Emergency Care in the United States Health System

Board on Health Care Services

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu



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Hospital-Based Emergency Care: At the Breaking Point FUTURE OF EMERGENCY CARE HOSPITAL-BASED EMERGENCY CARE AT THE BREAKING POINT Committee on the Future of Emergency Care in the United States Health System Board on Health Care Services INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Hospital-Based Emergency Care: At the Breaking Point THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 282-99-0045 between the National Academy of Sciences and the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ); Contract No. B03-06 between the National Academy of Sciences and the Josiah Macy, Jr. Foundation; and Contract No. HHSH25056047 between the National Academy of Sciences and the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC), and the U.S. Department of Transportation’s National Highway Traffic Safety Administration (NHTSA). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Hospital-based emergency care : at the breaking point / Committee on the Future of Emergency Care in the United States Health System, Board on Health Care Services. p. ; cm. — (Future of emergency care series) Includes bibliographical references and index. ISBN-13: 978-0-309-10173-8 (hardback) ISBN-10: 0-309-10173-5 (hardback) 1. Hospitals—Emergency services. 2. Emergency medical services. I. Institute of Medicine (U.S.). Committee on the Future of Emergency Care in the United States Health System. II. Series. [DNLM: 1. Emergency Service, Hospital—United States. 2. Health Care Reform—United States. WX 215 H8261 2007] RA975.5.E5H67723 2007 362.11—dc22 2007000079 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Hospital-Based Emergency Care: At the Breaking Point “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Hospital-Based Emergency Care: At the Breaking Point THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Hospital-Based Emergency Care: At the Breaking Point COMMITTEE ON THE FUTURE OF EMERGENCY CARE IN THE UNITED STATES HEALTH SYSTEM GAIL L. WARDEN (Chair), President Emeritus, Henry Ford Health System, Detroit, Michigan STUART H. ALTMAN, Sol C. Chaikin Professor of National Health Policy, Heller School of Social Policy, Brandeis University, Waltham, Massachusetts BRENT R. ASPLIN, Associate Professor of Emergency Medicine, University of Minnesota and Department Head, Regions Hospital Emergency Department, St. Paul THOMAS F. BABOR, Chair, Department of Community Medicine and Health Care, University of Connecticut Health Center, Farmington ROBERT R. BASS, Executive Director, Maryland Institute for Emergency Medical Services Systems, Baltimore BENJAMIN K. CHU, Regional President, Southern California, Kaiser Foundation Health Plan and Hospital, Pasadena A. BRENT EASTMAN, Chief Medical Officer, N. Paul Whittier Chair of Trauma, ScrippsHealth, San Diego, California GEORGE L. FOLTIN, Director, Center for Pediatric Emergency Medicine, Associate Professor of Pediatrics and Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center, New York SHIRLEY GAMBLE, Chief Operating Officer, United Way Capital Area, Austin, Texas DARRELL J. GASKIN, Associate Professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland ROBERT C. GATES, Project Director, Medical Services for Indigents, Health Care Agency, Santa Ana, California MARIANNE GAUSCHE-HILL, Clinical Professor of Medicine and Director, Prehospital Care, Harbor-UCLA Medical Center, Torrance, California JOHN D. HALAMKA, Chief Information Officer, Beth Israel Deaconess Medical Center, Boston, Massachusetts MARY M. JAGIM, Internal Consultant for Emergency Preparedness Planning, MeritCare Health System, Fargo, North Dakota ARTHUR L. KELLERMANN, Professor and Chair, Department of Emergency Medicine and Director, Center for Injury Control, Emory University School of Medicine, Atlanta, Georgia WILLIAM N. KELLEY, Professor of Medicine, Biochemistry & Biophysics, University of Pennsylvania School of Medicine, Philadelphia

