6
Capstone Workshop in Washington, D.C.

The final dissemination workshop was held at the National Academies in Washington, D.C. The meeting was opened by Institute of Medicine (IOM) executive officer Susanne Stoiber, and Nels Sanddal, president of the Critical Illness and Trauma Foundation and chair of IOM’s workshop planning group. They welcomed all those present.

SUMMARY OF THE THREE REGIONAL WORKSHOPS

Brent Eastman, chief medical officer of ScrippsHealth, presented a summary of the discussions from the three regional workshops in Salt Lake City, Chicago, and New Orleans. Dr. Eastman noted that the overall message he heard expressed at previous workshops was the need to unite and collectively move forward with the IOM agenda. “It cannot be done by one agency, by one region of the country, or by one individual,” he said.

He pointed to several areas of strong interest and agreement among attendees of the regional workshops:

  • Research. Research in the areas of emergency medical services (EMS), emergency medicine, and trauma are at a disadvantage. The IOM committee recommended the Department of Health and Human Services (DHHS) study whether a dedicated National Institutes of Health (NIH) center or institute is needed; workshop participants said that a dedicated center or institute is needed and called for its creation.

  • Pediatrics. Workshop participants agreed that Congress should



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Future of Emergency Care: Dissemination Workshop Summaries 6 Capstone Workshop in Washington, D.C. The final dissemination workshop was held at the National Academies in Washington, D.C. The meeting was opened by Institute of Medicine (IOM) executive officer Susanne Stoiber, and Nels Sanddal, president of the Critical Illness and Trauma Foundation and chair of IOM’s workshop planning group. They welcomed all those present. SUMMARY OF THE THREE REGIONAL WORKSHOPS Brent Eastman, chief medical officer of ScrippsHealth, presented a summary of the discussions from the three regional workshops in Salt Lake City, Chicago, and New Orleans. Dr. Eastman noted that the overall message he heard expressed at previous workshops was the need to unite and collectively move forward with the IOM agenda. “It cannot be done by one agency, by one region of the country, or by one individual,” he said. He pointed to several areas of strong interest and agreement among attendees of the regional workshops: Research. Research in the areas of emergency medical services (EMS), emergency medicine, and trauma are at a disadvantage. The IOM committee recommended the Department of Health and Human Services (DHHS) study whether a dedicated National Institutes of Health (NIH) center or institute is needed; workshop participants said that a dedicated center or institute is needed and called for its creation. Pediatrics. Workshop participants agreed that Congress should

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Future of Emergency Care: Dissemination Workshop Summaries increase funding for the federal Emergency Medical Services for Children (EMS-C) program to $37.5 million per year. Overcrowding/surge capacity. The overcrowding of emergency departments (EDs) is a result of a hospital-wide capacity problem and was a major concern for many workshop attendees. Many communities are struggling on a daily basis with the challenges of crowding, boarding, and ambulance diversion. The absence of surge capacity to handle normal patient volumes makes it clear that the system is not well prepared to handle disasters. Uncompensated care. Emergency care in the United States has become “the safety net of the safety net” for uncompensated care, and providers desperately need financial support from Congress. Uncompensated care is also contributing to a shortage of specialists willing to treat patients in the ED. Liability. The IOM committee recommended studying the problem, but workshop attendees said resoundingly, “Don’t study it, just fix it.” Regionalization. The single best solution to many of the problems in the emergency care system, including the shortage of nurses, physicians, and specialists, is regionalization. Regionalization would ensure that an individual who is critically ill or injured anywhere in the country would receive expeditious transport to a level of care commensurate with his or her condition. There was resounding support for regionalization at the workshops. Disaster preparedness. Workshop participants agreed that for too long EMS has been left out of disaster planning and funding streams. In fiscal year 2002-2003 only 4 percent of the Department of Homeland Security’s (DHS’s) $3.8 billion budget went to EMS. Yet EMS will be at the heart of any disaster response. Workforce. There is a shortage of emergency care personnel on all fronts: physicians, nurses, and emergency medical technicians (EMTs). Creative strategies are needed to address these shortages and improve provider competencies. The main point of contention raised at the regional workshops, Dr. Eastman said, had to do with the IOM committee’s recommendation for the creation of a single federal lead agency for emergency and trauma care in DHHS. While there are a number of very dedicated individuals and agencies with responsibility for some component of emergency care at the federal level, the committee proposed this recommendation as a way to overcome the current fragmentation of authority that exists and to improve federal communication and coordination. Some constituents, however, called first

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Future of Emergency Care: Dissemination Workshop Summaries for evaluating the efficacy of the Federal Interagency Committee on Emergency Medical Services (FICEMS) to fill this role. Dr. Eastman also said that workshop participants noted that the IOM reports paid insufficient attention to certain topics, namely geriatrics, mental health and substance abuse, the nursing shortage, and a single-payer system. He acknowledged that these are all very important issues, although some fall outside the bounds of the committee’s charge. Also, addressing all issues to the extent desired by some would have extended the report process well beyond the time frame of two and a half years. To advance the agenda at the federal level, workshop attendees expressed a need for advocates to develop a common voice, a common language, and a clear, consistent message. Demonstration projects are also critical, Dr. Eastman noted, since there is great variation in emergency care systems across the country. Some workshop attendees cautioned against waiting for Congress to act. Initiative and leadership are needed at every level. Many of the IOM committee’s recommendations are targeted to providers and provider organizations, and there should be “change from within.” Finally, Dr. Eastman concluded by saying that the agenda for change must always be driven by what is in the best interest of patients. REACTIONS TO THE IOM REPORTS Response from Federal Agencies Mr. Sanddal moderated the first panel of representatives from federal agencies. National Highway Traffic Safety Administration Marilena Amoni, associate administrator at the National Highway Traffic Safety Administration (NHTSA), noted that her agency has provided federal leadership for EMS since 1966. Key activities include leading the development of the National Standard Education Curricula and the EMS Agenda for the Future, as well as developing standards for technical program assessments of statewide EMS systems. She also emphasized NHTSA’s long-standing collaboration with DHHS and its more recent partnering with DHS for many of the administration’s activities. For example, NHTSA is working with DHS to integrate disaster preparedness into the existing EMS infrastructure, and it is working with DHHS and DHS to develop pandemic flu guidelines for EMS and the 9-1-1 system. Ms. Amoni commended the IOM committee for its vision for a co-ordinated, regional, and accountable emergency care system, noting that

