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Future of Emergency Care: Dissemination Workshop Summaries 5 Workshop in New Orleans, Louisiana The third dissemination workshop focused on prehospital emergency medical services (EMS) and disaster preparedness issues. The workshop began with opening remarks from Alan Miller of Tulane University. He welcomed attendees and emphasized the importance of visitors coming to New Orleans to witness the recovery from Hurricane Katrina and taking note of the work that still needs to be done. He also spoke about the unique situations and environments in which Tulane physicians have provided emergency care over the past 14 months, in vans, ships, a department store, and clinics. Tulane Hospital reopened in February 2006, and it remains the only hospital and emergency department (ED) in downtown New Orleans. Despite all of the challenges over the past year, the Tulane School of Medicine has had a banner year, with record funding for research and the largest entering medical class in the school’s history. Dr. Miller concluded by saying that he hoped the lessons learned from Hurricane Katrina have made the nation better prepared for future disasters. REFORMING HEALTH CARE Following a summary of the findings and recommendations from the Institute of Medicine (IOM) reports by committee members Nels Sanddal, Brent Eastman, and Tommy Loyacono, Senator David Vitter (R-LA) spoke about several goals for reforming health care in New Orleans and nationwide. First, he discussed the need to disband the two-tier health care system under which access and quality depend on one’s income. The New Orleans recovery represents a once-in-a-lifetime opportunity to fundamentally re-
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Future of Emergency Care: Dissemination Workshop Summaries design the health care system to improve services for low-income groups. Second, he spoke of the importance of investing in a national health care information technology system. Such a system would have aided displaced New Orleans residents, who received health services in different parts of the country following Hurricane Katrina. Third, the medical liability system is in need of reform. Senator Vitter noted that he is a cosponsor of the Access to Emergency Medical Services Act, which would provide liability protection and increase compensation for emergency providers. Finally, Senator Vitter discussed the movement toward pay for performance under Medicare, advocating for a system in which physicians receive higher reimbursement for reporting quality measures. Several members of the audience posed questions to the senator. Domenic Esposito, from the University of Mississippi, discussed a recent Harris Poll showing that when Americans were informed about the function and efficacy of trauma centers, they were willing to pay a tax to support trauma systems. However, the federal program for trauma was eliminated from the federal budget. In response, Senator Vitter said that he believes that EMS is best handled at the local level and best supported by local taxes. Tina Coker of Lakeview Regional Medical Center raised a suggestion that health departments expand services using advance practice nurses to help alleviate ED crowding. Senator Vitter said that he did not have the expertise to comment but that he was open to the suggestion. Ricardo Martinez of the Schumacher Group thanked the senator for his support of the Access to Emergency Medical Services Act and inquired about its chances for passage and ways for providers to show support for the bill. Senator Vitter said that its passage is directly proportional to Republicans’ success in the November 2006 elections. REACTIONS TO THE IOM REPORTS Regional Perspectives A panel of state and local representatives participated in a conversation about the reports based on a series of questions set in advance. The discussion was moderated by Dr. Eastman, chief medical officer of ScrippsHealth. Respondents included Bill Brown, executive director of the National Registry of Emergency Medical Technicians (EMTs); James Moises, an emergency physician at Tulane University Hospital and president of the Louisiana Chapter of the American College of Emergency Physicians; Sandra Robinson, deputy director of the New Orleans Health Department; and Suzanne Stone-Griffith, assistant vice president of quality at the Hospital Corporation of America.
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Future of Emergency Care: Dissemination Workshop Summaries What Are the Key Messages of the IOM Reports? Ms. Stone-Griffith said that the key messages of the IOM reports are that the system is fragmented and underfunded, and that regionalization of emergency care is needed. Dr. Moises highlighted several challenges described in the report, including ED crowding, the on-call specialty shortage, limited capacity for an increase in surge capacity, the burden of uncompensated care, and fragmentation of the EMS system. He noted the need for liability reform and increased funding dedicated to improving emergency care for children. In response to a question by Dr. Eastman, he noted that ED crowding could probably be reduced if patients had better access to primary care. Dr. Robinson began by stating that the IOM reports were a joy to read and very comprehensive. She explained that the residents of Louisiana have among the highest rates of morbidity and mortality in the country. Instead of receiving ongoing care for their conditions, residents seek episodic care in EDs, in large part because many are uninsured. She also noted that the key messages of the reports included improving provider education and training and the importance of coordination. Mr. Brown said that the reports’ emphasis on fragmentation without standardization was key. There is a need to measure system performance and conduct research to drive standardization of practices. Are There Any Important Points that the IOM Reports Missed? Mr. Brown said that, although the reports were very thorough, the retention of EMTs deserved more emphasis. Approximately every 5 years, the entire EMS workforce turns over; for every EMT who works for 10 years, there are 2 who quit in less than one year. The reports do not make it clear to policy makers that retention is a significant problem. Dr. Robinson noted that the reports failed to discuss reimbursement issues surrounding primary care, which is key to addressing some of the ED overcrowding issues. Dr. Moises said that, although the reports are very comprehensive, four areas received too little attention: geriatrics, mental health, the nursing shortage, and ED capabilities. Geriatric emergency care is of growing importance as the baby boomers age because geriatric patients require more work-ups and more time in the ED. Psychiatric care is another growing problem for EDs because of the lack of facilities to care for patients with mental health problems. The nursing shortage is a problem not only in EDs but also throughout the hospital. Finally, Dr. Moises said that he wished the reports were more forceful in saying that not all EDs are optimal for all time-sensitive illnesses.
