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However, the problems are becoming more apparent, and this provides a catalyst for change.

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The committee calls for concerted, cooperative efforts at multiple levels of government and the private sector to finally break through and achieve these goals. This vision rests on the broad goals of improved coordination, expanded regionalization, and increased transparency and accountability, each of which is discussed in turn. The chapter then profiles current approaches of states and local regions that exhibit these features.

As described in Chapter 2 , EMS occupies a space that overlaps three major silos: health care, public health, and public safety. In most cases, these three systems are not aligned, and their means of communicating or coordinating with one another are highly limited. Within health care, there is considerable fragmentation along a number of dimensions relating to EMS.

EMS personnel arriving at the scene of an incident often do not know what to expect regarding the number of injured or their condition McGinnis, They also are frequently unaware of which hospitals are on diversion status and which are ready to receive the type of patient they are transporting. Lack of coordination between EMS and hospitals can result in delays that compromise care.

In addition, deployment of air medical services is often not well coordinated. While air medical providers are not permitted to self-dispatch, a lack of coordination at the ground EMS and dispatch level sometimes results in multiple air ambulances arriving at the scene of a crash even when all are not needed.

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Similarly, police, fire, and EMS personnel and equipment often overcrowd a crash scene because of insufficient coordination regarding the appropriate response. In addition, in many communities there is little interaction between emergency care services and community safety net providers, even though the two share a common base of patients, and their actions may affect one another substantially. The absence of coordination represents missed opportunities for enhanced access, improved diagnosis, patient follow-up and compliance, and enhanced quality of care and patient satisfaction.

Coordination between EMS and public health agencies could also be improved. Through their regular activities, EMS providers have information that could serve as a barometer for both illness and injury trends within the community, potentially assisting state and local public health departments.

However, communication links between these agencies are often not well established. Moreover, although prevention activities are generally limited in the emergency care setting, utilization of emergency services represents an important opportunity for imparting information on injury prevention to patients.

Emergency care providers could benefit from the resources and experiences of public health agencies and experts in establishing injury prevention activities. Finally, perhaps now more than ever, with the threat of bioterrorism and outbreaks of diseases such as avian influenza, it is essential that EMS, EDs, trauma centers, and state and local public health agencies partner to conduct surveillance for disease prevalence and outbreaks and other health risks.

Emergency responders can recognize the diagnostic clues that may indicate an unusual infectious disease outbreak so that public health authorities can respond quickly GAO, c. However, a partnership that allows for improved communication of information between emergency care providers and public health officials must first be in place.

The value of integrating and coordinating emergency and trauma care has long been recognized. Although the drive toward system development waned when federal funding of EMS was folded into state block grants in , the goal of system planning and coordination has remained paramount within the emergency and trauma care community. In , the National Highway Traffic. EMS of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring….

EMS maintains liaisons, including systems for communication with other community resources, such as other public safety agencies, departments of public health, social service agencies and organizations, health care provider networks, community health educators, and others…. EMS is a community resource, able to initiate important follow-up care for patients, whether or not they are transported to a health care facility.

NHTSA, , pp. While the concept of a highly integrated emergency and trauma care system as articulated by NHTSA was not new, progress toward its realization has been slow. Nevertheless, there have been important successes in the coordination of emergency and trauma care services that point the way toward solutions to the problem of fragmentation.

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The most important example of such successes is the trauma system, which has developed a comprehensive and coordinated approach to the care of injured patients. The pediatric intensive care system is a leading example of regional coordination among hospitals, community physicians, and EMS providers Gausche-Hill and Wiebe, These examples demonstrate the possibilities for enhanced coordination across the system as a whole. Communication is critical to establishing systemwide coordination. An effective communications system is the glue that can hold together effective, integrated emergency and trauma care services.

It provides the key link between dispatch and EMS responders and is necessary to ensure that on-line medical direction is available when needed. It enables dispatchers to offer prearrival instructions to callers requesting an ambulance.


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Good communication is necessary to link EMS personnel with other public safety providers, such as police, fire and emergency management,. Effective communication also facilitates medical and operational oversight and quality control within the system. In Chapter 5 , the committee stresses the importance of fully integrated communications systems to link EMS with hospital, public safety, public health, and emergency management personnel.

The objective of regionalization is to improve patient outcomes by directing patients to facilities with experience in and optimal capabilities for any given type of illness or injury. Substantial evidence demonstrates that doing so improves outcomes and reduces costs across a range of high-risk conditions and procedures, including cardiac arrest and stroke Grumbach et al.

The literature also supports the benefits of regionalization of treatment for severely injured trauma patients in improving patient outcomes of care, reducing mortality from traumatic injury, and lowering costs Jurkovich and Mock, ; MacKenzie, ; Mann et al. Formal protocols within a region for prehospital and hospital care contribute to improved patient outcomes as well Bravata et al. In addition, organized trauma systems have been shown to add value in facilitating performance measurement and promoting research. While regionalization of trauma services to high-volume centers is optimal when feasible, Nathens and Maier argued for an inclusive trauma system in which smaller facilities have been verified and designated as lower-level trauma centers.

They suggested that the quality of care may be substantially better in such facilities than in those outside the system, and comparable to national norms. Inclusive trauma systems are designed to cover the entire continuum of care of the injured patient, from the site of injury through acute care and, when appropriate, rehabilitation.

Such a system requires the committed involvement of all qualified medical facilities in the region. An efficient triage system, coupled with established transfer agreements, is required to ensure that patients receive the right care in the right place at the right time. Regionalization may also be a cost-effective strategy for developing and training teams of response personnel. Regionalization benefits triage,. The case for regionalization of emergency services is strong, but not absolute. Regionalization can adversely impact the overall availability of clinical services in a community if directing a large number of patients to a regional program leads to elimination of needed services at other facilities.

