3
Workshop in Salt Lake City, Utah

The first dissemination workshop, held at Primary Children’s Medical Center in Salt Lake City, Utah, focused on pediatric emergency care and care in rural areas. Edward Clark, medical director of Primary Children’s Medical Center and the opening speaker, explained that Utah has the highest birth rate and the youngest population in the nation and that the state faces many of the emergency care challenges highlighted in the Institute of Medicine (IOM) reports. Primary Children’s, one of 21 hospitals in the Intermountain Health Care System, is one of 42 children’s hospitals in the nation and one of 11 children’s hospitals with a level 1 trauma designation. The hospital serves as a pediatric center covering five states in the inter-mountain West, over 400,000 square miles. Its 34-bed pediatric intensive care unit (PICU), one of the largest in the country, is the only PICU between Denver and San Francisco. Because of the hospital’s large catchment area, it receives approximately 1,500 patients by helicopter each year.

Following the opening remarks by Dr. Clark, three IOM committee members, Nels Sanddal, Brent Eastman, and Marianne Gausche-Hill, provided an overview of the findings and recommendations from the three IOM reports.

REACTIONS TO THE IOM REPORTS

Federal Perspectives

David Sundwall, director of the Utah Department of Health and IOM committee member, emphasized the importance of looking beyond the IOM



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Future of Emergency Care: Dissemination Workshop Summaries 3 Workshop in Salt Lake City, Utah The first dissemination workshop, held at Primary Children’s Medical Center in Salt Lake City, Utah, focused on pediatric emergency care and care in rural areas. Edward Clark, medical director of Primary Children’s Medical Center and the opening speaker, explained that Utah has the highest birth rate and the youngest population in the nation and that the state faces many of the emergency care challenges highlighted in the Institute of Medicine (IOM) reports. Primary Children’s, one of 21 hospitals in the Intermountain Health Care System, is one of 42 children’s hospitals in the nation and one of 11 children’s hospitals with a level 1 trauma designation. The hospital serves as a pediatric center covering five states in the inter-mountain West, over 400,000 square miles. Its 34-bed pediatric intensive care unit (PICU), one of the largest in the country, is the only PICU between Denver and San Francisco. Because of the hospital’s large catchment area, it receives approximately 1,500 patients by helicopter each year. Following the opening remarks by Dr. Clark, three IOM committee members, Nels Sanddal, Brent Eastman, and Marianne Gausche-Hill, provided an overview of the findings and recommendations from the three IOM reports. REACTIONS TO THE IOM REPORTS Federal Perspectives David Sundwall, director of the Utah Department of Health and IOM committee member, emphasized the importance of looking beyond the IOM

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Future of Emergency Care: Dissemination Workshop Summaries reports and their recommendations to recognize and acknowledge the human side of pediatric emergency care. He described how the federal Emergency Medical Services for Children (EMS-C) program, like many other federal health care programs, had its origins in policy makers’ personal medical experiences. Over 25 years ago, Dr. Sundwall’s daughter was very seriously injured by an automobile. She received good emergency care and survived. Years later, when Dr. Sundwall was working in Washington, DC, for Senator Orrin Hatch, he met another congressional staff member who had a poor experience with the pediatric emergency care system. Together, they partnered to write the legislation that created the EMS-C program. Dr. Sundwall emphasized how pleased he was that his daughter’s terrible injury translated into assistance for many other children. He noted that one of the IOM committee’s recommendations was for Congress to increase the modest federal funding for the EMS-C program to $37.5 million. There continues to be enormous strains on the emergency care system nationwide, and the EMS-C program is well positioned to help address those challenges for children. Another challenge facing the emergency care system is its ability to respond to disasters. According to John Agwunobi, assistant secretary for health in the U.S. Department of Health and Human Services (DHHS), one of the essential components of a prepared nation is the presence of a robust, well-funded, well-staffed, connected emergency care system. A community will be better prepared for disasters if it has resources (e.g., defibrillators, ventilators) in place, citizens who are trained in cardiopulmonary resuscitation and understand how to access the system, academics conducting research and developing training programs for health professionals, and communications systems that connect the various responders. Adm. Agwunobi emphasized that it is not appropriate to rely entirely on the federal government to improve emergency preparedness. A truly robust emergency care system must be supported by communities. The average citizen needs to understand the capabilities of the emergency care system and the resources needed for the system to maintain operations. People also need to understand that we are all responsible for supporting the emergency medical system. In the event of a large-scale disaster, such as pandemic influenza, Adm. Agwunobi explained, the system currently does not have all the personnel or the resources that would be needed to respond. That means that communities are going to have to rely on outside health professionals and laypersons to assist. The Medical Reserve Corps (MRC) is one available resource. The MRC consists of groups of volunteer physicians, nurses, dentists, emergency personnel, and others who come together on a volunteer basis to assist in the event of an emergency. They will be available to augment the local health care workforce in the event of a disaster, expanding

