APPENDIX E
Recommendations and Responsible Entities from the Future of Emergency Care Series



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Emergency Care for Children: Growing Pains APPENDIX E Recommendations and Responsible Entities from the Future of Emergency Care Series

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Emergency Care for Children: Growing Pains HOSPITAL-BASED EMERGENCY CARE: AT THE BREAKING POINT   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other Chapter 2: The Evolving Role of Hospital-Based Emergency Care 2.1 Congress should establish dedicated funding, separate from Disproportionate Share Hospital payments, to reimburse hospitals that provide significant amounts of uncompensated emergency and trauma care for the financial losses incurred by providing those services. X X                   2.1a Congress should initially appropriate $50 million for the purpose, to be administered by the Centers for Medicare and Medicaid Services.                       2.1b The Centers for Medicare and Medicaid Services should establish a working group to determine the allocation of these funds, which should be targeted to providers and localities at greatest risk; the working group should then determine funding needs for subsequent years.                       Chapter 3: Building a 21st-Century Emergency Care System 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 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.   X X             X  

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Emergency Care for Children: Growing Pains 3.2 The National Highway Traffic Safety Administration, in partnership 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.     X             X   3.3 The Department of Health and Human Services should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency and trauma care system performance.   X                   3.4 The Department of Health and Human Services should adopt regulatory changes to the Emergency Medical Treatment and Active Labor Act and the Health Insurance Portability and Accountability Act so that the original goals of the laws will be preserved, but integrated systems can be further developed.   X                   3.5 Congress should 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. X X                  

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Emergency Care for Children: Growing Pains   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 3.6 Congress should 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), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care. X X                   Chapter 4: Improving the Efficiency of Hospital-Based Emergency Care 4.1 The Centers for Medicare and Medicaid Services should remove the current restrictions on the medical conditions that are eligible for separate clinical decision unit (CDU) payment.             X         4.2 Hospital chief executive officers should adopt enterprisewide operations management and related strategies to improve the quality and efficiency of emergency care.   X                  

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Emergency Care for Children: Growing Pains 4.3 Training in operations management and related approaches should be promoted by professional associations; accrediting organizations, such as the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance; and educational institutions that provide training in clinical, health care management, and public health disciplines.                   X X 4.4 The Joint Commission on Accreditation of Healthcare Organizations should reinstate strong standards designed to sharply reduce and ultimately eliminate ED crowding, boarding, and diversion.                     X 4.5 Hospitals should end the practices of boarding patients in the emergency department and ambulance diversion, except in the most extreme cases, such as a community mass casualty event. The Centers for Medicare and Medicaid Services should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing, and other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures, and incentives for implementation, monitoring, and enforcement of these standards.   X         X         Chapter 5: Technology and Communications 5.1 Hospitals should adopt robust information and communications systems to improve the safety and quality of emergency care and enhance hospital efficiency.             X         Chapter 6: The Emergency Care Workforce 6.1 Hospitals, physician organizations, and public health agencies should collaborate to regionalize critical specialty care on-call services.             X     X X

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Emergency Care for Children: Growing Pains   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 6.2 Congress should appoint a commission to examine the impact of medical malpractice lawsuits on the declining availability of providers in high-risk emergency and trauma care specialties, and to recommend appropriate state and federal actions to mitigate the adverse impact of these lawsuits and ensure quality of care. X                     6.3 The American Board of Medical Specialties and its constituent boards should extend eligibility for certification in critical care medicine to all acute care and primary care physicians who complete an accredited critical care fellowship program.                   X X 6.4 The Department of Health and Human Services, the Department of Transportation, and the Department of Homeland Security should jointly undertake a detailed assessment of emergency and trauma workforce capacity, trends, and future needs, and develop strategies to meet these needs in the future.   X X X               6.5 The Department of Health and Human Services, in partnership with professional organizations, should develop national standards for core competencies applicable to physicians, nurses, and other key emergency and trauma professionals, using a national, evidence-based, multidisciplinary process.   X               X   6.6 States should link rural hospitals with academic health centers to enhance opportunities for professional consultation, telemedicine, patient referral and transport, and continuing professional education.           X X        

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Emergency Care for Children: Growing Pains Chapter 7: Disaster Preparedness 7.1 The Department of Homeland Security, the Department of Health and Human Services, the Department of Transportation, and the states should collaborate with the Veterans Health Administration (VHA) to integrate the VHA into civilian disaster planning and management.   X X               X 7.2 All institutions responsible for the training, continuing education, and credentialing and certification of professionals involved in emergency care (including medicine, nursing, emergency medical services, allied health, public health, and hospital administration) should incorporate disaster preparedness training into their curricula and competency criteria.           X       X X 7.3 Congress should significantly increase total preparedness funding in fiscal year 2007 for hospital emergency preparedness in the following areas: strengthening and sustaining trauma care systems; enhancing emergency department, trauma center, and inpatient surge capacity; improving emergency medical services’ response to explosives; designing evidence-based training programs; enhancing the availability of decontamination showers, standby intensive care unit capacity, negative pressure rooms, and appropriate personal protective equipment; and conducting international collaborative research on the civilian consequences of conventional weapons terrorism. X                     Chapter 8: Enhancing the Emergency Care Research Base 8.1 Academic medical centers should support emergency and trauma care research by providing research time and adequate facilities for promising emergency care and trauma investigators, and by strongly considering the establishment of autonomous departments of emergency medicine.             X        