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Future of Emergency Care: Dissemination Workshop Summaries NHTSA’s activities have been consistent with this focus. She also applauded a number of specific IOM recommendations, including the call for a common scope of practice, state licensing reciprocity, national certification for paramedics, and national accreditation for paramedic education programs. Ms. Amoni noted that NHTSA made the same recommendations in the National EMS Education Agenda for the Future, published in 2000. She also endorsed the IOM committee’s call for evidence-based care and the collection of data, saying that she concurs with the need for data to drive both policy and patient care decisions, and evidence-based prehospital protocols are a step in the right direction. She also added that partnerships with professional associations and organizations are critical to developing evidence-based models of prehospital care protocols for treatment, triage, and the transport of patients. Ms. Amoni said that NHTSA has aggressively moved toward acquiring data, noting that the IOM reports failed to sufficiently recognize the extensive EMS data project, the National EMS Information System (NEMSIS) under way among federal, state, and local agencies. It is an effort to systematically gather and share standardized data on patient care. To date, 48 states have agreed to implement NEMSIS, and 5 have submitted data to the national repository at NHTSA. She said NEMSIS is critical to help develop and ensure accountable, data-driven, and medically directed local and regional EMS systems. Federal Emergency Management Agency Glenn Cannon, director of response for the Federal Emergency Management Agency (FEMA), commented that, although the agency received criticism for its response to Hurricane Katrina, it is working hard to restore the public’s faith and confidence. The mission of the agency is to save lives and property and reduce suffering from disasters, and agency staff is working tirelessly to accomplish that. Mr. Cannon highlighted the Emergency Medical Services Institute in Pittsburgh, a regional EMS council that serves a 10-county area around the city, as a model system. Among its many responsibilities, the institute coordinates emergency care services, licenses ambulances, trains and credentials EMS personnel, oversees quality, collects data, and promotes and provides public information and education to the community regarding EMS. The 10-county area is part of a larger region in western Pennsylvania, called Region 13, in which country governments signed intergovernmental agreements to work together for the provision of emergency services, public safety services, and antiterrorism disaster response services. Region 13 is a DHS and FEMA-designated best practice model. Within the region is the Center for Emergency Medicine at the University of Pittsburgh, which

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Future of Emergency Care: Dissemination Workshop Summaries is one of the few programs in the country in which emergency medicine residents respond to prehospital calls. Residents provide service in the field with paramedics, which gives the residents broader exposure and helps keep paramedics’ knowledge current. Mr. Cannon spoke of several initiatives that FEMA is working on that will strengthen its relationships with the health care community and medical emergency services. Initiatives include a national credentialing system to help verify and identify the qualifications of emergency personnel who respond to an accident or disaster; a comprehensive integrated national mutual aid and resource management system, which provides and tracks logistical supplies and equipment “so that everyone has what they need”; model interstate mutual aid legislation for state and local responders; and an effort to implement communications interoperability in every major city by the end of 2007 and all the states by the end of 2008. Also, Mr. Cannon said, FEMA is establishing a national advisory council to ensure effective federal preparedness, and council members will include health and EMS professionals. Centers for Medicare and Medicaid Services Thomas Gustafson, deputy director of the Centers for Medicare and Medicaid Services (CMS), touched on several payment-related issues concerning emergency care services. First, CMS has introduced new coding for emergency care in the outpatient department, including a code for trauma. The new trauma code was designed to recognize the increased resources needed for trauma cases. Second, the IOM committee called for CMS to revise payment for inpatient care to address the boarding problem—in other words, to adjust the relative profitability of elective cases and ED admissions. CMS is in the process of adjusting the diagnostic-related group (DRG) system with the goal of paying more accurately for all patients. It remains to be seen whether this will have much impact on the problem of patient boarding. Third, regarding the IOM committee’s recommendation to expand reimbursement for clinical decision units, Dr. Gustafson clarified that CMS does not pay for care in these units; it pays for observation services for three conditions regardless of whether they are in clinical decision units or not. CMS is considering the advice from an outside panel to make two more conditions eligible for payment. Dr. Gustafson explained that CMS has been very cautious about proceeding further on the issue of payment for observation services, because it is an area that has been substantially abused in the past. Fourth, regarding ambulance services, the IOM recommended that CMS pay for the readiness of these services. It is the belief of CMS that it already does so by incorporating readiness costs into rates for individual

