The Status of the Nation’s Emergency Management System Gail L. Warden Chair, Committee on The Future of Emergency Care in the United States Health System in the United States Health System President Emeritus, Henry Ford Health System The National Emergency Management Summit March 5, 2007

Overview Statement of Task Hospital-Based Emergency Care:  Key problems Emergency Medical Services  Key problems Emergency Care for Children Emergency Preparedness:  Issues impacting hospitals  Emergency medical services considerations  Pediatric disaster preparedness Recommendations

Statement of Task (In Brief) The objectives of this study were to: (1) examine the emergency care system in the U.S.; (2) explore its strengths, limitations, and future challenges; (3) describe a desired vision of the emergency care system; and (4) recommend strategies required to achieve that vision. The study also examined the unique challenges associated with the provision of emergency services to children and adolescents, and evaluate progress since the publication of the IOM’s 1993 report, Emergency Medical Services for Children In addition, the study examined prehospital EMS and included an assessment of the current organization, delivery, and financing of EMS services and systems, and assess progress toward the EMS Agenda for the Future

Key Problems Overcrowding: 40 percent of hospitals report ED overcrowding on a daily basis Boarding: patients waiting 48 hours or more for an inpatient bed Ambulance Diversion: Half a million ambulance diversions in 2003 Uncompensated Care: results in financial losses and closures for EDs and trauma centers Inefficiency: Limited use of tools to address patient flow to reduce crowding

Key Problems (continued) On-Call Specialists: unavailability of specialists to provide emergency and trauma consultation Inadequate Emergency Preparedness: surge capacity, training, planning, and personal protective equipment Fragmentation: limited coordination of the regional flow of patients Accountability: lack of system performance measurement; public reporting; financial incentives Research: Inadequate funding and infrastructure

Key Problems Fragmentation: Lack of coordination between local service providers; between EMS and public safety; and between EMS and air medical services. Uncertain Quality: Little or no performance data; lack of national standards for training and credentialing. Disaster Preparedness: Inadequate training, equipment, funding. Evidence Base: limited understanding of effectiveness.

State of Pediatric Emergency Care Only 6 percent of EDs have all essential pediatric supplies and equipment needed for managing pediatric emergencies. Many emergency providers receive little training in pediatric emergency care. Many medications prescribed to children are “off label.” Disaster preparedness plans largely overlook the needs of children.

Emergency Preparedness

Issues Impacting Hospitals SURGE CAPACITY: Most operating at full capacity Insufficient space and equipment Availability of specialists Lack of agreement to transfer PLANNING AND COORDINATION: Lack of communication system Need for coordination between hospitals, ambulances, EMS, and public safety agencies Inadequate planning for disaster events Need for coordination between local, state, regional and federal agencies

Issues Impacting Hospitals (continued) TRAINING: Disaster response requires specialized training in the clinical management of disaster victims and in appropriate institutional procedures in a disaster environment Disaster drills are infrequent and not well-coordinated with other agencies PROTECTING THE STAFF: Little guidance is provided to hospitals about what personal protection equipment should be available There is a need for substantial training in disease recognition, decontamination and containment procedures

Emergency Medical Services Considerations Cities and regions are often served by multiple call centers EMS agencies do not effectively coordinate their services with emergency departments and trauma centers Communication between EMS and public agencies is fragmented, often on different radio frequencies, and they lack common operating procedures There are no national standards for training EMS personnel EMS agencies lack protective equipment to effectively respond to chemical, biological or nuclear threats

Pediatric Disaster Preparedness Minimize parent–child separation Improve the level of pediatric expertise on disaster response teams Address pediatric surge capacity Develop specific medical and mental health therapies, as well as social services, for children Conduct disaster drills for a pediatric mass casualty incident

Recommendations Create a Coordinated, Regionalized Accountable System:  All participants from EMS, to ED, to governmental agencies fully coordinate their activities and integrate communication to ensure a seamless system  Develop performance metrics for the various elements of the system and report them to the public  Create a lead agency in the federal government to insure their success

Recommendations (continued) Hospitals Should Reduce Crowding and Create Surge Capacity:  Improve hospital efficiency and patient flow through operational management methods and information technologies  The JCAHO should re-instate strong standards to require implementation

Recommendations (continued): Funding:  Increase funding for research to determine the best ways to organize and deliver emergency services, particularly EMS service  Increase reimbursement for safety-net hospitals who carry large uninsured case burdens  Increase funding for disaster preparedness at all levels of the emergency care system, particularly for training, personal protective equipment and planning  Increase funding for pediatric emergency care

Recommendations (continued) Enhance Pediatric Personnel in Emergency Care:  ED’s and EMS agencies should see that there are pediatric coordinators to ensure appropriate equipment, training and services for children  Conduct research to determine the appropriateness of many medical treatments, medications and medical technologies for the care of children. Once determined, plans should ensure their availability

Summary/Conclusion The future of our Nation’s emergency management system is highly dependent upon the improvement of the emergency care system for our country.