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Hospital-Based Emergency Care: At the Breaking Point PETER M. LAYDE, Professor and Interim Director, Health Policy Institute and Co-Director, Injury Research Center, Medical College of Wisconsin, Milwaukee EUGENE LITVAK, Professor of Health Care and Operations Management Director, Program for Management of Variability in Health Care Delivery, Boston University Health Policy Institute, Massachusetts RICHARD A. ORR, Associate Director, Cardiac Intensive Care Unit, Medical Director, Children’s Hospital Transport Team of Pittsburgh and Professor, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pennsylvania JERRY L. OVERTON, Executive Director, Richmond Ambulance Authority, Virginia JOHN E. PRESCOTT, Dean, West Virginia University School of Medicine, Morgantown NELS D. SANDDAL, President, Critical Illness and Trauma Foundation, Bozeman, Montana C. WILLIAM SCHWAB, Professor of Surgery, Chief, Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia MARK D. SMITH, President and CEO, California Healthcare Foundation, Oakland DAVID N. SUNDWALL, Executive Director, Utah Department of Health, Salt Lake City

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Hospital-Based Emergency Care: At the Breaking Point SUBCOMMITTEE ON HOSPITAL-BASED EMERGENCY CARE BENJAMIN K. CHU (Chair), Regional President, Southern California, Kaiser Foundation Health Plan and Hospital, Pasadena STUART H. ALTMAN, Sol C. Chaikin Professor of National Health Policy, Heller School of Social Policy, Brandeis University, Waltham,Massachusetts BRENT R. ASPLIN, Associate Professor of Emergency Medicine, University of Minnesota and Department Head, Regions Hospital Emergency Department, St. Paul JOHN D. HALAMKA, Chief Information Officer, Beth Israel Deaconess Medical Center, Boston, Massachusetts MARY M. JAGIM, Internal Consultant for Emergency Preparedness Planning, MeritCare Health System, Fargo, North Dakota KENNETH W. KIZER, President, Chief Executive Officer, and Chairman, Medsphere Systems Corporation, Aliso Viejo, California PETER M. LAYDE, Professor and Interim Director, Health Policy Institute and Co-Director, Injury Research Center, Medical College of Wisconsin, Milwaukee EUGENE LITVAK, Professor of Health Care and Operations Management Director, Program for Management of Variability in Health Care Delivery, Boston University Health Policy Institute, Massachusetts JOHN R. LUMPKIN, Senior Vice President, The Robert Wood Johnson Foundation, Princeton, New Jersey W. DANIEL MANZ, Director, Emergency Medical Services Division, Vermont Department of Health, Burlington JOHN E. PRESCOTT, Dean, West Virginia University School of Medicine, Morgantown C. WILLIAM SCHWAB, Professor of Surgery, Chief, Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia JOSEPH L. WRIGHT, Executive Director, Child Health Advocacy Institute, Children’s National Medical Center; Professor of Pediatrics, Emergency Medicine & Community Health, George Washington University Schools of Medicine and Public Health, Washington, District of Columbia; and State EMS Medical Director for Pediatrics, Maryland Institute for Emergency Medical Services Systems, Baltimore Study Staff ROBERT B. GIFFIN, Study Co-Director and Senior Program Officer SHARI M. ERICKSON, Study Co-Director and Program Officer MEGAN MCHUGH, Senior Program Officer

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Hospital-Based Emergency Care: At the Breaking Point BENJAMIN WHEATLEY, Program Officer ANISHA S. DHARSHI, Research Associate SHEILA J. MADHANI, Program Officer CANDACE TRENUM, Senior Program Assistant

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Hospital-Based Emergency Care: At the Breaking Point Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: E. JOHN GALLAGHER, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York KRISTINE M. GEBBIE, Center for Health Policy, Columbia University School of Nursing, New York, New York LEWIS R. GOLDFRANK, Department of Emergency Medicine, New York University School of Medicine, New York University Medical Center and Bellevue Hospital Center, New York JERRIS R. HEDGES, School of Medicine, Oregon Health & Science University, Portland GARY JOHNSON, Department of Family Medicine, University of Nevada School of Medicine, Reno