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Future of Emergency Care: Dissemination Workshop Summaries Ms. Stone-Griffith added that, although she thought the reports were excellent, she disagreed with the IOM committee’s recommendation for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to enact tougher standards against crowding and boarding. She noted that JCAHO enacted a leadership standard related to the efficient flow of patients through the hospital in 2005. She also said that the reports speak a lot about the increased funding that will be needed, but they do not offer much advice for strategies that providers can immediately undertake in the absence of funding increases. Finally, Ms. Stone-Griffith noted that there is a need to align regulations for hospitals. An example, she said, is that hospitals are expected to provide all patients with the same standard of care, so they place admitted patients in beds in the ED when inpatient beds are not available. However, the state of California will fine a hospital if they exceed the number of licensed beds in use. Incentives and regulations for providers should be better aligned. What Are the Top Priority Areas for Action, and What Are the Barriers to Implementation? According to Ms. Stone-Griffith, there are two fundamental issues that need to be addressed. First, there must be a strategy to improve the placement of psychiatric patients, who often have very long lengths of stay in an ED. Second, there must be something done to address the problem of access to care for the 45 million uninsured people in the United States. Ms. Stone-Griffith also added the importance of system-thinking and systems training, particularly for front-line hospital managers who are currently not well prepared to deal with systems challenges. The problems must be addressed in a collaborative manner with all stakeholders at the table. Dr. Moises noted that the IOM reports may raise the awareness of policy makers to these issues. The barriers to implementation are not yet known; they will become more apparent after policy makers respond to the reports. He emphasized that some improvements can be undertaken immediately; for example, hospitals can improve technologies and adopt dashboards and communities can work toward regionalization. Providers should work with JCAHO to set up guidelines on crowding and boarding that are flexible, depending on a hospital’s circumstances. There is also a need for greater public awareness that not all providers are capable of providing optimal care for pediatric patients, and there should be a move toward national accreditation for EMTs. Dr. Robinson added that funding will serve as an important barrier to action. Many hospitals will not reopen in New Orleans because administrators recognize that a large amount of uncompensated care would be demanded. She also discussed technology and the real-time communications
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Future of Emergency Care: Dissemination Workshop Summaries systems among hospitals that are needed, not only to share patient medical records, but also so that providers can cooperate and coordinate with one another. Mr. Brown expressed concern that prehospital EMS will get overshadowed by emergency medicine if a federal lead agency for emergency care is created. He said that his top priority would be to make sure that EMS stays at the forefront of attention given to the IOM reports and within a federal lead agency, if a lead agency is created. Selling the reports is going to be difficult, according to Mr. Brown. There is a lot of inertia that must be overcome in order to implement any recommendations. He observed that other reports, including the EMS Agenda for the Future and EMS Education Agenda for the Future have been dust collectors. Although the IOM reports are generating a lot of discussion, there must be a sustaining and driving desire to get the recommendations implemented in order to see results. Final Statements Dr. Eastman invited each of the panelists to make a brief final statement. Ms. Stone-Griffith emphasized the need for all individuals to take active steps—even within their own silos—to chip away at the problems described in the reports. However, going forward, all stakeholders will need to collaborate. In addition, all constituencies—nurses, EMTs, physicians—need to recognize that we are in a new era of emergency medicine and must change the culture and mind set to work together in a new way. Dr. Moises noted that the American College of Emergency Physicians (ACEP) supports the IOM reports and is working in Washington, DC, to try to move forward with some of the recommendations. He also noted that, despite all the problems in the system, emergency physicians and nurses work in EDs by choice. Dr. Robinson added that all health care providers should work together for the good of the system and make sure that the public and policy makers understand the critical situation of the nation’s emergency care system. Mr. Brown concluded that providers need to “quit talking and start acting.” Open Discussion Dr. Esposito, a neurosurgeon, stated that organized neurosurgery believes the IOM reports are among the best pieces of work published on emergency care in the past 15 years. He also described how, after Hurricane Katrina, there is only one level 1 trauma center in the state of Mississippi, and it is failing financially. He noted three solutions to the problem: regionalization, improved reimbursement, and liability relief. He also voiced
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Future of Emergency Care: Dissemination Workshop Summaries disagreement with the concept of using acute care surgeons to perform selected neurosurgical procedures in the ED, a strategy proposed by some groups to improve access to on-call specialists. Tom Judge from Lifeflight of Maine congratulated the committee on the reports and made several comments. First, he noted that for years the public has been assured that if they call EMS, the system will respond to their needs. Today the public is doing just that, but their utilization is often characterized as inappropriate or a misuse of resources. He warned that stakeholders should be careful using language such as “inappropriate use” or “misuse” given the promises made to the public. Second, the report does not talk enough about demand, specifically, rising demand, and sources of demand for emergency services. Third, the reports call for a considerable amount of new funding; however, there is a need to look at alternative models for emergency care that could be developed in the absence of new funding. Finally, he expressed strong support for a federal lead agency for emergency care in the