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Future of Emergency Care: Dissemination Workshop Summaries the capacity of the local system. There are over 450 MRC units across the country and 10 in Utah. Nonprofessional health care workers may also play an important role in preparedness. On September 11, 2001, non-health care professionals stood beside police, emergency medical services (EMS) personnel, and firefighters ready to save lives. Their response demonstrated that the public is willing to support the system. A community may be in a position to save many more lives if it embraces non-emergency-response personnel and trains them in the basic skills of emergency response. An example would be training individuals to care for friends and family members with influenza. Another challenge is the lack of resources (ventilators, medications, etc.) available in the event of a disaster. The Health Resources and Services Administration (HRSA) has invested $2 billion in hospital preparedness in recent years. Initially the funding was targeted at building committees, developing hospital response plans, and forging partnerships. In subsequent years, the funding has been used to build connections between hospitals, develop common communication standards, and invest in shared assets, such as tele-help systems. Funding has also been used to enhance joint exercises and, in doing so, has helped ensure that hospitals partner with key organizations in their planning efforts. Today HRSA’s funding is directed at the priorities identified by the states. The HRSA funding stream will continue in the future and is complementary to the billions of dollars spent by the Department of Homeland Security to address preparedness. When attendees were invited to ask questions or make a comment, Frederick Blum, president of the American College of Emergency Physicians (ACEP), noted that one of the shortcomings of many preparedness plans is that they end with the delivery of patients to the emergency department (ED); rarely do plans include contingencies in case EDs are not fully functional during or after a disaster. Adm. Agwunobi agreed that as disaster plans are developed, greater consideration should be given to that issue. The focus must go beyond the treatment of patients to also consider the integration of patients back into the community, cleanup, and the rebuilding of homes. Adm. Agwunobi noted that the emergency care system has come a long way over the past several decades. The system in place today would have made the country proud 50 years ago. However, today we recognize that much work is left to do. The process of preparing a nation does not occur overnight. It requires the diligent inventory of community assets, strengths, and the building of partnerships and a framework on which to prepare. It should be incremental and flexible. Some may ask, “When will we be prepared?” but preparedness has no end point. There will always be new threats and further improvements to be made.

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Future of Emergency Care: Dissemination Workshop Summaries Regional Perspectives A panel of state and local representatives participated in a conversation about the IOM reports based on questions set in advance of the workshop. The discussion was moderated by IOM committee member Brent Eastman, chief medical officer of ScrippsHealth. Respondents included Paul Patrick, director of EMS for the State of Utah; Janet Griffith Kastl, director of the Office of EMS and Trauma for the State of Washington; James Antinori, an emergency physician in Salt Lake City; Denise King, director of education at Parkview Community Hospital in Southern California; and Joseph Hansen, executive director of the Critical Illness and Trauma Foundation in Bozeman, Montana. What Are the Key Messages of the IOM Reports? Mr. Patrick identified several key messages from the three reports: the emergency care system is underfunded, more pediatric training is needed for all providers, crowding and boarding of patients in the ED must be reduced, and the emergency care system is fragmented and is seeking a stronger identity. Ms. Griffith Kastl said that her primary excitement about the reports is their emphasis on a systems approach. The reports recognize the interdependent relationship between prehospital care, hospital-based care, and all the providers that deliver care in those environments. Dr. Antinori and Ms. King noted that the key messages of the reports, particularly those related to the lack of funding for emergency care and ED crowding, were not surprising and have been discussed for years in the emergency physician and nursing communities. The importance of the reports lies in their ability to reach a large audience and to educate the public about the problems in the emergency care system. Dr. Antinori also noted that the problems in the emergency care system are getting worse; he hopes that the message reaching the public is that the emergency care system might not be there when needed, regardless of patients’ level of income, education, or status in the community. Mr. Hansen identified several key messages, first noting that EMS has traditionally lacked a strong identity. The reports call for a lead federal agency for emergency care to be created in DHHS. The reports also describe how EMS is underfunded and data are inadequate to measure the quality of care being provided. The National EMS Information System (NEMSIS) can serve as a model for improving EMS data collection. Finally, Mr. Hansen discussed the importance of the system for pediatric patients. The report calls for increases in funding for the federal EMS-C program.

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Future of Emergency Care: Dissemination Workshop Summaries Are There Any Important Issues that the IOM Reports Missed? Mr. Hansen expressed disappointment that most of the examples concerning EMS in the reports involved paramedics treating patients. There is a general assumption that advanced life support and paramedic care are required to provide quality care, but limited evidence supports that assumption. Ms. King noted that although the IOM reports address the nursing workforce shortage, they do not include any concrete recommendations for a solution to the problem. The same is true of workplace safety. Ms. King and Dr. Antinori said that the geriatric population deserved more attention in the reports. Geriatric patients have a unique set of health problems and treatment options, and there will be a huge surge in that population over the next 20 years. They also agreed that while psychiatric patients do not require much clinical time, providers spend a disproportionate time on the disposition of those patients, an issue that was not adequately discussed in the reports. Ms. Griffith Kastl and Mr. Patrick said that the reports did not discuss the role and responsibilities of state EMS and trauma agencies, noting that a successful regional system requires leadership at the state level. Ms. Griffith Kastl also noted a lack of discussion of prevention issues. Mr. Patrick added that although rural emergency care is mentioned, the reports generally appeared to be written from an urban perspective. Finally, he noted that the reports call for a federal lead agency for emergency care but do not give enough consideration to the Federal Interagency Committee on EMS (FICEMS), which could serve as a home for emergency care at the federal level. What Are the Top Priority Areas for Action? What Are Some of the Barriers to Implementation? Mr. Patrick identified the following priority areas for action: reimbursement for EMS treat and release under Medicare, a common scope of practice for EMS, a revision of the Health Insurance Portability and Accountability Act (HIPAA) laws for data collection, and increased funding for the EMS-C program. Barriers include a lack of coordination of EMS across state and territorial jurisdictional lines and a lack of funding for the coordination of efforts. Ms. Griffith Kastl said that there must be funding devoted to systems development. Also, there should be stronger leadership at the federal level, which FICEMS may be able to provide. Another priority issue is to reduce crowding in EDs, and the reports provide many good ideas for doing so. Health care politics and individuals’ resistance to change serve as barriers.

