I was hoping that we could all get involved in this topic. Pick your own favorite of the myriad and discuss.

The Future of Emergency Care in the US

Emergency Care for Children: Growing Pains (http://www.iom.edu/CMS/3809/16107/35002.aspx)

Hospital Based Emergency Care: At the Breaking Point (http://www.iom.edu/CMS/3809/16107/35007.aspx)

Emergency Medical Services at the Crossroads (http://www.iom.edu/CMS/3809/16107/35010.aspx)

Any takers? Of note, I think this discussion will help all of us be more educated when it comes to interview questions.

Ok, I guess I'll start this show.

EMS at the Crossroads

Much has been stated recently about how there is no central body that directs the nation's EMS. This leads to differences in types of training, as well as levels of training between communties. It also causes the biggest problem, and that is lack of one standard for communication. Because the E-911 system is different for Fire/Rescue than it is for the police, they often have to call dispatch in order to get the other to come, rather than being able to communicate with people who may simply be out of direct earshot. Also, as has been pointed out here, there is no set standard for what kind of information should be directed towards the ED as the units are coming in.
The worst problem, IMO, is that the aeromedical divisions are either underutilized or misutilized in the current scheme. Modern day US is not Vietnam, so the systems are different, but it drives me up the wall to see helicopters bringing in non-critical patients. Not only does that waste resources, it limits that bird from going out if someone actually does need it. There needs to be greater federal oversight to keep this from happening, and at the same time, there needs to be more direction as to when birds cannot fly. All too often, people die because someone thought they could fly into a scene that they could not. This is more evident in communities where there are competing helicopters, as one will take over when the other refuses to fly due to conditions. There are cases where crashes have happened due to this.
In the future, when more hospitals are specialized (ie, stroke center, heart center), there will also need to be a better dispatch system than the one currently in place, so that people can get to where they will receive the best care (not as much an issue in rural areas). This will require units to go outside of their normal ranges, which will cause certain geographic locales to be underserved during this trip. This is no different than when the only ALS truck in a given county goes on transport to the "big city" and leaves their county without aid. There should be a way to put another bus in that area so that there isn't a gap in medical services.
That's about all I have for now.
Any comments?

Just as an aside to IbnSina's remarks, which I wholeheartedly agree with, these issues really do start at a governmental level. As it is, EMS oversight and funding is now provided by three separate entities each of which have different biases and different goals for the future of EMS. The first step is to consolidate under ONE overseeing agency. Second would be to provide a *strong* political lobbying voice to educate those in control of the funding, so that we can obtain a fair share that is commensurate to the job we do. For example, IbnSina's post indicated problems with the current systems of communication. Currently my county agency is a test site for the DHHS newly proposed trunking system. There are two problems already, even though it has still in the process of being implemented. First, DHHS only provides half the cost of implementation. Therefore only the city proper will be afforded the new system. The rest of the county will still be on the old system. Second, only those units assigned to a call will be able to listen in. So you still have to go through dispatch to add personnel, even if it is from your agency. (I like to post and jump calls, so I definitely don't like not knowing where other units are and what they are doing.)

As far as the training issues, there was a big deal a couple years ago about creating nationally recognized training levels (and names for them) so that it would not only be consistent from county to county, but state to state. Last I heard was that after the second draft, it was decided that this would be state optional because the federal funding was revoked. We are back to square one, essentially.

It seems that crowded EDs are a what hospitals admins would want in the sense that you don't make money off an empty room (same reason that they probably aren't inclined to build more medicine wards to house patients currently boarding in the ED). So how can we get a lot of empty rooms to get built, ready and waiting for a disaster to happen, if it doesn't seem profitable?

Actually, to play the devil's advocate, perhaps educating the public about when to use (or specifically not to use) the ED may be a good start. I have no data to support this, but it may actually be more cost effective to see fewer patients, assuming the ones we treat will provide reimbursement and require admission to the hospital. Think about how many drunk, homeless, high, tooth pain, knee pain, toe pain, etc wait in an ED bed. In the last sentence, I provided 6 commonly seen (sometimes multiple visits in a single shift) patients that will each recieve a bill for at least $200 (or more depending on how it is billed) but will likely never pay it (or the other 6 bills they recieved from other ED's in the past few weeks). For those 6 people who occupied potentially 6 beds in a busy ED, that makes up for one critical patient, who occupies one bed, and can be billed the same amount. Now imagine there is no ambulance divert from your full ED (because those 6 people aren't there) and you can place 5 more critical patients in those beds. Now, just for sake of argument, lets say of those six patients 1/3 will actually pay their bill. Not to confuse you, but you just doubled your collections by only seeing two patients.

Don't get me wrong - I like treating everyone and helping people, but I also think the public has a greater deal of responsibility to use the ED appropriately. Doing so will increase revenue, provide more resources in the case of a true large-scale emergency, and help contribute more to the failing economy of our emergency care system.

For the most part, this is what many ED's are doing. However, the EMTALA provision mandates that every patient who enters the ED must be evaluated by a qualified medical caregiver for a screening exam before they can be discharged or referred to another treatment location. The only cases where this is exempt is if there is an urgent care center or "fast track" that is part of the formal ED. If you are the only attending on a busy night, full waiting room, etc, you still have to see everyone in your waiting room before you can discharge them, according to EMTALA...

Ibsina: good diea to look over this stuff before interview season. I just saw this discussion and thought I'd join in.

I was on EMRA's Task Force that reviewed the IOM report and made recommendations to the Council. We put together a brief report that should give you guys the cliff notes you're looking for. There's a 1 page (or less) summary of each chapter along with the recommendations in the IOM report. The last page of the report also has our recommendations to the council which all passed (some wtih minor revisions). I've attached a shortened version of our report. Hope this is what you guys were looking for. Sorry I had to take some stuff out and break it up into 2 parts for SDN to let me attach it.

x

Actually, to play the devil's advocate, perhaps educating the public about when to use (or specifically not to use) the ED may be a good start.

I rotated through an ED in New Zealand, as well as lived there for a short while, and I remember a fairly wide-spread government sponsored advertisement campaign to educate the public about when not to go to the ED (i.e., flu/cold-like symptoms, minor pains or injuries, etc.) and when to go. I don't have any data as to how it all turned out, but during my shifts there, I do remember seeing less non-sick and more sick.

Turtle

As a 10-year veteran paramedic and soon-to-be MS1, I've found most of what I've read on the IOM reports on EMS and Hospital to be right on target. There are a lot of specific issues addressed in the EMS report regarding fractured data, standardization and centralized oversight. But the take-home message is that EMS is, in fact, at the crossroads; the crossroads of public safety and healthcare.

For this reason, the interoperability b/w other Pub Saf agencies will continue to challenge those in EMS. EMS is never the on-scene authority (even in medical emergencies, which are the vast majority of fire responses). EMS is rarely included in any disaster planning or implementation; it seems the fire department even works more with hospitals on this issue. For these reasons, local governments that manage communications aren't interested in talking to EMS.

Since EMS interacts with multiple EDs and are rarely affiliated with any of them, they are disconnected from access to meaningful outcome statistics. It becomes cumbersome to coordinate data collection on outcomes of a single prehospital condition among 33 receiving hospitals. Rarely, have I seen circumstances where EMS participates in ED planning on managing their prehospital patients (disaster or not). The hospital certainly does it's part to influence what occurs in the field. Where's the continuity of care and collaboration we're striving for?

Well, in any case, it's a mess. I know I don't have all the answers, but I'm passionate about emergency medicine and prehospital care. In the long run, I'll try to do my part.