Department of Health and Human Services (DHHS). Linda McKibben from the Lewin Group asked whether the epidemiology of ED boarding, in terms of who is at risk for being boarded, contributed to the committee’s decision to recommend the elimination of patient boarding. Dr. Eastman responded, saying research indicates that the ill effects of patient boarding occur not only to those who are boarded but also to other patients in the ED. Mr. Sanddal added that he was not aware of research on the epidemiology of patient boarding. Patrice Greenawalt from the Oklahoma City Department of Health described two changes under way in Oklahoma that are helping to relieve ED overcrowding. First, there has been a big change in tribal medicine, in which hospitals are shrinking in size but increasing their ambulatory outpatient component. Second, in one community, hospitals are seeing a decrease in ED patient flow after forming a partnership with the local federally qualified health center, which is available to provide primary care to uninsured patients. Dr. Martinez noted that it is easier to move forward legislatively when groups representing providers and hospitals demonstrate strong support for an initiative. He asked whether there were any strategies that would appeal to both the hospital industry and emergency providers that could gain collective support. Dr. Eastman responded, saying that at ScrippsHealth, specialists take on the risk and responsibility of an exclusive contract for on-call services and receive reasonable reimbursement for doing so. That arrangement works well for all parties. Ms. Stone-Griffith agreed with Dr. Martinez’s comment, saying it is easier to move legislation forward when stakeholders’ incentives are aligned, which is currently not the case. Ray Bias of Acadian Ambulance Service asked what the professional
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Future of Emergency Care: Dissemination Workshop Summaries organizations were doing to improve recruitment and retention of personnel. Mr. Brown said that the National Association of EMTs will hold a summit on workforce that will address retention strategies. There is not a lot of information available on whether previous strategies have been successful. Mr. Loyacono added that in order to improve retention, there is a need to make the job for EMTs more achievable. Currently, it is a physically demanding job with long shifts working outside, sometimes in extreme temperatures. In addition, EMTs should be compensated at a level commensurate with their counterparts with similar education and responsibilities, including police and firefighters. Paramedics are generally underpaid compared with other professions with similar education levels. Dr. Moises added that there is a new locally designed program to increase paramedic recruitment by pushing paramedics to a higher level of practice. Paramedics receive more training than what is normally required and are providing advanced prehospital care. They are able to make a bigger difference in the field, which makes the job more attractive. Arthur Yancey, deputy director of health for EMS in Fulton County, Georgia, expressed support for the concept of regionalized emergency care and discussed the dynamics of regional councils. In order to be effective and not purely advisory, regional councils must have funding and organizational authority. In the early years of EMS development, regional councils received federal funding and had authority to develop EMS systems. When the funding was withdrawn in the early 1980s, the regional councils became advisory in nature. In order to regionalize emergency care services, there will have to be funding for the councils—a point that the IOM reports do not address. John Newcomb from the U.S. Alliance of Emergency Medicine highlighted a section of one of the IOM reports on hospital-based emergency care, which said that there are not enough residency-trained, board-certified emergency physicians in the United States to staff all EDs, so physicians from other specialties remain an essential part of the ED workforce. Dr. Newcomb asked whether the IOM committee believes that non-residency-trained, non-board-certified physicians can attain the core competencies recommended to practice competent emergency medicine. Dr. Eastman responded that the key point is to have all emergency physicians committed to providing good care and participate in a regionalized system in which patients can be transferred to a higher level of care, if necessary. Similarly, Mr. Sanddal added that whether a non-residency-trained, non-board-certified physician can attain all of the same competencies as someone trained in the field is unclear; however, they can certainly attain the skills needed to perform basic tasks (e.g., open an airway, insert an endotracheal tube, start an intravenous drip) to stabilize and transfer patients to a higher level facility if necessary. Dr. Moises added that it is not practical to mandate that all
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Future of Emergency Care: Dissemination Workshop Summaries emergency physicians be residency trained and board certified; however, the public has a right to know the qualifications of their providers. Milton Tenenbein from the American Academy of Pediatrics emphasized that the problems of crowding, boarding, and diversion are symptoms of a problem in the hospital system, not just a problem in the ED. And it is not simply a problem of uninsurance. In Canada, where residents are covered under a universal public health insurance system, similar problems persist. To address ED crowding, boarding, and diversion, it is essential to focus on problems in the inpatient side of the hospital. A FEDERAL PERSPECTIVE Jeffrey Runge, chief medical officer of the Department of Homeland Security (DHS), provided the keynote address and spoke about the development of EMS and its remarkable progress over the past 30 years. Although many parts of the emergency care system are stressed and on the verge of collapse, EMS is not. EMS is in a state of evolution that reflects advances in emergency medicine, the advent of trauma systems, and EMS advocacy at the federal, state, and local levels. It has also benefited from many national reports and studies on EMS, the IOM reports being the most recent. Dr. Runge explained that one of his responsibilities involves enhancing federal advocacy for EMS and putting into place institutions that will help the agency prepare for, respond to, and recover from disasters. It is the responsibility of DHS, DHHS, and the Department of Transportation to shore up institutions, provide equipment and training, support common standards, conduct exercises, and plan for