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Hospital-Based Emergency Care: At the Breaking Point D. RANDY KUYKENDALL, Emergency Medical and Trauma Services Section, Health Facilities & Emergency Medical Services Division, Colorado Department of Public Health & Environment, Colorado Springs RONALD V. MAIER, Department of Surgery, Harborview Medical Center, Seattle, Washington MITCHELL T. RABKIN, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts SARA ROSENBAUM, Department of Health Policy, School of Public Health and Health Services, The George Washington University Medical Center, Washington, District of Columbia ALEX B. VALADKA, Department of Neurological Surgery, University of Texas Medical School at Houston Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Enriqueta C. Bond, Burroughs Wellcome Fund, and Don E. Detmer, American Medical Informatics Association. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Hospital-Based Emergency Care: At the Breaking Point Foreword The state of emergency care affects every American. When illness or injury strikes, Americans count on the emergency care system to respond with timely and high-quality care. Yet today, the emergency and trauma care that Americans receive can fall short of what they expect and deserve. Emergency care is a window on health care, revealing both what is right and what is wrong with the care delivery system. Americans increasingly rely on hospital emergency departments because of the skilled specialists and advanced technologies they offer. At the same time, the increasing use of the emergency care system represents failures of the larger health care system—the growing numbers of uninsured Americans, the limited alternatives available in many communities, and the inadequate preventive care and chronic care management received by many. The resulting demands on the system can degrade the quality of emergency care and hinder the ability to provide urgent and lifesaving care to seriously ill and injured patients wherever and whenever they need it. The Committee on the Future of Emergency Care in the United States Health System, ably chaired by Gail Warden, set out to examine the emergency care system in the United States; explore its strengths, limitations, and future challenges; describe a desired vision of the emergency care system; and recommend strategies required to achieve that vision. Their efforts build on past contributions of the National Academies, including the landmark National Research Council report Accidental Death and Disability: The Neglected Disease of Modern Society in 1966, Injury in America: A Continuing Public Health Problem in 1985, and Emergency Medical Services for Children in 1993.

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Hospital-Based Emergency Care: At the Breaking Point acts of terrorism. During any such event, local hospitals and emergency departments will be on the front lines. Yet of the millions of dollars going into preparedness efforts, a tiny fraction has made its way to medical preparedness, and much of that has focused on one of the least likely threats—bioterrorism. The result is that few hospital and EMS professionals have had even minimal disaster preparedness training; even fewer have access to personal protective equipment; hospitals, many already stretched to the limit, lack the ability to absorb any significant surge in casualties; and supplies of critical hospital equipment, such as decontamination showers, negative pressure rooms, ventilators, and intensive care unit beds, are wholly inadequate. A system struggling to meet the day-to-day needs of the public will not have the capacity to deal with a sustained surge of patients. FRAMEWORK FOR THIS STUDY This year marks the fortieth anniversary of the publication of the landmark National Academy of Sciences/National Research Council report Accidental Death and Disability: The Neglected Disease of Modern Society. That report described an epidemic of automobile-related and other injuries, and harshly criticized the deplorable state of trauma care nationwide. The report prompted a public outcry, and stimulated a flood of public and private initiatives to enhance highway safety and improve the medical response to injuries. Efforts included the development of trauma and prehospital EMS systems, creation of the specialty in emergency medicine, and establishment of federal programs to enhance the emergency care infrastructure and build a research base. To many, the 1966 report marked the birth of the modern emergency care system. Since then, the National Academies and the Institute of Medicine (IOM) have produced a variety of reports examining various aspects of the emergency care system. The 1985 report Injury in America called for expanded research into the epidemiology and treatment of injury, and led to the development of the National Center for Injury Prevention and Control within the Centers for Disease Control and Prevention. The 1993 report Emergency Medical Services for Children exposed the limited capacity of the emergency care system to address the needs of children, and contributed to the expansion of the EMS-C program within the Department of Health and Human Services. It has been 10 years, however, since the IOM examined any aspect of emergency care in depth. Furthermore, no National Academies report has ever examined the full range of issues surrounding emergency care in the United States.

