FUTURE OF EMERGENCY CARE

REGIONALIZING EMERGENCY CARE

Workshop Summary

Ben Wheatley, Rapporteur

Board on Health Care Services

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu



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FUTURE OF EMERGENCY CARE REGIONALIZING EMERGENCY CARE Workshop Summary Ben Wheatley, Rapporteur Board on Health Care Services

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This study was supported by Contract No. HHSP233200800008T, Task Order #21 between the National Academy of Sciences and the Emergency Care Coordination Center, part of the Office of the Assistant Secretary for Preparedness and Response in the Department of Health and Human Services; other contributors include the American College of Emergency Physicians and the Society of Academic Emergency Medicine. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the workshop participants and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-15151-1 International Standard Book Number-10: 0-309-15151-1 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. Regionalizing Emergency Care: Workshop Summary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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

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PLANNING COMMITTEE ON REGIONALIZING EMERGENCY CARE WORKSHOP1 ARTHUR KELLERMANN (Chair), Professor and Associate Dean for Health Policy, Emory University School of Medicine ROBERT BASS, Executive Director, Maryland Institute for Emergency Medical Services Systems DREW DAWSON, Director, Office of Emergency Medical Services, National Highway Traffic Safety Administration, Department of Transportation A. BRENT EASTMAN, Chief Medical Officer and Chair of Trauma Services, Scripps Health MICHAEL HANDRIGAN, Acting Director, Emergency Care Coordination Center, Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services JON KROHMER, Principal Deputy Assistant Secretary and Chief Medical Officer, Department of Homeland Security JEFFREY S. UPPERMAN, Director of Trauma, Children’s Hospital Los Angeles Study Staff BEN WHEATLEY, Program Officer ASHLEY McWILLIAMS, Senior Program Assistant ROGER HERDMAN, Board Director 1 IOM planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteur and the institution. 

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: BRENT ASPLIN, Chair, Department of Emergency Medicine, Mayo Clinic College of Medicine MARY JAGIM, Client Engagement Manager, Intelligent Insites RICARDO MARTINEZ, Executive President of Medical Affairs, The Schumacher Group JOSEPH WAECKERLE, Chief Medical Officer, Office of Homeland Security, State of Missouri Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by MEGAN McHUGH, Health Research and Educational Trust. Appointed by the Institute of Medicine, she was responsible for making certain that ii

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iii REVIEWERS an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the author and the institution.

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Contents OVERVIEW 1 WORKSHOP INTRODUCTION 7 1 REGIONALIZED TRAUMA CARE: PAST, PRESENT, AND FUTURE 11 Emergency Care Regionalization in the 1970s, 11 The States’ Perspective, 12 Centralized Authority, 13 Trauma System Lessons, 14 Audience Discussion, 15 2 EMERGING MODELS OF REGIONALIZATION 25 Acute STEMI Care, 25 Considerations in Regionalizing Cardiac Arrest, 26 The Emergence of Stroke as an Emergency, 27 A Hub-and-Spoke Wheel Model for Children, 28 Audience Discussion, 29 3 LESSONS FROM OTHER SYSTEMS 37 Regionalization in the Department of Veterans Affairs, 37 The U.S. Armed Forces Joint Theater Trauma System, 41 Accountable Care Organizations, 44 Audience Discussion, 46 References, 49 ix

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x CONTENTS 4 REGIONALIZATION: POTENTIAL AND PITFALLS 51 Financing a Regional Hospital from a Local Tax Base, 51 Regionalizing Rural Prehospital Care, 53 Diluting Paramedic Experience, 54 Addressing Suburban Access Challenges, 55 Distribution of Services to Outlying Areas, 56 A Surgical Specialist’s Perspective, 58 Audience Discussion, 59 Reference, 64 5 GOVERNANCE AND ACCOUNTABILITY 65 Regionalization in the Marketplace of Ideas, 65 The State’s Role in Regionalization, 68 Operation Regionalization, 69 What’s in It for Us?, 70 Building “Systemness,” 71 Audience Discussion, 73 References, 81 6 FINANCING 83 Safety Net Hospitals, 83 Network of Community Hospitals, 84 A Revised Model for EMS Reimbursement, 85 Trauma Care Resources, 86 A Health Plan’s Perspective, 87 Audience Discussion, 88 7 DATA AND COMMUNICATIONS 95 EMS Communications Challenges, 96 Standardizing EMS Data Collection, 98 Linking with Automatic Crash Notification, 99 The Birmingham Alabama Regional System, 100 Audience Discussion, 102 Reference, 108 8 PREPAREDNESS 109 Linking Daily Emergency Care and Disaster Preparedness, 110 Regionalization and Preparedness for Catastrophic Events, 111 Catastrophic Medicine Operations in Texas, 112 A Culture of Preparedness, 115 Audience Discussion, 116 Reference, 121

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xi CONTENTS 9 WRAP-UP DISCUSSION WITH FEDERAL PARTNERS 123 Win-Win Regionalization, 125 Envisioning a Congressional Action Plan, 126 The Role of a Federal Lead Agency, 127 Building a Unified System, 129 Liability Reform, 130 APPENDIXES A Workshop Agenda 131 B Workshop Presenters and Participants 141 C The Future of Emergency Care: Key Findings and Recommendations from 2006 Study 149

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List of Figures and Boxes FIGURES 3-1 Care delivery in the military’s joint theater trauma system, 43 5-1 A more inclusive regionalization model, 68 7-1 Core elements of emergency medical services systems, 97 8-1 Regionalized response to catastrophic events in Texas: lessons learned, 114 BOXES 3-1 Challenges Related to Regionalization, 40 3-2 Lessons from Previous Regionalization Experience, 41 5-1 Lessons Learned in North Carolina, 72 xiii

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