contingencies. However, when a disaster occurs, the public will call 9-1-1. Therefore, the quality of local response defines the quality of the overall response. Ultimately, preparedness is local. Dr. Runge spoke about the importance of collecting data and developing evidence-based standards. He said that the National EMS Information System (NEMSIS) deserved greater attention in the IOM reports. Once sufficiently utilized, NEMSIS has the potential to create a stronger evidence base for EMS. However, he was pleased that the reports advocated for a national scope of practice, accreditation for paramedic education programs, and national EMS certification. While many question the need for national standards, all patients deserve a minimum standard of proficiency when they call 9-1-1, just as they do when they enter an ED. In addition, paramedics and other first responders should have minimum standards for personal protective equipment. Dr. Runge also addressed EMS funding, noting the divide between prehospital and hospital-based reimbursement and between EMS funding and funding for police and firefighters. The House Appropriations Com-
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Future of Emergency Care: Dissemination Workshop Summaries mittee recognized this divide and made it clear that DHS must address the funding disparities. Dr. Runge’s office is in the midst of a reorganization to ensure that medical preparedness is an important component in the 2007 DHS grant guidance. Dr. Runge said that he disagreed with the IOM committee’s recommendation for the creation of a lead federal agency for emergency care within DHHS. Instead, he said that a structured, formalized interagency process—the Federal Interagency Committee on EMS (FICEMS)—should provide leadership and advocacy for emergency care at the federal level. Although FICEMS has been in existence for many years, it had no statutory authority until 2005. Since then, it has become more effective through high-level agency involvement. FICEMS will give the federal government a starting point for implementing the IOM committee’s recommendations. Following Dr. Runge’s remarks, Mr. Judge expressed appreciation to Dr. Runge for his commitment to emergency care leadership at the federal level, but noted that in the year since FICEMS gained statutory authority, there have not been any results. In response, Dr. Runge said that FICEMS will produce results in the next six months to a year. FICEMS is stronger today because of its dual-level involvement of program-level staff as well as political appointees from various federal agencies. A STATE PERSPECTIVE Jimmy Guidry, the state health officer of Louisiana, spoke about some of the ongoing initiatives to improve emergency care and emergency preparedness. For the past four years, the state has been working through the legislative process in partnership with EMS, hospitals, emergency physicians, and surgeons, to develop the Louisiana Emergency Response Network (LERN). LERN will help coordinate the regionalized hospital system that was formed in the state after September 11 with support from a grant from the Health Resources and Services Administration (HRSA). LERN will have a medical command and control center to help coordinate the transportation of patients to the optimal facilities. It will track which hospitals have available beds and will be able to determine which hospitals have the expertise and technologies available to treat different types of patients. The legislature provided $3.5 million for the project this year. Another important state initiative under way is the redesign of the health care system after Hurricane Katrina. As part of the redesign, the state is trying to find a way to ensure that all residents have access to a medical home, in part to relieve some of the patient load for EDs. One strategy involves creating more federally qualified health centers to address the needs of the uninsured and serve as a medical home for those patients.
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Future of Emergency Care: Dissemination Workshop Summaries One of the challenges of developing a medical home is that the home must be convenient and accessible. Dr. Guidry observed that policies regarding funding and reimbursement will be key to the success of LERN and the redesign of the health care system. For example, the network’s command center will make decisions about where to transport trauma patients, who are often uninsured. Such patients often require specialized, expensive care and may spend hours in an operating room. Naturally, there will be limited incentive for physicians and hospitals to participate in this system if they do not get paid for their services. With regard to the redesign, DHHS Secretary Leavitt is encouraging the state to make sure that funding follows the patients. ADVANCING PREHOSPITAL EMERGENCY MEDICAL SERVICES The first afternoon session focused on EMS. Four presentations on various EMS issues were followed by an open discussion. The session was moderated by IOM planning group member Ray Bias. Air Medical Services Tom Judge, executive director of Lifeflight of Maine, discussed several issues in air medical services. He began by acknowledging the IOM’s recommendation for states to assume regulatory oversight of the medical aspects of air medical services. He noted that, over past 18 months, the Association of Air Medical Services, the National Association of State EMS Officials, and the National Association of EMS Physicians have been working on model state regulations in this area. Mr. Judge spoke about the growth in air medical services over the past decade and how it is a signal of improvement in care. If Critical Access Hospitals are providing good care, then there will be more air transport needed to move patients to higher level facilities. Also, 70 percent of air medicine transports are hospital-to-hospital, which represents care provided to high-acuity patients, not simply fast transport from a scene of an emergency to a hospital. Air medicine involves the deployment of the tertiary care center into a mobile setting for both the stabilization and transport of patients. He described a number of issues and unanswered questions in air medicine that need to be addressed. For example, there is a series of questions about system design, medical oversight, and how patients are selected. For example, if automatic crash notification technology is adopted in all cars, how will that impact EMS? Also, many issues in aviation need to be resolved, including safety concerns; regulatory issues; and preparedness, infrastructure, and technology costs. All of the reimbursement in EMS is geared toward funding the lowest model of systems, not the highest.