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Hospital-Based Emergency Care: At the Breaking Point That is what this committee set out to do. The objectives of the study were to (1) examine the emergency care system in the United States; (2) explore its strengths, limitations, and future challenges; (3) describe a desired vision for the system; and (4) recommend strategies for achieving this vision. STUDY DESIGN The IOM Committee on the Future of Emergency Care in the United States Health System was formed in September 2003. In May 2004, the committee was expanded to comprise a main committee of 25 members and three subcommittees. A total of 40 main and subcommittee members, representing a broad range of expertise in health care and public policy, participated in the study. Between 2003 and 2006, the main committee and subcommittees met 19 times; heard public testimony from nearly 60 speakers; commissioned 11 research papers; conducted site visits; and gathered information from hundreds of experts, stakeholder groups, and interested individuals. The magnitude of the effort reflects the scope and complexity of emergency care itself, which encompasses a broad continuum of services that includes prevention and bystander care; emergency calls to 9-1-1; dispatch of emergency personnel to the scene of injury or illness; triage, treatment, and transport of patients by ambulance and air medical services; hospital-based emergency and trauma care; subspecialty care by on-call specialists; and subsequent inpatient care. Emergency care’s complexity can also be traced to the multiple locations, diverse professionals, and cultural differences that span this continuum of services. EMS, for example, is unlike any other field of medicine—over one-third of its professional workforce consists of volunteers. Further, EMS has one foot in the public safety realm and one foot in medical care, with nearly half of all such services being housed within fire departments. Hospital-based emergency care is also delivered by an extraordinarily diverse staff—emergency physicians, trauma surgeons, critical care specialists, and the many surgical and medical subspecialists who provide services on an on-call basis, as well as specially trained nurses, pharmacists, physician assistants, nurse practitioners, and others. The division into a main committee and three subcommittees made it possible to break down this enormous effort into several discrete components. At the same time, the committee sought to examine emergency care as a comprehensive system, recognizing the interdependency of its component parts. To this end, the study process was highly integrated. The main committee and three subcommittees were designed to provide for substantial overlap, interaction, and cross-fertilization of expertise. The committee concluded that nothing will change without cooperative and visionary lead-

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Hospital-Based Emergency Care: At the Breaking Point ership at many levels and a concerted national effort among the principal stakeholders—federal, state, and local officials; hospital leadership; physicians, nurses, and other clinicians; and the public. The committee hopes that the reports in the Future of Emergency Care series will stimulate increased attention to and reform of the emergency care system in the United States. I wish to express my appreciation to the members of the committee and subcommittees and the many panelists who provided input at the meetings held for this study, and to the IOM staff for their time, effort, and commitment to the development of these important reports. Gail L. Warden Chair

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Hospital-Based Emergency Care: At the Breaking Point Acknowledgments The Future of Emergency Care series benefited from the contributions of many individuals and organizations. The committee and Institute of Medicine (IOM) staff take this opportunity to recognize and thank those who helped in the development of the reports in the series. A large number of individuals assembled materials that helped the committee develop the evidence base for its analyses. The committee appreciates the contributions of experts from a variety of organizations and disciplines who gave presentations during committee meetings or authored papers that provided information incorporated into the series of reports. The full list of presenters is provided in Appendix C. Authors of commissioned papers are listed in Appendix D. Committee members and IOM staff conducted a number of site visits throughout the course of the study to gain a better understanding of certain aspects of the emergency care system. We appreciate the willingness of staff from the following organizations to meet with us and respond to questions: Beth Israel Deaconess Medical Center, Boston Medical Center, Children’s National Medical Center, Grady Memorial Hospital, Johns Hopkins Hospital, Maryland Institute for EMS Services Systems, Maryland State Police Aviation Division, Richmond Ambulance Association, and Washington Hospital Center. We would also like to express appreciation to the many individuals who shared their expertise and resources on a wide range of issues: Karen Benson-Huck, Linda Fagnani, Carol Haraden, Lenworth Jacobs, Tom Judge, Nadine Levick, Ellen MacKenzie, Dawn Mancuso, Rick Murray, Ed

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Hospital-Based Emergency Care: At the Breaking Point Racht, Dom Ruscio, Carol Spizziri, Caroline Steinberg, Rosemary Stevens, Peter Vicellio, and Mike Williams. This study received funding from the Josiah Macy, Jr. Foundation, the National Highway Traffic Safety Administration (NHTSA), and three agencies within the Department of Health and Human Services: the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Health Resources and Services Administration (HRSA). We would like to thank the staff from those organizations who provided us with information, documents, and insights throughout the project, including Drew Dawson, Laurie Flaherty, Susan McHenry, Gamunu Wijetunge, and David Bryson of NHTSA; Dan Kavanaugh, Christina Turgel, and David Heppel of HRSA; Robin Weinick and Pam Owens of AHRQ; Rick Hunt and Bob Bailey from CDC’s National Center for Injury Prevention and Control; and many other helpful members of the staffs of those organizations. Important research and writing contributions were made by Molly Hicks of Keene Mill Consulting, LLC. Karen Boyd, a Christine Mirzayan Science and Technology Fellow of the National Academies, and two student interns, Carla Bezold and Neesha Desai, developed background papers. Also, our thanks to Rona Briere, who edited the reports, and to Alisa Decatur, who prepared them for publication.