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Emergency Care for Children: Growing Pains   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 8.2 The Secretary of the Department of Health and Human Services should conduct a study to examine the gaps and opportunities in emergency and trauma care research, and recommend a strategy for the optimal organization and funding of the research effort. X X X X X             8.2a This study should include consideration of training of new investigators, development of multicenter research networks, funding of General Clinical Research Centers that specifically include an emergency and trauma care component, involvement of emergency and trauma care researchers in the grant review and research advisory processes, and improved research coordination through a dedicated center or institute.                       8.2b Congress and federal agencies involved in emergency and trauma care research (including the Department of Transportation, the Department of Health and Human Services, the Department of Homeland Security, and the Department of Defense) should implement the study’s recommendations.                       8.3 States should ease their restrictions on informed consent to match federal law. X                     8.4 Congress should modify Federalwide Assurance Program regulations to allow the acquisition of limited, linked, patient outcome data without the existence of a Federalwide Assurance Program.                      

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Emergency Care for Children: Growing Pains EMERGENCY MEDICAL SERVICES AT THE CROSSROADS   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other Chapter 3: Building a 21st-Century Emergency Care System 3.1 The Department of Health and Human Services and National Highway Traffic Safety Administration, in partnership with professional organizations, should 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.   X X             X   3.2 The National Highway Traffic Safety Administration, in partnership 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.     X             X   3.3 The Department of Health and Human Services should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency and trauma care system performance.   X                   3.4 Congress should 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. X X                  

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Emergency Care for Children: Growing Pains   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 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 medical services (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and design and monitor the transition to its assumption of the responsibilities outlined above. The working group should include representatives from federal and state agencies and professional disciplines involved in emergency and trauma care. X X                   3.6 The Department of Health and Human Services should adopt rule changes to the Emergency Medical Treatment and Active Labor Act and the Health Insurance Portability and Accountability Act so that the original goals of the laws will be preserved, but integrated systems can be further developed.   X                   3.7 The Centers for Medicare and Medicaid Services should 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.   X                  

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Emergency Care for Children: Growing Pains Chapter 4: Supporting a High-Quality EMS Workforce 4.1 State governments should adopt a common scope of practice for emergency medical services personnel, with state licensing reciprocity.           X           4.2 States should require national accreditation of paramedic education programs.           X           4.3 States should accept national certification as a prerequisite for state licensure and local credentialing of emergency medical services providers.           X           4.4 The American Board of Emergency Medicine should create a subspecialty certification in emergency medical services.                   X   Chapter 5: Advancing System Infrastructure 5.1 States should assume regulatory oversight of the medical aspects of air medical services, including communications, dispatch, and transport protocols.           X           5.2 Hospitals, emergency medical services agencies, public safety departments, emergency management offices, and public health agencies should develop integrated and interoperable communications and data systems.             X X     X 5.3 The National Coordinator for Health Information Technology should fully involve prehospital emergency medical services leadership in discussions about design, deployment, and financing of the National Health Information Infrastructure.   X                  

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Emergency Care for Children: Growing Pains   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other Chapter 6: Preparing for Disasters 6.1 The Department of Health and Human Services, the Department of Transportation, the Department of Homeland Security, and the states should elevate emergency and trauma care to a position of parity with other public safety entities in disaster planning and operations.   X X X   X           6.2 Congress should substantially increase funding for emergency medical services–related disaster preparedness through dedicated funding streams. X                     6.3 Professional training, continuing education, and credentialing and certification programs for all the relevant professional categories of emergency medical services personnel should incorporate disaster preparedness into their curricula and require the maintenance of competency in these skills.     X     X       X X Chapter 7: Optimizing Prehospital Care Through Research 7.1 Federal agencies that fund emergency and trauma care research should target an increased share of research funding at prehospital emergency medical services research, with an emphasis on systems and outcomes research.   X X X X           X 7.2 Congress should modify Federalwide Assurance Program regulations to allow the acquisition of limited, linked patient outcome data without the existence of a Federalwide Assurance Program. X                    