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Future of Emergency Care: Dissemination Workshop Summaries Regarding costs, the public should be educated about the cost of EMS interventions and lives saved. For example, it costs approximately $820 per life saved to place defibrillators in the community; however, other interventions are much more costly. He concluded by saying that the single most important recommendation from the IOM reports is the call for building accountability into the emergency care system. Improving Funding, Reducing Crowding, and Enhancing Disaster Response Kurt Krumperman, senior vice president of federal affairs and strategic initiatives at Rural/Metro discussed three issues that were raised in the IOM reports: EMS financing, ED overcrowding, and disaster preparedness and response. In the area of EMS financing, Mr. Krumperman began by describing the poor payer mix facing EMS systems. Only 18 percent of transports are for privately insured patients; 26 percent are for uninsured patients. The balance of transports are for Medicare and Medicaid patients; Medicare reimburses ambulance service below average cost and Medicaid reimburses at approximately 50 percent of the Medicare amount. He called for Congress to create a funding mechanism similar to the disproportionate share hospital funding for ambulance services and increase Medicare and Medicaid rates. He also added that reimbursement should account for the cost of readiness. Traditionally, the first response infrastructure has been funded through community tax support, and ambulance transport fees have been the source of funding for ambulance service infrastructure and the cost of providing the service. However, recently there has been a trend toward using some portion of the ambulance transport fees to support first response infrastructure. This practice has been encouraged by several rulings by the Office of the Inspector General. Mr. Krumperman noted the importance of developing a separate funding mechanism for first response, and called for Congress to develop an EMS infrastructure grant program similar to the one available for fire services. Regarding ED crowding, he said that ambulance parking needs to end and there are potential EMS solutions to this problem. As discussed in the IOM reports, developing alternative destinations for patients and treat-and-refer strategies should be explored through pilot projects. There are several areas of the country already experimenting with various strategies to reduce ED crowding, ambulance parking, or both, and the outcomes should be evaluated. One such strategy deserving of study is Nevada’s law requiring a 30-minute patient offload time at hospitals. Finally, Mr. Krumperman discussed disaster preparedness and response. The Emergency Management Assistance Compact (EMAC) is a congres-
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Future of Emergency Care: Dissemination Workshop Summaries sionally ratified organization that provides form and structure to interstate mutual aid. EMAC assisted with the response to Hurricane Katrina and Hurricane Rita in 2005. He identified several shortcomings of EMAC: for example, many states have not yet received payment for their response to the hurricanes, and EMAC largely excludes nongovernmental EMS. He encouraged the EMS community to be more engaged at the local, state, and federal level and push for Congress to develop an EMS set-aside for disaster response. Finally, he called on DHHS and DHS to host a stakeholder summit to address federal response issues. Implementation of EMS Strategies Drexdall Pratt, head of the Office of Emergency Medical Services, Division of Facility Services, North Carolina Department of Health and Human Services, discussed implementation issues surrounding many of the IOM committee’s recommendations for EMS. Many of the recommendations call for the use of evidence-based practices, but to date evidence is limited on the effectiveness of EMS personnel and services. Mr. Pratt discussed the imperative for states to collect data on each patient encounter; however, states struggle with data collection. In North Carolina, it was a challenge to get the state legislature and providers to understand the importance of collecting data on each encounter. Today the state collects full patient charts for each encounter, but no financial support is provided by the state for this effort. North Carolina’s data collection system is funded by the National Highway Traffic Safety Administration, HRSA, and private foundations. Mr. Pratt added that North Carolina is submitting data to NEMSIS, which has the potential to be an important resource of EMS information, but there is no funding to sustain NEMSIS over the long term. Once a state develops a data system, there must be a way to analyze the data and make them available to providers so that they can improve their practices. Mr. Pratt’s office developed tool kits, which allow providers to view their response times. The office is now moving toward making information on clinical areas, such as stroke and trauma, available to providers. Mr. Pratt also discussed the IOM committee’s recommendation to standardize prehospital protocols, describing North Carolina’s effort to standardize protocols across the 101 systems in the state. The local chapter of ACEP developed the set of protocols; however, local systems still deviate from those standards. The state is considering mandating that all systems use the protocols, but there has been considerable resistance from the local systems. Another challenge with the development of standardized protocols is that they need to be maintained with the rapidly changing health care
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Future of Emergency Care: Dissemination Workshop Summaries environment. To be useful, they must be frequently revised, and funding would be needed to sustain the updating process. Mr. Pratt also discussed the IOM committee’s recommendation for demonstration projects, noting that such an effort could be successful with regionalized medical direction, standardized protocols, education programs, and a NEMSIS-based data system using standardized performance improvement initiatives. However, Mr. Pratt questioned whether $88 million, the amount proposed by the IOM committee, would be enough to fund a demonstration program over five years. Finally, Mr. Pratt concluded by discussing the work of some of the EMS systems in rural North Carolina. The systems partnered with social services and public health, and EMTs go into the community and visit elderly residents. They check blood pressure levels and make sure patients are taking their medications properly. If they find