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Future of Emergency Care: Dissemination Workshop Summaries Dr. Antinori said that personnel issues are among the top-priority areas for action. Even if the system adopts the best information technology or the best resources, it will make little difference if personnel are unavailable to treat patients. There must be more training of providers or strategies developed to retain providers, and that will require additional funding. It will also require addressing the liability problem. Dr. Antinori identified politics and money as the main barriers to action. Ms. King spoke about different priorities at different levels: local, state, and federal. She counted 43 recommendations targeted to federal-level entities, noting that there is great potential for politics to serve as a barrier to implementation. For example, there may be turf battles between the federal agencies about who should lead emergency care. There may also be turf battles in the professional ranks among physicians, nurses, emergency medical technicians (EMTs), and firefighters about who takes the lead; it must be a collaborative effort, according to Ms. King. Hospital efficiency is another area for action, and she noted that there are many hospitals that are taking steps to improve efficiency. Some of the barriers to these efforts include HIPAA, the Emergency Medical Treatment and Active Labor Act, and nurse staffing ratios in California. Open Discussion Dr. Eastman invited members of the audience to ask a question or make a brief comment. Jerris Hedges from the Society for Academic Emergency Medicine raised the issue of workforce shortages in rural areas, noting the need to enhance training opportunities and expand the number of providers in rural areas. Mr. Sanddal agreed, noting that there should be some exploration of alternative training models for health care providers in rural areas, including the use of simulation training, which is discussed in the IOM reports. Donna Thomas, a member of the IOM committee, also added that more research is needed to determine the types of training that are most beneficial as well as the frequency of training needed for providers to maintain competencies. Denise Love of the National Association of Health Data Organizations, noting the high utilization of EDs for preventable conditions and primary care, inquired whether the committee considered recommendations to fix the primary care system. Similarly, Jeff Schunk of Primary Children’s Medical Center asked whether the committee considered universal health care during its deliberations. Dr. Gausche-Hill noted that consideration of universal coverage was beyond the scope of the committee’s charge, but also that universal coverage may not address the high rates of ED utilization. In fact, several studies indicate that insured individuals also use the ED

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Future of Emergency Care: Dissemination Workshop Summaries for nonurgent conditions and many also face barriers to accessing primary care. Bill Jermyn, EMS medical director for the state of Missouri, noted that the IOM report on prehospital care did not focus much attention on the issue of patient safety. He added that state medical directors see patient safety as a significant problem, one that is of an unknown size due to a lack of data. Mr. Sanddal responded by saying that the committee focused on recommendations for building the infrastructure that would allow for the evaluation and monitoring of patient safety and quality. Tommy Loyacono, a member of the IOM committee, mentioned the need for EMS to develop a culture that encourages the reporting of errors. Clay Mann, from the Intermountain Injury Control Research Center, spoke about the importance of research in emergency care and found it surprising that the reports did not contain a recommendation to provide financial support to states and hospitals for the collection of standardized data across regions, states, and the nation. Mr. Sanddal responded that the reports do contain some language about the need to standardize and collect data, but the committee did not issue a specific recommendation for financial support to states and hospitals for that purpose. LeeAnn Phillips, a regional EMS director from New Mexico, noted that the committee did not address the issue of reimbursement for illegal immigrants. Members of the committee agreed that it is an important issue, but one that was not discussed in great detail by the committee. Finally, Debra Wynkoop of Utah Hospitals and Health Systems Association and Dr. Blum raised the issue of specialty hospitals, noting that specialty hospitals are drawing paying patients and surgical specialists away from general hospitals. Dr. Gausche-Hill noted that specialty hospitals are briefly addressed in the hospital-based report. Certainly there will always be a need for general hospitals to have personnel available who are capable of at least stabilizing patients and transferring them to a higher level or specialty facility. It will be important to integrate specialty facilities into a regional system, making sure that the system is designed so that all patients have access to the specialty services they need. LEADING CHANGE Brent James, executive director of the Institute for Health Care Delivery Research, Intermountain Health Care, delivered the luncheon address and discussed health care quality and the need for providers to take an active role in improving emergency care. Dr. James explained that the emergency care reports are the latest from the IOM that address quality issues in health care delivery. In 1999 the IOM released To Err Is Human, which created controversy because it provided

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Future of Emergency Care: Dissemination Workshop Summaries a conservative estimate of the number of people who die each year from medical errors at hospitals. In 2001, the IOM released Crossing the Quality Chasm, which served as a prescription for reform. The title was drawn from the second paragraph of the executive summary, “Between the health care we have and the care we could have lies not just a gap, but a chasm.” The IOM reports on the emergency care system draw similar conclusions. The well-established literature on quality leads to three conclusions, according to Dr. James. First, there is great variation in clinical care delivery across the United States, and inappropriate care is common. There have been about 40,000 peer-reviewed articles documenting variation in care over the past 30 years. Jack Wennberg, the father of research on variation in care in Medicare, found that Medicare patients in Florida consume 2.5 times more resources than similar patients in Minnesota and that the patients in Florida have about a 2 percent higher mortality rate than their counterparts in Minnesota. The second conclusion was highlighted in To Err Is Human. The authoring committee estimated that between 44,000 and 98,000 preventable deaths each year are directly associated with care delivered in hospitals. More recent analyses indicated that this was a conservative estimate. It includes only injuries of commission (in which care actively harmed the patient) in an inpatient setting. The estimate does not include injuries in the outpatient settings or injuries of omission (in which a treatment that is known to work was not administered), which is an even greater problem. The final conclusion is that there is a striking inability to deliver care that is proven to be effective. One of the best illustrations of that literature comes from Beth McGlynn, who looked at injuries of omission and commission in six major metropolitan areas and found that American health care provides appropriate care about 54.9 percent of the time. The literature on health care quality presents a picture of failure, and the IOM reports on emergency care provide even more evidence of failure. However, Dr. James argued that the conclusions about the health care system that one draws depend on one’s perspective. It is important to look back and reflect on how far the health care system has advanced. A very recent article in the New England Journal of Medicine assessed the value of medical spending in the United States. It showed that life expectancy has risen from 49 years for a child born in 1900 to 77 years for a child born in 2000, which represents a phenomenal success story. Prior to 1900, life expectancy was fairly constant, but around 1900, medical care became more organized and scientific methods were applied more systematically in delivery. Between 1900 and 1960, there was a 20-year gain in life expectancy or 3.5 years in each decade. Most of this gain was due to public health improvements and control of epidemic disease, and the trend has continued. Since 1960, there has been about 1.75 years of life expec-