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Hospital-Based Emergency Care: At the Breaking Point Contents     SUMMARY   1      Study Charge,   1      The Challenge of High Demand and Inadequate System Capacity,   2      Findings and Recommendations,   4      Achieving the Vision of a 21st-Century Emergency Care System,   12 1   INTRODUCTION   17      A Growing National Crisis,   19      Impact on Quality and Patient Safety,   23      Purpose of This Study,   27      Study Scope,   29      Study Approach,   30      A Note about Terminology,   31      Organization of the Report,   32 2   THE EVOLVING ROLE OF HOSPITAL-BASED EMERGENCY CARE   37      Imbalance between Demand and Capacity,   38      The Emergency Department as a Core Component of Community Ambulatory Care,   42      Reimbursement for Emergency and Trauma Care,   52      Challenges of Care for Mental Health Conditions and Substance Abuse,   59      Rural Emergency Care,   65      Summary of Recommendations,   70

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Hospital-Based Emergency Care: At the Breaking Point 3   BUILDING A 21ST-CENTURY EMERGENCY CARE SYSTEM   81      The Goal of Coordination,   82      The Goal of Regionalization,   87      The Goal of Accountability,   94      Current Approaches,   102      A Proposal for Federal, State, and Local Collaboration through Demonstration Projects,   107      Need for System Integration and a Federal Lead Agency,   110      Summary of Recommendations,   124 4   IMPROVING THE EFFICIENCY OF HOSPITAL-BASED EMERGENCY CARE   129      The ED in the Context of the Health Care Delivery System,   129      Understanding Patient Flow through the Hospital System,   131      Impediments to Efficient Patient Flow in the ED,   135      Strategies for Optimizing Efficiency,   139      Overcoming Barriers to Enhanced Efficiency,   152      Summary of Recommendations,   160 5   TECHNOLOGY AND COMMUNICATIONS   165      Information Technology in the Health Care Delivery System,   167      Information Technology in the Emergency Department,   171      New Clinical Technologies,   190      Barriers to the Adoption of Information Technology,   194      Prioritizing Investments in Emergency Care Information Technology,   200      Summary of Recommendations,   202 6   THE EMERGENCY CARE WORKFORCE   209      Physicians,   210      Nurses and Other Critical Providers,   229      Enhancing the Supply of Emergency Care Providers,   236      Building Core Competencies,   238      Addressing the Issue of Provider Safety,   240      Increasing Interprofessional Collaboration,   243      Addressing the Shortage of Rural Emergency Care Providers,   247      Summary of Recommendations,   251 7   DISASTER PREPAREDNESS   259      Defining Disaster,   260      Critical Hospital Roles in Disasters,   265      Challenges in Rural Areas,   281      Federal Funding for Hospital Preparedness,   283

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Hospital-Based Emergency Care: At the Breaking Point      Summary of Recommendations,   285 8   ENHANCING THE EMERGENCY CARE RESEARCH BASE   291      Emergency Medicine Research,   293      Trauma and Injury Control Research,   304      Barriers to Emergency Care Research,   311      Summary of Recommendations,   315     APPENDIXES     A   Committee and Subcommittee Membership   321 B   Biographical Information for Main Committee and Hospital-Based Emergency Care Subcommittee   323 C   List of Presentations to the Committee   337 D   List of Commissioned Papers   343 E   Statistics on Emergency and Trauma Care Utilization   345 F   Historical Development of Hospital-Based Emergency and Trauma Care   353 G   Recommendations and Responsible Entities from the Future of Emergency Care Series   365     INDEX   383

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Hospital-Based Emergency Care: At the Breaking Point HOSPITAL-BASED EMERGENCY CARE

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