a problem, they notify county case workers. While there are no data to support the effectiveness of these efforts, many believe that the home visits reduce the number of ED visits in the county. Mr. Pratt noted that EMS should receive some reimbursement for these efforts. Advice Nurse Call Center in Fulton County, Georgia Arthur Yancey, deputy director for EMS, Fulton County Department of Health and Wellness, described the advice nurse call center (ANCC) referral program under way in the county. Dr. Yancey began his presentation with a quote from the IOM report Emergency Medical Services at the Crossroads: “While EMS systems are frequently organized to address major traumas and serious medical emergencies that are an important part of EMS, they often overlook the fact that the overwhelming majority of EMS patients have relatively minor complaints. More effectively managing the entire spectrum of complaints that result in an EMS response could make the system more patient-centered.” Under the program, a subset of callers speaks with an advice nurse rather than receive onsite services from EMS. The ANCC referral program has several goals. First, the program attempts to link callers to definitive services, enroll callers in a primary care program, and arrange transportation to a point of service, as needed. Second, the program matches EMS expertise and resources to 9-1-1 calls for which on-scene skills are required, decreases response times to calls for which timely on-scene care and hospital transport are vital, and promotes disaster readiness by offering paths to medical care independent of on-scene EMS response or EDs. Third, the program strives to achieve financial savings for the EMS system. The referral program uses a medical priority dispatch program to identify 9-1-1 callers for the program. Certain callers who may have more
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Future of Emergency Care: Dissemination Workshop Summaries complicated conditions, for example, those age 65 and older, are not entered into the program. Creation of the program required advice nurse call takers as well as enabling technology for the additional phone lines to those nurses. The program includes a continuous quality improvement effort that is currently under way. The quality improvement effort includes tracking 9-1-1 call taker performance (i.e., an evaluation of the appropriateness of callers referred to the program), taking a survey of callers, tracking EMS response time changes, and calculating financial savings. Dr. Yancey concluded by saying that public access to emergency medical pool dispatch is an essential component of the EMS service. EMS begins with a phone call to the 9-1-1 center, and the information provided to the callers must be medically appropriate. Alternative care services (e.g., poison control centers, suicide hotlines, advice nurse call centers) appropriate to callers’ needs and provided through specialty call centers are components of that system. Medical direction is crucial for each of these alternative care services for efficient, safe, and ethical care. Considerable financial, operational, medical, and emergency preparedness benefits are expected from the ANCC referral program. Open Discussion Bill Brown voiced disagreement with two conclusions drawn in the report Emergency Medical Services at the Crossroads. First, where the IOM committee calls for states to accept national certification as a prerequisite for state licensure and credentialing of paramedics, the text notes that requiring national certification would increase the cost of licensure. Mr. Brown contended that national accreditation is less expensive than having all states develop their own processes. Second, the report says that the difficulty of the national exams could result in a reduction in the provider pool. Mr. Brown noted that the states that have adopted the national registry have found no reduction in the number of people who enter the system; however, some of those individuals have to take the exam more than once. Mr. Judge added that many EMS agencies operate across state lines, and there is no legal framework for doing so. There must be reciprocity at the state level, and the only way to have reciprocity is to have a known entity in charge of certification. Juliette Saussy, New Orleans EMS, expressed concern that some believe that the standards for EMS should be lowered in order to attract and maintain the workforce. Dr. Saussy said that standards should not be lowered, but raised. EMTs will not take pride in a profession in which standards are low. Also, the public needs to view EMS as a profession. If standards are
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Future of Emergency Care: Dissemination Workshop Summaries raised and tests are made more difficult, the workforce will be proud to wear the EMS badge. Debra Cason from the University of Texas, Southwestern Medical Center, and the National Association of EMS Educators, noted that the association is very supportive of the National Education Agenda for the Future, including the call for a national scope of practice, national certification, and accreditation for paramedic programs. She added that she is currently working on the education standards, and one of the challenges is making sure that, as new technologies or practices are developed, EMS educators integrate those elements into the curriculum. Updating the information for the workforce is very important. Mr. Judge agreed, mentioning a study showing that the single best predictor of how a physician treats hypertension is the year he or she graduated from medical school. Keeping up with the thousands of journal articles published each year is not a simple task. ADVANCING DISASTER PREPAREDNESS AND RESPONSE The second afternoon session focused on disaster preparedness and response. Three presentations by panelists were followed by an open discussion. The session was moderated by IOM planning group member Ricardo Martinez. Racial Disparities in Emergency Care and Disaster Preparedness Albert Morris, president of the National Medical Association, spoke about how the emergency care system and disaster preparedness pose crucial challenges for minority patients and physicians. In contrast to whites, blacks are more likely to be uninsured, use the ED for primary care, wait longer in the ED, and not receive pain medication. While there is a paucity of research on racial disparities in emergency care, evidence suggests that emergency medicine faces some of the same disparity challenges confronting other medical specialties. Minorities face a number of challenges that make them more vulnerable in the event of a disaster. Prior to September 11, blacks were more likely to suffer severe and preexisting health problems, not have a primary care provider, distrust the government and health care system, and work in jobs involving close public contact in comparison to whites. If a disaster involved a major anthrax attack, there would be additional challenges associated with infection control, quarantine compliance, and disease management because of issues of distrust in the black population. A survey of Katrina evacuees found that 32 percent were unemployed, 42 percent were high school graduates, 32 percent earned less than $10,000 per year, 70 percent had no bank account or credit card, 52 percent had no health insurance, 32