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Future of Emergency Care: Dissemination Workshop Summaries tancy gained per decade. According to Dr. James, medicine is “routinely achieving miracles,” but we often overlook that progress. Depending on one’s perspective, the health care system can be said to be failing or achieving miracles. Dr. James added that IOM committees almost always address their recommendations to the U.S. Congress; however, most members of Congress have competing agendas and will not take time to understand the reports. The importance of the reports therefore stems from their careful analysis of major problems and their ability to reach the professionals who are actively providing care. Those involved in emergency care should look for ways to stimulate change from within, rather than wait for Congress to act. The most effective change almost always happens from within. ADVANCING PEDIATRIC EMERGENCY CARE The first afternoon session focused on pediatric emergency care. Four presentations were followed by an open discussion. The session was moderated by IOM committee member Marianne Gausche-Hill. Pediatric EMS Kathleen Brown, a pediatric emergency medicine physician at Children’s National Medical Center, provided a summary of the IOM committee’s recommendations that pertain to pediatric prehospital care and discussed implementation issues. In the area of training and skills maintenance, the IOM committee recommended that every health professional credentialing and certification body related to pediatric emergency care define pediatric emergency core competencies and require practitioners to receive the appropriate level of initial and continuing education necessary to achieve and maintain those competencies. There continues to be great variability in the pediatric training and continuing education that prehospital providers receive. Dr. Brown noted that the National Highway Traffic Safety Administration developed a prehospital model curriculum that includes pediatric components; however, there continues to be great variability in the extent to which the states follow the curriculum. States often use it as a guide but do not necessarily follow it faithfully. The EMS-C program encourages states to include pediatric training in the recertification process for EMTs. One of the program’s performance measures tracks trends in pediatric education for paramedics. The IOM committee also recommended that EMS agencies (as well as hospitals) appoint pediatric coordinators to provide pediatric leadership for the organization. Dr. Brown noted that there may be some incentives that the EMS-C state or regional coordinator can offer EMS agencies to

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Future of Emergency Care: Dissemination Workshop Summaries encourage the appointment of pediatric coordinators. For example, the state might offer to provide an analysis of the agency’s data or offer special training opportunities to staff. EMS-C coordinators may also be able to influence the state EMS directors to mandate pediatric coordinators at the agency level. The IOM committee also recommended the development of evidence-based model pediatric protocols for pediatric prehospital care. The IOM committee recommended that these protocols be developed within 18 months, which, according to Dr. Brown, is very ambitious. However, the National Association of EMS Physicians developed model protocols for pediatrics that have been reviewed by a number of organizations, which can serve as a starting point. The EMS-C program, which provided support for the development of the model protocols, may decide to update those protocols. Dr. Brown also discussed the IOM committee’s recommendation that EMS agencies and hospitals adopt family-centered care into practice. There are a couple of important barriers to the adoption of family-centered care. The first is a fear on the part of providers, particularly when it comes to allowing family members to be present for certain procedures, of violating HIPAA, making themselves more vulnerable to lawsuits, or both. The other barrier has to do with resources and having the funding necessary to promote a family-centered environment. For example, it is costly for hospitals to remodel waiting rooms to make them more family-friendly and for hospitals and EMS agencies to have someone on staff specifically to provide support to families. To address these barriers, Dr. Brown said that education is important, and there are several resources that providers can use to improve education. The National Association of EMTs developed guidelines for family-centered care in EMS, and the Emergency Nurses Association developed a handbook on how to institute family-centered care in the ED. The Ambulatory Pediatric Association, the Institute for Family Centered Care, and the American Hospital Society also have resources that could be of use to emergency providers. Providers also must educate those with resources on importance of family-centered care in order to make the implementation of family-centered care a priority in EMS agencies and hospitals. Patient Safety Karen Frush of Duke University Health System spoke on patient safety. Emergency care is provided in a high-risk and highly complex environment in which providers are at risk of making errors every day. Although other industries, such as aviation and nuclear power, face similar levels of risk, those industries have implemented systems and processes to mitigate risk

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Future of Emergency Care: Dissemination Workshop Summaries and improve safety. In fact, according to Dr. Frush, these high-reliability organizations have incredible safety records. Although more research is needed on the subject of patient safety in the emergency care setting, there are steps that federal agencies, EMS agencies, and hospitals can undertake immediately to improve safety. To reduce errors in the administration of medication to children, according to Dr. Frush, a clinical tool should be developed to help emergency care providers standardize and simplify dosing. Currently a length-based measurement tape is available to assist with dosing, and although it has some limitations, it can serve as a prototype. Dr. Frush said that a panel of experts—providers, manufacturers, pharmacists, and vendors—should be convened to develop medication standards for pediatric patients. That group can define ideal standards based on the currently available evidence, recognizing that more research and evidence will be used to refine the standards in the future. The issue of dosing extends to other forms of treatment as well, including radiation. At least one vendor has designed a computed tomography (CT) scanner that can be adjusted for dosing. Once a standard for pediatrics is available, providers can appropriately dose the amount of radiation to which patients are exposed. Dr. Frush also discussed several steps that hospitals and EMS agencies can undertake in order to implement evidence-based approaches for reducing errors and improving patient safety more generally. First, providers need to assess risk in their environments. If providers understand that they work in a high-risk environment, then they will recognize that it is their responsibility to reduce risk as much as possible. Provider organizations can also adopt strategies of active surveillance. There are programs currently available in which safety teams examine the clinical area in the ED and ask providers on the front line about risks that might harm patients. It is important to identify these risks so that changes can be made. In addition, there should be voluntary reporting systems available in every ED so that all providers, patients, and families can let administrators know about concerns they have related to risk. Another opportunity is for providers and families to share stories. Federal legislation was passed to allow provider organizations to form patient safety organizations. Dr. Frush noted that a national patient safety organization for pediatric emergency care is needed to allow providers to submit stories and share lessons learned. Teamwork among providers is also important to reducing medical errors; however, health care providers are not typically trained in teamwork. Reflecting on her own nursing and physician training, Dr. Frush noted that she was trained “in a silo,” but was then sent into the clinical area and expected to function as part of a team. This remains true under the current education systems for EMTs, nurses, and physicians. The didactic

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Future of Emergency Care: Dissemination Workshop Summaries and interactive training currently available can improve providers’ ability to communicate and work as members of a team. There are also consultants that will come to health care organizations to facilitate teamwork. Team training is beginning to be implemented in some medical and nursing schools, and it is important to assess which methods work best and move toward implementing those models. Finally, Dr. Frush noted that providers need to include the family when they take care of children in the emergency department. Health care providers need further training on how to say, “I’m sorry” and to disclose appropriately to patients and families when medical errors occur. If, as the IOM committee recommended, patients and family members should be integrated into the care team, providers need to learn how to communicate these messages. Research Although there have been tremendous strides in pediatric emergency care in previous decades, many gaps remain and pediatric research continues to lag behind adult research. According to Nathan Kuppermann, chair and director of research in the Department of Emergency Medicine at the University of California, Davis, School of Medicine, compared with adults, much less is known about treatment of life-threatening pediatric injuries and illnesses, such as cardiac arrest, shock, and drowning. More information is also needed to assess pediatric emergency care on the IOM’s six aims of quality health care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. In order to address these gaps in knowledge, several barriers must be overcome in addition to the limited funding available for research. The first is the limited number of individuals trained in pediatric emergency care research and limited protected time for researchers. Dr. Kuppermann explained that often investigators are under such tremendous pressure to achieve clinical productivity that little time is left for research. The epidemiology of pediatric emergency events poses another barrier. Important events occur at any given hospital only sporadically. To study certain conditions, researchers need to pool data to obtain sufficient diversity to generate findings that are generalizable. The complexity of obtaining informed consent in the ED serves as another barrier. Finally, the lack of an appropriate infrastructure prevents research collaboration between prehospital and hospital providers. Dr. Kuppermann emphasized the need to expand multicenter research, in which data from a number of hospitals are pooled to improve sample size. Multicenter research promotes collaboration among investigators from different organizations and with different clinical backgrounds (e.g., pre-

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Future of Emergency Care: Dissemination Workshop Summaries hospital providers, critical care physicians, ED physicians and nurses). The capabilities of multicenter research should also be investigated for their ability to transfer research results into the practitioner community. An example of a multicenter research network is the Pediatric Emergency Care Applied Research Network, which is funded by the EMS-C program of the Maternal and Child Health Bureau at HRSA. It is the first federally funded research network focused on pediatric emergency care. The challenge is that, while multicenter research networks can produce definitive findings, the studies are expensive. Investigators need to educate and make the case to Congress for funding and a dedicated institute within the National Institutes of Health, according to Dr. Kuppermann. Another challenge is that the sharing of information is complicated in a multicenter research network because of the institutional review board (IRB) process. Each institution has its own IRB with different guidelines. In order to address this challenge, there should be better collaboration among IRBs regarding the interpretation of federal regulations, and perhaps federal policy makers also need to revisit federal regulations regarding the sharing of data for research purposes. One possibility is to create a single, centralized IRB for an entire research network. The generalizability of findings from multicenter networks is another challenge. Most research is conducted at pediatric centers; however, more than 90 percent of pediatric emergency care is provided at general hospitals. There is a need to incorporate general hospitals into research. It is important to train community practitioners in some basic research principles and give incentives to hospitals to participate in multicenter research. Workforce Emergency care providers are expected to deliver appropriate care to all types of patients, including children, adults, seniors, pregnant women, among others. However, according to Jeff Schunk, professor in the Department of Pediatrics, University of Utah School of Medicine, it is a tremendous challenge for providers to have the competencies to care for all types of patients. There are particular challenges associated with the care of children because of their unique anatomical, physiological, developmental, and emotional differences in comparison to adults. Pediatric training makes up about 15 to 16 percent of residency time in emergency medicine training programs. However, only about 38 percent of the practicing ED physicians are trained and board-certified in emergency medicine. Only 3 percent of ED physicians are residency trained or board-certified in pediatrics. Other emergency physicians are trained in such areas as family practice or internal medicine and are likely to receive relatively

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Future of Emergency Care: Dissemination Workshop Summaries little formal training in pediatrics or pediatric emergency care, according to Dr. Schunk. Dr. Schunk added that there are training challenges in nursing, as well. For example, ED nurses tend to be less experienced than nurses who work in other health care settings. More experienced nurses often select positions that do not involve working the long hours or evenings that may be required in the ED. Also, while nurses have the option of becoming a certified emergency nurse (CEN), there is no mandate for the additional training or certification. As a result, there were only 13,000 CENs in 2003. Some hospitals require nurses to take pediatric training, such as pediatric advanced life support or advanced pediatric life support courses, but many do not. Another challenge related to the pediatric competencies of emergency providers is maintaining pediatric skills after training. Some providers rarely see critically ill or injured children. A study in Los Angeles County found that it would take roughly 20 years for every provider to be exposed to important life-threatening skills if they waited for on-the-job training. In the absence of regular exposure to critically ill children or continuing pediatric education, pediatric skill levels deteriorate. More research should be conducted on when and how skills deteriorate and techniques that can be used to maintain those skills, according to Dr. Schunk. As a result of these challenges, the IOM committee recommended that every health professional credentialing and certification body related to pediatric emergency care define pediatric emergency core competencies and require practitioners to receive the appropriate level of initial and continuing education necessary to achieve and maintain those competencies. This recommendation is a first step toward the creation of core competencies that are essential for emergency care providers at different levels. According to Dr. Schunk, there are no significant fiscal barriers for enacting this recommendation. Implementation will require focus and energy from certification bodies and a recognition that creating core competencies is important. The committee also recommended that the DHHS collaborate with professional organizations to convene a panel of individuals with multidisciplinary expertise to develop, evaluate, and update pediatric emergency care clinical practice guidelines and standards of care. Previous research has shown high variability in management of the common pediatric conditions, including croup, fever, bronchiolitis, febrile seizures, sedation, even within an institution. The purpose of this recommendation is to eliminate that variability. However, Dr. Schunk noted that eliminating variability in care has not been a priority for physicians. Even when faced with evidence that their current practice is not optimal, it is difficult to get physicians to change their care behavior. Clinical guidelines are known to assist in decision making; however, in a review of 1,000 guidelines, only 15 applied to pediatric emergency care. It is up to practitioners to overcome some of the

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Future of Emergency Care: Dissemination Workshop Summaries historical problems with trying to standardize practice, recognizing that providers will not lose their identity by, for example, using the same antibiotics for otitis media or if they agree on whether steroids should be used in bronchiolitis or not. Open Discussion During the open discussion period, Robert Bolte from Primary Children’s Medical Center echoed earlier comments that the lack of universal health care is at the root of many problems facing the emergency care system. Mr. Sanddal once again noted that addressing universal coverage was beyond the scope of the committee’s charge. Dr. Bolte also noted that the Office of Management and Budget recently reviewed the EMS-C program and gave it a mediocre evaluation at best. He asked about strategies for addressing the evaluation and pushing for increased funding for the program. Dr. Gausche-Hill responded by saying that the evaluation was critical because the program could not demonstrate measurable improvements in the outcomes of pediatric emergency care that could be attributed specifically to the program. Certainly, injury and death rates have declined in recent years, and although the EMS-C program has developed many important products and can demonstrate changes at the state level, a direct link between program activities and patient outcomes will be difficult to prove. Dr. Hedges noted that one of the biggest hurdles to conducting research on resuscitation is getting IRB approval using the mandate of the Food and Drug Administration (FDA) for community notification and consultation. He described the process as very laborious, and it may even get worse in the future. The FDA will be holding hearings to look at how they might standardize the community notification and consultation process. In his view, the FDA needs to hear about how important research is in the prehospital environment and understand that some of the barriers are impairing the ability to discern what treatments are best. The afternoon presenters, including Dr. Kuppermann and Dr. Brown, agreed with the comment, noting the importance of addressing this issue quickly. Dr. Brown added that she is involved in a study that was requested by the federal government, yet it still took three years to clear the IRB process. EMERGENCY CARE IN RURAL AREAS The second afternoon session focused on emergency care in rural areas. Four presentations were followed by an open discussion. The session was moderated by Nels Sanddal, IOM committee member and chair of the workshop planning group.

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Future of Emergency Care: Dissemination Workshop Summaries ED Physician Perspective Frederick Blum, an emergency physician practicing in West Virginia and president of the ACEP, identified problems concerning emergency care in rural areas, noting that many of the problems stem from the same challenges that affect emergency care in urban and suburban areas. First, he discussed the prevalence of ED crowding and ambulance diversion. In urban areas, ED crowding and ambulance diversions are commonplace. Patients have difficulty getting into the ED, and they have difficulty getting transferred to an inpatient unit or discharged to another facility. In rural areas, ED crowding is generally not a problem. Although patients can access ED care relatively quickly, once at the ED, they experience similar problems with transfer and discharge as patients in urban areas. One of the complicating factors in rural areas is that many rural hospitals have closed or have converted to Critical Access Hospitals with limited inpatient capacity. In addition, some rural facilities do not accept pediatric inpatients, making it very difficult to quickly place such patients. Ambulance diversion in rural areas is uncommon simply because there are typically no other facilities to send diverted ambulances. However, ambulances in rural areas face the challenge of transporting patients across great distances; this is one of the problems associated with regionalized care. Patients are transported out of their service areas and, as a result, ambulances are out of commission for long periods of time. For volunteer squads, this presents a major problem, since there may not be another ambulance on duty to respond to incoming calls when the local ambulance is several hours away. The second priority area is reimbursement. According to Dr. Blum, ED physicians and nurses are the only source of health care for millions of Americans. Inadequate reimbursement for emergency care places the safety net at great risk. Dr. Blum noted that a 5 percent cut is scheduled for physician reimbursement under Medicare in each of the next six years. Not only does the reduction in reimbursement hurt ED physicians, but it may also increase their workload if other physicians disenroll patients from their practices because of the pay cut. A related financial concern is professional liability. While access to specialists is a problem in many parts of the country, the problem is even more acute in rural areas. A few years ago in West Virginia, no insurers would write policies for specialists to provide services in the ED at any price. The state lost virtually all specialty surgeons, including every private neurosurgeon. Surgeons in the state went on strike, the state legislature took action, and the surgeons are beginning to return to practice in the state. Dr. Blum also noted workforce issues as a priority issue for rural areas. In order to increase the emergency medicine workforce in rural areas, Dr.

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Future of Emergency Care: Dissemination Workshop Summaries Blum argued that there needs to be increased training in rural areas. Until a few years ago, the entire north central part of the United States lacked an emergency medicine residency program. In recent years, programs were started in Utah, Nebraska, and Iowa. However, there continues to be a gap in the coverage of residency training programs in the country. Speaking of his experience in West Virginia, Dr. Blum noted that when residents are trained in rural areas, they tend to stay in rural areas. In order to address these challenges, he spoke of the need for providers to engage in advocacy efforts, either by directly contacting policy makers or by supporting political action committees through their professional organizations. Subspecialty Care in Rural Areas Richard Ellenbogen, an adult and pediatric neurosurgeon, spoke about subspecialty care in rural areas, with a focus on neurosurgery. Dr. Ellenbogen practices at Harborview Medical Center and Children’s Hospital in Seattle, Washington. Children’s Hospital is the only pediatric level 1 trauma center in five states, covering the populations of Washington, Wyoming, Alaska, Montana, and Idaho. Those five states cover 25 percent of the land mass in the United States but only 8 percent of the population. The state of emergency care across this region, according to Dr. Ellenbogen, is relatively strong simply because the states have been very organized, particularly in comparison to the other parts of the country. The need for neurosurgeons at the two hospitals is great. In the Northwest, 20 percent of the severe injuries and 50 percent of deaths have a head or spine component. To provide an overview of the types of cases seen by a neurosurgeon in a rural referral system, Dr. Ellenbogen gave an overview of 100 consecutive ED patients arriving at the two hospitals in which he works. Patients included 25 operative trauma patients, 19 nonoperative head and spine cases, 14 broken shunts, 12 tumors, 12 hemorrhages, 5 infections, 5 postoperative cases, 5 cerebrospinal fluid leaks, and 3 miscellaneous consults. Dr. Ellenbogen emphasized that although the IOM reports focused on trauma care, neurosurgeons also provide a great deal of generalized specialty care in the ED because specialists are in short supply in rural areas. A recent survey by the American Association of Neurological Surgeons found that over 93 percent of responding neurosurgeons take ED call (i.e., are available on call); 85 percent of respondents said that they were required to do so. And 50 percent of respondents who take ED call said that they did not receive a monetary stipend for doing so. The survey also asked respondents whether they limited their practice. Liability was the overriding concern of physicians who limited their practice.

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Future of Emergency Care: Dissemination Workshop Summaries Dr. Ellenbogen highlighted three challenges associated with the availability of specialty care. First, there are simply not enough board-certified neurosurgeons to cover all EDs at all times. Second, specialists rely heavily on nurses and nurse practitioners to handle their caseload; however, the nursing shortage is making that difficult. And third, the cost of maintaining subspecialists in rural areas is extraordinary. To set up a neurosurgical or orthopedic center in a rural hospital costs millions of dollars because of the equipment and technology needed. Dr. Ellenbogen emphasized the need for regionalization and the use of telemedicine to improve the accessibility of subspecialty care in rural areas. Not all hospitals can or should be providing subspecialty care. There should be clear lines of transport so that patients are directed to the most appropriate facilities for their conditions. Implementing regionalization will be difficult because hospitals view specialty services as profitable lines of business. Reflecting on his practice in the military, Dr. Ellenbogen also noted the importance of telemedicine to access expertise when a neurosurgeon is not available nearby. However, there must be improvements in the standardization of CTs and magnetic resonance imaging. Currently it is impossible to transfer images from one hospital to another. The Perspective of a State EMS Official Dia Gainor, chief of the Emergency Medical Services Bureau for the Idaho Department of Health and Welfare, spoke about the roles of state EMS agencies and their capacity to introduce change to improve EMS and related emergency health care systems. Ms. Gainor argued that state agencies serve as the locus for EMS system change, and that state EMS agencies are accustomed to and comfortable with the various federal agencies and FICEMS to provide leadership in EMS. Every state and U.S. territory has a lead EMS agency that has been studying the federal EMS standards for the past 30 years and has received EMS-C funding and trauma program funding. One of the goals of state EMS agencies is to implement change in the manner and order that is most logical, necessary, and achievable. Consistency is created wherever and whenever possible. EMS system development through state EMS agencies is similar to the model used for law enforcement. With federal inspiration, state police organizations and local law enforcement implement and support local programs. Ms. Gainor emphasized that a federalized EMS system in the United States would not be appropriate. Individuals at the state level who conduct system assessments and capacity evaluations are in the best positions to make determinations about system priorities and improvement initiatives. One of the troubling trends in EMS is that, although many rural sys-

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Future of Emergency Care: Dissemination Workshop Summaries tems rely almost entirely on volunteer personnel, a diminishing number of individuals is willing to volunteer. It is the state EMS agencies’ responsibility to track these trends and monitor turnover. At the state level, the EMS offices can evaluate those trends and identify whether the system is at a crisis point. State systems also ensure that rural areas of the state receive due consideration in the distribution of resources and funding. In addition, states play an important role in data collection and research. Ms. Gainor emphasized the importance of NEMSIS, an effort to create a national EMS database. Standards for the system have been selected, and many states are already contributing data; many others are prepared to participate in the next few years. State Rural Health Office Chris Tilden from the Office of Local and Rural Health in the Kansas Department of Health and Environment spoke about rural EMS and its position in the safety net. He also discussed several areas of concern for rural EMS. Dr. Tilden commented on the IOM committee’s recommendation for states to accept national certification as a prerequisite for state licensure and local credentialing. Although it is a goal that should be pursued, challenges lie ahead. For example, the national registry implemented computer-adapted testing, but there are only two testing sites in the state of Kansas. Dr. Tilden expressed concerns about declining access for local EMS providers who may not want to travel to the testing site. The state is considering the development of an alternative testing model, and a number of other states are looking in that direction as well. Reimbursement issues are also critical in rural areas. Currently Medicare will not reimburse for prehospital services unless transport is provided. For rural areas, this is a harmful policy because they receive a relatively low volume of calls. Dr. Tilden emphasized the need to develop a system that takes into account the costs associated with readiness and allows for payment without transport. Consideration should also be given to ways that EMS agencies in frontier counties can develop additional capacities to provide preventive and primary care services. There have been a number of short-lived but successful models in the United States and Canada. Dr. Tilden also discussed the federal Rural Hospital Flexibility Program, which allows cost-based reimbursement for critical access hospitals and EMS providers so long as they are 35 miles from another facility. Recently the program loosened the restrictions on cost-based reimbursement for critical access hospitals, but the 35-mile provision for EMS remains in effect. There is support in Congress to loosen the restrictions on EMS, and doing so would help support the costs associated with readiness.

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Future of Emergency Care: Dissemination Workshop Summaries Information technology in EMS is critical, but EMS is often left out of national discussions on information technology. For example, the Universal Service Fund provides access to broadband services at affordable prices to rural health care providers, but not to EMS. However, last year the Office of the National Coordinator for Health Information Technology at DHHS began to recognize and speak about EMS issues related to information and communications technology. The last issue Dr. Tilden discussed is community assessment and planning, noting that it is very important to work toward integration and regionalization. The communities are ultimately going to make the decisions about the types of care to provide, and they need to be given the tools to make informed decisions. Health care organizations and the Critical Illness and Trauma Foundation have been instrumental in developing tools to aid in those decisions. Dr. Tilden emphasized that emergency care stakeholders need to engage their state offices of rural health so that the offices learn more about EMS. The state offices are charged with helping develop rural EMS networks, but there are offices that do not know much about EMS. In addition, provided that the EMS Trauma Program is reauthorized, Dr. Tilden discussed the need for the Rural and EMS Trauma Technical Assistance Center to be refunded to work with state offices of rural health and promote EMS activity at the state level. Open Discussion Several members of the audience made comments or raised questions about the rural workforce. Ms. Gainor noted that historically states have not adequately tracked the rural workforce challenges associated with EMS; however, some states are beginning to track workforce issues more closely. As an example, in Iowa, the state is surveying every individual who does not renew his or her state EMS credentials to find out why. Mr. Sanddal added that a study on the EMS workforce, funded by the National Highway Traffic Safety Administration, is currently under way. The study will identify whether there is a broad shortage of EMS personnel or whether there are maldistributions in labor that must be addressed. A question was raised about the training of the emergency care workforce and whether there have been any lessons learned about having providers from urban areas conduct training in smaller communities. Mr. Sanddal noted that in the prehospital environment, common wisdom used to be that if training was brought to the rural area, attendance and participation would be greater and instructors would be inclined to return to provide additional training. However, over time, it has become clearer that many rural providers are interested in traveling to the larger communities for their

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Future of Emergency Care: Dissemination Workshop Summaries training for social and other reasons. In addition, rural providers tend to prefer to reserve their evenings and weekends for family and use vacation time to receive training during the week. There needs to be more creativity in strategies for meeting the training needs of rural providers. Dr. Blum noted the importance of being respectful in the way the rural workforce is described and addressed. Special interest groups often emphasize deficiencies of the rural workforce in terms of their ability to care for certain types of patients, for example, children or trauma victims. The rural workforce has close connections to the community and needs to be viewed as a partner rather than providers that need to be “saved from themselves.” Thomas Foley from the American College of Surgeons’ Rural Trauma Committee described the Rural Trauma Development Course, which brings together all providers who care for trauma victims in a rural community, including prehospital providers, and provides direction on how to manage care during “the golden hour,” the 60 minutes after the occurrence of trauma during which a victim’s chances of survival with definitive care are greatest. The course is taught by instructors from an urban trauma center. Experience from the course has shown that participants from both the community hospitals and the trauma centers develop a sense of understanding and camaraderie, and it has worked to foster the relationship between the two groups. CLOSING Mr. Sanddal closed the workshop, thanking the panelists and attendees for their participation. He acknowledged that some differences of opinion exist concerning a few of the IOM committee’s recommendations; however, there are many more areas of agreement. He encouraged the workshop attendees to move forward collectively to push for change in those areas of common agreement.