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Emergency Care for Children: Growing Pains 7.3 The Secretary of the Department of Health and Human Services should conduct a study to examine the research gaps and opportunities in emergency and trauma care research, and recommend a strategy for the optimal organization and funding of the research effort. This study should include consideration of the training of new investigators, the development of multicenter research networks, the involvement of emergency medical services researchers in the grant review and research advisory processes, and improved research coordination through a dedicated center or institute. Congress and federal agencies involved in emergency and trauma care research (including the Department of Transportation, the Department of Health and Human Services, the Department of Homeland Security, and the Department of Defense) should mplement the study’s recommendations. X X X X X             EMERGENCY CARE FOR CHILDREN: GROWING PAINS   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Societies Other Chapter 3: Building a 21st-Century Emergency Care System 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 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.   X X             X  

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Emergency Care for Children: Growing Pains   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Societies Other 3.2 The National Highway Traffic Safety Administration, in partnership 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, including children.     X             X   3.3 The Department of Health and Human Services should 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.   X                   3.4 Congress should 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. X X                   3.5 The Department of Health and Human Services should adopt rule changes to the Emergency Medical Treatment and Active Labor Act and the Health Insurance Portability and Accountability Act so that the original goals of the laws are preserved, but integrated systems may further develop.   X                  

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Emergency Care for Children: Growing Pains 3.6 Congress should 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), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and design and monitor the transition to its assumption of the responsibilities outlined above. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care. X X                   3.7 Congress should appropriate $37.5 million per year for the next 5 years to the Emergency Medical Services for Children program. X                     Chapter 4: Arming the Emergency Care Workforce with Knowledge and Skills 4.1 Every pediatric- and emergency care–related health professional credentialing and certification body should define pediatric emergency care competencies and require practitioners to receive the level of initial and continuing education necessary to achieve and maintain those competencies.                   X   4.2 The Department of Health and Human Services should collaborate with professional organizations to convene a panel of individuals with multidisciplinary expertise to develop, evaluate, and update clinical practice guidelines and standards of care for pediatric emergency care.   X               X  

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Emergency Care for Children: Growing Pains   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Societies Other 4.3 Emergency medical services agencies should appoint a pediatric emergency coordinator, and hospitals should appoint two pediatric emergency coordinators—one a physician—to provide pediatric leadership for the organization.             X X       Chapter 5: Improving the Quality of Pediatric Emergency Care 5.1 The Department of Health and Human Services should fund studies of the efficacy, safety, and health outcomes of medications used for infants, children, and adolescents in emergency care settings in order to improve patient safety.   X                   5.2 The Department of Health and Human Services and the National Highway Traffic Safety Administration should fund the development of medication dosage guidelines, formulations, labeling, and administration techniques for the emergency care setting to maximize effectiveness and safety for infants, children, and adolescents. Emergency medical services agencies and hospitals should incorporate these guidelines, formulations, and techniques into practice.   X X       X X       5.3 Hospitals and emergency medical services agencies should implement evidence-based approaches to reducing errors in emergency and trauma care for children.             X X       5.4 Federal agencies and private industry should fund research on pediatric-specific technologies and equipment used by emergency and trauma care personnel.   X X X         X    

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Emergency Care for Children: Growing Pains 5.5 Emergency medical services agencies and hospitals should integrate family-centered care into emergency care practice.             X X       Chapter 6: Improving Emergency Preparedness and Response for Children Involved in Disasters 6.1 Federal agencies (the Department of Health and Human Services, the National Highway Traffic Safety Administration, and the Department of Homeland Security), in partnership with state and regional planning bodies and emergency care providers, should convene a panel with multidisciplinary expertise to develop strategies for addressing pediatric needs in the event of a disaster. This effort should encompass the following:   X X X X             Development of strategies to minimize parent–child separation and improved methods for reuniting separated children with their families. Development of strategies to improve the level of pediatric expertise on disaster medical assistance teams and other organized disaster response teams. Development of disaster plans that address pediatric surge capacity for both injured and noninjured children. Development of and improved access to specific medical and mental health therapies, as well as social services, for children in the event of a disaster. Development of policies to ensure that disaster drills include a pediatric mass casualty incident at least once every 2 years.                      

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Emergency Care for Children: Growing Pains   Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Societies Other Chapter 7: Building the Evidence Base for Pediatric Emergency Care 7.1 The Secretary of Health and Human Services should conduct a study to examine the gaps and opportunities in emergency care research, including pediatric emergency care, and recommend a strategy for the optimal organization and funding of the research effort. This study should include consideration of the training of new investigators, development of multicenter research networks, involvement of emergency and trauma care researchers in the grant review and research advisory processes, and improved research coordination through a dedicated center or institute. Congress and federal agencies involved in emergency and trauma care research (including the Department of Transportation, Department of Health and Human Services, Department of Homeland Security, and Department of Defense) should implement the study’s recommendations.   X X X X             7.2 Administrators of state and national trauma registries should include standard pediatric-specific data elements and provide the data to the National Trauma Data Bank. Additionally, the American College of Surgeons should establish a multidisciplinary pediatric specialty committee to continuously evaluate pediatric-specific data elements for the National Trauma Data Bank and identify areas for pediatric research.                     X