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Future of Emergency Care: Dissemination Workshop Summaries percent did not have a list of medications, and 40 percent were physically unable to leave or had to care for someone unable to leave. The reality of minority health and disaster management is that blacks and other minorities are more vulnerable to a health crisis under normal conditions, and inordinately more vulnerable in the event of a disaster. Dr. Morris added that this reality must be specifically addressed to advance emergency care and disaster preparedness for all citizens. The National Medical Association’s Environmental Health and Bioterrorism Task Force published a series of recommendations to improve disaster preparedness for all citizens, among them: provide specialized disaster training for health care providers, include minorities at all levels of disaster planning and emergency management, ensure that emergency plans specifically address minorities and other vulnerable populations, perform disaster needs assessments of minority and other vulnerable populations, ensure that medical distribution plans can overcome identified access barriers for minorities and other vulnerable populations, and provide culturally relevant disaster materials and resources. Dr. Morris concluded by saying “the rising tide will not lift all boats.” Disaster planning efforts must be customized to fit the members of a community, and we are only as strong as our weakest link. Disaster Planning for Children Paul Sirbaugh, associate medical director of the Emergency Center and director of prehospital medicine, Texas Children’s Hospital (TCH), described efforts, successes, and lessons learned during TCH’s effort to help Hurricane Katrina evacuees who were transported to the Astrodome in Houston, Texas. Approximately 30 percent of patients in the Astrodome’s health clinic were children. The volunteers from TCH who worked in the clinic had a combined 50 years of experience caring for acutely ill and injured children. The pediatric clinic had 24/7 physician coverage, including pediatric emergency medicine physician coverage, a pediatric emergency physician overseeing triage, four generalists, and many other volunteer physicians from the community caring for patients. If needed, subspecialty services were available through EMS transport to TCH. Nurse coverage and lab services were available at all times. In addition, a clinic pharmacy was created and was stocked twice per day. EMS personnel were available quickly if a patient needed transport to the hospital. Approximately 3,500 pediatric patients were treated onsite over 14 days; fewer than 50 patients were transported to the hospital. What began as a 2-bed pediatric clinic grew to a clinic with 33 acute care pediatric beds, 50 IV observation beds with medical oversight, and 400 isolation beds
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Future of Emergency Care: Dissemination Workshop Summaries without medical oversight. During the two weeks, TCH never experienced overcrowding and the ED never went on divert. The hospital lost several key personnel while they worked in the Astrodome, but the financial costs were minimal. Dr. Sirbaugh identified several things that went right during the response. For example, patients received rapid and superb medical attention, there was an appropriate level of cooperation from incident command, there were abundant resources, including volunteers, and there was a sound exit strategy. The TCH staff left after 14 days. However, he also identified a number of areas for improvement, which included involving pediatric experts earlier in the process, identifying and registering evacuees earlier, preventing the separation of parents and children, and moving toward online medical records. Dr. Sirbaugh emphasized several points to attendees, the first of which was not to wait for rescue. If there is going to be a rescue, it is unlikely to happen during or immediately after the disaster. Also, plan for and create the solutions and find resources that already exist within the community. There are many untapped resources in the community that should be accessed before recreating some of the same resources. Find the resources and ask for help. Give those providing the resources some control and remove any obstacles in their way. Disaster Preparedness and Response: Keys to Effective Implementation Dr. Randy Pilgrim, president and chief medical officer of the Schumacher Group, began his remarks by noting how overwhelming it can be to develop an all-hazards preparedness and response plan with so many different critical components for disaster response and preparedness. Based on his experience working with 37 EDs that implemented disaster plans after Hurricane Katrina and Hurricane Rita, Dr. Pilgrim identified three key steps to effective implementation of disaster planning: lay the foundation, narrow gaps, and fund for results. First, laying the foundation refers to getting individuals prepared, and the most fundamental level is personal preparedness. Individuals need to develop a family preparedness plan, and DHS provides important guidance in that area. In addition, individuals need to be able to communicate. There are 13 electronic methods of communication, and individuals should learn multiple methods and have them available in the event of a disaster. Finally, leadership is an important piece for laying the foundation. Second, Dr. Pilgrim described the importance of narrowing the gaps. There is so much information that has been published about how to prepare personally, institutionally, regionally, locally, and nationally. The knowledge