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Future of Emergency Care: Dissemination Workshop Summaries services. Payment for treat-and-release services, as recommended by the IOM committee, would require a change in statute to implement. The ambulance benefit under Medicare is currently a transportation benefit. Also, regarding the IOM committee’s recommendation that CMS permit Medicare reimbursement for ambulance transport to more destinations, such as dialysis centers, Dr. Gustafson clarified that Medicare already pays for transport to dialysis centers, but CMS will have to study the possibility of doing the same for ambulatory care centers. Finally, Dr. Gustafson said that a technical advisory group will be issuing recommendations for changes to the Emergency Medical Treatment and Active Labor Act (EMTALA). He clarified that the act does not forbid regionalization. Nothing prevents hospitals from sharing on-call physicians, but formal agreements must be in place. Those agreements do not relieve a hospital from its EMTALA obligations. Department of Homeland Security Jeffrey Runge, chief medical officer at DHS, said that the core of incident management is how well citizens with injuries are treated and how well we are able to rally the institutions that are used every day. In the event of a disaster, people will call 9-1-1, and the responders will be local providers. While preparedness is also a federal issue, preparedness is fundamentally a local issue. Dr. Runge also said that DHS is essentially an integrator. It does not have a specific territory, but brings together sister agencies in order to improve preparedness. He added that DHHS, DHS, the Department of Transportation, the White House, state and local government, and the private sector all have to work together to fix the emergency care system. He said that the lead federal agency for EMS in the federal government is FICEMS, and the participants in FICEMS will work their best to create a regional system. He emphasized that reforms to the emergency care system must involve an interagency process. He also discussed funding for emergency preparedness and the disparity between hospital and prehospital reimbursement and between EMS funding and the funding for other first responders. Congressional appropriators have made it clear that DHS must fix the problem that EMS received only about 4 percent of DHS first responder funding in 2002 and 2003. Dr. Runge said that he is reorganizing his office to make sure that the requirements for medical preparedness are emphasized in the grant guidance in the future. Dr. Runge also added that “crisis” is a word that is overused to describe emergency care. While parts of the emergency care system are in dire need

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Future of Emergency Care: Dissemination Workshop Summaries of fixing, the system has advanced a long way since the 1970s. Emergency care is a victim of its own success. Finally, Dr. Runge emphasized the need to move beyond opinion, but to do so, good data systems must be in place. Office of Public Health Emergency Preparedness W. Craig Vanderwagen, assistant secretary for public health emergency preparedness at DHHS, thanked the IOM committee and the agencies that supported the study for their contribution and willingness to examine the broad set of emergency care issues. Dr. Vanderwagen noted that DHHS has created a study group that is looking in extensive detail at the IOM committee’s findings and recommendations. Leadership was identified as the highest priority area for improvement. Internally, DHHS must be more effective in providing a coherent approach to how the department handles emergency care issues. He added that the recently passed Pandemic and All Hazards Preparedness Act calls for the secretary of DHHS to promote improved emergency medical services, medical direction, system integration, research, uniformity of data collections, treatment protocols, and policies with regard to public health emergencies. He said that DHHS has made a commitment to building regional capabilities and supporting regional activities. One of the lessons learned from Hurricane Katrina is that regional capacities should be built both locally and in the regional aspects of private- and public-sector activities. His office is expanding its regional staff, and the Health Resources and Services Administration (HRSA) grant program will include regionalization as a target. DHHS is also working to support the development of regional mobile response capability, noting that regional capabilities may have more merit than developing an isolated federal asset that is moved to various locations. A regional asset that will be built, owned, and cared for by people locally will be more responsive to local needs. Dr. Vanderwagen concluded by emphasizing the importance of research and analysis of data, noting that earlier in his career he worked with the Indian Health Service, which implemented an electronic health record. The data produced allowed researchers to analyze the effectiveness of the care delivered, and it helped staff understand where systems were failing and explore the quality of individual providers. Open Discussion Mr. Sanddal invited members of the audience to ask a question or to make a brief comment. Nancy Bonalumi, president of the Emergency

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Future of Emergency Care: Dissemination Workshop Summaries Nurses Association, expressed disappointment that the IOM reports devoted minimal attention to the nation’s nursing shortage. Mr. Sanddal responded that the reports explain that the workforce shortage is systemic across all disciplines (physicians, nurses, EMTs) and acknowledged that they may not have discussed the issues at a level of depth that would meet the satisfaction of all provider groups. Edward Cornwell III, speaking on behalf of the Committee on Trauma of the American College of Surgeons, thanked the speakers from the federal agencies for their work and said that the problems under discussion are very similar to the problems that the trauma system experienced in previous decades. He encouraged the federal agencies to rely on the American College of Surgeons for guidance and support. Many states and regions have invested resources in trauma care, and research indicates that it has led to improved patient outcomes. Dr. Cornwell also responded to Dr. Runge’s remark about not characterizing the state of emergency care as a crisis. He said that the shortcomings in the system are a crisis to those who have lost lives because of a lack of access. Dr. Runge responded by saying that “it is not a crisis until the people feel it,” and those in the trauma and emergency medicine communities “have done such a great job of making lemonade out of lemons that the people don’t yet feel it.” He described the IOM reports as the canary in the coal mine and a harbinger of things to come, but until the public feels it, they will not demand reform. Also in response to Dr. Cornwell’s comments, Mr. Sanddal said that the inclusive trauma model is heralded in the IOM reports as a model on which other response capabilities can be built. Alex Valadka, representing the American Association of Neurological Surgeons and Congress of Neurological Surgeons, said that a major problem with regionalization is that smaller outlying hospitals ask level 1 trauma centers to admit patients with minor injuries or trauma, flooding level 1 trauma centers and causing them to go on diversion. He acknowledged that hospitals could have written agreements to deal with this problem, but “that doesn’t really happen out in the real world.” Dr. Gustafson acknowledged that it is a very real problem and the EMTALA technical advisory group is examining it. Thomas Judge, representing the Association of Air Medical Services, began his remarks by expressing support for FICEMS. He also mentioned that, while disproportionate share hospital funding does not cover the full cost of uncompensated care for hospitals, EMS does not receive any federal funding to support uncompensated care. He also described how Medicaid reimbursement for ambulance service varies widely across states but generally pays well below the cost of care. Mr. Judge also noted that, under DHS rules, little money has gone to improve infrastructure, such as the creation

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Future of Emergency Care: Dissemination Workshop Summaries of helipads. Finally, he noted that NEMSIS did not receive appropriate emphasis in the IOM reports. Linda Degutis, president-elect of the American Public Health Association, agreed with Dr. Runge’s earlier comment that the public has not felt the true failings of the emergency care system. They will not recognize that there is a problem until the system does not perform. In addition, she urged the organizations present at the workshop to form a coalition to move things forward and advocate collectively for change. In order to do this, organizations will have to let go of their individual interests and work together. Congressional Staff Panel Robert Bass, executive director of the Maryland Institute for EMS, moderated the congressional staff panel. Panelists included Jennifer Bryning, public health preparedness policy director for the Senate Health, Education, Labor and Pensions (HELP) Committee, Subcommittee on Bioterrorism and Public Health Preparedness; Debbie Curtis, chief of staff for Representative Pete Stark (D-CA); Lisa Henning Raimondo, military nurse detailee in the office of Senator Daniel K. Inouye (D-HI); and Billy Wynne, health council for the Senate Finance Committee. Ms. Bryning focused her remarks on the just-passed Pandemic and All Hazards Preparedness Act (S.3678), explaining that the legislation will be key to addressing the IOM committee’s recommendation for stronger disaster preparedness and the creation of a coordinated, regionalized, and accountable system. The act does two main things: reauthorizes the 2002 Bioterrorism Act and builds on the Project Bioshield Act of 2004. Specifically, the new law makes the secretary of DHHS responsible for public health and medical preparedness in response to emergencies and unifies DHHS preparedness and response programs under an official, namely, Dr. Vanderwagen. It also moves the National Disaster Medical System from DHS to DHHS. The act also provides funds for state and local preparedness by reauthorizing over $1 billion in grants to state and local entities for public health and medical preparedness. For the first time, the law stresses accountability by requiring that DHHS establish evidence-based benchmarks and performance standards to measure progress and require states and other funding entities to report on their progress. The act also improves public health security by modernizing how public health departments detect, respond to, and manage the public health threats by collecting instant electronic information. It also strengthens public health infrastructure by offering loan repayments as a way to recruit and train a stronger public health workforce to respond to emergencies. The act will also help speed

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Future of Emergency Care: Dissemination Workshop Summaries up emergency medical response by improving training, logistics, and planning for health care providers and volunteers. It promotes the use of mobile hospitals and alternative federal facilities to help handle a surge in patients, and it makes it easier for health care providers to respond and volunteer during emergencies. Ms. Raimondo focused her remarks on emergency care for children. Through the reauthorization of the Emergency Medical Services for Children Act, Senator Inouye hopes that there will be continued improvements in EMS for children nationwide. She told the audience that the senator intends to represent their interests at the beginning of the 110th Congress by offering a bill to reauthorize the act. A similar bill was presented last year and referred to the Senate HELP Committee but was not acted on. She expressed more optimism about moving forward with the bill with Senator Edward Kennedy (D-MA) as chairman of the committee. Ms. Curtis praised IOM reports for their ability to bring problems to the public’s attention; however, she said, they fall short of prescribing legislative ways to fix problems in the system. She added that many of the recommendations are fairly small (for example, the creation of a lead federal agency for emergency care and having the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) enact tougher standards on crowding, boarding, and diversion) and do not provide Congress with clear direction. Ms. Curtis added that it is “unconscionable” that the nation’s EDs are not prepared for children and that Congress should not be needed to intervene to make sure that the nation’s emergency rooms are prepared for children. Medical institutions need to do a better job in that regard. Endorsing the IOM committee’s recommendation for regionalization, Ms. Curtis acknowledged that implementing it might require some changes to EMTALA. But she warned that Representative Stark, as the author of EMTALA, may not approve changes to the law lest others take the opportunity to do harm to it. She noted that EMTALA is the one law that guarantees access to health care to everyone in the country. She emphasized that as we address the crisis facing EDs, we must not end up doing harm by closing the doors to people who need the access to care. Ms. Curtis noted that Los Angeles passed a tax increase to address a crisis in ED funding after running a public advertising campaign. She said making Congress act on something as big as reforming the EMS system will require a nationwide realization that the issue is a problem not only for the uninsured, but for all individuals. Regarding the issue of the shortage of on-call specialists, she said that hospitals “bring this on themselves” by paying doctors extra for taking call. It used to be understood that as a condition of having admitting privileges at a hospital, specialists were on call for certain amounts of time. She

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Future of Emergency Care: Dissemination Workshop Summaries suggested that Congress could alter the conditions of participation under Medicare to deal with the problem. Finally, Ms. Curtis warned about the growth of specialty hospitals, noting that they grow when Congress does not act. She said that she recently met with a group of hospital leaders who discussed the possibility of creating freestanding EDs. While not prepared to say whether these are a good idea or not, she emphasized that we need to think about the most constructive ways for a health care system to function. It must work well for both providers and patients. Mr. Wynne described several areas of activity for the Senate Finance Committee. A recently passed Senate bill introduces pay for performance for physicians under Medicare. It encourages, through financial incentives, physicians to report selected quality measures that have been vetted by specialty societies and will be tracked by CMS. Mr. Wynne said that pay for performance is a trend that is likely to continue in the future, and it is a priority area for committee chairman Senator Max Baucus (D-MT). He noted that committee staff will be looking for help in how to implement pay for performance in the emergency care sector. Mr. Wynne also said that refinement of DRG codes used in hospital inpatient payment will continue to be on the congressional agenda. Inequities in the DRG payment system may be fostering the proliferation of specialty hospitals, and are another concern of Senator Baucus. The committee will continue to look at the impact of specialty hospitals on community care and on community hospitals. Another area that is likely to receive more attention in the upcoming Congress is the uninsured. He speculated that there probably will not be any major reforms, but it will be an area of greater focus than in the past. Turning to regionalization, Mr. Wynne raised the issue of how variations in medical services and volume across the country drive costs and affect the supply of physicians, including specialists and primary care doctors. He said the Medicare Payment Advisory Commission is going to issue a report on the sustainable growth rate formula for physician payment, and he expects it will receive much attention. Mr. Wynne noted that rural issues are another top priority area for Senator Baucus. He concluded by saying that among the most immediate priorities for the new Congress will be the reauthorization of the State Children’s Health Insurance Program. Open Discussion Brian Keaton, president of the American College of Emergency Physicians (ACEP), noted that in the six months since the release of the IOM reports, nothing has changed. The IOM did a remarkable job of identifying

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Future of Emergency Care: Dissemination Workshop Summaries Applied Research Network (PECARN), a 21-hospital network that sees 900,000 children. One challenge for multicenter research, Dr. Kuppermann said, is funding; such studies are expensive. Investigators need to advocate for congressional funding and a dedicated institute in NIH. Another challenge is that the sharing of information in multicenter research networks is complicated by the IRB process. Each institution has its own IRB with different guidelines. He observed that sometimes you need 25 IRBs to agree on a protocol. Making findings from multicenter networks generalizable is another challenge. Most research is conducted at pediatric centers, but more than 90 percent of pediatric emergency care is provided at general hospitals. More hospitals need to be incorporated into research. Community practitioners should be trained in basic research principles and hospitals given incentives to participate in multicenter research. Turning to research goals, Dr. Kuppermann noted the variations in emergency care among the community hospitals that see the great majority of children. He emphasized the need to identify factors associated with inequities and solutions to them. A key solution is finding better ways to maintain skills in providers who do not see children frequently. Dr. Patterson spoke on prehospital EMS research and began by describing a list of challenges to research identified by his peers: a paucity and lack of uniformity of data, obtaining consent, few funding opportunities, no real home for EMS research, limited NIH knowledge and awareness of EMS, and few trained EMS researchers. This list is very similar to the challenges identified in the National EMS Research Agenda. Unlike researchers who can rely on the many public use datasets already available in the health care field, EMS investigators have to create their data from various sources or conduct primary data collection. Dr. Patterson illustrated this challenge with his dissertation, in which he sought to identify the prevalence of medically unnecessary EMS transports of children by collecting ED and EMS data. He ran into so many challenges that it took him 12 months to create a dataset. By comparison, a student colleague obtained and analyzed a public-use dataset and wrote the results section of his dissertation—all in three months. Dr. Patterson described two opportunities for improving EMS data for research. The National Registry of Emergency Medical Technicians has a strong history of collecting workforce data on EMTs and paramedics. If the registry had the capacity to collect data on nonnationally registered EMTs, it would allow researchers to conduct more meaningful studies on the EMS workforce. Also, the NEMSIS project is a central repository for state EMS databases, and one day its data will be used to answer questions about response times and model designs.

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Future of Emergency Care: Dissemination Workshop Summaries Regarding informed consent, he noted that the blood substitute Polyheme has sparked a good deal of public controversy. The Food and Drug Administration (FDA) decided to hold hearings to determine if the current informed consent framework, known as the final rule, is adequate or needs modification. Those who have written on the issue appear to believe the final rule is too broad and better guidance is needed. The consensus reached by the Resuscitation Outcomes Consortium may help the FDA refine that language. This presents an opportunity to improve the ability of emergency physicians or those in prehospital care to do research in emergency situations. Other key challenges, including lack of appreciation for research among EMS professionals, the lack of skilled researchers, and inadequate funding for research should be discussed in terms of creating a viable EMS research career path for clinicians and doctorally trained researchers. Unlike researchers who focus on major diseases, EMS investigators have few opportunities for postdoctoral training or even dissertation-supported research and even fewer opportunities to find an academic home doing EMS research. Still, Dr. Patterson said, there are a few funding opportunities for EMS research. One place to look is the NIH Roadmap Initiative, which focuses on training researchers to be multidisciplinary and encourages involvement in community-based research. If NIH and the academic institutions that support emergency medicine research would recognize EMS as a vehicle for improving and increasing community-based research, it would help a great deal. As for systems-level research, many federal agencies have the capacity to support a competitive grant program and demonstration projects focused on EMS systems and workforce research. The question, Dr. Patterson concluded, is who at the national level (i.e., federal agencies and associations) will take the lead and promote opportunities for EMS research. Open Discussion Lisa Myer of Cornerstone Government Affairs, which represents Advocates for EMS, said that NEMSIS funding is a top agenda issue for the group. She urged attendees to write letters to members of Congress in support of funding for NEMSIS. Robert Neumar, chair of the ACEP Research Committee, asked if the panelists had ideas on how advocates could work with the government to build a research training infrastructure for emergency care, aside from the NIH Roadmap Initiative. Dr. Patterson responded, noting that the National Registry of Emergency Medical Technicians, perhaps with support from NHTSA, provides funding for two research fellows at Ohio State University, and the fellows are housed at the National Registry. That is one example,

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Future of Emergency Care: Dissemination Workshop Summaries and it could be applied to other organizations. Dr. Barsan added that the ACEP Research Committee has developed many solid recommendations in this area. He also noted that there has been some talk about an initiative to create a home for emergency medicine that spans multiple institutes at NIH rather than creating a specific institute for emergency medicine research. Response from Federal Agencies Involved in Emergency Care Research Representatives from several federal agencies were invited to discuss their reactions to the research findings and recommendations in the IOM reports as well as from earlier panels. Panelists included Chris DeGraw, deputy director of the Division of Research, Training and Education at the Maternal and Child Health Bureau (MCHB) of HRSA; Irene Fraser, director of the Center for Delivery, Organization and Markets at the Agency for Healthcare Research and Quality (AHRQ); Richard Hunt, director of the Division of Injury Response at the Centers for Disease Control and Prevention’s (CDC’s) National Center for Injury Prevention and Control; Major Chetan Kharod, an Air Force major, emergency physician, and assistant professor in the Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences (USU); and John Marler, associate director for clinical trials at the NINDS. Dr. DeGraw described how the MCHB’s research program funds extramural, investigator-initiated research that covers a number of topics and issues and different types of research; its annual budget is $10 million. It reviews 90-100 applications annually, makes 8-10 new awards a year, and has a portfolio of 40-50 active projects at any one time. Currently, two projects are related to pediatric emergency care. The bureau also provides some core funding for three research networks, including PECARN. The bureau is also part of the Interagency Committee on EMSC Research. It began in the mid-1990s to raise the quality and quantity of research on EMS for children by integrating the topic into federal research agendas. One way the committee has sought to do this is through joint research announcements. Collaborating agencies include the MCHB, CDC, AHRQ, and several of the institutes at NIH. PECARN is the first federally funded research network focused on pediatric emergency care. Its purpose is to develop an infrastructure capable of overcoming barriers to pediatric EMS research. Its mission is to conduct high-priority, multi-institutional research on the prevention and management of acute illnesses and injuries in children and youth of all ages. It represents a collaboration at the MCHB between the EMS-C program and the research program. PECARN promotes multicenter research (investigators still must find their own research funding), supports collaboration among investigators, and encourages informational exchanges.

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Future of Emergency Care: Dissemination Workshop Summaries PECARN is operationalized through five cooperative agreements with the EMS-C program that support a centralized data management coordinating center at the University of Utah and four research nodes at academic centers across the country, each of which hosts a regional network of hospital EDs, creating 21 research sites in all. A steering committee reviews and approves PECARN research proposals. Dr. DeGraw added that future plans for PECARN include finalizing and implementing a formal agenda to guide future research proposal development, designing a plan to encourage the transfer of network findings to practice, and improving collaboration with practitioners and researchers to enhance the two-way education and the exchange of ideas and information between the treatment and research communities. Dr. Fraser said improving emergency care is going to require systemwide solutions, so research must focus on systems, too. That will require strong, linked data on robust measures, evidence of how to improve the care systems themselves, and systematic collection and implementation of the evidence. A DHHS study recently found 91 data sources with information on emergency care and preparedness, including two highlighted extensively in the IOM reports: CDC’s National Hospital Ambulatory Medical Care Survey and AHRQ’s Healthcare Cost and Utilization Project (HCUP). However, the study also found that better linkages and coordination across data systems, much better data capacity, and strong quality measures are needed. These are the areas of interest for AHRQ, which is not focused on any specific diseases, but rather on health systems research. HCUP now has 37 state partners through whom it collects and standardizes all hospital discharges in those states. HCUP contains 90 percent of all discharges in the country, which amounts to a detailed census of inpatient hospital care. It also includes ambulatory surgery and ED services from a growing number of states. Using inpatient data from HCUP, researchers have information on patients who enter the hospital through the ED. The data allow analysis of the clinical conditions that lead to admission, and one of the findings of an AHRQ research study is that half of uninsured inpatients are admitted through the hospital from the ED; one-fourth of privately insured patients are admitted through the ED. The inpatient data have been used with an array of quality indicators that the agency has developed. The measures are now used for public reporting in nine states. A new emphasis for AHRQ is on the HCUP ED data. Currently 22 HCUP partners provide ED data in their states, and several more states plan to participate in the future. Going forward, Dr. Fraser said that AHRQ is working to expand the ED data to create a national ED dataset, and in the next few years will start production of ED quality indicators.

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Future of Emergency Care: Dissemination Workshop Summaries Dr. Fraser also highlighted research in practice-based organizations that AHRQ is supporting. Accelerating Change and Transformation in Organizations and Networks (ACTION) consists of 15 very large provider-based consortia that conduct applied practical research through task orders with AHRQ. ACTION includes most hospitals and physician practices in the country. There is considerable volume and diversity in these settings, and, most importantly, they enjoy considerable buy-in from their operational leadership. Dr. Fraser added that if a group of EDs from around the country wanted to collaborate, they would probably find that they are already in the network. Finally, Dr. Fraser mentioned two opportunities for research support from AHRQ. The agency recently posted a special emphasis notice on research to improve health care systems, and ED care is specifically mentioned. Also, the agency recently posted new grant opportunities focused on health information technology and safety in the ambulatory care arena, and ambulatory care is specifically defined to include ED care. Dr. Hunt addressed acute injury care research. The IOM committee called for the secretary of DHHS to undertake a study to examine gaps and opportunities in emergency care and trauma research, and CDC recently undertook a similar effort to revise its injury research agenda. A multidisciplinary process was used to examine gaps and create an agenda for acute injury care. The process involved representatives of other federal agencies and the corporate sector to make sure that the effort was complementary and not redundant with other efforts. The resulting research agenda priorities identified were translation of research into practice; treatment; disasters; on-site interventions; outcome measures; and individual, cross-cultural, and community outcomes. Dr. Hunt described several efforts to begin work on the research agenda. First, intramural research is under way, for example, to examine bomb injuries and international lessons learned from explosion injuries. CDC is also conducting a cost-benefit analysis of the traumatic brain injury treatment guidelines. Second, CDC is awarding grants for research on the care of the acutely injured. It received 38 grant proposals that were equally distributed among the priority areas. Four proposals were funded on the following topics: pediatric injury–posttraumatic stress disorder, trauma outcomes improvement, children and blunt abdominal trauma, and the mechanism of injury in field triage. These awards were developed collaboratively with other federal agencies. Dr. Hunt emphasized that CDC is also addressing other recommendations from the IOM committee. With regard to the committee’s call for emergency and trauma care research for prehospital EMS with an emphasis on systems and outcome research, Dr. Hunt said that CDC is looking at

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Future of Emergency Care: Dissemination Workshop Summaries the entire system, not just operating rooms, trauma surgery, and EDs; their work is inclusive of EMS, and they have worked hard to be complementary to the initiatives developed in the National EMS Research Agenda. Also, as called for in the IOM reports, the CDC is placing a growing focus on high-probability disaster events. Dr. Hunt concluded by noting that CDC is working to address acute injury research with its federal colleagues from the Department of Defense (DoD), the Department of Transportation, and DHHS. Major Kharod spoke about the unique issues in military emergency care research. He began by distinguishing medicine in the military (for troops at home) from military medicine, which is practiced during military operations. While medicine in the military is similar to the civilian practice of emergency medicine, military medicine is a very different discipline, one that involves austere environments, resource limitations, and a lack of physical security. He noted that the role of military medicine is expanding from the provision of compassionate and competent care to also include public health and preventive medicine, humanitarian disaster response, and field research. There are opportunities for the military to contribute to advances in civilian practice. The golden hour and the use of blood substitutes are examples of developments from military research. Major Kharod discussed the barriers to military research, which include strategic, operational, and tactical barriers. Strategic barriers refer to the mind set about research. While research is part of DoD’s mission and a number of military institutes are involved in research, its value to different groups varies. It is highly valued by combat commanders who want to ensure that their troops return home safely. Academic centers have a moderate interest in research, but military medical treatment facilities have less interest in conducting research. Operational barriers to conducting research include the multidisciplinary nature of emergency medicine research, enrolling research subjects, and obtaining informed consent waivers. Informed consent waivers require approval from the secretary of defense. Tactical barriers include the high operations tempo, lack of physical security, and staffing issues, all of which make it difficult to conduct research. However, USU is good at developing multicenter research teams that involve its staff and its teaching hospitals, military medical centers, DoD research facilities, and civilian facilities. It is also good at improving research collaboration between civilian and military researchers, various medical specialties, the military services, and among the medical corps. Looking forward, USU can potentially serve as an interagency hub for research, providing protected time and funding and training for researchers. It could also be a conduit of military research and operational education. It could also

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Future of Emergency Care: Dissemination Workshop Summaries expand the presence of emergency medicine in the university by developing a core faculty and research base. Dr. Marler described two major projects that demonstrate how emergency medicine can help in the development of clinical treatments. The Special Program of Translational Research in Acute Stroke (SPOTRIAS) began five years ago when the NINDS noticed a lack of new treatments for stroke under development. SPOTRIAS involves seven national centers that take promising treatments and develop them in pilot studies. The centers are required to work in close cooperation with EDs. Of the 12 fellowships at the centers, 2 are held by emergency physicians. While the SPOTRIAS is focused on pilot programs, a second effort is under way to conduct phase III studies. NINDS developed the Neurological Emergencies Treatment Trials (NETT) to conduct multiple trials in multiple diseases. NETT involves several hub centers and has a coordinating center at the University of Michigan. NINDS requires that emergency physicians participate in the leadership at the hub sites. An emergency physician is the principal investigator at the majority of sites, and the principal investigator at the coordinating center it is Dr. Barsan. Going forward, the vision for NETT is to engage clinicians and providers at the front lines of emergency care to conduct large multicenter clinical trials to answer research questions of neurological importance. The NETT structure will be utilized to achieve economies of scale enabling cost-effective, high-quality research. NINDS has evolved to realize that if they are going to get patients that they need in their trials at a time when the patients can respond to treatment, they need not only to work with emergency physicians, but also to have them participate in the design and leadership of the studies. Dr. Marler concluded by describing some of the special challenges associated with research for neurological emergencies. One is urgency: patients must be recruited into studies in minutes, not hours. Another is the need for multidisciplinary involvement throughout the medical care system from EMS to rehabilitation. And third, conditions in the ED complicate informed consent. Open Discussion Dr. Kellermann pointed out that while emergency care accounts for some 43 percent of all hospital admissions and 11 percent of all outpatient encounters, only one-half of 1 percent of health care research dollars are targeted to emergency care research, according to one study. How, he asked the panelists, might the issues involved in emergency care research be more effectively constituted to obtain a bigger share of research dollars? Dr. Marler said one key message he heard during the meeting was that any shift in funding is a zero-sum game, so efficiencies have to be identified to have

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Future of Emergency Care: Dissemination Workshop Summaries additional funding. NIH is trying to focus its research on practical and important issues that will lead to savings in lives and money. Dr. Hunt added that strong numbers, such as the ones that Dr. Kellermann provided, help make the case for more research funding. In addition, cost-benefit analyses of treatment may be able to demonstrate improved health outcomes and monetary savings, which could lead policy makers to support emergency care research. Dr. Fraser added that research should be coordinated—in other words, a study on health information technology can also provide useful findings on emergency care. Ms. Bonalumi said the Emergency Nurses Association Foundation has collaborated with ACEP to cosponsor research, and it has proved to be a very valuable partnership. Physicians and nurses collaborate every day at the patient’s bedside to deliver care, she reminded attendees, and emergency nurses can and should participate in developing research agendas. Dr. Kellermann concurred, noting that a brain injury study at Emory University could not have been possible without the help of both emergency and intensive care unit nurses. Tammy Estrada, a senior nurse at Memorial Health University Medical Center in Savannah, said that senior leadership from her hospital believed in the IOM reports so much that they sent a delegation to the workshop with the hope that they would return with a plan to support ED improvement efforts. She said during the course of the day she learned that CMS is unlikely to make many changes to Medicare reimbursement, Congress wants more specific recommendations to act on, outside agencies may need to be employed to raise public awareness, and more research in emergency care is needed. What, she asked, should she tell her hospital’s senior leadership about the next steps to support the IOM’s agenda? Dr. Kellermann agreed that those were messages heard during the day, but there were many other positive developments. Many of the key health staffers in Congress were present and engaged in conversation, and one of the most powerful legislators in Congress participated in a discussion of emergency care issues after most other members had left town for recess. He also said that in 20 years he has never seen a similar collection of individuals in the same room to discuss emergency care issues. He encouraged attendees to build on the momentum, working collaboratively to pressure Congress for action. Mr. Sanddal added that the concepts of coordination, regionalization, and accountability can start at home. Providers can look for opportunities in their own health care delivery system to figure out how to better serve patients in their catchment area by working collaboratively with other organizations and other disciplines. Dr. Neumar said that, in the current fiscal climate, an emergency care institute or center at NIH seems impossible. He asked for panelists’ reactions to the potential short-term solution of an office in the Office of

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Future of Emergency Care: Dissemination Workshop Summaries the Director at NIH that would be responsible for coordinating efforts in emergency care and improving research in NIH. Dr. Marler said that such an office might be useful, but he added that the crux of the problem is really a data collection issue. Most of the research dollars that NINDS provides goes into paying people to collect data that have already been collected, sometimes three or four times, and there are incredible translational problems. Each center in the NINDS network uses different data collection methods. Just as the federal agencies cannot talk to each other, in terms of data, individual emergency physicians working in different departments or academic centers cannot communicate, either. If emergency physicians from different departments or centers would organize to improve data transmission and communication, they would be ahead of the rest of medicine. Dr. Kellermann asked about the possibility of a FICEMS-like committee for emergency care research across agencies and institutes, in which agencies could pool resources and ideas. Major Kharod responded in full support of the idea, noting that waiting for the “100 percent solution” would take too long. He suggested undertaking the 75 percent solution and improving it as it moves forward. Dr. Williams said that a stronger case for federal funding could be made if the resulting research outcomes could be used to prevent traumatic brain injury, thereby resulting in monetary savings. Dr. Hunt agreed that prevention is an important component of the patient encounter in the ED and noted that two divisions in CDC’s injury center are prevention oriented. Dr. Kellermann added that emergency care providers are some of the most effective advocates for prevention, because they see what happens when prevention fails. Dr. Fraser noted that prevention is more than individual preventive care. It also includes public policies, for example, helmet laws. Research from AHRQ has found that there are high costs associated with the absence of helmet laws, and much of those costs are borne by the states. Aisha Liferidge, president of the Emergency Medicine Residents’ Association, said that many of its members have expressed interest in practicing in rural areas if a loan repayment program would be offered. The association proposed a resolution to ACEP petitioning that emergency medicine be included in the national health corps scholarships. Charles Cairns, one of the authors of the ACEP report on research, said that the ACEP report recommended specific training awards for emergency physicians within each institute. He asked Dr. Marler whether the success of the efforts at the NINDS in terms of incorporating emergency medicine research could be leveraged to incorporate similar efforts at other institutes. Dr. Marler said yes. NINDS developed their initiatives because they realized the potential that emergency physicians had to offer to NINDS research. However, he noted that it is not possible to have dedicated awards for every

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Future of Emergency Care: Dissemination Workshop Summaries specialty. NIH is moving toward CTSAs, which are nonspecialized training programs. He noted that many people at NIH would be enthusiastic to see CTSA applications from emergency care researchers. Dr. Smithey said that as collaborations between communities and organizations move forward, there is a lot of confusion over the Health Insurance Portability and Accountability Act and the Family Educational Rights and Privacy Act laws in terms of what information people are allowed to share. The confusion over these laws impedes the ability of providers to treat patients. Dr. Hollander noted that in response to the recent request for information of the NIH Roadmap Initiative, both SAEM and ACEP submitted independent proposals that were similar. Both proposals called for a trans-NIH research network using the NINDS model to promote emergency care and emergency medicine research. He urged the workshop attendees to go to the roadmap website, look at the proposals, and post a public comment, noting that this is an opportunity for NIH to hear from emergency care stakeholders. Finally, Dr. Degutis raised the suggestion that when research applications are submitted to federal agencies, someone who understands emergency care should be involved in the review process. She speculated that one of the reasons that emergency care researchers do not submit applications or why their applications receive low scores is because the reviewers do not understand emergency care. CLOSING Mr. Sanddal closed the meeting, expressing thanks to the panelists, IOM staff, and sponsors of the IOM study and the dissemination workshops. He noted that a strong message from the four dissemination workshops is that it will take collaboration and leadership to continue to move the agenda forward. While there are many “islands of excellence” in emergency care across the country, they are surrounded by “seas of mediocrity.” A national agenda, national focus, and national leadership are needed to bridge the gap between the islands of excellence, so that one day a patient’s genetic code will be at least equally important to his or her zip code in determining outcomes.

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