The survival of small rural facilities may require the identification and treatment of patients who do not require the capacities and capabilities of larger facilities, as well as repatriation to a local facility for long-term care and follow-up after stabilization at a tertiary center.

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  7. It is important to take a systems approach that considers the full effects of regionalization on a community. Determining the appropriate metrics for this type of analysis and defining the process for applying those metrics within each region raise significant research and practical issues. Nonetheless, in the absence of rigorous evidence to guide the process, planning authorities should take the above factors into account in developing regionalized systems of emergency and trauma care.

    Also, the committee is wary of regionalization that results in directing patients to specialty hospitals that do not provide comprehensive emergency services, as these facilities can drain financial resources from those hospitals that do provide such care GAO, b; Dummit, The design of the emergency and trauma care system envisioned by the committee bears similarities to the inclusive trauma system originally conceived and first proposed and developed by CDC, and adapted and disseminated by the American College of Surgeons ACS.

    Trauma care is optimized in the region through protocols and transfer agreements that are designed to direct trauma patients to the most appropriate level of care available given the type of injury and relative travel times to each center. Under this program, on-site consultation is provided when requested by the lead agency of a region. The consultation is performed by a multidisciplinary team, which evaluates all components of the system and offers specific recommendations for raising the system to the next level, regardless of how embryonic or mature the system may be.

    An important feature of these consultations is that they cover the entire continuum of care. A number of regions have sought and received such a consultation. All providers can play a role in supplying emergency care in their community according to their capabilities. Initially, this categorization might simply be based on the existence of a service—for example, the availability of a cardiac catheterization laboratory or coverage by a neurosurgeon.

    Eventually, the categorization process might evolve to include more detailed information—for example, the availability of specific emergency procedures and on-call specialty care and indicators of quality, including both service-specific outcomes and general indicators, such as time to treatment, frequency of diversion, and ED boarding. Prehospital EMS could be similarly categorized according to ambulance capacity, availability, credentials of EMS personnel, advanced life support ALS and pediatric ALS, treat and release and search and rescue capabilities, disaster readiness e.

    A standard national approach to the categorization of emergency and trauma care providers is needed. Categories should reflect meaningful differences in the types of emergency and trauma care available, yet be simple enough to be understood easily by the provider community and the public.

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    The use of national definitions would ensure that the categories would be understood by providers and by the public across states or regions of the country and would promote benchmarking of performance. Therefore, the committee recommends that the Department of Health and Human Services and the National Highway Traffic Safety Administration, in partnership with professional organizations, convene a panel of individuals with multi disciplinary expertise to develop evidence-based categorization systems for.

    The results of this process would be a complete inventory of emergency and trauma care assets for each community, which should be updated regularly to reflect the rapid changes in delivery systems nationwide. The development of the initial categorization system should be completed within 18 months of the release of this report.

    Once understood, the basic classification system proposed above could be used to determine the optimal destination for patients based on their condition and location. However, more research and discussion are needed to determine the circumstances under which patients should be brought to the closest hospital for stabilization and transfer as opposed to being transported directly to the facility offering the highest level of care, even if that facility is farther away.

    Debate continues over whether EMS personnel should perform ALS procedures in the field, or rapid transport to definitive care is best Wright and Klein, The answer to this question likely depends, at least in part, on the type of emergency condition. It is evident, for example, that whether a patient will survive out-of-hospital cardiac arrest depends almost entirely on actions taken at the scene, including rapid defibrillation, provision of cardiopulmonary resuscitation CPR , and perhaps other ALS interventions.

    Delaying these actions until the unit reaches a hospital results in dismal rates of survival and poor neurological outcomes. Conversely, there is little that prehospital personnel can do to stop internal bleeding from major trauma. In this instance, rapid transport to definitive care in an operating room offers the victim the best odds of survival. In cases of out-of-hospital cardiac arrest, properly trained and equipped EMS personnel can provide all needed interventions at the scene. In fact, research has shown that failure to reestablish a pulse on the scene virtually ensures that the patient will not survive, regardless of what is done at the hospital Kellermann et al.

    On the other hand, the scoop and run approach makes sense when a critical intervention needed by the patient can be provided only at the hospital.

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    Decisions regarding the appropriate steps to take should be resolved using the best available evidence. Therefore, the committee recommends that the National Highway Traffic Safety Administration, in partnership. The transport protocols should also reflect the state of readiness of given facilities within a region at a particular point in time. Real-time, concurrent information on the availability of hospital resources and specialists should be furnished to EMS personnel to support transport decisions.

    Development of an initial set of model protocols should be completed within 18 months of the release of this report. These protocols would facilitate much more uniform treatment of injuries and illnesses nationwide so that all patients would receive the current standard of care at the most appropriate location. The protocols might require modification to reflect local resources, capabilities, and transport times; however, they would acknowledge the fact that the basic pathophysiology of human illness is the same in all areas of the country. Once in place, the national protocols could be tailored to local assets and needs.

    The process for updating the protocols will also be important because it will dictate how rapidly patients will receive the current standard of care.

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    The patient must be transported to the emergency department best prepared for his particular problem…. Hospital emergency departments should be surveyed … to determine the numbers and types of emergency facilities necessary to provide optimal emergency treatment for the occupants of each region…. Once the required numbers and types of treatment facilities have been determined, it may be necessary to lessen the requirements at some institutions, increase them in others, and even redistribute resources to support space, equipment, and personnel in the major emergency facilities.

    Once the decision has been made to transport a patient, the responding ambulance unit should be instructed—either by written protocol or by on-line medical direction—which hospital should receive the patient see Figure This instruction should be based on developed transport.