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Future of Emergency Care: Dissemination Workshop Summaries is available, but preparedness plans often do not reflect the knowledge, performance does not reflect the plan, and outcomes measures are not well developed. He added that in the 37 EDs for which the Schumacher Group had responsibility, performance did not reflect the plans during and after Hurricane Katrina, in part because the foundation was not set and the training for the plan was insufficient. Finally, Dr. Pilgrim discussed funding for results, meaning that funding should be directed in a manner that encourages organizations to achieve specific outcomes. In order to fund for results, there needs to be well-chosen, focused priorities, perhaps developed by a lead federal agency for emergency care. There is also a need for models of training that are designed and proven to produce the performance desired. Finally, there must be a level of accountability. According to Dr. Pilgrim, funding for results could involve a “pay for preparedness” model similar to pay for performance under Medicare, in which better prepared institutions would reap greater financial rewards. The financial incentive structure must also be developed in a way that rewards those who invest in the system. If one particular hospital in a community is well prepared and serves all the community’s health care needs during a disaster, that hospital’s financial status may be harmed. Rewarding investors means ending the financial disincentives for investing in preparedness and creating a mechanism for support to ensure that prepared organizations are reimbursed at a reasonable level after a disaster. Open Discussion Dr. Martinez asked the panel whether there is more, less, or the same level of communication between the right groups of people today than before Hurricane Katrina. Dr. Sirbaugh responded that in his region greater communication has made a huge difference. Dr. Morris agreed. Dr. Pilgrim said that there is more communication today than before, but it is still not optimal. Several local physicians reflected on their experience during and after Hurricane Katrina. David Klein, a neurosurgeon and professor at Louisiana State University, discussed three issues of importance after Hurricane Katrina: communications, coordination, and care. First, when the hurricane hit, communication lines were disrupted and people could not reach family members. Dr. Klein could not reach his family for 3 or 4 days. Second, there was a failure of coordination. Dr. Klein and several patients at Charity Hospital waited in a garage where helicopters were supposed to evacuate the 75 patients and stranded hospital personnel, but the helicopters did not come for more than a day. With regard to care, Dr. Klein said that he was surrounded by nurses, maintenance workers, security guards, and other personnel from the hospital who cared a lot and worked hard after
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Future of Emergency Care: Dissemination Workshop Summaries the hurricane. State, local, and national leaders expressed care but lacked coordination to act. Dr. Moises was working at Tulane University Hospital during the storm and stayed in the area following the hurricane, after the city was evacuated. He said that there were only a handful of local physicians, and a few physicians from the 82nd Airborne Division in New Orleans to care for the 25,000 to 30,000 residents who remained in the city. He said that there were many things done wrong and many things done right. The staff of Charity Hospital was incredibly dedicated, and many people working minimum wage jobs at the hospital stayed and took care of patients. But the problem with Charity Hospital is that the state abandoned the facility, waiting or expecting the federal government to evacuate the patients. Dr. Moises added that the state of Louisiana and city of New Orleans were not prepared for a true disaster. All of the planning done in advance was for inconveniences—a loss of power or disruption in services. He emphasized that planning must be conducted for a true disaster, one in which everything collapses—not just for two hours, but for a week. Dr. Moises also spoke about the disaster management assistant teams (DMATs), noting how grateful the city was for their assistance. He noted the importance of bringing in the right types of individuals. For example, Dr. Sirbaugh’s clinic, which was staffed with pediatric experts, transferred only 1 percent of pediatric patients to the children’s hospital. If that team had lacked pediatric expertise and 10 percent of its patients had to be transferred, it would have overwhelmed Houston’s hospitals. One of the problems with the DMATs that came to New Orleans is that few included pediatricians or pediatric emergency physicians. In response to the comments made by Dr. Moises, Dr. Morris noted the importance of developing leadership in the disaster planning stage and making sure that leaders are credible spokespeople in the community. Dr. Sirbaugh added that leaders need to recognize their limitations and identify other individuals who might be able to contribute. Disaster planning needs to include pediatric and geriatric representatives; a leader cannot simply appoint a public health official who has not cared for patients in years to lead the medical response. He added that both the IOM committee and the American Academy of Pediatrics called for increased pediatric expertise and pediatric representation on DMATs. Currently, there are only a few pediatric DMATs in the country. The teams must also have access to pediatric supplies and equipment. Dr. Robinson made the final comment, noting that the only group that was flexible and capable of making decisions and acting quickly after Hurricane Katrina was the military. She said that as she was setting up health clinics immediately after the storm, she made several requests to the 82nd Airborne, and they were able to meet those requests. When similar requests
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Future of Emergency Care: Dissemination Workshop Summaries were made to other government agencies, they were denied because the requests were outside the organization’s authority or guidelines. She added that leaders, especially political leaders, are frequently blamed for not being able to act in a disaster, but they are dealing with policies, regulations, and guidelines that must work from within. Dr. Robinson noted that in times of disaster, we need to give flexibility and authority to leaders so they can make quick decisions. CLOSING Mr. Sanddal closed the meeting, thanking attendees for their participation. He noted that the day-to-day work of providing care for the sick and injured in the United States is held together by a very fragile system of good will and ingenuity. The IOM committee and many of the workshop presenters provided direction and tools for improving emergency care and disaster preparedness, but now is the time for action.
Representative terms from entire chapter: