[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
EMERGENCY CARE CRISIS: A NATION UNPREPARED FOR PUBLIC DISASTERS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON EMERGENCY
PREPAREDNESS, SCIENCE, AND TECHNOLOGY
of the
COMMITTEE ON HOMELAND SECURITY
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
JULY 26, 2006
__________
Serial No. 109-94
__________
Printed for the use of the Committee on Homeland Security
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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COMMITTEE ON HOMELAND SECURITY
Peter T. King, New York, Chairman
Don Young, Alaska Bennie G. Thompson, Mississippi
Lamar S. Smith, Texas Loretta Sanchez, California
Curt Weldon, Pennsylvania Edward J. Markey, Massachusetts
Christopher Shays, Connecticut Norman D. Dicks, Washington
John Linder, Georgia Jane Harman, California
Mark E. Souder, Indiana Peter A. DeFazio, Oregon
Tom Davis, Virginia Nita M. Lowey, New York
Daniel E. Lungren, California Eleanor Holmes Norton, District of
Jim Gibbons, Nevada Columbia
Rob Simmons, Connecticut Zoe Lofgren, California
Mike Rogers, Alabama Sheila Jackson-Lee, Texas
Stevan Pearce, New Mexico Bill Pascrell, Jr., New Jersey
Katherine Harris, Florida Donna M. Christensen, U.S. Virgin
Bobby Jindal, Louisiana Islands
Dave G. Reichert, Washington Bob Etheridge, North Carolina
Michael T. McCaul, Texas James R. Langevin, Rhode Island
Charlie Dent, Pennsylvania Kendrick B. Meek, Florida
Ginny Brown-Waite, Florida
______
SUBCOMMITTE ON EMERGENCY PREPAREDNESS, SCIENCE, AND TECHNOLOGY
Dave G. Reichert, Washington, Chairman
Lamar S. Smith, Texas Bill Pascrell, Jr., New Jersey
Curt Weldon, Pennsylvania Loretta Sanchez, California
Rob Simmons, Connecticut Norman D. Dicks, Washington
Mike Rogers, Alabama Jane Harman, California
Stevan Pearce, New Mexico Nita M. Lowey, New York
Katherine Harris, Florida Eleanor Holmes Norton, District of
Michael McCaul, Texas Columbia
Charlie Dent, Pennsylvania Donna M. Christensen, U.S. Virgin
Ginny Brown-Waite, Florida Islands
Peter T. King, New York (Ex Bob Etheridge, North Carolina
Officio) Bennie G. Thompson, Mississippi
(Ex Officio)
(II)
C O N T E N T S
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Page
STATEMENTS
The Honorable Dave G. Reichert, a Representative in Congress from
the State of Washington, and Chairman, Subcommittee on
Emergency Preparedness, Science, and Technology
Prepared Statement............................................. 1
Oral Statement................................................. 2
The Honorable Bill Pascrell, Jr., a Representative in Congress
from the State of New Jersey, and Ranking Member, Subcommittee
on Emergency Preparedness, Science, and Technology............. 4
The Honorable Bennie G. Thompson, a Representative in Congress
from the State of Mississippi, and Ranking Member, Committee on
Homeland Security.............................................. 6
The Honorable Donna M. Christensen, a Representative in Congress
from the U.S. Virgin Islands................................... 62
The Honorable Charlie Dent, a Representative in Congress from the
State of Pennsylvania.......................................... 57
The Honorable Norman D. Dicks, a Representative in Congress from
the State of Washington........................................ 60
The Honorable Nita M. Lowey, a Representative in Congress from
the State of New York.......................................... 64
Witnesses
Dr. Robert R. Bass, Member, Committee on the Future of Emergency
Care, Institute of Medicine:
Oral Statement................................................. 7
Prepared Statement............................................. 9
Dr. Frederick Blum, President, American College of Emergency
Physicians:
Oral Statement................................................. 12
Prepared Statement............................................. 14
Ms. Mary Jagim, Member, Emergency Nurses Association:
Oral Statement................................................. 37
Prepared Statement............................................. 39
Dr. Steven Krug, Chairman, Committee on Pediatric Emergency
Medicine, American Academy of Pediatrics:
Oral Statement................................................. 43
Prepared Statement............................................. 46
EMERGENCY CARE CRISIS: A NATION
UNPREPARED FOR PUBLIC HEALTH
DISASTERS
----------
Wednesday, July 26, 2006
U.S. House of Representatives,
Committee on Homeland Security,
Subcommittee on Emergency Preparedness,
Science, and Technology,
Washington, DC.
The subcommittee met, pursuant to call, at 2:03 p.m., in
Room 210, Cannon House Office Building, Hon. David Reichert
[chairman of the subcommittee], presiding.
Present: Representatives Reichert, Rogers, Dent, Pascrell,
Dicks, Lowey, Christensen, and Thompson.
Mr. Reichert. The Committee on Homeland Security,
Subcommittee on Emergency Preparedness, Science and Technology,
will come to order. The subcommittee will hear testimony today
from health and medical experts about the state of emergency
and medical preparedness and response in the United States.
We are in a different room today for us, so I think I see
people in the back. This is like a--it is kind of in a tunnel
here.
Thank you all for being here. Yes, bowling alley, Bill
says--it kind of reminds me of. But I have an opening statement
I would like to give and we will move to other members to give
their opening statement.
And let me just first welcome our distinguished witnesses
this morning, and thank you so much for taking time out of your
busy schedule to be here with us. And we look forward to your
testimony.
I would like to congratulate the Members first, before we
get started on the subcommittee, on the passage yesterday of
H.R. 5852, the 21st Century Emergency Communications Act of
2006, by a vote of 414 to 2. The members of the subcommittee
didn't just develop this bipartisan legislation overnight. It
was a series of hearings and a product of hard work over the
past spring to address the state of emergency communication in
our country. And I would like to extend my thanks to Mr.
Pascrell, Ranking Member of the subcommittee, for all of his
hard work on this legislation and Mr. Thompson, the Ranking
Member of the full committee for his hard work and leadership
on this issue, and all the subcommittee members.
Given the success of our series of hearings on emergency
communications, it is my intent for the subcommittee to
replicate this process in the future.
That is, pick the problematic policy issue, hold hearings
examining a variety of perspectives on that topic, and then
move bipartisan legislation based on the record established by
those hearings through the legislative process.
I think a few issues more problematic or more important
than the state of emergency of medical preparedness response in
the United States--I can think of only a few issues more
problematic. And that is why today's hearing will be the first
in a series of hearings examining our Nation's emergency
medical care crisis from prehospital treatment to mass
decontamination and mortuary services. There is no question
about the state of our Nation's readiness to handle a surge of
sick or injured persons during a public health energy
emergency. We are neither prepared nor capable of responding.
According to recent reports released by the Institute of
Medicine and the American College of Emergency Physicians,
emergency medicine in the United States is at its breaking
point. Emergency rooms are dwindling and overcrowded.
Ambulances are routinely diverted. Key specialists in
neurosurgery and trauma care are often unavailable. And
emergency rooms often lack the equipment and supplies needed to
treat patients, especially children.
I could go on and on. The problems are legion. As the
tragic events in New Orleans and other communities along the
gulf coast made clear, this is a real problem.
The hospital and public health infrastructure currently in
place in most areas of the country is barely adequate to get
through a busy Saturday night in the emergency room and,
believe me, as a law enforcement officer I have been in
emergency rooms on a Saturday night.
Indeed, the potential threat of a mass trauma event from a
weapon of mass destruction or pandemic influenza outbreak would
quickly overwhelm our already overstretched emergency medical
system. Homeland security must include preparing our Nation for
public health emergencies. But given the multiple problems
facing our Nation's emergency medical system, can we honestly
say that America could cope with the immediate medical needs of
thousands of people injured by an act of terrorism? Are we
prepared to handle the needs of hundreds of thousands, if not
millions, injured by a weapon of mass destruction? Quite
frankly, the answer is no.
It is for this reason that today's hearing is so important.
This hearing will help set the stage for the subcommittee's
activities in this area of medical preparedness and response,
which, I am sad to say, has not received as much as attention
as it deserves.
The subcommittee's intent therefore will focus its
attention on a number of medical preparedness and response
issues, including the extent of collaboration between the
Departments of Homeland Security and Health and Human Services,
where the national disaster medical system should be located,
whether the metropolitan medical response system is as robust
as it needs to be, and whether our Nation's emergency medical
services personnel have the support necessary to fulfill their
responsibilities.
I am eager to hear the testimony of our witnesses today.
And I look forward to working with you to ensure that we as a
Nation will be able to care for our citizens, regardless of the
circumstances.
Again, thank you for joining us.
[The information follows:]
Prepared Statement of Chairman Dave Reichert
Let me first welcome our distinguished witnesses. We greatly
appreciate your appearance before us today and look forward to your
testimony.
Before we begin, I'd be remiss if I didn't congratulate the Members
of this Subcommittee on the passage yesterday of H.R. 5852, the ``21st
Century Emergency Communications Act of 2006,'' by a vote of 414 to 2.
The Members of the Subcommittee didn't just develop this bi-partisan
legislation overnight. Rather, H.R. 5852 was the product of a series of
hearings held this past Spring on the state of emergency
communications. I'd like to extend my thanks to Bill Pascrell, the
ranking Member of this Subcommittee, for his hard work on this
legislation.
Given the success of our series of hearings on emergency
communications, it is my intent for the Subcommittee to replicate this
process in the future--that is, pick a problematic policy issue, hold
hearings examining a variety of perspectives on that topic, and then
move bi-partisan legislation based on the record established by those
hearings through the legislative process.
I can think of few issues more problematic or important than the
state of emergency medical preparedness and response in the United
States. That is why today's hearing will be the first in a series of
hearings examining our Nation's emergency medical care crisis. From
pre-hospital treatment and mass prophylaxis to mass decontamination and
mortuary services, there is no question about the state of our Nation's
readiness to handle a surge of sick or injured persons during a public
health emergency--we are neither prepared nor capable of responding.
According to recent reports released by the Institute of Medicine
and the American College of Emergency Physicians, emergency medicine in
the United States is at its breaking point. Emergency rooms are
dwindling and overcrowded. Ambulances are routinely diverted. Key
specialists in neurosurgery and trauma care are often unavailable. And
the equipment and supplies needed to treat patients, especially
children, are often unavailable.
I could go on and on--the problems are legion. As the tragic events
in New Orleans and other communities along the Gulf Coast made clear,
this is not merely a theoretical problem. The hospital and public
health infrastructure currently in place in most areas of the country
is barely adequate to get through a busy Saturday night in the
emergency room, let alone treat the thousands of sick and injured
resulting from a catastrophic act of terrorism, a natural disaster, or
other emergency. Indeed, the potential threat of a mass trauma event
from a weapon of mass destruction or pandemic influenza outbreak would
quickly overwhelm our already over-stretched emergency medical system.
Homeland security must include preparing our Nation for public
health emergencies. But, given the myriad problems facing our Nation's
emergency medical system, can we honestly say that America could cope
with the immediate medical needs of thousands of people injured by an
act of terrorism? Are we prepared to handle the needs of hundreds of
thousands, if not millions, injured by a weapon of mass destruction?
Quite frankly, the answer is no.
It is for this reason that today's hearing is so important. This
hearing will help set the stage for this Subcommittee's activities in
the area of medical preparedness and response, which, I'm sad to say,
has not received as much attention as it deserves.
The Subcommittee, therefore, will focus its attention on a number
of medical preparedness and response issues, including:
The extent of collaboration between the Departments of
Homeland Security and Health and Human Services;
Where the National Disaster Medical System should be
located;* Whether the Metropolitan Medical Response System is
as robust as it needs to be; and
Whether our Nation's emergency medical services
personnel have the support necessary to fulfill their
responsibilities.
I am eager to hear the testimony of our witnesses, and I look
forward to working with you to ensure that we, as a Nation, will be
able to care for our citizens regardless of the circumstances. Thank
you again for joining us this afternoon.
Mr. Reichert. And the Chair now recognizes Mr. Pascrell,
the Ranking Member, for his statement.
Mr. Pascrell. I want to thank our good friend, Chairman
Reichert, for charting the course for the subcommittee that has
gone virtually unexplored in Congress.
This hearing will be the first in a series of hearings
examining the state of medical preparedness and response in the
United States. I don't think I am engaging in excessive
hyperbole, Mr. Chairman, when I say this is about as important
an issue as we can possibly address.
The fact is this: The emergency medical care in the United
States is on the verge of ruin.
We have a declining number of emergency rooms, as the
Chairman just pointed out, that are already dangerously
overcrowded and too often unable to provide the expertise
needed to manage seriously ill people in a safe and competent
manner.
I have seen hospitals in New Jersey that have an
infrastructure in place that is barely adequate to get through
an average Saturday evening, let alone effectively treat the
thousands of sick and injured resulting from a devastating act
of terrorism or natural disaster or any emergency.
New Jersey is better equipped than most States. Nationwide
we have a veritable epidemic of inadequate emergency care. It
is a crisis that cannot be ignored.
You don't have to take my word for it. Just read the grim
conclusions from a series of recently released reports by the
Institute of Medicine on the Future of Emergency Care, as well
as the National Report Card on the State of Emergency Medicine
issued by the American College of Emergency Physicians.
According to the Institute of Medicine, few hospitals have
personnel trained in disaster preparedness. Most hospitals have
inadequate medical equipment and supplies needed for an influx
of entries, and most hospitals have ineffective isolation
capacities needed to quarantine infectious patients.
Another major concern is the lack of critical specialists
in emergency medicine available to treat patients in our
Nation's emergency departments. This lack of on-call
specialists can obviously lead to tragic, heartbreaking
results.
And things are getting worse. From 1993 to 2003, the United
States population grew by 12 percent, but emergency room visits
grew by 27 percent. From 90 million to 114 million people use
the emergency rooms.
In that same period, 425 emergency departments closed,
along with about 700 hospitals and nearly 200,000 beds. I mean,
I am not a mathematical wizard, but you can figure out the
mathematics here. We are heading for disaster.
I know Massachusetts put forth a health plan, universal
health plan for the State, several months ago, bipartisan plan
which is primarily directed at covering children who don't have
health insurance coverage. The primary purpose of that plan is
to keep people out of emergency rooms. They figure they are
going to save millions and millions of dollars in doing that.
We should be doing that anyway--anyway--regardless of what
the situation could possibly be. But we have in our hands here
a real difficult situation which we are going to hopefully try
to address.
In 2003, over 500,000 ambulances were diverted from the
hospital where they normally would have delivered a patient
because the emergency room was full.
2004, 70 percent of urban hospitals reported that their
emergency departments had been on diversion at least once.
About 14 percent of emergency room patients end up admitted
to the hospital. A study by the Government Accountability
Office in 2003 found that 20 percent of emergency departments
had to board patients in hallways or other temporary spaces for
an average of 8 hours before a bed opened. We are talking about
the United States of America here. We are not talking about
Calcutta.
Lets get that straight. This can't continue.
With the threats of terror and natural disasters lurking,
we have to be prepared for every worst-scene scenario. Many
proposals we have for easing the solution--the situation
ranging from new regional systems to improve the flow of
patients to the most appropriate and least crowded emergency
rooms, to an infusion of money to cover unpaid emergency care
to bolster preparedness for large-scale disasters. Fixing this
problem will require money.
It is my hope that through the leadership of the
subcommittee, Congress can start tackling these critical
problems, perhaps even be able to get the powers that be in
this institution to stop focusing on gay marriage, flag
burning, tax breaks for millionaires, and instead focus on real
problems and real issues that truly affect the lives of our
citizens. Oh, that is something different.
I look forward to hearing from our witnesses today, Mr.
Chairman, and thank you for putting us together.
Mr. Reichert. Thank you Mr. Pascrell.
Before we get started and move to Mr. Thompson, I would
like to ask unanimous consent to enter into the record a report
issued by the American College of Surgeons, entitled ``A
Growing Crisis in Patient Access to Emergency Surgical Care.''
Without objection, so ordered.
Mr. Reichert. The Chair now recognizes the Ranking Member
of the full committee, Mr. Thompson.
Mr. Thompson. Thank you, Mr. Chairman. I appreciate the
opportunity to give these comments during this hearing, as well
as to support the comments of Ranking Member Pascrell who just
presented earlier.
Mr. Chairman, while firefighters and law enforcement are
our first line of defense, our hospitals, EMS personnel and
public health agencies also stand directly on the front lines.
Unfortunately our Nation's emergency medical system has
received little focus from this Congress and this
administration. As we all know, terrorists threaten to use
biological, chemical, radiological and traditional explosive
weapons against the United States. If successful, an attack has
the potential to result in a large amount of casualties.
In addition, naturally occurring catastrophes such as
hurricanes and pandemic flu also have the potential to
overwhelm many of our communities. How the United States
responds to such an attack or natural disaster will depend upon
the preparedness of local hospitals, outpatient facilities,
emergency medical services and health care professionals. It
would also depend on the preparedness of States and the Federal
Government to augment local capabilities.
While preparing for, preventing, and responding to any
large incident is a local responsibility, the Federal
Government has a significant role in assisting cities and
States to ensure that they are ready. So where do we stand as a
country right now? In June of this year, the Institute of
Medicine released three reports culminating its extensive look
at the state of the emergency care system in the United States.
According to the report, most hospitals are not prepared for
public health emergencies.
Few hospitals have personnel trained in disaster
preparedness, and most hospitals have inadequate equipment and
beds needed for an incident resulting in a large surge of
patient. In fact, Mr. Chairman, from 1993 to 2003, the U.S.
population grew by 12 percent, but the emergency room visits
grew by 27 percent, from 90 million to 114 million. In that
same period, 425 emergency room departments closed, along with
about 700 hospitals and nearly 200,000 beds.
In addition, a report released in June by the Institute of
National Security and Counterterrorism at Syracuse University
entitled ``Are We Ready'' examined the strategic national
stockpile and whether America is truly ready to respond to a
public health emergency.
The report found overlaps in management, jurisdiction,
confusion in decision-making situations, and a lack of full
capacity in supply and distribution.
Mr. Chairman, I would like unanimous consent to introduce a
copy into the record.
Mr. Reichert. Without objection.
Mr. Thompson. Thank you very much. I would also like to
personally thank and acknowledge the work of Barbara Andersen,
Adam Piner, Nicholas Rossmann, Kerri Weir, Dan Wilder, Jason
Yaley and Matthew Zeller. These graduate students, under the
direction of Professor William Banks, produced a thorough
report with many excellent recommendations that I urge my
colleagues to look at.
I would like to thank the witnesses again for appearing
before us today and I look forward to that testimony.
I yield back.
Mr. Reichert. Thank you, Mr. Thompson.
Other members of the subcommittee are reminded that opening
statements must be submitted for the record.
We are pleased to have with us our distinguished witnesses
today.
First we have Dr. Robert Bass, the Executive Director of
the Maryland Institute for Emergency Medical Services System
and a Member of the Institute of Medicine's Committee on the
Future of Emergency Care.
Dr. Frederick Blum, the President of the American College
of Emergency Physicians and an Associate Professor of Emergency
Medicine, Pediatrics, and Internal Medicine at the West
Virginia University School of Medicine.
Ms. Mary Jagim, Internal Consultant for Emergency
Preparedness and Pandemic Planning for MeritCare Health System
in Fargo, North Dakota and Past President of Emergency Nurses
Association.
And, finally, Dr. Steven Krug, the head of Pediatric
Emergency Medicine at Children's Memorial Hospital in, Chicago,
Illinois, and the Chairman of the Committee on Pediatric
Emergency Medicine for the American Academy of Pediatrics.
Let me remind the witnesses, please, that their entire
written statement will appear in the record. We ask that
witnesses strive to limit their testimony to no more than 5
minutes.
Mr. Reichert. The Chair now recognizes Dr. Bass.
Dr. Bass.
STATEMENT OF ROBERT R. BASS, M.D.
Dr. Bass. Good morning Mr. Chairman, members of the
subcommittee, my name is Robert Bass. I am the Executive
Director of the Maryland Institute for EMS Systems, that is the
State EMS agency in Maryland, and I served as a member of the
Institute of Medicine's Committee on the Future of Emergency
Care in the U.S. Health System.
The Institute of Medicine's Committee on the Future of
Emergency Care in the United States was formed in September 03
and consisted of 40 national experts from fields including
emergency care, trauma, pediatrics, health care administration,
public health and health services research.
I will briefly summarize the committee's findings and
recommendations, giving particular attention to those that
relate to emergency preparedness.
In 2003, nearly 114 million visits were made to hospital
emergency departments. Emergency care has made important
strides over the past 40 years. Yet just beneath the surface, a
growing crisis in emergency care is brewing, one that could
imperil everyone's access to care.
Many emergency departments--EDs as we call them today--are
severely overcrowded with patients, many of whom are being held
in ED because no inpatient bed is available. When crowding
reaches dangerous levels, hospitals often divert ambulances to
other facilities. This prolongs ambulance transport times and
disrupts established patterns of care. And because crowding is
rarely limited to a single hospital, commonly a community may
experience a health care equivalent of a rolling blackout where
overcrowding just rolls from hospital to hospital and
everyone's access to care is affected, insured and uninsured
alike.
Physician shortages are another problem. Gaps in specialist
coverage, especially surgical, deprive patients of necessary
care once they arrive in the ED.
With many hospitals already operating at or above capacity,
it is difficult to envision how they could absorb a surge of
casualties from a disaster or major act of terrorism.
Regardless of the cause of the disaster, our Nation's emergency
care system simply lacks the capacity to mount an effective
response.
Training for EMS personnel and hospital staff in disaster
procedures is limited.
Many hospitals lack critical infrastructure to manage the
consequences of a large-scale population emergency. Protecting
hospitals and their staff from secondary contamination in the
event of biological or chemical events poses extraordinary
challenges.
The outbreak of SARS in Toronto was triggered in part by a
young man who spent his first night in a crowded Toronto ED
with what was thought at the time to be a simple case of
pneumonia. An important tool of limiting the spread of air-
borne pathogens is negative pressure rooms that are engineered
to keep airborne germs from spreading. The number of such rooms
in hospitals in the United States is very limited.
Training in and access to personal protective equipment for
hospitals as well as prehospital EMS personnel is inadequate.
Disaster response capabilities are also hindered by poor
communications and a lack of coordination.
Health care and EMS professionals are frequently not
included in local disaster planning. Fragmentation of local
efforts is mirrored by a lack of coordination at the Federal
level. Federal responsibility for emergency care is spread
across multiple agencies and departments.
As a result, large amounts of funding are directed towards
some priorities but not others that may be a greater priority.
There are presently 52 Centers for Public Health Preparedness
funded by the CDC to address various aspects of bioterrorism,
but not one federally funded center focused on civilian
consequences of terrorist bombings; yet we know that explosives
are the most common instrument of terrorism worldwide.
Funding received by hospitals is inadequate to enable them
to develop the needed surge capacities for disasters, much less
a major flu epidemic.
The needs of children have been largely overlooked,
especially in disaster scenarios. Children are far more
vulnerable to the consequences of disasters than adults.
I would just like to highlight a few committee
recommendations. First and foremost, the best way to ensure an
effective response in the event of a disaster is to create an
energy care system that effectively functions on a day-to-day
basis.
The committee recommends that Congress, number one,
establish a federally funded demonstration program to develop
and test various approaches to regionalize delivery of
prehospital and hospital care, and, number 2, designate a lead
agency for emergency care in the Federal Government.
The committee recommends that States actively promote
regionalized emergency care services to ensure that the right
hospital--excuse me--that the right patient gets to the right
hospital in the right time.
The committee also recommends that Congress significantly
increase preparedness funding in fiscal year 2007 for hospitals
in the U.S. in a number of key areas, and that EMS be brought
to a parity level with other public safety entities in disaster
planning and operations.
The committee further recommends that disaster response
topics be included as essential elements in the training,
continuing education, and credentialing of all emergency care
professionals.
To address the special needs of pediatric patients in
preparing for disasters, the committee made a number of
specific recommendations which are included in its reports.
Finally, the committee concluded that there should be
greater integration of the Veterans Affairs health care
resources into civilian disaster planning.
In closing, if the system's ability to respond on a day-to-
day basis is already compromised to a serious degree, how will
it respond to a major medical or public health emergency?
Strong measures must be taken by Congress, the States,
hospitals, and other stakeholders to achieve the level of
response that Americans expect and deserve.
Thank you for the opportunity for testifying. I would be
happy to answer any questions that the subcommittee might have.
Mr. Reichert. Thank you, Dr. Bass.
[The statement of Dr. Bass follows:]
Prepared Statement of Robert R. Bass
INTRODUCTION
Good morning, Mr. Chairman and members of the Subcommittee. My name
is Robert Bass. I am Executive Director of the Maryland Institute of
EMS Systems and I served as a member of the Institute of Medicine's
Committee on the Future of Emergency Care in the U. S. Health System.
THE IOM
The Institute of Medicine, or IOM as it is commonly called, was
established in 1970 under the charter of the National Academy of
Sciences to provide independent, objective, evidence-based advice to
the government, health professionals, the private sector, and the
public on matters relating to medicine and health care.
THE STUDY
The Institute of Medicine's Committee on the Future of Emergency
Care in the U.S. Health System was formed in September 2003 to examine
the full scope of emergency care; explore its strengths, limitations
and challenges; create a vision for the future of the system; and make
recommendations to help the nation achieve that vision. The Committee
consisted of 40 national experts from fields including emergency care,
trauma, pediatrics, health care administration, public health, and
health services research. The Committee produced three reports--one on
prehospital emergency medical services (EMS), one on hospital-based
emergency care, and one on pediatric emergency care. These reports
provide complimentary perspectives on the emergency care system, while
the series as a whole offers a common vision for the future of
emergency care in the United States.
This study was requested by Congress and funded through a
Congressional appropriation, along with additional sponsorship from the
Josiah Macy Jr. Foundation, the Agency for Healthcare Research and
Quality, the Health Resources and Services Administration, the Centers
for Disease Control and Prevention, and the National Highway Traffic
Safety Administration.
I will briefly summarize the Committee's findings and
recommendations, giving particular attention to those that relate to
emergency preparedness.
GENERAL FINDINGS
Emergency and trauma care are critically important to the health
and well being of Americans. In 2003, nearly 114 million visits were
made to hospital emergency departments--more than 1 for every 3 people
in the United States. While many Americans need emergency care only
rarely, everyone counts on it to be available when needed.
Emergency care has made important strides over the past 40 years:
emergency 9-1-1 service now links virtually all ill and injured
Americans to an emergency medical response; EMS systems arrive to
transport patients to advanced, life-saving care; and scientific
advances in resuscitation, diagnostic testing, trauma care and
emergency medical care yield outcomes unheard of just two decades ago.
Yet just beneath the surface, a growing crisis in emergency care is
brewing; one that could imperil everyone's access to care.
Many emergency departments (EDs) today are severely overcrowded
with patients, many of whom are being held in the ED because no
inpatient bed is available. The widespread practice of holding admitted
patients in the ED ties up precious space, equipment, and staff that
cannot be used to meet the needs of incoming patients.
When crowding reaches dangerous levels, hospitals often divert
ambulances to other facilities. In 2003, U.S. hospitals diverted more
than 500,000 ambulances--an average of one per minute. Diversion may
provide a brief respite for a beleaguered staff, but it prolongs
ambulance transport times and disrupts established patterns of care. It
also creates ripple effects that can compromise care throughout the
community. Because crowding is rarely limited to a single hospital,
decisions to divert ambulances can prompt others to do the same. When
this happens, a community may experience the health care equivalent of
a ``rolling blackout''. Everyone's access to care is affected--insured
and uninsured alike.
Physician shortages are another problem. The rising cost of
uncompensated care, fear of legal liability for performing risky
procedures, and disruptions of daily practice and home lives has led
more surgical specialists to opt out of taking ED call. Gaps in
specialist coverage increase the frequency of ambulance diversion,
because hospitals cannot accept certain types of patients if no
specialist is available to treat them.
SHORTCOMINGS IN THE EMERGENCY CARE SYSTEM'S CAPACITY TO RESPOND TO
DISASTERS
With many hospitals already operating at or above capacity, it is
difficult to envision how they could absorb a surge of casualties from
a disaster or major act of terrorism. A sustained outbreak of disease,
whether triggered by an emerging strain of influenza or intentional
release of a bioterror agent, would be even more problematic because
casualties would keep arriving for days, weeks, or months. But
regardless of whether a disaster is the result of terrorism, human
error, a natural disaster, or epidemic, our nation's emergency care
system simply lacks the capacity to mount an effective response. In
light of these concerns, the IOM Committee's recommendations have a
special urgency.
Training for EMS personnel and hospital staff in disaster
procedures is limited. Despite the self-evident fact that mass-casualty
events produce mass casualties, only 4 percent of Department of
Homeland Security first responder funding in 2002 and 2003 was directed
to emergency medical services. As a result, few EMS personnel have
received adequate training in how to respond to chemical, biological,
radiological, nuclear, and explosive (CBRNE) terrorism, much less
natural disasters.
In addition to lack of capacity, many hospitals lack critical
infrastructure, such as sufficient intensive care unit (ICU) beds,
ventilators, and decontamination units to manage the consequences of a
large scale population emergency.
Protecting hospitals and their staff from secondary contamination
in the event of biological or chemical events poses extraordinary
challenges. The outbreak of severe acute respiratory syndrome (SARS) in
Toronto was triggered, in part, by a young man who spent his first
night in a crowded Toronto ED with what was thought at the time to be a
simple case of pneumonia. In the process, he infected two nearby
patients, both of whom subsequently died of SARS (as did the first
patient), but not before they infected scores of others, some of whom
also died.
If a patient with SARS walked into an American emergency department
tonight, the effect would be like tossing a lighted match into a
tinder-dry forest.
An important tool in limiting the spread of airborne pathogens is
negative pressure rooms that are engineered to keep airborne germs from
spreading throughout the emergency department. Unfortunately, the
number of such rooms is very limited, and is generally restricted to a
handful of tertiary care hospitals in each major population center.
Staff must also be protected through appropriate personal protective
equipment and respirators. Currently, staff training and provision of
equipment are inadequate.
Disaster response capabilities are also hindered by poor
communications and lack of coordination. EMS, hospitals, and public
safety often lack common radio frequencies, much less interoperable
communication systems. These technological gaps are compounded by
cultural gaps between public safety providers and emergency care
personnel. In many communities, emergency management and homeland
security meetings are held without a single health care professional in
the room, even though, (in the words of one of my fellow committee
members), ``Sometimes, in a disaster, people get hurt.''
Fragmentation of local efforts is mirrored by lack of coordination
at the federal level. Federal responsibility for emergency care is
spread across multiple agencies and departments. This may explain, in
part, why large amounts of funding are directed towards some
priorities, but not others. For example, federal spending on
bioterrorism and emergency preparedness in the Department of Health and
Human Services (DHHS) rose from $237 million in fiscal year 2000 to 9.6
billion in fiscal year 2006. During this same time period, the Congress
eliminated the Trauma/EMS Systems Program at DHHS from the federal
budget. There are presently 52 Centers for Public Health Preparedness
with federal funding to address various aspects of bioterrorism, but
not one federally funded center focusing on the civilian consequences
of terrorist bombings. Explosives are the most common instrument of
terrorism worldwide.
The current level of funding received by hospitals is inadequate to
enable them to develop needed surge capacity for disasters, much less a
major flu epidemic.
The needs of children have been largely overlooked, especially in
disaster scenarios. Children are far more vulnerable to the
consequences of disasters than adults, both physiologically and
psychologically. For example, if children sustain burns, they have a
greater likelihood of life-threatening fluid loss and susceptibility to
infection. If they sustain blood loss, they develop irreversible shock
more quickly. Because they are closer to the ground, and have a faster
metabolic rate, they are more vulnerable to the effects of toxic gases.
Additionally, if separated from their caregiver, they lose their
protection and support system. In spite of this, the needs of children
are often overlooked in disaster planning. Many states do not address
pediatric needs in their disaster plans, and disaster drills frequently
lack a realistic pediatric component. Presently few sheltering sites
ensure the availability of resources for children, including formula,
diapers, and cribs.
COMMITTEE RECOMMENDATIONS
The Committee offers several recommendations to address these
inadequacies.
First, and most important, the best way to insure an effective
response in the event of a disaster is to create an emergency care
system that effectively functions on a day-to-day basis. The Committee
believes that this can best be accomplished by building a nationwide
network of regionalized, coordinated, and accountable emergency care
systems. To promote the development of these systems, the Committee
recommends that Congress: 1) establish a federally funded demonstration
program to develop and test various approaches to regionalize delivery
of prehospital and hospital-based emergency care, and 2) designate a
lead agency for emergency care in the federal government to increase
accountability, minimize duplication of efforts and fill important gaps
in federal support of the system.
The Committee recommends that states actively promote regionalized
emergency care services. This will help insure that the right patient
gets to the right hospital at the right time, and help hospitals retain
sufficient on-call specialist coverage. Disaster planning would take
place within the context of these regionalized systems so that patients
get the best care possible in the event of a disaster. Integrating
communications systems would improve coordination of services across
the region; not only during a major disaster but on a day-to-day basis.
In addition to offering these general recommendations for
strengthening the emergency care system, the Committee developed
specific recommendations to enhance disaster preparedness. For example,
to address concerns about lack of surge capacity, inadequate training,
and insufficient protection of hospitals and staff, the Committee
recommends that Congress significantly increase preparedness funding in
FY 2007 for hospitals and EMS in a number of key areas--surge capacity;
trauma care systems; EMS response to explosives; training programs;
availability of decontamination showers, standby ICU capacity, negative
pressure rooms, and personal protective equipment; and research on
response to conventional weapons terrorism. In addition, the Committee
recommends that EMS be brought to a level of parity with other public
safety entities in disaster planning and operations.
The Committee further recommends that disaster response topics be
included as essential elements in the training, continuing education,
and credentialing of emergency care professionals (including medicine,
nursing, EMS, allied health, public health, and hospital
administration).
To address the special needs of pediatric patients in preparing for
disasters, the Committee made a number of specific recommendations:
minimizing parent--child separation; enhancing the level of pediatric
expertise on organized disaster response teams; including pediatric
surge capacity in disaster planning; improving access to pediatric-
specific medical, mental health, and social services in disasters; and
developing policies that ensure that disaster drills include a
meaningful pediatric component.
Finally, the Committee concluded that the Veterans Affairs (VA)
hospital system is an underutilized resource for emergency preparedness
at the local level. Therefore, there should be greater integration of
VA resources into civilian disaster planning.
CLOSING
The Committee believes that the nation's emergency care system is
in serious peril. If the system's ability to respond on a day-to-day
basis is already compromised to a serious degree, how will it respond
to a major medical or public health emergency? The Committee believes
that strong measures must be taken by Congress, the states, hospitals
and other stakeholders to achieve the level of response that Americans
expect and deserve. The Committee's recommendations provide concrete
actions that can, and should lead to an emergency care system that is
capable of providing safety and security for all Americans.
Thank you for the opportunity to testify. I would be happy to
address any questions the Subcommittee might have.
Mr. Reichert. The Chair recognizes Dr. Blum.
STATEMENT OF FREDERICK BLUM, M.D.
Dr. Blum. Thank you, Mr. Chairman. My name is Rick Blum. I
am the President of the American College of Emergency
Physicians. I am a practicing emergency physician in
Morgantown, West Virginia. I can tell you the problems you have
outlined today are present in small-town America as well as
large cities.
In the past few years, we have had the unfortunate
experience in this country of experiencing some of the biggest
disasters, both natural and man-made, that we have ever had.
During those events, the American public has come to rely on
the emergency department as a key player in the care of--in the
medical needs of the patient that result from those disasters.
We have become very good at doing more and more with less
and less. But that has a limit, and we are here today to talk
about that limit.
This testimony today comes not only from my own experience,
but the thousands of members of the American College of
Emergency Physicians, and it also comes from data that has
already been outlined here from the Institute of Medicine and
from the national report card that the College put out earlier
this year.
For several years now, the College has worked to raise
awareness of these issues. It is perhaps a symptom of how good
we have become at doing more and more with less and less that
so far we don't feel like these messages have been heard.
But right now as we sit here today, every minute of every
day an ambulance is being diverted away from an emergency
department.
Right now, as we sit here today, there are hospitals,
probably in this city--certainly in most cities in the
country--where patients critically ill oftentimes are lying in
the hallways and waiting hours to get into inpatient beds.
This creates a gridlock situation in our emergency
departments that prevents us from doing what we know how to do,
which is take care of patients as they present to the emergency
department. We simply have no place to see them.
What are the contributing factors to this situation? Well,
there are many. First of all, there is lack of access to basic
health care for many Americans. It would be a misconception to
think that our emergency departments are crowded with people
that don't need to be there.
It is more appropriate to say that they are crowded with
people who, if they had access to reasonable health care
somewhere else, would have their health care conditions not get
to the point where they need an emergency department.
Most of our patients actually need to be in the emergency
department, but many of them are there because they can't get
basic health care.
We also have a significant lack of inpatient beds; that has
already been outlined today, over 200,000 in the past few years
decrease.
We have tried to control cost in this country by
controlling our building of hospital beds, which I think has
been a flawed public policy. We also have a growing population
and the baby boomers are still pretty healthy. They have not
even hit the system in big numbers yet. And when they do, most
of us are predicting a pretty disastrous situation.
We have a shortage of nurses and other providers. You are
going to hear more about that today, I am sure. It is a
critical shortage. We cannot staff the beds we do have in this
Nation in inpatient beds or in the emergency department because
of the shortage.
We have reduced reimbursement for Medicare, Medicaid, and
other payers to the point where 50 percent of all emergency
care in this country is not reimbursed. That is simply not a
sustainable business model for most hospitals. They often make
the decision to close their emergency department rather than to
continue to lose money at that rate. That is simply not
sustainable. And that is at a time when the number of ED visits
have gone up and the number of EDs have dropped, as you've
mentioned.
To be prepared, we really must take steps now to shore up
the critical infrastructure of the emergency care system in
this country. And I am not talking about ventilators or
negative pressure rooms. I am talking about human resources and
I am talking about basic support.
If an emergency department closes, if a trauma center
closes, it closes for everybody, whether you have insurance or
not. We have seen that in communities around the country; in
Las Vegas, when they lost their trauma center and patients were
being shipped to California.
My written testimony outlines specifics. I won't repeat
them all here. I will summarize four.
We simply have to increase surge capacity by ending the
practice of boarding patients in the emergency department. We
have proposed some specific measures, including H.R. 3875 and
Senate bill 2750.
We must promote protocols and information systems that
collect real-time data on diversion and on capacity and also
provide the function of syndromic surveillance.
We must make sure that Homeland Security agencies at both
the Federal, State, and local levels recognize that emergency
care in the emergency department is part of the first response.
We know that 75 to 80 percent of patients in many disasters
bypass many agencies and come directly to the emergency
department.
Emergency physicians and nurses simply must play a role in
planning for these disasters. We must be included, as I said,
as first responders.
I can tell you--I will sum up by saying that when the next
big disaster occurs, the Nation's emergency physicians and
nurses will be there. They will be doing their job, just as
they did in Katrina where they cared for patients for days,
without food or water or electricity or linen. We will be
there. We will be doing our job as best we can, but please let
us do that job effectively by giving us the resources that we
need. Thanks.
Mr. Reichert. Thank you Dr. Blum.
[The statement of Dr. Blum follows:]
Prepared Statement of Frederick C. Blum, M.D., F.A.C.E.P., F.A.A.P.
Introduction
At an alarming and increasing rate, America's emergency departments
are overcrowded and understaffed to meet the needs of patients. An
ambulance is diverted away from a hospital every minute in our country.
Patients admitted to the hospital every minute in our country. Patients
admitted to the hospital lie in hallways for days waiting for transfer
to inpatient beds. America's ability to ``surge'' in a crisis is
greatly diminished or eliminated altogether. This is affecting the
nation's ability to respond to acts of terrorism and save lives during
disasters, such as Hurricane Katrina.
Mr. Chairman and members of the subcommittee, my name is Dr. Rick
Blum, and I would like to thank you for allowing me to testify on
behalf of the American College of Emergency Physicians, the largest
specialty organization in emergency medicine, with nearly 24 000
members committed to advancing emergency care.
The testimony I give is not only from the experiences of emergency
physicians, but from the findings of the Institute of Medicine reports,
released in June, and of a National Report Card on the State of
Emergency Medicine, released in January.
ACEP has been working to raise awareness among lawmakers and the
public of the critical conditions facing emergency patients today and
how this is affecting the ability of emergency physicians and nurses to
``surge'' in a crisis. These the findings of a 2003 GAG report on
crowding; conducting a stakeholder summit last year; and commencing a
rally on the west lawn of the U.S. Capitol attended by nearly 4,000
emergency physicians to promote H.R. 3875/S. 2750, the ``Access to
Emergency Medical Services Act''.
And we know from our experience with Hurricane Katrina that more
people would have lived had surrounding hospitals had more surge
capacity.
ACEP is the largest specialty organization in emergency medicine,
with nearly 24 000 members who are committed to improving the quality
of emergency care through continuing education, research, and public
education. ACEP has 53 chapters representing each state, as well as
Puerto Rico and the District of Columbia, and a Government Services
Chapter representing emergency physicians employed by military branches
and other government agencies.
At an alarming and increasing rate, emergency departments are
overcrowded, surge capacity is diminished or being eliminated
altogether, ambulances are diverted to other hospitals, patients
admitted to the hospital are waiting longer for transfer to inpatient
beds, and the shortage of medical specialists is worsening. These are
the findings Institute of Medicine (10M) report ``Hospital-Based
Emergency Care: At the Breaking Point,'' which was just released on
June 14. I emergency physicians, but they are not.
ACEP for years now has been working to raise awareness of the
critical condition that exists in delivering high-quality emergency
medical care with lawmakers and the public. More recently, these
efforts included promoting the findings of a 2003 Government
Accountability Office (GAO) report on emergency department crowding;
conducting a stakeholder summit in July 2005 to discuss ways in which
overcrowding in America emergency departments could be alleviated;
commencing a rally on the west lawn of the U.S. Capitol in September
2005 attended by nearly 4 000 emergency physicians to promote the
introduction of H.R. 3875/S. 2750, the ``Access to Emergency Medical
Services Act;'' and releasing our first ``National Report Card on the
State of Emergency Medicine'' in January 2006.
ACEP National Report Card on the State of Emergency Medicine
ACEP's ``National Report Card on the State of Emergency Medicine''
is an assessment of the support each state provides for its emergency
medicine systems. determined using 50 objective and quantifiable
criteria to measure the performance of each state and the District of
Columbia. Each state was given an overall grade plus grades in four
categories Access to Emergency Care, Quality and Patient Safety, Public
Health and Injury Prevention, and Medical Liability Reform.
In addition to the state grades, the report card also assigned a
grade to the emergency medicine system of the United Sates as whole.
Eighty-percent of the country earned mediocre or near-failing grades,
and America earned a C--, barely above a D.
Overall, the report card underscores findings of earlier
examinations of our nation safety net--that it is in desperate need of
change if we are to continue our mission of providing quality emergency
medical care when and where it is expected.
Emergencv Department Overcrowding and Lack of Surge Capacity
As the frontline of emergency care in this country, emergency
physicians are particularly aware of how the lack of surge capacity in
our nation's emergency departments is affecting patients. Here are two
true patient stories that with ACEP that illustrate this point:
I know of a little girl with abdominal pain who came to a crowded
emergency department in Texas. The waiting room was crowded with
people, and there was literally no room for her to lie down. So she
went home, and her appendix burst. The ambulance raced her back to the
hospital where she was treated right away. She nearly died, and it took
three months for her to recover. Three months of needless fear, pain,
suffering and costs that would have been avoided--and could have been
avoided.
I know of a 50-year-old Ohio man with chest pain who came to an
overcrowded emergency department. The initial EKG showed no signs of
heart attack, so he had to wait in the waiting room due, because no
beds were available. His pain worsened and he arrested in the waiting
room and died while waiting for a bed.
The root of this problem exists due to lack of capacity in our
nation's emergency departments. To be clear, I am not discussing
crowded emergency department waiting rooms, but the actual treatment
areas of emergency departments.
Overcrowded emergency departments threaten access to emergency care
for everyone--insured and uninsured alike--and create a situation where
the emergency department can no longer safely treat any additional
patients. This problem is particularly acute after a mass-casualty
event, such as a man-made or natural disaster.
Every day in emergency departments across America, critically ill
patients line the halls waiting hours--sometimes days--to be
transferred to inpatient gridlock, which means other patients often
wait hours to see physicians, and some leave without being seen or
against medical advice.
Contributing factors to overcrowding include a lack of hospital
inpatient beds; a growing elderly population and nationwide shortages
of nurses, physicians and hospital support staff. As indicated by the
10M report, another factor that directly impacts emergency department
patient care and overcrowding is the shortage of on-call specialists
due to: fewer practicing emergency and trauma specialists; lack of
compensation for providing theses services to high percentage of
uninsured and underinsured patients; substantial demands on quality of
life; increased risk of being sued and high insurance and relaxed
Emergency Medical Treatment and Labor Act (EMTALA) requirements for on-
call panels.
ACEP and Johns Hopkins University conducted two national surveys,
one in the spring of 2004 and another in the, to determine how current
regulations and the practice climate are affecting the availability of
medical specialists to care for patients in the nation's emergency
departments. The key findings of these reports include:
Access to medical specialists deteriorated
significantly in one year. quarters (73 percent) of emergency
department medical directors reported inadequate on-call
specialist coverage, compared with two-thirds (67 percent) in
2004.
Fifty-one percent reported deficiencies in coverage
occurred because specialists left their hospitals to practice
elsewhere.
The top five specialty shortages cited in 2005 were
orthopedics; plastic surgery; neurosurgery; ear, nose and
throat; and hand surgery. Many who remain have negotiated with
their hospitals for fewer on-call coverage hours (42 percent in
2005 compared with 18 percent in 2004).
Two anonymous stories dramatize the complex challenges of the on-
call problem:
I know of a 23 year-old male who arrived unconscious at a small
hospital in Texas. It turned out he had a neurosurgical
services. Ten minutes away was a hospital with plenty of
neurosurgeons, but the hospital would not accept the patient
because the on-call neurosurgeon said he needed him to be at a
trauma center with an around-the-clock ability to monitor the
patient. All the trauma centers or hospitals larger were on
``divert.'' The patient FINALLY was accepted by a hospital many
miles away, with a 90-minute Life flight helicopter transfer.
The patient died immediately after surgery.
I know of a 65 year-old male in emergency department complaining of
abdominal pain. showed a six-centimeter abdominal aortic aneurysm and
he was unstable for CT scanning. The hospital had no vascular surgeon
available within 150 miles; a general surgeon was available, but he
refused to take the patient out-of-state. The emergency team reversed
the Coumadin transferred the patient three hours away to the nearest
Level I trauma center, but he died on the operating table. I understand
he probably would have lived had there not been a three-hour delay.
In addition, reductions in reimbursement from Medicare, Medicaid
and other payers, as well as payment denials, continue to reduce
hospital resource capacities. To compensate hospitals have been forced
to operate with far fewer inpatient beds than they did a decade ago.
Between 1993 and 2003, the number of inpatient beds declined by 198 000
(17 percent). This means fewer department, and the health care system
no longer has the surge capacity to deal with sudden increases in
patients needing care.
The overall result is that fewer inpatient beds are available to
emergency patients who are admitted to the hospital. Many admitted
patients are ``boarded'' or left in the emergency department waiting
for an inpatient bed, in non-clinical spaces--including offices
storerooms, conference rooms--even--halls--when emergency departments
are overcrowded.
The majority of America's 4,000 hospital emergency departments are
operating ``at'' or ``over'' critical capacity. Between 1992 and 2003,
emergency department visits rose by more than 26 percent, from 90
million to 114 million, representing an average increase of more than 2
million visits per year. At the same time, the number of hospitals with
emergency departments declined by 425 (9 percent), leaving fewer
emergency departments left to treat an increasing volume of patients,
who have more serious and complex illnesses, which has contributed to
increased ambulance diversion and longer wait times at facilities that
remain operational.
According to the 2003 report from the Government Accountability
Office (GAO), overcrowding has multiple effects, including prolonged
pain and suffering for patients long emergency department waits and
increased transport times for ambulance patients. This report found 90
percent of hospitals in 2001 boarded patients at least two hours and
nearly 20 percent of hospitals reported an average boarding time of
eight hours.
There are other factors that contribute to overcrowding, as noted
by the GAO report including:
Beds that could be used for emergency department
admissions are instead being reserved for scheduled admissions,
such as surgical patients who are generally more profitable for
hospitals.
Less than one-third of hospitals that went on
ambulance diversion in fiscal year 2001 reported that they had
not cancelled any elective procedures to minimize diversion.
Some hospitals cited the costs and difficulty of
recruiting nurses as a major barrier to staffing available
inpatient/ICU beds.
To put this in perspective, I would like to share with you the
findings of the on hospital-based emergency care, which was just
released on June 14:
Emergency department overcrowding is a nationwide phenomenon
affecting rural and urban areas alike (Richardson et al.,
2002). In one study, 91 percent of EDs responding to a national
survey reported overcrowding as a problem; almost 40 percent
reported that overcrowding occurred daily (Derlet et al.,
2001). Another study, using data from the National Emergency
Department Overcrowding Survey (NEDOCS), found that academic
medical center EDs were crowded on average 35 percent of the
time. This study developed a common set of criteria to identify
crowding across hospitals that was based on a handful of common
elements: all ED beds full, people in hallways, diversion at
some time waiting room full, doctors rushed, and waits to be
treated greater than hour (Weiss et al., 2004; Bradley, 2005).
As previously mentioned in my statement, ACEP has been working with
emergency physicians, hospitals and other stakeholders around the
country to examine ways in which overcrowding might be mitigated. Of
note, ACEP conducted a roundtable discussion in July 2005 to promote
understanding of the causes and implications of emergency department
overcrowding and boarding, as well as define solutions. included an
addendum to my testimony of strategies, while not exhaustive or
comprehensive, which still hold promise in addressing the emergency
department overcrowding problem.
Ambulance Diversion
Another potentially serious outcome from overcrowded conditions in
the emergency department is ambulance diversion. It is important to
note that ambulances are only diverted to other hospitals when crowding
is so severe that patient safety could be jeopardized.
The GAO reported two-thirds of emergency departments diverted
ambulances to other hospitals during 2001, with crowding most severe in
large population centers where nearly one in 10 hospitals reported
being on diversion 20 percent of the time (more than four hours per
day).
A study released in February by the National Center for Health
Statistics found that, on average, an ambulance in the United States is
diverted from a hospital every minute because of emergency department
overcrowding or bed shortages. This national study, based on 2003 data,
reported air and ground ambulances brought in about 14 percent of all
emergency department patients, with about 16.2 million patients arrived
by ambulance, and that 70 percent of those patients had urgent
conditions that required care within an hour. A companion study found
than tripled between 1998 and 2004.
According to the American Hospital Association (AHA), nearly half
of all hospitals (46 percent) reported time on diversion in 2004, with
68 percent of teaching hospitals and 69 percent of urban hospitals
reporting time on diversion.
As you can see from the data provided, this nation's emergency
departments are having difficulty meeting the day-to-day demands placed
on them. Overcrowded emergency departments lead to diminished patient
care and ambulance diversion. emergency departments have filled all of
their beds, there is no reasonable way to expect that these stressed
systems will be able to suddenly create the surge capacity necessary to
effectively manage a pandemic, natural disaster, terrorist attack or
other mass-casualty event.
ACEP Recommendations
We must take steps now to avoid a catastrophic failure of our
medical infrastructure and we must take steps now to create capacity,
alleviate overcrowding and improve surge capacity in our nation's
emergency departments.
As my colleague, ACEP Board member David Seaberg, M.D, C.P.E.,
F.A.C.E.P., noted in his testimony before a joint hearing conducted by
this subcommittee and the Prevention of Nuclear and Biological Attack
Subcommittee on February 8, ACEP has developed a 10-point plan to
achieve these goals and we continue to urge Congress to enact these
measures in order to effectively manage a pandemic, natural disaster,
terrorist attack or other mass-casualty event. We have noted where
ACEP's recommendations are complimented by several key I0M report
proposals, which I have included as an addendum to my testimony.
1. We must increase the surge capacity of our nation's emergency
departments by ending the practice of ``boarding'' admitted patients in
emergency departments because no inpatient beds are available. As
mentioned previously in my this will require changing the way hospitals
are funded to allow for inpatient and intensive care unit surge
capacity to manage this burden. This proposal is specifically addressed
in the I0M report recommendations (# 4.4 and # 4.5).
2. We must time data for syndromic surveillance, hospital inpatient
and emergency department capacities and ambulance diversion status.
Collection of this data is vital to developing appropriate protocols.
3. Homeland, State, and Local levels need to understand that
hospitals and Emergency Departments are part of the community Critical
Infrastructure. We can not have response and recovery in a disaster
without fully functioning, protected, and connected health resources.
This proposal is specifically addressed in the IOM report
recommendation (# 6.1).
4. We must require hospitals and communities that are severely
affected by a natural or man-made disaster, or even a severe influenza
outbreak, to postpone elective admissions until the crisis has abated.
We must develop a way to compensate those facilities for their loss of
revenue.
5. Command and control of disaster medical response must be more
coordinated across federal, state and local agencies and departments.
6. We must establish a committee of stakeholders and disaster
medicine experts from the public--and private-sectors and academic
institutions to develop and/or refine national medical preparedness
priorities and standards. We must change the national preparedness
culture to one which is consensus-driven and evidence-based.
7. We must provide federal and state funding to compensate
hospitals and emergency departments for the unreimbursed cost of
meeting their critical public health and safety-net roles to ensure
these emergency departments remain open and available to provide care
in their communities. This proposal is specifically addressed in the
IOM report recommendation (# 2.1).
8. We must establish a sustainable funding mechanism for disaster
preparedness for hospitals, emergency departments and emergency
management that is tied to national benchmarks and deliverab1es.
9. To ensure and are considered in any national allocation of
resources and protective measures Congress should continue to include
them in any definitions regarding first responders to disasters, acts
of terrorism and epidemics.
10. Congress should pass H.R. 3875/S. 2750, the ``Access to
Emergency Medical Services Act'' which provides incentives to hospitals
to reduce overcrowding and provides reimbursement and liability
protection for EMTALA-related care.
Conclusion
Emergency departments are a health care safety net for everyone--
the uninsured and the insured. Unlike any other health care provider,
the emergency department is open for all patients who seek care, 24
hours a day, 7 days a week, 365 days a year. We provide care to anyone
who comes through our doors, regardless of their ability to pay. At the
same time, when factors force an emergency department to close, it is
closed to everyone and the community is denied a vital resource.
America's emergency departments are already operating at or over
capacity. changes are made to alleviate emergency department
overcrowding, the nation's health care safety, the quality of patient
care and the ability of emergency department personnel to respond to a
public health disaster will be in severe peril.
While adopting crisis measures to increase emergency department
capacity may provide a short-tenn solution to a surge of patients,
ultimately we need long-tenn answers. The federal government must take
the steps necessary to strengthen our resources and prevent more
emergency departments from being permanently closed. In the last ten
years, the number and age of Americans has increased significantly.
During that same time, while visits to the emergency department have
risen by tens of millions, the number of emergency departments and
staffed inpatient hospital beds in the nation has decreased
substantially. This trend is simply not prudent public policy, nor is
it in the of the American public.
Let me close by assuring you that in any local, regional or
national disaster or epidemic the nation's emergency physicians and
emergency nurses will be there to do their jobs, as was evident during
the Hurricanes Katrina and Rita, as well as the terrorist attacks on
September 11. ACEP urges this committee and the U. S. Congress to
consider the 10-point plan that I have presented here today and
specifically advocate the enactment of H.R. 3875/S. 2750, the ``Access
to Emergency Medical Services Act.''
Every day we save lives across America. Please give us the capacity
and the tools we need to be there for you when and where you need us. .
. today, tomorrow and when the next major disaster strikes the citizens
of this great country.
Attachments
Overcrowding strategies outlined at the roundtable discussion ``Meeting
the Challenges of Emergency Department Overcrowding/Boarding,''
conducted by the American College of Emergency Physicians (ACEP) in
July 2005
Strategies currently being employed to mitigate emergency department
overcrowding:
Expand emergency department treatment space. According
to a Joint Commission on Accreditation of Health care
Organizations (JCAHO) standard (LD.3.11), hospital leadership
should identify all of the processes critical to patient flow
through the hospital system from the time the patient arrives,
through admitting, patient assessment and treatment and
discharge.
Develop protocols to operate at full capacity., when
emergency patients have been admitted, they are transferred to
other units within the hospital. This means that the pressure
to find space for admitted patients is shared by other parts of
the hospital.
Address variability in patient flow. This involves
assessing and analyzing patient arrivals and treatment relative
to resources to determine how to enhance the movement of
patients through the emergency department treatment process and
on to the appropriate inpatient floors.
Use queuing as an effective tool to manage provider
staffing. According to an in article in the Journal of the
Society for Academic Emergency Medicine, surveyors found that
timely access to a provider is a critical measure to quality
performance. an environment where emergency department's are
often understaffed, analyses of arrival patterns and the use of
queuing models can be extremely useful in identifying the most
effective allocation of staff.
Maximize emergency department efficiency to reduce the
burden of overcrowding and expanding their capacity to handle a
sudden increase or surge in patients.
Manage acute illness or injury and the utilization of
emergency services in anticipatory guidance. In its policy
statement on emergency department overcrowding issued in
September 2004, the American Academy of Pediatrics noted: ``The
best time to educate families about the appropriate use of an
emergency department, calling 911, or calling the regional
poison control center is before the emergency occurs. Although
parents will continue to view and respond to acute medical
problems as laypersons, they may make better-informed decisions
if they are prepared.''
Place beds in all inpatient hallways during national
emergencies, which has been effectively demonstrated in Israel.
Improve accountability for a lack of beds with direct
reports to senior hospital staff as done in Sturdy Memorial
Hospital.
Set-up discharge holding units for patients who are to
be discharged in order not to tie-up beds that could be used by
others. The 2003 GAO report found that hospitals rely on a
number of methods used to minimize going on diversion,
including using overflow or holding areas for patients.
Establish internal staff rescue teams. This concept
involves intense collaboration between emergency department
staff and other services in the hospital when patient volume is
particularly high.
Improve coordination of scheduling elective surgeries
so they are more evenly distributed throughout the week. For
example, Boston Medical Center had two cardiac surgeons who
both scheduled multiple surgeries on Wednesdays. The Medical
Center improved the cardiac surgery schedule by changing block
time distribution so one surgeon operated on Wednesdays and the
other operated on Fridays.
Employ emergency department Observation Units to
mitigate crowding.
Strive to minimize delays in transferring patients.
Support new Pay-for-Performance measures, such as
reimbursing hospitals for admitting patients and seeing them
more quickly and for disclosing measurements and data.
Monitor hospital conditions daily, as done by some EMS
community disaster departments.
Institute definitions of crowding, saturation,
boarding by region with staged response by EMS, public health
and hospitals. For example, the Massachusetts Chapter of ACEP
has been working with its Department of Public Health (DPH) on
this issue for several years, which has resulted in the
development of a ``best practices'' document for ambulance
diversion and numerous related recommendations including
protocols regarding care of admitted patients awaiting bed
placement. The chapter's efforts also resulted in the
commissioner of DPH sending a letter to all hospitals outlining
boarding protocols.
Seek best practices from other countries that have
eased emergency department crowding.
Improve internal information sharing through technology.
Strategies and innovative suggestions to planning or testing phases:
Physicians should work to improve physician leadership
in hospital decision-making.
Hospitals should expand areas of care for admitted
patients. In-hospital hallways would be preferable to emergency
department hallways. admission and there are 20 hallways
available, putting one patient per hallway would be preferable
to putting all 20 in the emergency department, which only
prevents others from accessing care.
Design procedures to facilitate quicker inpatient bed
turnover, with earlier discharges and improved communications
between the housekeeping and admission departments.
Offer staggered start times and creative shifts that
would offer incentives to those who couldn't work full-time or
for those who would benefit from having a unique work schedule.
Collect data to measure how patients move through the
hospital.
Address access to primary care and issues to
facilitate patient care that supply lists of clinics and other
community-based sources of care.
Communities should increase the number of health care
facilities and improve access to quality care for the mentally
ill.
Policymakers should improve the legal climate so that
doctors aren't forced to order defensive tests in hopes of
fending off lawsuits.
Ensure emergency medical care is available to all
regardless of ability to insurance coverage and should
therefore be treated as an essential community service that is
adequately funded.
Lawmakers should enact universal health insurance that
includes benefits for primary care services.
Appendix E
Recommendations and Responsible Entities from the Future of Emergency Care Series
HOSPITAL-BASED EMERGENCY CARE: AT THE BREAKING POINT
--------------------------------------------------------------------------------------------------------------------------------------------------------
EMS Private Professional
Congress DHHS DOT DHS DOD States Hospitals Agencies Industry Organizations Other
-------------------------------------------------------------------------------------------------------------------------------------------------------- Chapter 2: The Evolving Role of Hospital-Based Emergency Care
--------------------------------------------------------------------------------------------------------------------------------------------------------
2.1 Congress should establish dedicated funding, separate
from DSH payments, to reimburse hospitals that provide
significant amounts of uncompensated emergency and
trauma care for the financial losses incurred by
providing those services.
Congress should initially appropriate $50 X X .... ...
million for the purpose, to be administered by the
Centers for Medicare and Medicaid Services..
CMS should establish a working group to .........
determine the allocation of these funds, which should
be targeted to providers and localities at greatest
risk; the working group should then determine funding
needs for subsequent years.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 3: Building a 21st-Century Emergency Care System
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.1 The Department of Health and Human Services and ......... X X ... ... ...... ......... ........ ........ X .....
National Highway Traffic Safety Administration, in
partnership with professional organizations, should
convene a panel of individuals with multidisciplinary
expertise to develop an evidence-based categorization
system for EMS, EDs, and trauma centers based on adult
and pediatric service capabilities.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.2 The National Highway Traffic Safety Administration, ......... ..... X ... ... ...... ......... ........ ........ X .....
in partnership with professional organizations, should
convene a panel of individuals with multidisciplinary
expertise to develop evidence-based model prehospital
care protocols for the treatment, triage, and transport
of patients.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.3 The Department of Health and Human Services should ......... X .... ... ... ...... ......... ........ ........ ............. .....
convene a panel of individuals with emergency and trauma
care expertise to develop evidence-based indicators of
emergency care system performance.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.4 The Department of Health and Human Services should ......... X .... ... ... ...... ......... ........ ........ ............. .....
adopt regulatory changes to the Emergency Medical
Treatment and Active Labor Act (EMTALA) and the Health
Insurance Portability and Accountability Act (HIPAA) so
that the original goals of the laws are preserved but
integrated systems may further develop.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.5 Congress should establish a demonstration program, X X .... ... ... ...... ......... ........ ........ ............. .....
administered by the Health Resources and Services
Administration, to promote regionalized, coordinated,
and accountable emergency care systems throughout the
country, and appropriate $88 million over 5 years to
this program.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.6 Congress should establish a lead agency for emergency X X .... ... ... ...... ......... ........ ........ ............. .....
and trauma care within 2 years of the publication of
this report. The lead agency should be housed in the
Department of Health and Human Services, and should have
primary programmatic responsibility for the full
continuum of EMS, emergency and trauma care for adults
and children, including medical 9-1-1 and emergency
medical dispatch, prehospital EMS (both ground and air),
hospital-based emergency and trauma care, and medical-
related disaster preparedness. Congress should establish
a working group to make recommendations regarding the
structure, funding, and responsibilities of the new
agency, and develop and monitor the transition. The
working group should have representation from federal
and state agencies and professional disciplines involved
in emergency and trauma care.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 4: Improving the Efficiency of Hospital-Based Emergency Care
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.1 Hospital chief executive officers should adopt ......... ..... .... ... ... ...... X ........ ........ ............. .....
enterprise-wide operations management and related
strategies to improve the quality and efficiency of
emergency care.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.2 The Centers for Medicare and Medicaid Services should ......... X .... ... ... ...... ......... ........ ........ ............. .....
remove the current restrictions on the medical
conditions that are eligible for separate clinical
decision unit (CDU) payment.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.3 Training in operations management and related ......... ..... .... ... ... ...... ......... ........ ........ X X
approaches should be promoted by professional
associations; accrediting organizations, such as the
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) and the National Committee for
Quality Assurance (NCQA); and educational institutions
that provide training in clinical, health care
management, and public health disciplines.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.4 The joint Commission on the Accreditation of ......... ..... .... ... ... ...... ......... ........ ........ ............. X
Healthcare Organizations (JCAHO) should reinstate strong
standards that sharply reduce and ultimately eliminate
ED crowding, boarding, and diversion.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.5 Hospitals should end the practices of boarding ......... X .... ... ... ...... X ........ ........ ............. .....
patients in the ED and ambulance diversion, except in
the most extreme cases, such as a community mass
casualty event. The Centers for Medicare and Medicaid
Services should convene a working group that includes
experts in emergency care, inpatient critical care,
hospital operations management, nursing and other
relevant disciplines to develop boarding and diversion
standards, as well as guidelines, measures, and
incentives for implementation, monitoring, and
enforcement of these standards.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 5: Technology and Communication
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.1 Hospitals should adopt robust information and ......... ..... .... ... ... ...... x ........ ........ ............. .....
communications systems to improve the safety and quality
of emergency care and enhance hospital efficiency.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 6: The Emergency Care Workforce
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.1 Hospitals, physician organizations, and public health ......... ..... .... ... ... ...... X ........ ........ X X
agencies should collaborate to regionalize critical
specialty care on-call services.
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.2 Congress should appoint a commission to examine the X ..... .... ... ... ...... ......... ........ ........ ............. .....
factors responsible for the declining availability of
providers in high-risk emergency and trauma care
specialties, including the role played by medical
malpractice liability in specific, and to recommend
targeted state and federal actions to mitigate the
adverse impact of the responsible factors and ensure
quality of care.
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.3 The American Board of Medical Specialties and its ......... ..... .... ... ... ...... ......... ........ ........ X X
constituent Boards should extend eligibility for
certification in critical care medicine to all acute
care and primary care physicians who complete an
accredited care fellowship program.
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.4 The Department of Health and Human Services, the ......... X X X ... ...... ......... ........ ........ ............. .....
Department of Transportation, and the Department of
Homeland Security should jointly undertake a detailed
assessment of emergency and trauma workforce capacity,
trends, and future needs, and develop strategies to meet
these needs in the future.
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.5 The Department of Health and Human Services, in ......... X .... ... ... ...... ......... ........ ........ X .....
partnership with professional organizations, should
develop national standards for core competencies
applicable to physicians, nurses, and other key
emergency and trauma professionals, using a national,
evidence-based, multidisciplinary process.
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.6 States should link rural hospitals with academic ......... ..... .... ... ... X X ........ ........ ............. .....
health centers to enhance opportunities for professional
consultation, telemedicine, patient referral and
transport, and continuing professional education.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 7: Disaster Preparedness
--------------------------------------------------------------------------------------------------------------------------------------------------------
7.1 The Department of Homeland Security, the Department ......... X X ... ... ...... ......... ........ ........ ............. X
of Health and Human Services, the Department of
Transportation, and the states should collaborate with
the Veterans Health Administration to integrate the VHA
into civilian disaster planning and management.
--------------------------------------------------------------------------------------------------------------------------------------------------------
7.2 All institutions responsible for the training, ......... ..... .... ... ... X ......... ........ ........ X X
continuing education, and credentialing and
certification of professionals involved in emergency
care (including medicine, nursing, EMS, allied health,
public health, and hospital administration) incorporate
disaster preparedness training into their curricula and
competency criteria.
--------------------------------------------------------------------------------------------------------------------------------------------------------
7.3 Congress should significantly increase total disaster
preparedness funding in FY 2007 for hospital emergency
preparedness in the following areas:
strengthening and sustaining trauma care
systems;.
enhancing ED, trauma center, and inpatient
surge capacity;.
improving EMS response to explosives.......... X
designing evidence-based training programs;...
enhancing the availability of decontamination
showers, standby ICU capacity; negative pressure
rooms, and appropriate personal protective equipment;.
conducting international collaborative
research on the civilian consequences of conventional
weapons (CW) terrorism..
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 8: Enhancing the Emergency and Trauma Care Research Base
--------------------------------------------------------------------------------------------------------------------------------------------------------
8.1 Academic medical centers should support emergency and ......... ..... .... ... ... ...... X ........ ........ ............. .....
trauma care research by providing research time and
adequate facilities for promising emergency care and
trauma investigators, and by strongly considering the
establishment of autonomous departments of emergency
medicine.
--------------------------------------------------------------------------------------------------------------------------------------------------------
8.2 The Secretary of the Department of Health and Human X X X X X ...... ......... ........ ........ ............. .....
Services should conduct a study to examine the gaps and
opportunities in emergency and trauma care research, and
recommend a strategy for the optimal organization and
funding of the research effort. This study should
include consideration of; training of new investigators;
development of multi-center research networks; funding
of General Clinical Research Centers (GCRCs) that
specifically include an emergency and trauma care
component; involvement of emergency and trauma care
researchers in the grant review and research advisory
processes; and improved research coordination through a
dedicated center or institute. Congress and federal
agencies involved in emergency care research (including
DOT, DHHS, DHS, and DoD) should implement the study's
recommendationS.
--------------------------------------------------------------------------------------------------------------------------------------------------------
8.3 Congress should modify Federalwide Assurance Program X ..... .... ... ... ...... ......... ........ ........ ............. .....
(FWA) regulations to allow the acquisition of limited,
linked, patient outcome data without the existence of an
FWA.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Appendix E
Recommendations and Responsible Entities from the Future of Emergency Care Series
EMERGENCY MECICAL SERVICES AT THE CROSSROADS
--------------------------------------------------------------------------------------------------------------------------------------------------------
EMS Private Professional
Congress DHHS DOT DHS DOD States Hospitals Agencies Industry Organizations Other
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 3: Building a 21-Century Emergency Care System
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.1 The Department of Health and Human Services and ......... X X ... ... ...... ......... ........ ........ X .....
National Highway Traffic Safety Administration, in
partnership with professional organizations, should
convene a panel of individuals with multidisciplinary
expertise to develop an evidence-based categorization
system for EMS, EDs, and trauma centers based on adult
and pediatric service capabilities.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.2 The National Highway Traffic Safety Administration, ......... ..... X ... ... ...... ......... ........ ........ X .....
in partnership with professional organizations, should
convene a panel of individuals with multidisciplinary
expertise to develop evidence-based, model prehospital
care protocols for the treatment, triage, and transport
of patients.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.3 The Department of Health and Human Services should ......... X .... ... ... ...... ......... ........ ........ ............. .....
convene a panel of individuals with emergency and trauma
care expertise to develop evidence-based indicators of
emergency care system performance.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.4 Congress should establish a demonstration program, X X .... ... ... ...... ......... ........ ........ ............. .....
administered by Health Resources and Services
Administration, to promote regionalized, coordinated,
and accountable emergency care systems throughout the
country, and appropriate $88 million over 5 years to
this program.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.5 Congress should establish a lead agency for emergency X X .... ... ... ...... ......... ........ ........ ............. .....
and trauma care within 2 years of the publication of
this report. This lead agency should be housed in the
Department of Health and Human Services, and should have
primary programmatic responsibility for the full
continuum of EMS, emergency and trauma care for adults
and children, including medical 9-1-1 and emergency
medical dispatch, prehospital EMS (both ground and air),
hospital-based emergency and trauma care, and medical-
related disaster preparedness. Congress should establish
a working group to make recommendations regarding the
structure, funding, and responsibilities of the new
agency, and develop and monitor the transition. The
working group should have representation from federal
and state agencies and professional disciplines involved
in emergency and trauma care.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.6 The Department of Health and Human Services should ......... X .... ... ... ...... ......... ........ ........ ............. .....
adopt rule changes to the Emergency medical Treatment
and Active Labor Act (EMTALA) and the Health Insurance
Portability and Accountability Act (HIPAA) so that the
original goals of the laws are preserved but integrated
systems may further develop.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.7 CMS should convene an ad hoc work group with ......... X .... ... ... ...... ......... ........ ........ ............. .....
expertise in emergency care, trauma, and EMS systems to
evaluate the reimbursement of EMS and make
recommendations regarding inclusion of readiness costs
and permitting payment without transport.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 4: Supporting a High quality EMS Workforce
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.1 State governments should adopt a common scope of ......... ..... .... ... ... X ......... ........ ........ ............. .....
practice for EMS personnel, with state licensing
reciprocity.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.2 States should require national accreditation of ......... ..... .... ... ... X ......... ........ ........ ............. .....
paramedic education programs.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.3 States should accept national certification as a ......... ..... .... ... ... X ......... ........ ........ ............. .....
prerequisite for state licensure and local credentialing
of EMS providers.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.4 The American Board of Emergency Medicine should ......... ..... .... ... ... ...... ......... ........ ........ X .....
create a subspecialty certification in EMS.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 5: Advancing System Infrastructure
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.1 States should assume regulatory oversight of the ......... ..... .... ... ... X ......... ........ ........ ............. .....
medical aspects of air medical services, including
communications dispatch, and transport protocols.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.2 Hospitals, trauma centers, EMS agencies, public ......... ..... .... ... ... ...... X X ........ ............. X
safety departments, emergency management offices, and
public health agencies should develop integrated and
interoperable communications and data systems.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.3 The Department of Health and Human Services should ......... X .... ... ... ...... ......... ........ ........ ............. .....
fully involve prehospital EMS leadership in discussions
about the design, deployment, and financing of the
National Health Information Infrastructure (NHh).
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 6: Preparing for Disasters
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.1 The Department of Health and Human Services, the ......... X X X ... X ......... ........ ........ ............. .....
Department of Transportation, the Department of Homeland
Security, and the states should elevate emergency and
trauma care to a position of parity with other public
safety entities in disaster planning and operations.
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.2 Congress should substantially increase funding for X ..... .... ... ... ...... ......... ........ ........ ............. .....
EMS-related disaster preparedness through dedicated
funding streams.
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.3 Professional training, continuing education, and ......... ..... X ... ... X ......... ........ ........ X X
credentialing and certification programs of all the
relevant EMS professional categories, should incorporate
disaster preparedness training into their curricula, and
require the maintenance of competency in these skills.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 7: Optimizing Prehospital Care through Research
--------------------------------------------------------------------------------------------------------------------------------------------------------
7.1 Federal agencies that fund emergency and trauma care ......... X X X X ...... ......... ........ ........ ............. X
research should target additional funding at prehospital
EMS research, with an emphasis on systems and outcomes
research.
--------------------------------------------------------------------------------------------------------------------------------------------------------
7.2 Congress should modify Federalwide Assurance Program X ..... .... ... ... ...... ......... ........ ........ ............. .....
(FWA) regulations to allow the acquistions of limited,
linked, patient outcome data without the existence of an
FWA.
--------------------------------------------------------------------------------------------------------------------------------------------------------
7.3 The Secretary of Department of Health and Human X X X X X ...... ......... ........ ........ ............. .....
Services should conduct a study to examine the gaps and
opportunities in emergency and trauma care research, and
recommend a strategy for the optimal organization and
funding of the research effort. This study should
include consideration of: training of new investigators;
development of multi-center research networks,
involvement of emergency medical services researchers in
the grant review and research advisory processes; and
improved research coordination through a dedicated
center or institute. Congress and federal agencies
involved in emergency care research (including
Department of Transportation, Department of Health and
Human Services, Department of Homeland Security, and
Department of Defense) should implement the study's
recommendations.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Appendix E
Recommendations and Responsible Entities from the Future of Emergency Care Series
EMERGENCY CARE FOR CHILDREN: GROWING PAINS
--------------------------------------------------------------------------------------------------------------------------------------------------------
EMS Private Professional
Congress DHHS DOT DHS DOD States Hospitals Agencies Industry Organizations Other
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 3: Building a 21st-Century Emergency Care System
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.1 The Department of Health and Human Services and ......... X X ... ... ...... ......... ........ ........ X .....
National Highway traffic Safety Administration, in
partnership with professional organizations, should
convene a panel of individuals with multidisciplinary
expertise to develop an evidence-based categorization
system for EMS, EDs, and trauma centers based on adult
and pediatric service capabilities.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.2 The National Highway Traffic Safety Administration, ......... ..... X ... ... ...... ......... ........ ........ X .....
in partnership with professional organizations, should
convene a panel of individuals with multidisciplinary
expertise to develop evidence-based model prehospital
care protocols for the treatment, triage, and transport
of patients, including children
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.3 The Department of Health and Human Services should ......... X .... ... ... ...... ......... ........ ........ ............. .....
convene a panel of individuals with emergency and trauma
care expertise to develop evidence-based indicators of
emergency care system performance, including performance
of pediatric emergency care.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.4 Congress should establish a demonstration program, X X .... ... ... ...... ......... ........ ........ ............. .....
administered by the Health Resources and Services
Administration, to promote regionalized, coordinated,
and accountable emergency care systems throughout the
country, and appropriate $88 million over 5 years to
this program.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.5 The Department of Health and Human Services should ......... X .... ... ... ...... ......... ........ ........ ............. .....
adopt rule changes to the Emergency Medical Treatment
and Active Labor Act and the Health Insurance
Portability and Accountability Act so that the original
goals of the laws are preserved but integrated systems
may further develop.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.6 Congress should establish a lead agency for emergency X X .... ... ... ...... ......... ........ ........ ............. .....
and trauma care within 2 years of the publication of
this report. The lead agency should be housed in the
Department of Health and Human Services, and should have
primary programmatic responsibility for the full
continuum of EMS, emergency and trauma care for adults
and children, including medical 9-1-1 and emergency
medical dispatch, prehospital EMS (both ground and air),
hospital-based emergency and trauma care, and medical-
related disaster preparedness. congress should establish
a working group to make recommendations regarding the
structure, funding, and responsibilities of the new
agency, and develop and monitor the transition. The
working group should have representation from federal
and state agencies and professional disciplines involved
in emergency and trauma care.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.7 Congress should appropriate $37.5 million each year X ..... .... ... ... ...... ......... ........ ........ ............. .....
for the next five years to the EMS-Program.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 4: Arming the Emergency Care Workforce with Knowledge and Skills
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.1 Every pediatric and emergency care-related health ......... ..... .... ... ... ...... ......... ........ ........ X .....
professional credentialing and certification body should
define pediatric emergency care competencies and require
practitioners to receive the appropriate level of
initial and continuing education necessary to achieve
and maintain those competencies.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.2 The Department of Health and Human Services should ......... X .... ... ... ...... ......... ........ ........ X .....
collaborate with professional organizations to convene a
panel of individuals with multidisciplinary expertise to
develop, evaluate, and update pediatric emergency care
clinical practice guidelines and standards of care.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.3 EMS agencies should appoint a pediatric emergency ......... ..... .... ... ... ...... X X ........ ............. .....
coordinator and hospitals should appoint two pediatric
emergency coordinators--one a physician--to provide
pediatric leadership for the organization.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 5: Improving the Quality of Pediatric Emergency Care
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.1 The Department of Health and Human Services should ......... X .... ... ... ...... ......... ........ ........ ............. .....
fund studies on the efficacy, safety, and health
outcomes of medications used for infants, children, and
adolescents in emergency care settings in order to
improve patient safety.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.2 The Department of Health and Humane Services and the ......... X X ... ... ...... X X ........ ............. .....
National Highway Traffic Safety Administration should
fund the development of medication dosage guidelines,
formulations, labeling, and administration techniques
for the emergency care setting to maximize effectiveness
and safety for infants, children and adolescents, EMS
agencies and hospitals should implement these
guidelines, formulations, and techniques into practice.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.3 Hospitals and EMS systems should implement evidence- ......... ..... .... ... ... ...... X X ........ ............. .....
based approaches to reduce errors in emergency and
trauma care for children.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.4 Federal agencies and private industry should fund ......... X X X ... ...... ......... ........ X ............. .....
research on pediatric-specific technologies and
equipment used by emergency and trauma care personnel.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.5 EMS agencies and hospitals should integrate family- ......... ..... .... ... ... ...... X X ........ ............. .....
centered care into emergency care practice.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 6: Improving Emergency Preparedness and Response for Children Involved in Disasters
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.1 Federal agencies (the Department of Health and Human
Services, the National Highway Traffic Safety
Administration, and the Department of Homeland Security)
in partnership with state and regional planning bodies
and emergency care provider organizations should convene
a panel with multidisciplinary expertise to develop
strategies for addressing pediatric needs in the event
of a disaster. This effort should
encompass the following:............................... ......... X X X X ...... ......... ........ ........ ............. .....
1) Development of strategies to minimize parent-child
separation and improved methods for reuniting
separated children with their families..
2) Development of strategies to improve the level of
pediatric expertise on disaster Medical Assistance
Teams and other organized disaster response teams..
3) Development of disaster plans that address pediatric
surge capacity for both injured and non-injured
children..
4) Development of and improved access to specific
medical and mental health therapies, as well as social
service, for children in the event of a disaster..
5) Development of policies that ensure that disaster ......... ..... .... ... ... ...... ......... ........ ........ ............. .....
drills include a pediatric mass casualty incident at
least once every 2 years..
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chapter 7: Building the Evidence Base for Pediatric Emergency Care
--------------------------------------------------------------------------------------------------------------------------------------------------------
7.1 The Secretary of DHSS should conduct a study to ......... X X X X ...... ......... ........ ........ ............. .....
examine the gaps and opportunities in emergency care
research, including pediatric emergency care, and
recommend a strategy for the optimal organization and
funding of the research effort. This study should
include consideration of training of new investigators,
development of multicenter research networks,
involvement of emergency and trauma care researchers in
the grant review and research advisory processes, and
improved research coordination through a dedicated
center or institute. Congress and federal agencies
involved in emergency and trauma care research
(including the Department of Transportation, Department
of Health and Human Services, Department of Homeland
Security, and Department of Defense) should implement
the study's recommendations.
--------------------------------------------------------------------------------------------------------------------------------------------------------
7.2 Administrators of statewide and national trauma ......... ..... .... ... ... ...... ......... ........ ........ ............. X
registries should include standard pediatric-specific
data elements and provide the data to the NTDB.
Additionally, the American College of Surgeons should
establish a multidisciplinary pediatric specialty
committee to continuously evaluate pediatric-specific
data elements for the NTDB and identify areas for
pediatric research.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mr. Reichert. The Chair recognizes Ms. Jagim.
STATEMENT OF MARY JAGIM
Ms. Jagim. Good, Mr. Chairman and members of the
subcommittee. Thank you so much for convening this hearing
today and allowing us to speak with you.
I am Mary Jagim, the Internal Consultant for Emergency
Preparedness and Pandemic Planning for MeritCare Health System
in Fargo, North Dakota, and I was a member of the committee
that oversaw the development of IOM reports.
I am here today, though, representing the Emergency Nurses
Association where I have served on the board of directors and
was the 2001 president. ENA, with over 30,000 members, is the
only professional nursing organization directed toward defining
the future of emergency nursing and emergency care. And on
behalf of ENA I appreciate the opportunity to discuss our
concerns regarding hospital surge and mass trauma care
capacity.
Over the past 5 years, millions of dollars have gone to
strengthen our country's disaster preparedness. However, one
area, as you have heard, still has not received the level of
support it needs to prepare for mass casualty episodes. It is
emergency care providers and hospitals, the ones who provide
the emergency medical care for patients and family members
during a disaster. Hospitals and EMSs have been underfunded,
undersupported, and, in many cases, just plain left out. And it
is the emergency care system of our country that right now is
the most fragile, most oversaturated, and most fragmented of
all of our health care needs.
So despite national expectations that our emergency care
system on a day-to-day basis is there for people, instead, it
is extremely overloaded and vulnerable, lacking the ability to
respond appropriately when needed. How then is it to respond
when the extraordinary occurs?
I want to focus most of my comments, though, on a vital
role within our emergency preparedness response system, and
that is the role of the emergency nurse.
There is an expansive skill set and knowledge base required
to be an emergency nurse, as we must be prepared to care for
every type of illness and injury of every age group, all of
whom are in a state of crisis when they come to our doors.
Nurses entering the field of emergency nursing need a
minimum of 2 years following their educational preparation
simply to acquire the core knowledge needed to work in an
emergency department. And years beyond those first two are
necessary to fully master their significant role as a
coordinator of patient care. For it is that coordinator-of-care
role, along with their critical thinking skills, that really
enables an emergency nurse to swiftly assess the situation at
hand and respond appropriately and bring to the patient the
resources they need at that moment in time.
Let's take, for example, the occurrence of a mass casualty
event in one of your communities. When that occurs, it is the
emergency nurse that receives the call from EMS that an event
has occurred and that multiple victims will be brought to the
hospital. It is that emergency nurse that activates the
hospital's response plan and calls in additional nurses and
physicians as well as others to assist. It is the emergency
nurse who then goes on to make arrangements to get all the
current emergency department patients either admitted,
discharged, or moved to other locations.
It is the ED nurse that organizes triage to receive the
arriving victims and who direct the EMS crews and coordinates
the disaster decontamination teams. It is emergency nurses then
who also stay at the patient's bedside providing care and
comfort in their time of need, and it is the nurses who notify
family members and console those who have lost loved ones.
And most likely, it was an emergency nurse who helped to
write the plan that activated the response, including the
procurement of appropriate supplies and equipment, and who
developed the educational training program and trained the
staff--that is, if those plans and training have occurred in
the first place.
The emergency nurse has a vital role, more precious right
now because of the nursing shortage. During the 10-year span
between 2002 and 2012 health care facilities will need to fill
more than 1.1 million R.N. job openings.
The nursing community has been urgently asking Congress to
increase funding for nursing workforce development programs,
and especially to increase funding for nursing faculty
preparation.
Do you know that the Federal investment in nursing
education is less than 600-thousandths of the total Federal
budget, whereas in 1974 during our last serious nursing
shortage, Congress appropriated 153 million for nurse
educational programs. In today's dollars that would be
equivalent to $592 million, which is about four times what the
Federal Government is currently putting towards nursing
education.
Applications to nursing programs have been increasing
during this past time, but in the last school year, 147,000
qualified applicants had to be turned away because there were
not enough faculty in the schools to teach them.
The results of the disparities in workforce supply and
demand are played out in staff shortages in the majority of
emergency departments and hospitals across this country. And it
results in staff who are struggling to provide care, to ED
crowding, to ambulance diversions, and to the patients who are
ultimately the ones who suffer. And the situation is only going
to get worse as our population ages.
The emergency nurses of this country have been
underrecognized and undervalued and truly undersupported in
their roles. Yet they so strongly desire to provide skills and
compassionate emergency care to their patients.
We ask you, please, to support the recommendations that ENA
has outlined in our written testimony and to work with us to
create a coordinated, regionalized, and accountable emergency
care system that is staffed, that is trained, and that is
prepared, so that when our communities need us we can be there.
We cannot achieve this alone. Thank you.
Mr. Reichert. Thank you Ms. Jagim.
[The statement of Ms. Jagim follows:]
Prepared Statement of Mary M. Jagim, RN, BSN, CEN, FAEN
Good morning, Mr. Chairman and members of the Subcommittee. Thank
you for convening this hearing to examine the current condition of
emergency care and its implications for maintaining security in our
nation. Characterized as ``overburdened, short of resources, under
funded, and fragmented'', the present situation is an environment where
emergency departments are less able to serve as the country's safety
net in ordinary situations, much less able to appropriately handle the
extraordinary events of natural and man-made disasters.
I am Mary Jagim, the Internal Consultant for Emergency Preparedness
and Pandemic Planning for MeritCare Health System in Fargo, North
Dakota, and a member of the Institute of Medicine's (IOM) committee
that oversaw the development of the report, Future of Emergency Care in
the United States Health Sys-tem. I am here today representing the
Emergency Nurses Association (ENA) where I have served on the Board of
Directors and as the 2001 President. ENA is the only professional
nursing organization dedicated to defining the future of emergency
nursing and emergency care through expertise, innovation, and
leadership. It serves as the voice of more than 30,000 members and
their patients through research, publications, professional
development, injury prevention, and patient education. Recognized as an
authority in the discipline of emergency care and its practice, ENA was
invited by the IOM to share its data and expertise on the current state
of U.S. emergency departments (EDs). On behalf of the Emergency Nurses
Association, I appreciate this opportunity to discuss with the
Subcommittee our particular concerns regarding hospital surge and mass
trauma care capacity.
MASS TRAUMA AND EMERGENCY NURSING CARE
Emergency nurses are no strangers to mass casualty challenges. We
engage continually in every aspect of patient care throughout the
emergency care system. Emergency nurses conduct triage, the first
application of medical care in the ED, assessing patient conditions and
swiftly prioritizing needs within a rapidly changing scenario. We
coordinate treatment and autonomously intervene at a moment's notice.
In addition, it is our role to invest quality time with patients and
their families as we teach them how to manage their conditions and
prevent injuries. Emergency nurses are a critical member of daily
emergency care and, owing to our requisite knowledge and skills, we
occupy a unique role on the team of professionals delivering mass
casualty care.
All hospitals and medical facilities across our country are
vulnerable to mass casualty incidents. A mass casualty incident occurs
as a result of an event where sudden and high patient volume exceeds an
ED's resources. Such events may include the more commonly realized
multi-car pile-ups, train crashes, hazardous material exposures in a
building or across a community, high occupancy structural fires, or the
extraordinary events such as pandemics, weather-related disasters, and
intentional catastrophic acts of violence. In all cases and degrees of
calamity, the emergency department is the entry point into the hospital
system and is the initial facility-based, patient-care area for victims
of a mass casualty incident.
FRAGMENTATION/REGIONALIZATION
ENA supports the IOM's assertion that the U.S. emergency care
system needs to be coordi-nated and regionalized. The IOM report
acknowledges that the nation's emergency care system is poorly prepared
to care for ill and wounded patients following a mass casualty
incident. It describes today's emergency care system as saturated,
highly fragmented, and variable. In its 2002 Mass Casualty Incidents
position statement, ENA recommended that emergency services be seamless
with 911 and dispatch, ambulances, emergency medical services (EMS)
personnel, hospital EDs, and trauma centers and specialists working in
a coordinated manner. The ENA believes emergency care also must be
regionalized to help ensure the patient is transported to the right
hospital at the right time for the right care.
ENA supports the immediate reinstatement of funding for the HRSA
Trauma-EMS Program in order to renew the work in the states toward
establishment of state-wide trauma systems. The Trauma-EMS Program,
administered by the Health Resources and Services Administration
(HRSA), provided states with grants for planning, developing, and
implementing statewide trauma care systems. Although only eight states
have fully developed trauma systems, these statewide healthcare systems
could be used as models for full regionalization of care. ENA
recognizes the necessity of the Trauma-EMS Program, which has been the
only federal source available to build a trauma system infrastructure
in the United States. When it existed, the Trauma-EMS Program, which
lost its funding in FY 2006, provided critical national leadership, and
leveraged additional scarce state dollars, to optimize trauma care
through system integration that offered seriously injured individuals,
wherever they lived, prompt emergency transport to the nearest
appropriate trauma center within the ``golden hour.'' The IOM report
bolsters support for such regionalized models of care by drawing on
substantial evidence that ``demonstrates that doing so [i.e., creating
a coordinated, regionalized system] improves outcomes and reduces costs
across a range of high-risk conditions and procedures.''
ENA supports the IOM's call for a series of research demonstration
projects that will put these ideas into practice by testing these
strategies under various emergency care conditions. Achieving this
result takes coordination, commitment of staff, development and
implementation of standards of care, a process for designating trauma
centers, and evaluation. To this end, ENA has advocated a
regionalization that gathers together all community stakeholders to
examine all alternatives for providing appropriate patient care and
better patient outcomes. Our organization supports a best practice of
coordinated, community-wide response planning, using a common framework
that is applicable to all hazards and that links local, state,
regional, and national resources.
DISASTER PREPAREDNESS
ENA supports development of basic and advanced continuing-education
courses and training to prepare emergency nurses in the care and
treatment of victims, across all age groups and diverse populations, of
mass casualty incidents. Disaster preparedness is an essential function
of frontline emergency nurses and the emergency care continuum.
Emergency preparedness for mass casualty incidents should be a major
part of an emergency nurse's training and should be reflected in the
work she or he does every day. Our organization, through its
conferences and publications, including the quarterly Disaster
Management and Response journal, provides its members with information
and resources on disaster preparedness. But as the IOM report points
out, in general, a lack of planning, training, and supplies, along with
limited federal funding, complicates the mass casualty readiness
situation at the hospital ED level across the country.
ENA joins the IOM in urging an increase in federal funding
allocated to assist hospitals in plan-ning, in training, and in
equipment and supply procurement for all-hazards disaster prepared-
ness. Although EDs play a significant role in the medical response to
major disaster events, a current imbalance exists in funding
allocations. Funding either has not reached all hospitals, or--for
those that received funding--the average amount was between $5,000 and
$10,000 in 2002 and 2003. Owing to the capacity needs and
infrastructure that must be advanced to meet the national goal of an
emergency care system ready to appropriately respond to all-hazards
disasters, the allocation of federal emergency preparedness funds is
grossly insufficient.
For example, a considerable amount of the federal funding has been
allocated to fire. Much of this funding has been used for equipment
procurement and training involving chemical and biological
contamination. Past experience has shown that in disasters of mass
contamination, only a portion--as little as 20 percent--of the victims
remain on scene for decontamination and medical care. The remaining 80
percent present at the hospital ED, where the appropriate equipment and
training have been under funded, if funded at all. The fire and EMS
personnel and equipment at the disaster scene are not available to
respond and assist with the decontamination needs of the majority of
the victims who are presenting to the ED. The allocation of emergency
preparedness monies to hospitals has been disproportionate to the share
of the medical response to major disaster events delivered by EDs.
Without specific funding provided to hospitals for the purposes of
planning, training, and procurement, these activities will not occur,
leaving hospitals under--or unprepared, and our national goal of
disaster preparedness unmet.
The ENA unites with COMCARE, a nonprofit national advocacy
organization dedicated to ad-vancing emergency communications, in
advocating that emergency communications systems and
``interoperability' are defined to include interorganizational data
communications and data communications generally. Coordinated and
comprehensive communication is another critical aspect of disaster
preparedness for mass casualty events. Appropriate protection of the
public requires continuous, redundant, and reliable systems of all
forms of communications and information technology. As a member of
COMCARE, ENA recognizes the vital nature of data and information
technology, whether supporting emergency alerts to agencies and the
public, shared systems for incident management and situational
awareness, patient tracking applications, resource management, or
scores of other uses. Fully interoperable parameters necessitate the
use of integrated, multimode emergency communications systems designed
to communicate with one another on demand in real time, and--as
necessary--support voice and data interchange between the emergency and
emergency support organizations, in addition to radio communications
with mobile staff.
ED nurses, along with all other medical and emergency responders,
need to be able to receive, send, and access all kinds of patient data
on a daily basis. An example is the frequent occurrences of patients
arriving at the ED on their own, by ambulance, or as a result of an
evacuation from another hospital without any information regarding
their medical history. Healthcare workers should have access to all of
the appropriate information: Who is the primary physician? What
medicines is the patient taking? What are the vitals? What treatments
have already been given? Our members need to communicate and share
information with other professions and jurisdictions so that we can
provide the best care possible to our patients during and after
everyday emergencies and mass casualty disasters.
ENA supports COMCARE in recommending that the local, regional, and
state emergency com-munications planning and implementation required by
current federal guidelines be conducted as an integrated whole,
including all organizations involved with emergency response, and all
forms of communications. We are concerned that the current planning
processes are focused too narrowly and are compromising our nation's
ability to rapidly improve our response capabilities. All organizations
involved in emergency preparation and responses need to participate in
planning and deployment. Furthermore, not only must funding guidelines
allow expenditures on software and emergency services information
technology in addition to equipment procurement, but the guidelines
also must provide for planning and training.
THE FOUNDATION OF THE EMERGENCY CARE SYSTEM
Preparing for hospital surge and mass trauma care capacity will not
happen without remediation of the general emergency care system
infrastructure.
NURSING WORKFORCE AND NURSING FACULTY SHORTAGES
The IOM report also notes that nursing shortages in U.S. hospitals
continue to disrupt hospital operations and are detrimental to patient
care and safety. Because of the unique insight and clinical knowledge
of an experienced emergency nurse, the nursing shortfalls constitute a
loss of expertise in the system. Nurses are not interchangeable
resources. The expertise of a seasoned ED nurse is critical to achieve
quality patient outcomes in a dynamic healthcare system that demands
competencies for a multitude of situations, including all-hazards mass
casualty events. Hospital staffing systems must acknowledge the need
for, and incorporate, training and education time and funding for
emergency nurses.
ENA agrees with the IOM's recommendation that federal agencies must
jointly undertake a detailed assessment of emergency and trauma
workforce capacity, trends, and future needs to develop strategies
meeting these needs in the future. Today's nursing shortage is very
real and very different from any experienced in the past. The existing
shortage is evidenced by an aging workforce and too few individuals
entering the profession. A critical factor exacerbating the national
nurse-workforce deficiency is the declining number of qualified nurses
available to teach future generations of registered nurses.
ENA supports the IOM's assertion that national standards for core
competencies applicable to nurses and other key emergency and trauma
professionals be developed using a national, evidence-based,
multidisciplinary process. To date, the ENA-affiliated Board of
Certification of Emergency Nursing (BCEN) has credentialed
14,000 Certified Emergency Nurses (CEN) and more than 1,000
Flight Registered Nurses (CFRN). BCEN also recently
announced the launch of the Certified Transport Registered Nurse
(CTRNTM) certification for nurses qualified to move patients
between medical facilities.
The ENA is on record advocating increased federal efforts to support:
Effective strategies for the recruitment, retention,
and continuing education of registered nurses working in
emergency departments, providing safe, efficient, quality care,
especially during crisis situations when the ED is crowded and
functioning above capacity; and
New strategies to increase the numbers of individuals
pursuing nursing careers, as well as initiatives to increase
qualified nursing faculty, who are vital to addressing the
nursing shortage.
CROWDING
Crowding in our nation's emergency departments is of increasing
concern. In our 2005 position statement Crowding in the Emergency
Department, ED crowding is described as ``a situation in which the
identified need for emergency services outstrips available resources in
the emergency department. This situation occurs in hospital emergency
departments when there are more patients than staffed ED treatment beds
and wait times exceed a reasonable period.''
When crowding occurs, patients are often placed in hallways and
other nontreatment areas to be monitored until ED treatment beds or
staffed hospital inpatient beds become available. In addition, crowding
may contribute to an inability to triage and treat patients in a timely
manner, as well as increased rates of patients leaving the ED without
being seen. As a result of crowding, hospitals often implement
ambulance diversion measures.
An emergency care system that is beyond saturation on a daily basis
will have limited ability to respond to the surge of patients related
to catastrophic events. The federal government must establish clear
leadership and directed funding support to coordinate the functions of
emergency care, as well as assist in providing system incentives for
nonemergency care that is delivered in areas outside of the ED.
One aspect of crowding that ENA continues to address concerns the
interpretation of emergency care's federally mandated regulations. ENA
wholeheartedly endorses unencumbered access to quality emergency care
by all individuals regardless of their financial status. However,
EMTALA, the Emergency Medical Treatment and Labor Act which ensures
public access to emergency services regardless of ability to pay, has
had the unintentional effect of increasing unnecessary visits to the ED
for acute and chronic conditions that do not meet the Centers for
Medicare and Medicaid Services' (CMS) definition of ``emergency medical
condition''.
ENA acknowledges an attempt by CMS to lessen the restrictions
regarding patients with nonemergent conditions. Despite a CMS
clarification, much confusion continues to surround this issue,
grounded in fear of possible reprisals for failure to strictly adhere
to EMTALA mandates. EMTALA continues to limit an ED's options to manage
its patient load by limiting its ability to send nonurgent patients
off-site for clinical care, rather than conducting a full medical
assessment in the ED. Nurses cannot tell a patient probable wait times
or suggest alternatives for care under the current rules. With severe
crowding and ambulance diversions identified as a national crisis,
compounded by the increase in patients using the ED for primary care,
some flexibility is needed for clinical judgment by an ED practitioner
(who has experienced an actual encounter with the patient) to identify
those patients who do not obviously meet the definition of an emergency
medical condition.
Notwithstanding EMTALA regulations, the problem of crowding is not
confined to the ED, and is considered a systems issue, which can be
examined at department and institution levels as well as at local,
regional, and national levels. The factors contributing to ED crowding
are numerous and varied and have been well documented in the
literature. The root causes of ED crowding are embedded in the crisis
of health care in the U.S., requiring solutions that may fall outside
of the ED's control. The ENA believes crowding is caused by
Hospital/trauma center closures;
Lack of inpatient beds, forcing emergency departments
to hold patients;
Increased use of emergency departments over the past
decade; and
Lack of universal access to primary and preventative
health care and the use of the emergency department for primary
care.
To address crowding, ENA recommends increased federal funding to
support:
Collaborative research by emergency nurses and
physicians to develop and implement new flow management
solutions for the emergency department to both prevent and
manage ED crowding;
Professional and public awareness programs as well as
legislative efforts to reduce visits to the ED by
(1) strengthening capacity for nonemergent care by
increasing access to primary care providers in the community
and teaching when and how to access emergency care; (2)
reducing the numbers of uninsured and underinsured; (3)
reducing trauma caused by preventable injuries, violence, and
substance abuse; and (4) improving prevention, wellness, and
disease management efforts; and
Evaluation and prioritized performance incentives that
increase capacity and efficiency, not only in the emergency
department, but within hospitals and other patient care
facilities in order to help reduce the burdens suffered by ED
patients when emergency departments become too crowded for
patients needing specialized care.
STATUTORY NATURE OF U.S. EMERGENCY CARE
When the American public is asked about its views on trauma centers
and trauma systems, large majorities value them as highly as having a
police or fire department in their community. In addressing the crucial
nature of regionalized trauma services, the IOM report notes that
trauma care ``is widely viewed as an essential public service.'' The
report further states that ``unlike other such services [e.g.,
electricity, highways, airports, and telephone service . . . created
and then actively maintained through major national infrastructure
investments] access to timely and high quality . . . trauma care has
largely been relegated to local and state initiative''.
The dilemma of emergency care with readiness for mass casualty
events runs deeper than the disparity between the perceptions of
emergency care as a public service and the funding underlying the
system. A distinctive policy characteristic of emergency care is that
emergency care is legislated (e.g., as previously suggested in the
EMTALA regulations discussion). Of all the health care disciplines,
emergency care is the one that is mandated by the United States
government. In effect, the government has promised the people that
emergency care will be a service to which the public has a lawful right
(not just a discretionary, moral right). This statutory nature holds
special implications, evoking general questions such as:
How does federal support of this public service
compare to support of other legislated services?; and
To what degree is the government legally accountable
for delivery of this right/public service?
For emergency care nurses, this legal requirement reinforces
respective professional duties and ethical commitments. As front-line
providers of emergency care, ENA believes it is essential that every
person in our country has access to a system that provides definitive
care as quickly as possible. The Emergency Nurses Association pledges
our efforts and our expertise to work with you and your colleagues to
assure the population's protection and well-being as homeland security
compels.
Mr. Reichert. The Chair now recognizes Dr. Krug.
STATEMENT OF STEVEN KRUG, M.D.
Dr. Krug. Thank you, Mr. Chairman, and I appreciate the
opportunity to testify today.
My name is Steven Krug. I am a pediatric emergency
physician, and I am the head of the Division of Emergency
Medicine at Children's Memorial Hospital in Chicago. Today I am
proud to represent the American Academy of Pediatrics where I
have the privilege of chairing the Academy's Committee on
Pediatric Emergency Medicine.
Emergency medical services are the foundation our Nation's
defense of public health disasters.
In addition to the many concerns raised by my colleagues
and within the IOM report regarding the overall health of our
Nation's emergency medical services, these systems also bear
some specific limitations in their ability to meet the medical
needs of children. It has been said that children are not
little adults, and this is especially true in an emergency or
during a disaster. Their developing minds and bodies place
children at disproportionate risk in a number of specific ways
in the event of a disaster or terrorist attack. For example,
children are particularly vulnerable to aerosolized biological
or chemical agents, because they normally breathe faster than
adults do and because these agents, being heavier than air,
tend to circulate down near the ground in the breathing zone of
children. There are dozens of other such crucial differences
that make children more vulnerable.
Once children are critically ill or injured, their bodies
respond very differently than adults in similar medical crises.
In addition to their physiological vulnerabilities, children
need different dosages in formulations of medications and
smaller-sized equipment specific to their needs.
This is an adult-sized endotracheal breathing tube. You
could not use this on a child. A small infant would require a
tube of this size.
In pediatric emergency medicine, one size does not fit all.
In fact, there are 12 different sizes between these two tubes.
You have got to have the right size for the right patient or
the patient is not going to survive.
In addition to having the appropriate medications and
resuscitation equipment, it is critical that all health care
workers be able to recognize the unique signs and symptoms of
children that indicate a life-threatening situation, and that
they then possess the skills to intervene accordingly.
The Institute of Medicine characterized the status of
pediatric emergency readiness in 2006 using the word
``uneven,'' noting that not all children have access to the
same quality of care. The report documents several examples of
the problem. I will just list a few.
Only 6 percent of emergency departments across the Nation
have all of the supplies necessary for managing pediatric
emergencies. Only half of hospitals have at least 85 percent of
those critical supplies. Of the hospitals that lack the ability
to provide care for pediatric trauma victims, only half of
those hospitals have written transfer agreements with hospitals
that actually have that capability.
Finally, pediatric emergency treatment patterns and
protocols vary widely across emergency care providers and
across geographic regions.
Each of these shortcomings has major implications for just
day-to-day emergency care and disaster preparedness. I can't
emphasize this next point enough. Systems that are unable to
meet everyday care needs for children, by definition, are
unlikely to be able to deliver the care that we need during a
time of disaster.
The IOM also observed that disaster plans have often
overlooked the needs of children, even though their needs
differ greatly from those of adults. One Federal program
provides a clear example of the general neglect of children's
issues in disaster planning.
HRSA's National Bioterrorism Hospital preparedness program
provides funds to States in localities to improve surge
capacity and other aspects of hospital readiness. In the most
recent grant guidance, HRSA required that all States establish
a system that allows for the triage treatment and disposition
of 500 adult and pediatric patients per 1 million population.
While pediatric patients are referenced, it is not really
clear whether they are required to be represented in proportion
to the number in the State's population. A State could arguably
plan for 499 adults and 1 child and actually satisfy the
guidance.
Outside of that single pediatric mention in benchmark for
surge capacity, children's issues are otherwise absent from the
guidance.
Surge capacity issues are fundamental but many other issues
require similar attention. We must plan for the availability of
drugs and antidotes in the appropriate formulations and dosages
for children. In many cases, medication dosing for children is
determined by their weight. A simple device known as a Braslow
tape--I have one right here--is a rather unique device which
actually helps emergency care providers to calculate the
weight-based dosing of vital resuscitation medications by
measuring the length of the patient. This allows those health
care providers to dose medications quickly and accurately.
Unfortunately, only about half of our disaster management
assistance teams have devices like this.
Perhaps the most important and successful Federal program
in improving emergency health care for children has been HRSA's
Emergency Medical Services for Children program, or EMSC. With
a modest budget allocation, EMSC has driven significant
improvements in pediatric emergency care, including disaster
preparedness.
As just one example, in the 21 years since the program was
established, child injury rates have dropped by 50--rather, by
40 percent, excuse me. The American Academy of Pediatrics fully
endorses the Institute of Medicine's comments regarding the
value of the EMSC program. The program should be reauthorized
and funded at or above the level recommended by the IOM.
The American Academy of Pediatrics has some specific
recommendations for policymakers regarding children in
emergency and disaster preparedness.
First, we must invest in creating effective local, State
and Federal disaster response systems built upon a healthy,
adequately funded, well coordinated, and functional emergency
medical services system.
Secondly, pediatricians should be included in emergency
planning at all levels of government and in all types of
planning. Standards for pediatric emergency readiness for
prehospital and hospital-based emergency services and the
regionalization of pediatric trauma and critical care should be
developed and implemented within every State and region.
Federal, State, and local disaster plans should include
specific protocols for the management of pediatric casualties,
including strategies to improve the level of pediatric
equipment and medication readiness and clinical expertise in
disaster response teams; improve access to pediatric medical
and surgical subspecialty care and pediatric mental health care
professionals; integrate schools and day care facilities in
local and regional disaster plans; minimize parent and child
separation and develop systems for the timely and reliable
reunification of families; address the care requirements of
children with special health care needs; and ensure the
inclusion of pediatric mass casualty incident drills at both
the Federal and State planning levels.
In addition, more research must be funded into all aspects
of pediatric emergency planning response and treatment.
And, lastly, the EMSC program should be authorized and
funded at or above the level recommended by IOM.
In conclusion, the American Academy of Pediatrics greatly
appreciates this opportunity to present our concerns and
recommendations related to pediatric emergency and disaster
preparedness at this afternoon's hearing. Our children must not
be an afterthought in emergency and disaster planning. They are
our most valuable resource.
The American Academy of Pediatrics looks forward to working
with you to protect and promote the health and well-being of
all children, especially in emergency and disaster situations.
Thank you.
Mr. Reichert. Thank you, Doctor.
[The statement of Dr. Krug follows:]
Prepared Statement of Dr. Steven Krug
I appreciate this opportunity to testify today before the Homeland
Security Subcommittee on Emergency Preparedness, Science and Technology
at this hearing, ``Emergency Care Crisis: A Nation Unprepared for
Public Health Disasters.'' My name is Dr. Steven Krug, and I am the
Head of the Division of Pediatric Emergency Medicine at Children's
Memorial Hospital in Chicago, Illinois and a Professor of Pediatrics at
the Northwestern University Feinberg School of Medicine. Today I am
proud to represent the American Academy of Pediatrics, a non-profit
professional organization of 60,000 primary care pediatricians,
pediatric medical sub-specialists, and pediatric surgical specialists
dedicated to the health, safety, and well-being of infants, children,
adolescents, and young adults. I have the privilege of chairing the
Academy's Committee on Pediatric Emergency Medicine.
BACKGROUND
Emergency medical services are the foundation of our nation's
defense for public health disasters. I expect today's panel members to
be unified in communicating a concern shared by emergency care
providers and healthcare consumers throughout our nation regarding the
ability of a fragmented, over-burdened and under-funded emergency and
trauma care system to meet the day-to-day needs of acutely ill and
injured persons. As you are aware, the Institute of Medicine recently
released a seminal report which indicates that our nation's emergency
care delivery system is in a state of crisis. Without a strong
emergency medical services system foundation, we will never be able to
build an effective response for mass casualty events, including natural
disasters or acts of terror.
In addition to the many concerns raised within the IOM report
regarding the overall health of our nation's emergency medical
services--issues that impact the day-to-day ability of pre-hospital and
hospital-based emergency care providers to respond to the needs of all
Americans--our emergency care systems also bear some specific and
persistent limitations in their ability to meet the medical needs of
children.i Adding further to this gap in the level of
emergency readiness between adult and pediatric care is the long-
standing observation that federal, state and local disaster planning
efforts have traditionally overlooked the unique needs of children. As
a representative of the Academy, and as an advocate for children, my
testimony will focus on issues concerning pediatric emergency
preparedness so you may better understand the unique challenges faced
by emergency medical care professionals as they treat ill and injured
children, and so that you may also appreciate the readiness gap in
pediatric emergency care.
Children Are More Vulnerable Than Adults
It has been said that children are not little adults, and this is
especially pertinent in a medical emergency or during a disaster. Their
developing minds and bodies place children at disproportionate risk in
a number of specific ways in the event of a disaster or terrorist
attack:
Children are particularly vulnerable to aerosolized
biological or chemical agents because they normally breathe
more times per minute than do adults, meaning they would be
exposed to larger doses of an aerosolized substance in the same
period of time. Also, because such agents (e.g. sarin and
chlorine) are heavier than air, they accumulate close to the
ground--right in the breathing zone of children.
Children are also much more vulnerable to agents that
act on or through the skin because their skin is thinner and
they have a larger skin surface-to-body mass ratio than adults.
Children are more vulnerable to the effects of agents
that produce vomiting or diarrhea because they have smaller
body fluid reserves than adults, increasing the risk of rapid
progression to dehydration or shock.ii
Children have much smaller circulating blood
volumes than adults, so without timely intervention, relatively
small amounts of blood loss can quickly tip the physiological
scale from reversible shock to profound, irreversible shock or
death. An infant or small child can literally bleed to death
from a large scalp laceration.
Children have significant developmental
vulnerabilities not shared by adults. Infants, toddlers and
young children may not have the motor skills to escape from the
site of a hazard or disaster. Even if they are able to walk,
young children may not have the cognitive ability to know when
to flee from danger, or when to follow directions from
strangers such as in an evacuation, or to cooperate with
decontamination.iii As we all learned from Katrina,
children are also notably vulnerable when they are separated
from their parents or guardians.
Children Have Unique Treatment Needs
Once children are critically ill or injured, their bodies will
respond differently than adults in similar medical crises.
Consequently, pediatric treatment needs are unique in a number of ways:
Children need different dosages and formulations of
medicine than adults--not only because they are smaller, but
also because certain drugs and biological agents may have
adverse effects in developing children that are not of concern
for the adult population.
Children need different sized equipment than adults.
In fact, emergency readiness requires the presence of many
different sizes of key resuscitation equipment for infants,
pre-school and school-aged children, and adolescents. From
needles and tubing, to oxygen masks and ventilators, to imaging
equipment and laboratory technology, children need equipment
that has been specifically designed for their size.
Children demand special consideration during
decontamination efforts. Because children lose body heat more
quickly than adults, mass decontamination systems that may be
safe for adults can cause hypothermia in young children unless
special heating precautions or other warming equipment is
provided.iv Hypothermia can have a profoundly
detrimental impact on a child's survival from illness or
injury.
Children sustain unique developmental and
psychological responses to acute illness and injury, as well as
to mass casualty events. Compared to adults, children appear to
be at greater risk for acute- and post-traumatic stress
disorders. The identification and optimal management of these
disorders in children requires professionals with expertise in
pediatric mental health.v
Children may be developmentally unable to
communicate their needs with health care providers. The medical
treatment of children is optimized with the presence of parents
and/or family members. Timely reunification of children with
parents and family-centered care should be a priority for all
levels of emergency care.
Children Need Care From Providers Trained to Meet Their Unique Needs
Because children respond differently than adults in a medical
crisis, it is critical that all health care workers be able to
recognize the unique signs and symptoms in children that may indicate a
life-threatening situation, and then possess the experience and skill
to intervene accordingly.vi As already noted, a child's
condition can rapidly deteriorate from stable to life-threatening as
they have less blood and fluid reserves, are more sensitive to changes
in body temperature, and have faster metabolisms. Once cardio-pulmonary
arrest has occurred, the prognosis is particularly dismal in children,
with less than 20% surviving the event, and with 75% of the survivors
sustaining permanent disability. Therefore, the goal in pediatric
emergency care is to recognize pre-cardiopulmonary arrest conditions
and intervene before they occur. While children represent 25 to 30% of
all emergency department visits in the U.S., and 5 to 10% of all EMS
ambulance patients, the number of these children who require this
advanced level of emergency and critical care, and use of the
associated cognitive and technical abilities, is quite small. This
creates a special problem for pre-hospital and hospital-based emergency
care providers, as they have limited exposure and opportunities to
maintain their pediatric assessment and resuscitation skills. In my
practice, a pediatric emergency department located in a tertiary urban
children's hospital and trauma center with over 50,000 annual visits,
we are able to maintain those skills. However, over 90% of children
receive their emergency care in a non-children's hospital or non-trauma
center setting. Emergency care professionals in many of these settings,
and most pre-hospital emergency care providers, simply may not have
adequate ongoing exposure to critically ill or injured children.
This vital clinical ability to recognize and respond to the needs
of an ill or injured child must be present at all levels of care--from
the pre-hospital setting, to emergency department care, to definitive
inpatient medical and surgical care. The outcome for the most severely
ill or injured children, and for the rapidly growing number of special
needs children with chronic medical conditions, is optimized in centers
that offer pediatric critical care and trauma services and pediatric
medical and surgical subspecialty care. As it is not feasible to
provide this level of expertise in all hospital settings, existing
emergency and trauma care systems and state and federal disaster plans
need to address regionalization of pediatric emergency care within and
across state lines and inter-facility transport as a means to maximize
the outcome of the most severely ill and injured children.
I have alluded to the growing number of children with chronic
medical conditions. Children with special health care needs vii
are the fastest growing subset of children, representing 15 to 20% of
the pediatric population.viii These children pose unique
emergency and disaster care challenges well beyond those of otherwise
healthy children. Our emergency medical services systems, and our
disaster response plans, must consider and meet the needs of this group
of children.
Pediatric Emergency Care Preparedness
Our nation's EMS system was developed in response to observed
deficiencies in the delivery of pre-hospital and hospital-based
emergency care to patients with critical illness or injury, with adult
cardiovascular disease and trauma representing the sentinel examples.
The Emergency Medical Services Act of 1973 helped to create the
foundation for today's EMS systems, stimulating improvements in the
delivery of emergency care nationally. Despite those improvements,
significant gaps remained evident in EMS care, particularly within the
pediatric population.ix, x
These gaps were present because early efforts at improving
EMS care did not appreciate that acutely ill and injured children could
not be treated as ``small adults.'' Children possess unique anatomic,
physiologic, and developmental characteristics which create vitally
important differences in the evaluation and management of many serious
pediatric illnesses and injuries. Unique pediatric health care needs
make it difficult for emergency care providers to provide optimal care
in adult-oriented EMS systems (e.g. personnel training, facility
design, equipment, medications).
In 1993, the Institute of Medicine (IOM) released a comprehensive
report, ``Emergency Medical Services for Children'', on the status of
pediatric emergency care. This study identified numerous concerns in
several major areas, including gaps in the pediatric training and
continuing education of emergency care providers, deficiencies in
necessary equipment, supplies and medications needed to care for
children, inadequate planning for pediatric emergency and disaster
readiness, and insufficient evaluation of patient outcomes and research
in pediatric emergency care.xi
Over a decade later, last month's IOM report ``Emergency Care
for Children: Growing Pains,'' demonstrates that while some
improvements have been achieved, the pediatric emergency readiness gap
still remains, noting:
Only 6% of emergency departments across the nation
have all of the supplies necessary for managing pediatric
emergencies.
Only half of hospitals have at least 85% of those
critical supplies.
Of the hospitals that lack the ability to provide care
for pediatric trauma victims, only half have written transfer
agreements with hospitals that possess that ability.
Many medications used in the emergency room setting
for children are prescribed ``off label,'' i.e. without Food
and Drug Administration approval for use in children.
Pediatric emergency care skills deteriorate quickly
without practice, yet training is limited and continuing
education may not be required for emergency medical technicians
(EMTs) in many areas.
Pediatric emergency treatment patterns and protocols
vary widely across emergency care providers and geographic
regions.
Shortages of equipment and devices and deficiencies in
pediatric training are exacerbated in rural areas.xii
Disaster preparedness plans often overlook the
needs of children even though their needs differ from those of
adults.
As stated in the IOM report, ``If there is one word to describe
pediatric emergency care in 2006, it is uneven.'' The specialized
resources available to treat critically ill or injured children vary
greatly based upon location. Some children have ready access to a
children's hospital or a center with distinct pediatric capabilities
while others must rely upon hospitals with limited pediatric expertise
or equipment. Some states have implemented pediatric readiness
guidelines for hospital emergency departments, but most have not. Some
states have organized trauma systems and designated pediatric
facilities while others do not. As trauma remains the leading cause of
death and disability for children, the absence of a trauma system is
particularly problematic for children. Lastly, state requirements for
the pediatric continuing education and certification for EMTs vary
widely. As a result, not all children have access to the same quality
of care.
Finally, more research is needed in all aspects of pediatric
emergency care. Due to the lack of scientifically validated research in
this area, most recommendations are the result of expert consensus, not
scientific evidence. More study is needed to advance the field and
ensure that the measures we are taking are effective.
Pediatric Disaster Readiness
Each of these shortcomings in day-to-day emergency care has major
implications for disaster preparedness. Emergency departments and
emergency medical services systems that are unable to meet everyday
pediatric care challenges are, by definition, unlikely to be prepared
to deliver quality pediatric care in a disaster.xiii
A unique consideration in pediatric emergency care and
disaster planning is the role of schools and day care facilities.
Children spend up to 80% of their waking hours in school or out-of-home
care. Schools and day care facilities must be prepared to respond
effectively to an acutely ill or injured child, and likewise, must be
fully integrated into local disaster planning, with special attention
paid to evacuation, transportation, and reunification of children with
parents.xiv Families should also be encouraged to engage in
advance planning for emergencies and disasters.xv
One key area of deficiency in our current disaster planning
is in pediatric surge capacity. Most hospitals have limited surge
capacity for patients of any kind. Even if beds may be available,
appropriately trained or experienced staff and the necessary equipment,
drugs and devices may not be. The use of adult critical care or
medical/surgical inpatient beds in hospitals with limited pediatric
expertise will likely prove to be an unacceptable option for the needs
of many ill or injured children. Optimal outcomes for these children
will only be achieved through regionalization of pediatric care and
surge capacity.
One federal program provides a clear example of the general neglect
of children's issues in disaster planning. The National Bioterrorism
Hospital Preparedness Program (NBHPP), administered by the Health
Resources and Services Administration (HRSA), is tasked with providing
funds to states and localities to improve surge capacity and other
aspects of hospital readiness. In the most recent grant guidance, HRSA
required that all states establish a system that allows for the triage,
treatment, and disposition of 500 adult and pediatric patients per 1
million population. While pediatric patients are referenced, it is
unclear whether they are required to be represented in proportion to
their numbers in the state's population. A state could arguably plan
for 499 adults and 1 child and satisfy the guidance. Moreover, that
guidance removed critical language that stated that NBHPP funds must
not supplant funding received under federal Emergency Medical Services
for Children grants and that strongly urged the incorporation of
behavioral health and psychosocial interventions for adults and
children into facility drills and exercises. Outside the pediatric
mention in the benchmark for bed surge capacity, children's issues are
essentially absent from the NBHPP guidance.xvi
Equipment and devices, as noted above, are a crucial
component of readiness. Because ``children'' encompass individuals from
birth through adolescence, it is often insufficient to have a single
size device to serve all children. In the case of respiratory masks,
for example, different sizes are needed for infants, young children,
and teenagers. Both individual facilities and large-scale programs,
such as the Strategic National Stockpile, must take this into account
and provide for these needs.
Similarly, drugs and antidotes must be available in appropriate
formulations and dosages for children. Infants cannot be expected to
take pills. Needles must be provided in smaller sizes. In many cases,
dosages for children should be determined not by age but by weight. A
simple device known as a Broselow tape can allow health care providers
to calculate dosages quickly and accurately. However, one study showed
that 46% of Disaster Medical Assistance Teams were lacking these tapes,
in addition to other critical pediatric equipment.xvii
Training is vital to pediatric preparedness. Many health care
providers have few, if any, opportunities to use critical pediatric
resuscitation and treatment skills. Skills that are not exercised
atrophy quickly. Presently, there is great variation in state standards
for required pediatric training and continuing education for pre-
hospital care providers and other first responders. Regular training
and education is central to ensuring that health care providers will be
able to treat children in a crisis situation. The same holds true for
facility and community emergency exercises and drills.
The issues of family reunification and family-centered care in
evacuation, decontamination and in all phases of treatment are
frequently overlooked. In the event of a disaster, both evacuation and
treatment facilities must have systems in place to minimize family
separation and methods for the timely and reliable reunification of
children with their parents. In addition, facilities must take into
account the need for family-centered care in all stages of care.
Infants and young children are typically unable to communicate their
needs to healthcare providers. Children of all ages are highly reliant
upon the presence of family during an illness or periods of distress.
Nearly all parents will be unwilling to be separated from their
children in a crisis situation, many even willing to forego emergency
treatment for themselves to be with their child. Hospitals must be
prepared to deal with these situations with compassion and
consistency.xviii
It has been a source of great frustration for many of my
pediatric and emergency medicine colleagues that our repeated calls for
improved pediatric emergency preparedness have gone unheeded for the
better part of a decade. As long ago as 1997, the Federal Emergency
Management Agency raised the concern that none of the states it had
surveyed had pediatric components in their disaster plans.xix
That same year, the American Academy of Pediatrics issued its first
policy statement entitled, ``The Pediatrician's Role in Disaster
Preparedness,'' with recommendations for pediatricians and
communities.xx In 2001, the American Academy of Pediatrics
formed its Task Force on Terrorism and issued a series of detailed
recommendations on various aspects of chemical, biological,
radiological and blast terrorism.xxi In 2002, Congress
created the National Advisory Committee on Children and Terrorism to
prepare a comprehensive public health strategy related to children and
terrorism. In 2003, the federal government sponsored a National
Consensus Conference on Pediatric Preparedness for Disasters and
Terrorism which, again, issued a laundry list of dozens of specific
recommendations.xxii Just last month, the IOM issued its
report on the pediatric aspects of the emergency care system.xxiii
Despite all of this, progress in pediatric preparedness has been slow,
fragmented, disorganized, and largely unmeasured and unaccountable.
The Emergency Medical Services for Children (EMSC) Program
The federal government has a crucial role in assuring pediatric
emergency and disaster preparedness through a variety of agencies and
programs, including the Department of Homeland Security, the Federal
Emergency Management Agency, the Centers for Disease Control and
Prevention, HRSA's National Hospital Bioterrorism Preparedness Program,
and others. Perhaps the most important and successful federal program
in improving emergency health care providers' ability to provide
quality care to children has been HRSA's Emergency Medical Services for
Children (EMSC) program. Created in 1984, the EMSC program was
established after data and clinical experience showed major gaps
between adult and pediatric emergency care at all levels. The program
has funded pediatric emergency care improvement initiatives in every
state, territory and the District of Columbia, as well as national
improvement programs.
Despite a modest budget allocation, EMSC has driven significant
improvements in pediatric emergency care, including disaster
preparedness. To its credit, EMSC has managed to effect these changes
despite the lack of pediatric emphasis in other related government
programs. EMSC has funded the development of equipment lists for
ambulances and hospitals, pediatric treatment protocols, and handbooks
for school nurses and other providers that would be critical in the
event of an emergency. EMSC supports training for emergency medical
technicians and paramedics who often have little background in caring
for children, and has underwritten the development of vital educational
materials and treatment guidelines. In the 21 years since the program
was established, child injury death rates have dropped by 40%.
As outlined in the IOM report, the EMSC program's resources and
over 20 years of effective leadership and collaboration with key
stakeholders have indeed led to important changes in pediatric
emergency care at the state level:
44 states employ pediatric protocols for online
medical direction of pre-hospital care at the scene of an
emergency;
48 states have identified and require all EMSC
essential equipment on EMS advanced life support ambulances;
36 of 42 states with state-wide computerized data
collections systems now produce reports on pediatric care;
20 states have pediatric emergency care laws or
pediatric emergency care related rules or regulations; and
12 states have adopted and disseminated pediatric
guidelines that characterize the facilities that have trained
personnel and equipment, medications and facilities to provide
pediatric care.
EMSC supports a National Resource Center (NRC) which acts as a
clearinghouse for educational resources on pediatric emergency care,
enabling countless communities to learn from each other's experience
and adopt proven models. EMSC also supports the National EMSC Data
Analysis Resource Center (NEDARC) which assists EMSC grantees and State
EMS offices to improve their ability to collect, analyze, and utilize
data to improve the quality of pediatric care.
EMSC has also been a very important source of funding for grants
that have contributed to increasing evidence-based care for acutely ill
and injured children. Research is an essential element in the
development of an evidence-based practice of medicine. The practice of
evidence-based pediatric emergency medicine is needed to provide the
best treatment for acutely ill or injured children. Unfortunately, in
many situations, emergency care providers must rely upon limited or
anecdotal experience, or an extrapolation from adult care standards
when treating children, because reliable research studies involving
acutely ill and injured children are few.
In recent years, EMSC has funded the establishment of the Pediatric
Emergency Care Applied Research Network (PECARN), the only network of
its kind supporting pediatric emergency care research. PECARN is
providing the infrastructure for critical research on the effectiveness
of interventions and therapies used in pediatric emergencies.
The recent IOM report contained a strong endorsement of the EMSC
program: ``the work of the EMSC program today remains relevant and
vital.'' The report acknowledged the need to address the serious gaps
that remain in pediatric emergency care and stated that ``The EMSC
program, with its long history of working with federal partners, state
policy makers, researchers, providers and professional organizations
across the spectrum of emergency care, is well positioned to assume
this leadership role.'' xxiv
The American Academy of Pediatrics fully endorses the IOM's
comments regarding the value of the EMSC program. While enormous
strides have been made in pediatric emergency care, much more remains
to be done. The program should be reauthorized and funded at or above
the level recommended by the IOM, which we hope would allow EMSC to
pursue pediatric emergency and disaster preparedness thoroughly and
aggressively.
POLICY RECOMMENDATIONS
The American Academy of Pediatrics has specific recommendations for
all policymakers regarding children and emergency and disaster
preparedness:
If our nation's over-burdened emergency and trauma
care systems are to respond effectively to a significant mass
casualty event, we must invest in creating effective local,
state and federal disaster response systems involving a
healthy, adequately-funded, well-coordinated and functional
emergency medical services system.
Standards for pediatric emergency readiness for pre-
hospital and hospital-based emergency services, and
regionalization of pediatric trauma and critical care, should
be developed and implemented in every state.
Evidence-based clinical practice guidelines for the
triage, treatment and transport of acutely ill and injured
children at all levels of care should be developed.
Pediatric emergency care competencies should be
defined by every emergency care discipline and professional
credentialing bodies should require practitioners to achieve
the level of initial and continuing education necessary to
maintain those competencies.
Primary care pediatricians and pediatric medical and
surgical subspecialists should be included in emergency and
disaster planning at every organizational level--at all levels
of government, and in all types of planning.
Emergency preparedness efforts should use an ``all-
hazards'' model that allows for holistic planning and
multipurpose initiatives, and should support family-centered
care at all levels of treatment.
Pediatric health care facilities (e.g. children's
hospitals, pediatric emergency departments, and pediatricians'
offices) should be included in all aspects of preparation
because they are likely to become primary sites for managing
child casualties.
Financial support should be provided to health care
facilities to address pediatric preparedness, including
maintaining surge capacity and creating specialized treatment
areas for children, such as isolation and decontamination
rooms.
Schools and day care facilities must be prepared to
respond to emergencies and must be fully integrated into local,
state and federal disaster plans, with special attention paid
to evacuation, transportation, and reunification of children
with parents.
Federal, state, and local disaster plans should
include specific protocols for the management of pediatric
casualties, including strategies to:
Minimize parent-child separation and implement
systems for the timely and reliable reunification of
families;
Improve the level of pediatric expertise on
disaster response teams (e.g. Disaster Management
Assistance Teams);
Improve access to pediatric medical and
surgical subspecialty care and to pediatric mental
health care professionals;
Address the care requirements of children with
special health care needs; and
Ensure the inclusion of pediatric mass
casualty incident drills at both federal and state
planning levels.
More research is needed regarding all aspects of
pediatric emergency planning, response, and treatment to
support the development of effective emergency therapies,
prevention strategies, and evidence-based clinical standards in
pediatric emergency medicine.
The Emergency Medical Services for Children (EMSC)
program should be reauthorized and funded at the level of $37.5
million per year, as recommended by the Institutes of Medicine
report, to support the continued improvement in pediatric
emergency and disaster preparedness.
Other Issues of Concern
In addition to hospital surge capacity and emergency room
preparedness, a number of other critical issues continue to be
neglected in the area of pediatric readiness.
Government organizational issues: Pediatric concerns must be
represented in all aspects of disaster planning and at all levels of
government, including issues such as evacuation strategies and large-
scale protocols.
Federal systems issues: Children's needs must be taken into account
in various federal systems. The Strategic National Stockpile must
contain equipment, devices and dosages appropriate for children.
Disaster Medical Assistance Teams must include individuals with
appropriate pediatric expertise. Pediatric casualties should be
simulated in all disaster drills.
Special disasters: Children have unique needs in certain types of
disasters. For example, in the event of a radioactive release, children
must be administered potassium iodide as quickly as possible and in an
appropriate form and dosage to prevent long-term health
effects.xxv
School and day care issues: Children spend up to 80% of their
waking hours in school or out-of-home care. Schools and day care
facilities must be integrated into disaster planning, with special
attention paid to evacuation, transportation, and reunification with
parents.xxvi
Credentialing. Health care providers are critical volunteers
in time of disaster. A comprehensive system for verifying credentials
and assigning volunteers appropriately is vital. HRSA's Emergency
System for Advance Registration of Volunteer Health Professionals
(ESAR-VHP) must be supported and accelerated.
Psychosocial concerns: Children's reactions vary greatly depending
on the child's cognitive, physical, educational, and social development
level and experience, in addition to the emotional state of their
caregivers. This presents unique challenges to providing quality mental
health care.xxvii
Evacuation and shelter issues: A top priority must be placed
on not separating parents from children in evacuations. In shelters,
special arrangements must be made for pregnant women and children with
special health care needs, as well as for the safety and security of
all children.
CONCLUSION
In conclusion, the American Academy of Pediatrics greatly
appreciates this opportunity to present our views and concerns related
to pediatric emergency care and disaster preparedness. While great
strides have been made in recent years, with many of these improvements
the direct result of the federal EMSC program, much more remains to be
done. America's children represent the future of our great nation, our
most precious national resource. They must not be an afterthought in
emergency and disaster planning. With focused, comprehensive planning
and the thoughtful application of resources, these goals can be
achieved. The American Academy of Pediatrics looks forward to working
with you to protect and promote the health and well-being of all
children, especially in emergency and disaster situations.
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xxv Committee on Environmental Health. Radiation
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xxvi Schools and Terrorism: A Supplement to the National
Advisory Committee on Children and Terrorism Recommendations to the
Secretary. August 12, 2003. http://www.bt.cdc.gov/children/PDF/working/
school.pdf
xxvii Hagan, J and the Committee on Psychosocial Aspects
of Child and Family Health and the Task Force on Terrorism.
Psychosocial Implications of Disaster or Terrorism on Children: A Guide
for the Pediatrician. Pediatrics, Vol. 116, No. 3, September 2005.
Mr. Reichert. I have a few questions and then we will move
to other members of the committee.
Part of the challenge of this committee--and as a new
Member of Congress, this is my freshman year--is trying to
identify how the Federal Government can really help rather than
hinder. So part of the reason for your presence here today and
your testimony is to help us understand the problem a lot more
clearly, hopefully, and then also have you help us identify
solutions to the problems that you so readily see every day
that you come to work.
So I have just jotted down lots of notes and the other
members have also. And some of the things I have noted from the
witnesses that they are also--not only are you presenting
problems, but you are presenting some solutions.
And we just want to know, really--I guess the first
question I have is for Dr. Bass. You mentioned in one of your
points that there should be some Federal funding in an effort
to put together a pilot program, a regional pilot program.
Would you describe that more for me, please?
Dr. Bass. Yes, sir, I will. The committee believes that
emergency care can best be delivered in the form of
regionalized care, where the bottom line is trying to get the
right patient to the right hospital in the right time. Meaning,
for instance, the trauma patient that has severe trauma gets to
a trauma center; the patient with an acute heart attack gets to
a center that can provide the right care; the pediatric patient
with critical care needs gets to a hospital that has the
ability to provide pediatric intensive care.
That system should be--there should be data collected as to
how that system performs, such as issues such as bypass,
response times, diversion issues, et cetera. So it should be
accountable. And it should be coordinated, meaning that
different elements of the system should be working together.
Hospitals should be working with the prehospital care, should
be working with disaster management, to make sure that the care
is integrated. The care that is provided in the prehospital
care environment should be completely seamless, if you would,
from the care that is provided in the emergency department, and
then the hospital as a continuum of care, and we should be able
to build on that. It can't be fragmented. It needs to be
coordinated. So coordinated, accountable, regionalized care is
one of the central themes of the IOM report.
Mr. Reichert. This would include EMS personnel, ambulance
personnel?
Dr. Bass. EMS emergency departments, specialty care trauma
centers, all of those would be included in that.
Mr. Reichert. And would include communication systems, I
suppose, in the health IT protocol?
Dr. Bass. Interoperable systems with respect to both data
and voice.
Mr. Reichert. Do you know if there is a community in the
Nation here that currently has a plan underway that--I am sure
most of these things start at the local level and thenSec.
Dr. Bass. I was in a difficult position while the committee
met. I really am very proud of the State of Maryland, and we
were cited as an example in the IOM report. And I am not saying
we have achieved all of the goals and recommendations in the
report, but we have a statewide system. It started with trauma
care in 1970. We have a statewide Medevac program. We know that
87 percent of our patients with serious injuries make it
primarily to a trauma center.
We are working on cardiac and stroke now. We have a
statewide communications system where hospitals can talk to
EMS, and we are adding public health to that now, and it is all
through a coordinated center that operates out of Baltimore.
Mr. Reichert. What has been your contact with the
Department of Homeland Security in putting this sort of a plan
together?
Dr. Bass. Well, we work fairly closely with DHS on a
variety of different projects. I met with Dr. Rungy, for
instance, who is the chief medical officer, on a number of
occasions.
Mr. Reichert. Federal grants awarded as a part of putting
this program in?
Dr. Bass. We get the State grants primarily, and then the
State grants we distribute through--we have a process that we
use to distribute through Homeland Security and our emergency
management agency. And I will say in my State, very proud to
say that the health and medical folks are there at the table.
Mr. Reichert. What sort of Federal grants then come to the
State, or are they part of the UASI?
Dr. Bass. We get UASI, we get State Homeland Security
grants, we get the HRSA bioterrorism grants. That comes through
the health department. And we have an agreement with the
hospitals, their support, and the health department; 10 percent
of that goes to prehospital care.
Mr. Reichert. And one last quick question. The Department
of Health and Human Services have been just as helpful, I would
imagine.
Dr. Bass. We have worked very closely with them as well,
and sometimes we wish they would work as closely with each
other as they do with us.
Mr. Reichert. That was my next question. I will complete my
questioning and move on to Mr. Pascrell.
Mr. Pascrell. Thank you very much, Mr. Chairman.
I am curious. We have four distinguished folks in front of
us on the panel, and I want to throw a specific problem at you
and I would like to know what your response and reaction is.
I have read about what is going on in New Orleans and in
the aftermath of people who lost their lives in a hospital.
Decisions had to be made in that hospital during a time of
crisis. That is easy for me to make value judgments, sitting
miles away. I don't know of what was going on in the doctors'
or the nurses' minds, the three of them, when they made the
decision. Or did they make that decision?
Do you think that the hospitals--you know, we talk about
being prepared; do we have an exit strategy? Do we have a
strategy that would assist in vacating hospitals, or any
facility for that matter, if there was a crisis?
I want your quick opinion, which is not fair to you, but
that is okay. I want your quick opinion about what you--how you
assess what has happened there, in that one particular hospital
with the doctor and two nurses, in view of the patients dying.
What does that reflect in the system, or is it just unique to
New Orleans or that hospital?
Dr. Krug.
Dr. Krug. I am not going to offer an ethical opinion to
their actions. But I guess I would comment that at the very
least, there was an extraordinary situation there, and in fact
what happened is also not just there but at other institutions
as well. We had patients and care providers stranded with no
help, with little security support, without basic
infrastructure, and with no clear understanding when they would
receive relief.
In the pediatric universe, in fact, the sickest of the
children at the children's hospitals were not evacuated by a
Federal or State response. They were evacuated through a
shared-aid system through other children's hospitals that sent
teams down to help them out. And in fact, because of
coordination issues, there was some hazard there.
So I am not surprised that there was a sense of
desperation. And, again, I can't comment on their actions. I am
not sure what the right thing is to do.
Mr. Pascrell. Ms. Jagim.
Ms. Jagim. I think that when it comes to evacuating
hospitals, that is a very complex issue and it certainly
articulates, I think, the need for community-wide planning and
regionalization also.
You need to have a plan, because when we sit down as a
community back in Fargo and talk about evacuation, it is
evacuating hospitals, nursing homes, group homes, all kinds of
places; and everybody thinks they can rely upon the the same
resources to accomplish that, and that is not realistic. And so
it is very complex.
And I think it is a great example of what is not in place
and what isn't going to work should another crisis occur.
Mr. Pascrell. Thank you. Dr. Blum.
Dr. Blum. I too can't comment about the specifics of that
case, I simply don't know enough about them to be able to
comment about that. I don't know enough about the specifics of
that case to comment specifically about the ethics or the
decision making that went into that.
I could make a few general comments, though, and that is
all emergency care, especially in the mass casualty, mass
illness situation, uses the principle of triage, which is
basically the principle of where can you do the most good for
the most people, you know, over a short period of time.
And during those times, sometimes very, very difficult
decisions have to be made about who gets care first--
Mr. Pascrell. Right.
Dr. Blum. Et cetera. So that is a general principle of
emergency care. As far as hospital evacuation is concerned,
understand that hospitals are very unique places. I could tell
you my hospital in Morgantown, West Virginia, if we had to
evacuate, the closest equivalent facility is over 100 miles
away. And to evacuate the type and complexity of patients we
have in that tertiary care hospital would require a massive
effort, probably a massive airlift effort. It is a nearly 500-
bed--
Mr. Pascrell. Are people talking about that?
Dr. Blum. There simply aren't the resources immediately
locally available to do that very easily, and so while we talk
about it, the solutions are not very obvious. It simply--and we
saw that in New Orleans. These were some very big hospitals
with lots and lots of patients, many of whom were very sick,
that needed to be evacuated, often under fire. And all I can
tell you is that at least from the emergency medicine
perspective, the docs stayed and took care of patients, often
bagging them by hand for long periods of time because there was
no power to the ventilators.
Dr. Bass. I would emphasize the importance of prior
planning, and, as was mentioned by one of my colleagues, I
believe a lot of folks believe they can call 911 and 911 will
help them with their evacuation. The problem is if you have 100
or 200 or 500, or as one of our counties might have, 7--or 800
facilities to evacuate, 911 can't handle all that.
So you have to know where the patients are, where the
people are that need to be evacuated, and that is not just
hospitals, it is nursing homes; now we have assisted living
facilities, we have a number of people. And we need to, one,
know where they are; two, have a plan, work with transportation
to, A, get appropriate vehicles, B, have routes planned, et
cetera. You have to do that kind of planning or you end up with
a situation where people are desperate.
Mr. Pascrell. Mr. Chairman, it would--it strikes me in the
testimony, I glanced through all of the panelists, and the
comments today, it strikes me that perhaps--just perhaps--you
cannot discuss emergency services without discussing the other
services of the hospital. And many of those hospitals are
hanging by a thread, and you can't expect the emergency room to
be in any better shape.
So we may, you know, we are not going to generalize to the
point of looking at the entire health system in its delivery
forces, although we may be forced to do that in order to
prepare for the worst.
Thank you, Mr. Chairman.
Mr. Reichert. Thank you, Mr. Pascrell.
And the Chair recognizes that are other committees and
subcommittees that certainly have jurisdiction over the issue
that we are discussing today. We are today focusing on Homeland
Security, and certainly the system is so interconnected that we
can't ignore one part of the problem to solve another part of
the problem. It is going to be solved together. So hopefully we
can work--as you have worked with Homeland Security, Dr. Bass,
and the Department of Health--we hope to work with the other
committees and subcommittees in helping the Nation be a lot
more ready for--a lot more prepared for any emergency that
might come into our trauma centers and emergency rooms.
The Chair now recognizes Mr. Dent.
Mr. Dent. Thanks, Mr. Chairman. Good afternoon.
In your opinion--and I know this is a question for all the
panelists--but what do you see is the level or extent to which
there is cooperation and coordination between Department of
Homeland Security and HHS for these types of public health
disasters or medical emergency situations?
Maybe, Dr. Bass, do you have any thoughts or insights on
this?
Dr. Bass. I would be candid. I have good friends and
colleagues in both agencies, but at the same time, I sometimes
get incredibly frustrated. I think during Katrina and Rita was
a good example of where, in trying to work with the two
agencies, we saw sometimes very sort of different approaches to
how they were going to address the needs of the folks who were
down in the gulf area, and, you know, one talking about
evacuation, the other talking about moving Federal treatment
facilities down into the area.
And that is--it is well and good to have different plans,
but at some point these plans need to come together and they
need to be integrated. And that is the one thing I think that I
can say on behalf of all of my State director colleagues, is
that we would really very much like to see DHS and DHHS work
more closely and in a more integrated way when things such as
Katrina and Rita occur.
Mr. Dent. Dr. Blum.
Dr. Blum. I think it is an evolving and improving
relationship. But from the perspective of my colleagues I would
say that both--both entities tend to take for granted the
emergency departments in the part of the equation. If you think
about it, most of the planning that goes on for disaster
preparedness has as its end point the delivery of a patient to
an emergency department.
In it is argued that very often no one has looked to see
whether that emergency department is able or capable of taking
care of the number and types of and complexities of patients it
might get from all those planning efforts that are aimed at
delivering the patient to the emergency department.
I guess my message today is that is a critical part of the
puzzle as well, that is a critical part of the planning; and if
we ignore that part, we have created an incredible system to
deliver a patient to a dysfunctional system and that doesn't
make any sense.
Ms. Jagim. I would just like to add I think that the
emergency department, as Dr. Blum had indicated, we have one
foot in the public response entity and we have one foot in a
private hospital business, and I think that that is a part of
why we have been left out of a lot of the disaster preparedness
conversations or planning because we are not seen as part of
that solely public emergency response, and I would like to see
more--at least on the frontlines--feel more integration and
more focused coordinated leadership related to emergency
response.
Mr. Dent. Dr. Krug?
Dr. Krug. I don't want to take up time here, but I soundly
agree with the comments made by my three colleagues. I think
there is good intention on both sides, but there really can
only be one plan and the plan has to reflect the reality of the
foundation or the response, which is the crisis we are here
talking with you guys about this morning or this afternoon.
Mr. Dent. And my final question and you don't have to give
long answers, but as you may be aware, there is a training
facility for these medical preparedness situations down at the
Noble Facility in Alabama. Have any of you taken advantage of
that training? Just anybody want to say anything, would you
like to comment on that?
Ms. Jagim. I think it is a great resource. I was there a
couple of years ago. I think it provides a lot of different
types of courses. The access--I am not sure that everybody has
all the information about it or has had an opportunity to
experience it, but I think it has provided a lot of education.
Mr. Dent. Thank you. Dr. Blum, do you want to say
something?
Dr. Blum. I have not taken advantage of the training at
that specific facility, but I have had some training in this
area. Again though, I want to emphasize that most natural and
even man-made disasters, the medical conditions that need to be
treated are medical conditions that we see and treat every day.
There are unique situations that we have to deal with depending
on the entity that is involved, but in the vast majority of
situations, you know, it is basic trauma care, it is basic
emergency care, and that is what we do every day.
Mr. Dent. And either Dr. Krug or Dr. Bass, you have had any
experience?
Dr. Bass. I am familiar with Noble and I think it is a
great resource but I think it is underutilized and a lot of
people don't know about it.
Mr. Dent. Thank you. Okay, yield back.
Mr. Reichert. Chair recognizes the ranking member of the
full committee, Mr. Thompson.
Mr. Thompson. Thank you very much and I appreciate the
testimony of our witnesses. One of the things we grapple with
is whether or not from a lessons learned standpoint if another
Katrina/Rita-type situation happened, are we in any better
situation today than we were 11 months ago? Have you seen in
your professional duties on a day to day, any leadership on the
part of DHS or HHS to better prepare your profession or the
communities you work in for these situations? And I will go
down the line.
Ms. Jagim. You know, the only difference I have seen in 11
months is we were finally able to get some funding at my
hospital within the last year to help with supplies and
equipment related to mass casualty or any type of patient surge
issues, but up until that point in time we had not received any
support.
Dr. Krug. I mean, there has certainly been ongoing planning
in various communities that were already engaged in the
process. However, I share your concern. I think there are a lot
of lessons to be learned from Katrina and I am not yet sure we
have taken the time to learn and react to what we have saw. So
I would be greatly concerned about what would happen if Katrina
came again this hurricane season, and then this also then gets
back to the point that we are here talking with you about, just
the overall system, the emergency delivery care system. This
year is no better than it was last year. In fact, it could be
one year more worn than it was a year ago because, if nothing
else, I am sure ED visits continue to rise.
Dr. Bass. I would offer that I know that the Gulf States
and surrounding States have been meeting together and working
very hard to help plan with some Federal support to do that. I
also know that HHS and DHS have been working together as well
to--and after beating up on them, I think it is fair to say to
we have seen some efforts for them to work together to make
sure that the Federal Government can come in and provide backup
to the States in an efficient and quick way.
So obviously the proof is going to be in the pudding. If we
have to face something like Katrina or Rita again, we will
know, but I think it is fair to say that we have seen some
evidence that there is an effort on the part of both
defendants.
Mr. Thompson. Well, Dr. Blum, let me give you another
question and you can take both of them. Our national response
plan says that certain things kick in once the incident of
national significance has been declared. Are you comfortable
that if that incident of national significance is declared that
the emergency response systems in this country can manage
another Katrina-type catastrophe at this point?
Dr. Blum. No. I am sorry. No. To answer the first question,
I believe the Federal performance and the State performance as
a follow-on to the immediate disaster I think will be improved
with the next event. I think the lessons learned from Katrina
in those areas will improve the imperformance at both the
Federal and State levels. But again I seem to be a broken
record on this, the initial response will be from--by the local
emergencies, by the local emergency departments, and their
infrastructure is stretched to the breaking point today, and so
the question of whether the local response will be adequate I
think is very much up in the air, and I can tell you without
qualification that the emergency care system in general in this
country, especially with regard to the emergency department, is
worse today than it was this same time last year and if we
don't change things it will be worse next year than it is
today.
Dr. Krug. I guess the one positive to this is we have been
doing our planning in Chicago both in hospitals and throughout
the city. What we learned from Katrina is that that basic tenet
of the Federal response is something that we can't rely upon,
and so we will be better prepared to function on our own for a
longer period of time because of that. And again, the proof
will be in the pudding. Let's hope it never happens again, but
we are going to have to wait and see what happens again the
next time this does happen.
Mr. Thompson. Thank you, Mr. Chairman.
Mr. Reichert. Thank you, Mr. Thompson. The Chair recognizes
Mr. Dicks.
Mr. Dicks. Thank you, Mr. Chairman. I want to thank you for
holding this hearing. I think this is a very appropriate
hearing, and one that I think--I am glad that we are getting
down to these kinds of issues. And I know this is a problem in
Washington State where I am from. Let me ask you, Dr. Blum, you
were pretty strong in saying the emergency room--emergency
department situation has declined. Is the reason for that
because the hospitals are closing down these emergency
departments because they don't want to have to pay the cost of
treating these people, many of which don't have insurance? I
think--what did you say, I think it was 50 percent do not have
insurance? Is this the reason this is happening at a time when
we should be strengthening the emergency medical system, faced
with these possibilities of terrorist attacks in the future,
what we are seeing is a national decline in these services that
people consider to be crucially essential?
Dr. Blum. Yes, sir, that is a huge part of it. It is not
the only cause.
Mr. Dicks. What else is it? Give me all the causes you can
think of.
Dr. Blum. I will try to summarize them. There are many.
There is increasing demand, first of all.
Mr. Dicks. That is because people don't have insurance,
right?
Dr. Blum. Well, there is multiple reasons for it. People do
not have insurance, 47 million Americans do not have insurance
at all. There is another probably 40 million Americans who are
underinsured and that is a big part of it. But even people with
insurance, there is an increasing demand. Managed care, one of
the side effects of managed care has been that primary care
practitioners are very, very tightly scheduled. So that if
there is any event that occurs in their patients' lives that
kind of falls outside that very, very tight schedule for the
practitioner, the emergency department is often the only option
to receive care, and so actually we have seen an increased
volume of patients in the number of patients that have
insurance as well as that don't have insurance. We have seen
declining reimbursement from insurance companies as they try to
figure out ways not to pay for emergency care.
Mr. Dicks. Including the Federal Government with the
reduced cost--reimbursements for Medicare and Medicaid?
Dr. Blum. That is correct. I went to a meeting earlier this
year in Washington where a senior official for Medicaid said in
the very same sentence that we are going to add a million new
people to the Medicaid rolls, and we are going to decrease the
budget by $10 billion. Well, you don't have to be a rocket
scientist to figure out that that doesn't make sense, and it
especially doesn't make sense for the emergency care aspect of
Medicaid. And that is using just one example.
Mr. Dicks. Let me ask one thing. In Washington State, for
example, we have--I think there is a Level 1 trauma care, isn't
that right, where the most severe injuries go, that is Harbor
View. We have created a little program in Pierce County with
the Madigan Army Hospital and some of the local hospitals in
Tacoma to have a Level 2, but that is it in the whole State of
Washington. And people have to be flown in by helicopter. If
they have a severe injury, they have to go to one of those two
places and many times it is the Harbor View and they are
underfunded now. They are having their funding cut off by the
State of Washington for some reason. I mean, is this happening
around the country? Is this not--I assume this is the same kind
of problem we are facing in other parts of the country.
Dr. Blum. Yes, sir. In many of those specialized care
entities, such as trauma centers, exist within the large public
hospital entities within the given State or city, and those
often bear disproportionate proportion of the under and
uninsured patient population. So their finances are more
vulnerable to any up or downswings that compare to, you know,
private hospitals, and that should be a concern to everybody
because when--West Virginia only has one Level 1 trauma center
in Morgantown. Only one for the whole State. If that closed, it
would close for everybody, whether you had insurance or not,
and I can tell you that it is a challenge to keep that trauma
center running whenever we--we also are the State's primary
provider of care for the uninsured and underinsured.
Mr. Dicks. Ms. Jagim, you mention--and I will ask everybody
else to respond. You mention the cutback in funding for nurses.
Is that now--where--that is in the Health and Human Services
budget I take it? In the Federal Government's--
Ms. Jagim. I believe so, yes.
Mr. Dicks. Or is that under Medicare?
Ms. Jagim. No. I think it is in Health and Human Services.
Mr. Dicks. And how many years has this been cut now?
Ms. Jagim. Well we--I think the amount of funding has been
fairly low but stable, but we need to increase it in order to--
Mr. Dicks. So we don't have enough nurses?
Ms. Jagim. Right. There is a shortage, and we need help to
fix it.
Mr. Dicks. And I would assume we are short emergency nurses
as well as nurses in general.
Ms. Jagim. Absolutely. Absolutely. And as I indicated, you
know, they are not an interchangeable resource. It requires a
lot to get them at the level that you need them to perform in
that emergency nursing role. And so it is not to be taken
lightly, and that is why we need to shore up the resources.
Mr. Dicks. Dr.Sec. ug, do you have a comment?
Dr. Krug. Just a couple of comments. It is true that the
underinsured and the uninsured are overrepresented in emergency
departments in comparison to their proportion in the Nation.
That said, it would be a mistake to simply look at that
population of patients and summarize that that is where the
problem exists. That is part of the problem, but in fact as
people have studied this, insurance has nothing to do with it.
It is access to a primary care provider. I have got great
insurance. I am a pretty savvy utilizer of health care. I can't
see my doctor when I get sick. So if I am really sick I have
one place to go. It is the emergency department. It has been
argued that the largest increase in emergency department
utilization over the past 5 years has not been by the uninsured
but by people with insurance. The other key points about
emergency department overcrowding is that emergency departments
are not only crowded with patients trying to get in, but with
patients trying to get out. And so in my emergency department
right now if I was to call there--
Mr. Dicks. Trying to get into the hospital.
Dr. Krug. Exactly. If I would call there right now, I am
just guessing, in our 16-bed emergency department where we jam
55,000 patients a year through every year, I would bet you five
of those beds are filled with patients waiting for beds
upstairs. And that is a phenomenon in every emergency
department or most emergency departments and particularly in
the ERs and places like trauma centers and tertiary care
centers, the places where you are sending the sickest patients
to begin with.
So there is a huge problem. And then it could be argued
that if we could actually build a bigger emergency department,
my next dilemma would be finding the people to work there. So
there is a shortage of emergency physicians, subspecialists,
and particularly of nursing. We are running into a brick wall
as it relates to nursing, at least based upon what I have seen.
Mr. Dicks. Thank you, Mr. Chairman.
Mr. Reichert. Thank you, Mr. Dicks. The Chair recognizes
Mrs. Christensen.
Mrs. Christensen. Thank you, Mr. Chairman. And I am going
to say it anyway, although I don't have to tell you how pleased
I am that we have finally gotten to this type of a hearing, and
I thank you and the ranking member for holding it. I also am
going to say in advance that this is where the rubber meets the
road for me, and I know a lot of times we are asked to abide by
bipartisan agreements. But if we don't address this in
legislation, and if relevant legislation does not
significantly-dress this, I am voting no. I am not going to be
a part of those agreements. We clearly are unprepared for what
is most likely to be--well, what is one of the most likely
terrorist events, and that is bioterrorism and especially in
our poor and our rural and our communities of color.
I have a lot of questions. I am sure I am going to end up
submitting some for you to send to our panelists. We received
this book last week, and I guess this would probably be
speaking of 2005, and it said, there are still no official
agreed upon measurable performance standards of accountability
for State bioterrorism and emergency public health preparedness
programs and activities.
Is that still the case, that we don't have any standards
that are at least the basic minimum standards that have been
communicated to emergency departments and hospitals that must
be met to reach a certain level of preparedness; is there any
standard that has been promulgated?
Dr. Bass. There are standards that are in the process now.
Mrs. Christensen. Within the Department of Homeland
Security?
Dr. Bass. Correct. Targeted capability lists, TCLs, that
have actually been underway. I think it is part of HSPD-8.
There are multidisciplinary processes. Again, I think to talk
about the fragmentation issue, DHS is doing that, but the ET
program is principally at HRSA. I will say now that we are
seeing some evidence that they are beginning to work together
and HRSA is willing to recognize, and they are beginning to
recognize each other's standards. So I believe that situation
is improving.
Mrs. Christensen. I am going to follow up with another
question. We have a chief medical officer who comes to the
Department of Homeland Security with good experience. Do you
think that office is necessary? What is the role--what should
the role of that officer be? Do you think it is a necessary
office? And what would you like--what would you like to see it
do? Anyone can answer.
Dr. Blum. I think it is critical. I don't think it is
necessary. I think it is critical. And I think you have a very,
very talented and an appropriate person in that position, and I
guess my view would be that that is a very undermanned
position, given the scope of problems that you all have to plan
for. It is inconceivable to me that any significant threat from
a homeland security standpoint wouldn't have huge medical
consequences, and the coordination of those activities via the
department I think are absolutely critical if we are really
going to effectively respond to the kinds of things that you
are talking about. And so I would say not only do you have--not
only is it appropriate that you have a very, very talented and
good person in that position, but I would say that they need a
lot more support in the future.
Ms. Jagim. I think I would echo that we would want to see
them have a much greater role than they have.
Mrs. Christensen. And the HBHPP, I put that down there,
abbreviation, but the National Bioterrorism Health Preparedness
Program I guess is supposed to support hospital readiness to
meet terrorists and other public health programs. What grade
would you give it in doing this?
Dr. Bass. Are you referring to the HRSA BT program again?
Mrs. Christensen. The bioterrorism hospital program, the
funding that goes to hospitals and--
Dr. Bass. I don't think--without doing a comprehensive
assessment, it would be difficult for me to put a grade on it.
I can say that they have been funding hospitals. I know it
comes through our Department of Health in Maryland, and it is
really the only source of dedicated funding that I am aware of
now.
Mrs. Christensen. Do you think that the funding is anywhere
near where it needs to be? I went to Highland Hospital. It is a
major trauma center in a big city, covering a big area of the
country, about 200,000.
Dr. Bass. If there is a limitation of the HRSA BT program,
it is the amount of funding. I believe it is somewhere around
$500 million, maybe slightly short of that now. If you divide
that among 50 States, that ends up being actually what, $10
million say, for instance, that my State would get that comes
down, and that money has to be divided up between what health
department is doing, and we take 10 percent for pre-hospital
care because we also want to make sure they are prepared,
trained, equipped to handle BT events. And then you have got
the amount coming to the hospitals, you divide that among 47
hospitals. It ends up being enough money to do a little bit of
training, to buy a little bit of equipment, but not really to
do the job.
Mrs. Christensen. Dr. Krug?
Dr. Krug. I don't have enough information to give it a
grade. I would comment that I agree with the math of Dr. Bass,
but arguably the money needs to be targeted towards the
foundation. Again, we are planning for acts of terrorism and it
is important that we do that, but we have arguably little
disasters that occur in our emergency department every day of
the week, flu season, trauma season, and I would comment that
there is variation in terms of what is happening on a state-by-
state level and in the arena of pediatrics, I am not sure we
would give them a terribly high score at this point.
Mrs. Christensen. If Dr. Blum could answer?
Dr. Blum. I have no problem giving a grade and it would be
incomplete for the reasons Steve mentioned. You know the whole
base of the pyramid of the response, which we believe to be,
you know, as I said, the emergency--emergency department is the
first response for 75 to 80 percent of the patients in most
scenarios that you could generate, and I can tell you very
little of that money has trickled down through all those
entities to the emergency department, even when the hospital
gets some, very--it seems that very little has actually gotten
to the place where the rubber actually does meet the road,
which is in the emergency department. So I would say
emphatically it is an incomplete grade.
Mrs. Christensen. Mr. Chairman, I don't want to ever--I
agree completely with what Dr. Krug said. Whatever funding we
have, if it doesn't prepare our hospitals, our emergency room
and the whole health system to meet the daily needs of the
communities around them, it is not going to be able to help us
in a terrorism or natural disaster event.
Mr. Reichert. Thank you, Mrs. Christensen. The Chair would
absolutely agree with that. And Mrs. Lowey is recognized.
Mrs. Lowey. Thank you very much. And I personally want to
thank the Chair and the ranking member for holding these
issues. I also sit on the Labor-HHS Appropriations Committee,
as you know, and these issues have been upper most on my mind
for many a year. And in fact, I can't resist asking you, have
you ever heard--do you interact with the HHS command center?
Have you heard of it?
Dr. Bass. I have. Yes, I have on occasion. I am a regional
person, and we have met with them during regional events.
Mrs. Lowey. Let me not play 20 questions here. But several
years ago--I won't ask the Chair and the ranking member if they
have heard of it. But several years ago our Appropriations
subcommittee was asked to visit the command center by Secretary
Thompson. It was an extraordinary room, Mr. Chairman, probably
four times the size of this. Screens everywhere, every hospital
was identified, every health facility was identified, and we
were all very optimistic that this was going to be a great,
great resource. Now, not criticizing any of the staff in this
room, but I was trying to remember the name of it, and I must
have asked at least a half dozen members of this staff,
including my own, who are all very efficient, and I won't ask
you, Mr. Chairman and Mr. Ranking Member, because I can see the
look on your face, but megamillions of our taxpayer dollars
were invested in this center and the whole idea was to evaluate
and coordinate surge capacity. If an avian flu epidemic broke
out, God forbid, in New York City or the suburbs where I am the
Congresswoman, they would know exactly how many beds are here,
how many beds are there, who has sufficient supplies of
everything that is necessary. Well, needless to say, I have
been talking to my hospitals. They haven't heard of it either,
and there hasn't been any interaction.
So my first question was, Dr. Bass responded, have you--and
you have important responsibilities. Has there been any contact
with the HHS command center? Do you feed into it? Do you have
confidence that the Federal--I see you shaking your head--that
the Federal Government really knows what is happening in every
part of this country? Now, I have no idea, Mr. Chairman,
whether this is still functioning, whether the millions of
dollars that have been invested are just sitting there in the
equipment, and maybe some of us should visit again or find out
whether it has functioned. I see one head shaking. What about
Dr. Blum, are you aware of this?
Dr. Blum. In my role in my regular job, it wouldn't be my
role to regularly interact with an entity like that. So I would
have to say no, that I have not interacted with it, but I would
speculate that they would have difficulty currently in the
environment as it exists meeting their mission because of the
data problems that we have in the interoperatability of the
data systems that we have. That is one--if you will remember,
that is one of the recommendations we have as a college is to
develop a uniform way of collecting data on capacity and
diversion, et cetera, and that doesn't exist right now, and
until it does exist there is no way for any entity to really
collect the data and do the function that you described.
Dr. Bass. I was going to say, in Maryland we have our
communication center we call SYSCOM/EMRC, which is in
Baltimore, and one of its principal tasks is to stay in touch
with all the hospitals. We have links with all the hospitals.
We have a tool that is a web-based tool we call FRED, Facility
Resource Emergency Database. And in an emergency, we can use
FRED to inform the hospitals of what is happening but also FRED
can bring information back from a hospital, like how many beds
they have, how many doses of antibiotics, ventilators, things
like that, and we do that statewide in Maryland.
Mrs. Lowey. Do you report to the Federal Government?
Dr. Bass. Other States--not many other States do it on a
statewide basis. Many communities do but I will reiterate what
Dr. Blum said, the problem here is it comes back to the data
interoperatability issue, in that the way we collect it and
other people is not the same. We count things differently. And
I will tell you just last week I saw a proposal from HHS to
pull that together. Their goal is to be able to pull in the
data from Maryland and other communities and hopefully all
States would be doing what we are doing in Maryland and put
that in their database.
Mrs. Lowey. Well, I will save the rest of my questions
because the red light is on, but I hate to say it is business
as usual, Mr. Chairman. We went to visit this center at least 3
or 4 years ago. It was before my current staff was working on
the issue. And I am glad to know that someone there is
interested in pulling all this information together several
years later. So I would certainly suggest that we get an update
and find out what this center is doing, and I am glad to see
that the current administration of--I don't know which agency,
at HHS is beginning to think about using a facility such as
this and bringing the information together.
So I thank you and I thank you for your testimony, and I
think we all know that there is a lot more work to do,
certainly in my area, in the metropolitan region of New York,
and we appreciate your service to your community and your
country. Thank you.
Mr. Reichert. Thank you, Mrs. Lowey. We will direct the
staff to get us an update of the current status of the HHS
special operations centers so we have more detailed information
on that for all the members of this committee, and if the
witnesses could just bear with us a few more minutes, we want
to have a second round of questions. And it looks like there
might be three or four of us here to ask those additional
questions.
I want to go back and focus on the--I love to solve
problems. We have heard a lot about, you know, what the issues
are and what the problems are that we are facing and all the
way from Medicare to access to primary care and there is lots
of reasons that we don't have access, or some do have access,
and shortages of nurses and physicians and shortages of
facilities and instructors and professors with no training and
on and on. One of the things that we did in the bill that I
mentioned when we started this hearing, the interoperatability
bill, we listened to the people who were the ones doing their
job, and they helped us come up with some legislation. We don't
want to write legislation just for the sake of producing
paperwork and laws. So Federal standards are one thing. I heard
some discussion on that. And there was a mention of a need for
written transfer protocols. Is that something where the
Federal--the Department of Homeland Security or the Congress
could get involved in and helping to set some sort of standards
on, just for an example, one of the problems on written
protocols on transfers?
Dr. Bass. That really I believe is a State and regional
issue, and also the Joint Commission for the Accreditation of
Health Care Organizations also has requirements that hospitals
have transfer agreements. In my State we do that because we
have a regionalized system of care. We put out a booklet that
says, for instance, these are our trauma centers, these are our
burn centers, these are the hand centers, and those are
recognized regional centers. So there is no agreement required.
The hospital can know that within our system they can transfer
patients to those patients in our EMS providers and to know to
take those patients there primarily.
Mr. Reichert. So we know that the care to date--yes, sir,
doctor.
Dr. Krug. I agree it is not a Federal mandate, but the
simple observation is in spite of the joint commission process
and in spite of State rules and regulations, there are a
significant number of institutions that don't have that. So the
question then becomes--and this gets back to the fragmentation
of the process.
Mr. Reichert. Yes.
Dr. Krug. At some point if we want this all to work,
somebody is going to have to define a process that is fairly
consistent from one State to the next because it needs to be
consistent from one State to the next.
Mr. Reichert. We talked a little bit about identifying a
lead agency. Who would you suggest that might be? Anybody on
the panel.
Dr. Bass. A lead agency for emergency care? I think--
Mr. Dicks. At the Federal level, Mr. Chairman?
Mr. Reichert. Yes, Federal level.
Dr. Bass. At the Federal level, I mean, the Institute of
Medicine report recommends that that be at the HHS simply
because--not simply, but because of the fact that it looked at
this overarching system that would include trauma care,
emergency medicine, pre-hospital care, EMS for children, that
is really, I mean, that is all fundamentally related health
care and ideally that would be at HHS.
Mr. Reichert. Anyone else have an opinion?
Dr. Blum. Agree.
Mr. Reichert. Everyone would agree with that? And the key
then is to get DHS and HHS to communicate more clearly.
Dr. Bass. The other issue is that just because you have a
lead agency at HHS doesn't mean that other agencies aren't
significantly involved with that system and so not only does
there need to be a lead but there still needs to be
coordination, interoperatability, and so on, or we are just--
even with the lead agency we are going to be fragmented.
Mr. Reichert. Yes.
Ms. Jagim. If I could I just want to echo what Dr. Krug
said. Not all systems are as well coordinated as Dr. Bass'.
Certainly in my part of the world, we do not have the strength
of the Maryland system by any means. And I also want to point
out that many States yet have not even established a basic
trauma system. And you know that is kind of the blueprint that
we are using when we talk about regionalization, and that is a
stepping point. You know, we need to get--part of that basic
infrastructure that needs to be developed across the country,
that is the need for that central leadership to make sure that
every State gets onboard, every region is coordinated because
that is not so now.
Mr. Reichert. If you have thought--had the time to think
about this at all, what one piece of sort of legislation might
you think we could start to promote, work on to help--well, the
greatest need was the everyday service which goes beyond and
prepares us for the emergency that we might face some time in
the future. I guess you know how can the Federal Government--
how can Congress help you?
Ms. Jagim. Well, I will take a dive in. I think number one
is that strong central leadership point within the Federal
Government because I don't think--I don't see any way that we
can establish the coordinated regionalized care system that we
need that has interoperable communications without that central
Federal leadership. It is just not going to happen. And
secondly, I would say the need for the study on workforce
issues and how we can shore up that workforce or it is not
going to be there.
Mr. Reichert. Anyone else? Yes.
Dr. Blum. Well, I am going to be more specific. I think a
lead agency is a good start. But we could free up a huge amount
of capacity in this country in the Nation's emergency
departments if we--and I would also judge this to be relatively
low-hanging fruit as far as something that is doable. We could
free up a huge amount of capacity in the Nation's EDs if we
simply stop the practice of boarding admitted patients in the
emergency department. There is really nothing special about the
hallway in the emergency department as compared to a hallway up
on an inpatient unit. We could simply decide that this is not
an acceptable way to do business anymore and stop it. That
would free up a huge--as I said, a huge capacity and allows us
to at least have the space to do our job. If we don't have
enough nurses and don't have enough resources, we would at
least have the ability to have the space to do our job.
Mr. Reichert. Thank you.
Mr. Pascrell.
Mr. Pascrell. Dr. Blum, the National Disaster Medical
System, NDMS, supports State and local agencies, as you know,
during disasters. At the core of this system, there are the
disaster medical assistant teams, assistance teams. There are
regional teams of doctors and nurses and other health
professionals. Do you think that the NDMS is properly equipped
and organized to assist communities during large-scale
disasters? And then I am going to ask you, who are your
contacts in DHS and HHS? And what guidance are they providing
to you in terms of planning? Got the questions?
Dr. Blum. Yep. I think so. I think I will do better with
the first than the second. I think the disaster medical
assistance teams work very, very well at their defined role,
which is kind of a follow-on, you know, direct at the site of
the disaster sort of role. Unfortunately they don't go far
enough. There probably needs to be another type of response
that supports the disaster medical--the DMAT teams, and that
is--and the phenomenon here is one that we saw in Katrina very
clearly. We saw the destruction of the infrastructure, the
medical infrastructure in the directly affected areas. So what
happened then was the medical response pulled back to what we
would call in medicine the penumbra or the surrounding area so
that those hospitals became very rapidly overwhelmed with
patients from the disaster area. They were still functioning,
but their nurses, their doctors were overtaxed pretty quickly.
And we need some way--especially in a disaster like Katrina
that has week and month-long implications for medical care, we
need to figure out some way to support those surrounding
hospitals in a much more direct way than we do now.
I could tell you my own personal response. I am an
emergency physician. I am trained in the care of patients like
existed in Katrina. I tried to volunteer for a period of 2
weeks to go do exactly what I am talking about, which is
backfill in a functioning emergency department, and I
discovered there was no way for me to do that within the
Federal system. I had to sign up, you know, to be--to either do
a month stretch or more, and many, many of my colleagues found
that they were simply unable to help, which was their natural
instinct was, you know, I had some time off as it occurred,
which is rare, and I wanted to go help for a while, but it--the
politics and the bureaucracy of it was simply more than could
be done. I didn't want to go put a tube in my teeth and go dig
through wreckage. I just wanted to go to the surrounding
emergency department and go do my job to help the people who
were there, and it was not possible.
Mr. Pascrell. Are you getting guidance? You don't want to
answer that question.
Dr. Blum. Well, I am probably not the best person to ask
that question because I am not even the disaster guru at my own
hospital. That is just simply not my role. When it comes to
disaster management on a personal level, I am one of the
Indians, I am not one of the chiefs. So I am probably not the
best person to ask that question to.
I could tell you that our State has been very active in
planning, but again, I would reiterate the same thing that I
said before, that very rarely trickles down to the actual
emergency department.
Mr. Pascrell. Thank you.
Dr. Krug?
Dr. Krug. I would reiterate that point. The guidance that
we receive is probably indirect through actually again our
fragmented State. We work with both the Chicago Department of
Health and also the Illinois Department of Health and Human
Services because there is joint jurisdiction there. And so how
that guidance is interpreted is actually then I think
interpreted in part by the direct recipient of the grants,
which is the State or the city, and again from our perspective
as a children's hospital, there is nothing in that guidance
that helps us. So we actually do something well beyond what the
guidance would suggest for readiness.
I would reiterate Rick's point about the disaster response.
There were a lot of folks that wanted to help that couldn't
because there was no process to do that. In a variety of ways
and other than sort of the traditional way.
Secondly, I think that everything that we learned from
Katrina is that these responses need to be prepared to provide
support for a lengthy period of time. These response teams were
set up to go in and do good for a certain period of time and
then go back and maybe then send a second volley. Well, we need
to consider a second volley, a third, a fourth, a fifth, a
sixth, and today there is still a disaster there. There are
still underserved patients, both adults and children, whose
needs aren't being met because the hurricane came through and
ripped out the infrastructure and what is left is inadequate.
Mr. Pascrell. Thank you, Mr. Chairman.
Mr. Reichert. Mr. Dicks.
Mr. Dicks. Just a couple quick questions here. Let me just
ask you, do you agree with these numbers? The Institute of
Medicine report found that from 1993 to 2003 the U.S.
population grew by 12 percent but emergency room visits grew by
27 percent, from 90 million to 114 million. That is accurate,
right? In the same period, however, 425 emergency departments
closed along with 700 hospitals and nearly 200,000 beds, and I
would assume that is mainly for financial reasons. I know I
have a number of hospitals in rural Washington State where I
represent that are just barely hanging on, and you know, 50 or
60 percent of their patients are either Medicare or Medicaid,
and they don't--they just can't make it financially. So again,
I think this is a part of the problem that we are faced with
and that we have to--we as a Federal Government have to look
at.
Now, the other thing I was--that we have here is that--as
it says, as you know, the National Bioterrorism Hospital
Preparedness Program administered by HRSA now--are you aware of
this program? Prepares hospitals and supporting health care
systems to deliver coordinated and effective care to victims of
terrorism and other public health emergencies. The program
received $474 million in fiscal year 06. I know Congresswoman
Lowey knows about this because she is on that subcommittee. Is
that sufficient funding for that program? Should dollars be
distributed based on risk instead of population as it is now?
What do you think of that?
Ms. Jagim. You know, it is a little bit of both. The other
thing I just wanted to point out, too, you kind of touched on
it as far as rural hospitals in Washington. I think the thing
to keep in mind when it comes to rural facilities, we interface
with them. Of course I wouldn't be from North Dakota if I
didn't talk about rural hospitals. The problem that they have
is they have low population bases that they are working with.
Most of them in my State are critical access hospitals.
Mr. Dicks. Exactly. They have all switched because they get
a better reimbursement under Medicare.
Ms. Jagim. Fee for service payments instead of DRG-based,
which has been helpful for them. It saved them from closing.
Mr. Dicks. That is exactly the same for us.
Ms. Jagim. When it comes to emergency preparedness, they
have no depth of their bench, so to speak, to pull from as far
as resources for planning and training. You look at them and
you talk to them about it and they have this lost, glazed look
on their face. They are struggling out there, and they don't
have the depth of resources to help them accomplish what they
need to do to prepare. And that is where when you look at--they
are not a population base, but yet they are there, and they
serve in a very, very key role.
Mr. Dicks. Rural communities?
Ms. Jagim. Right. Right.
Mr. Dicks. Without the hospital they would be in deep
trouble?
Ms. Jagim. Exactly.
Mr. Dicks. Some of the communities actually bond themselves
to help subsidize the hospital, Mason County being one.
Ms. Jagim. If you don't have a regionalized system of some
sort, whether it is based on a trauma system or you have been
able to advance it beyond that, there is no linkages that are
occurring then between the rural hospitals and the larger
regional centers. And that needs to happen.
When we look at pandemic planning, where I am from in
Fargo, we don't have capacity in my hospital but we know that
there is some capacity, maybe in rural, maybe not. But we know
that if we are going to survive a catastrophic event, we are
going to have to do it together and not separate individual
entities, and that is where this concept of regionalization is
so vitally important.
Mr. Dicks. So--and I would assume that if we have an avian
influenza outbreak, that would be--we are all focused kind of
on hurricanes right now, but that is still hanging over our
head, right?
Ms. Jagim. Correct. And again, they have a short bench, you
know. So if you see an epidemic occurring, they may have some
limited space in their hospital. They don't have the resources.
If they lose 40 percent of their workforce, it goes from like
four people to one. You know what I mean? They just don't have
any depth. And I think that is really a concern, and you look
to our whole system. Most of the hospitals in the country are
community hospitals such as mine. There is many, many hundreds
of rural hospitals in the country. Your EMS system in rural
States such as mine is 98 percent volunteer. It is not paid. It
is volunteer, and you know, I think that we have got a lot of
weaknesses in the system.
Mr. Dicks. Dr. Krug.
Dr. Krug. Just to reiterate an important point that you
made. This is akin to Katrina. As we disaster plan, we think of
how we are going to provide services with existing resources to
a large number of victims. But what happens if some of those
victims are health care providers? The avian flu is a great
example of that. That scares us a lot at a fairly well
resourced institution. We have a big bench. So if we lost half
of our physicians, we could still run our emergency department.
Your average small community hospital loses its physician, what
do they do?
So the plans really need to consider that as well. We have
talked about a buddy system where the bigger, better resourced
institutions may need to be in a position to help others and
not just simply say send us your patients. We are going to need
to send them providers.
Mr. Dicks. Yes, Dr. Blum.
Dr. Blum. Well, I would like to put a little bit different
twist on this. I think you would have to build the entire
system up because you can't really predict how an epidemic or a
pandemic is going to evolve. It may be that rural America is
the answer and not the problem to a pandemic flu. If you look
at how human-to-human transmission occurs in a pandemic flu, it
is easy to conceive that urban areas may be increasingly
impacted--have increased impact early in an epidemic and the
capacity may actually exist for care in the rural parts of the
country. So I don't think you could look at it from where--
let's try to guess what is going to happen and where it is
going to happen. I think you have to build the entire system up
because you can't really predict how something like a pandemic
is going to evolve over time.
Mr. Dicks. And that hasn't been done, right?
Dr. Blum. That hasn't been done clearly. A critical access
hospital where most of the inpatient beds have been converted
to nursing home beds would be no help in a situation like that,
and they might be a great help in, you know, in a pandemic flu,
you know, if we needed additional hospital beds and capability.
Mr. Reichert. The gentleman's time has expired.
Mr. Dicks. Mr. Chairman, again, I compliment you for having
the hearing.
Mr. Reichert. Mrs. Lowey.
Mrs. Lowey. Thank you again and thank you to the panel.
This issue is so important I want to follow up on my
colleagues' comments and questions because I know in my
district, which is the suburbs of New York City, they can
barely accommodate increases in daily emergency room visits,
let alone effectively treat thousands of sick and injured
individuals resulting from an act of terrorism or public health
emergency. And that is in the New York Metropolitan Area.
We know that the Institute of Medicine study, the American
College of Emergency Physicians report both found that
hospitals across the country are not prepared to handle a
public health emergency with specific gaps in surge capacity.
Now, we know this. The Federal Government knows this. We have
been hearing about this since 9/11 over and over again.
So I guess my question is, what can, what should the
Federal Government do to assist hospitals in increasing their
surge capacity? For example, are there any Federal or State
guidelines for creating surge capacity? Should all U.S.
hospitals be required to increase hospital beds and staff by 20
percent--I am just throwing that out--within 8 hours of a
public health emergency?
I am really following up with your comment that it should
be dealt with in both the rural areas and our obvious areas
like New York City. Should there be specific guidance and
performance measures? Are you recommending them for surge
capacity? Has the Department of Health and Human Services even
estimated the cost of creating a minimal level of surge
capacity? And who is in--I am asking all of these together so
perhaps you can comment. Who is in charge actually of ensuring
that States and localities create the surge capacity for
treating people who became ill during a public emergency or
terrorist event?
Maybe I should stop at that point and have you respond. Who
is in charge? What should they be doing? Should the Federal
Government assume a greater responsibility? And maybe we will
all find out what that command center is doing these days with
all the money that has been invested in it. Whoever wants to
comment, that is fine.
Dr. Bass. I would argue that would really, in my
estimation, be the role of--the health department at the State
level should lead the process for looking at surge planning and
we do that in Maryland. We have had a process underway for
several years. We work very closely with the hospitals. And I
know that there are grants. I believe it is CDC grant. I don't
want to hold myself to that, but that is--that they are able to
use to help to fund that process, and I believe the Federal
Government should provide some guidelines, and they do, but
that it really boils down to the States and the regions taking
those guidelines and converting into operational plans, and
that is where the rubber hits the road.
Mrs. Lowey. Well, if the rubber hits the road and we have
an emergency and the State doesn't do what you think they
should do or that Maryland is doing, what is the Federal
Government's responsibility?
Dr. Blum?
Dr. Blum. Well, you probably won't like this answer, but
you know the infrastructure problems that I outlined with
regard to the emergency department quite frankly are not going
to be fixed by grants from, you know, Homeland Security. They
are not. They are simply too big and too pervasive. In order to
truly--
Mrs. Lowey. How about HHS? How about HHS?
Dr. Blum. Well, perhaps at that level. One of the problems
with emergency care in this country is that all the problems of
the health care delivery system seem to be focused and
concentrated in the emergency department. When any part of the
system doesn't work properly, the emergency department bears
the brunt of it. I think probably the simplest thing we could
do--and this isn't the purview of this committee, but figure
out how to share that burden across the entire health care, you
know, enterprise in this country, which we don't do right now.
The answer to who is in charge is everybody and nobody. It
depends on where you are. The State health department might be
the right place if they are used to and regularly talk to the
emergency departments. I could tell you in some States they do
not. Those conversations don't exist. And so the public health
sector makes the same assumption that the public does, which is
that the emergency departments are going to be there and
functioning and have the capacity and their planning all
reflects that.
Mrs. Lowey. If I could ask you--because I see my yellow
light is on. But this I think has to do with the funding. The
National Bioterrorism Hospital Preparedness Program, where you
get a lot of money from, is administered by the Health
Resources and Services Administration, and it does prepare
hospitals and supporting health care systems, and so on.
The program received $460 million in fiscal year 2006,
which is a $10 million decrease from fiscal year 2005. Given
all the needs that are out there, would you have recommended
that they cut the program or do you think we need to invest
more money in the program?
I don't want to put you on the spot, but I will.
Ms. Jagim. That is an easy question. No, it shouldn't have
been cut. And I would just like to tack on to the other
comments that have been made. I think the ability of the State
health department to assist with that surge capacity planning
is somewhat based upon the day-to-day strength of that health
department, and my personal perspective is I don't know that I
have a great deal of confidence in the strength of that in my
own home State, and I think, however, they have put some tools
into place, such as a bioterrorism wide area network that could
connect all the hospitals in times of crisis so that we can
communicate even when everything else goes down.
So they have helped us to develop some basic guidelines,
but I think the strength is variable across the country.
Dr. Krug. I have a local anecdote. A neighbor recently put
on an addition to their house. Apparently there wasn't enough
attention paid to the foundation of that addition. Can you
imagine what happened to the addition? It literally almost fell
off the house. Everybody thought that was pretty amusing in the
neighborhood.
We have a similar problem. We can actually give hospitals
lots of money to increase their surge capacity, but if you
don't deal with the foundation, if you don't deal with the
personnel issues, if you don't deal with the access and the
system issues, it is not going to work. It is really that
simple.
Mr. Reichert. Gentlelady's time has expired.
I thank the witnesses for your time and your testimony.
This was a very enlightening hearing, and as you can tell, the
members are eager to help find some solutions to the problems
that you described to us today, and the members of the
subcommittee may have some additional questions for the
witnesses, and if they do, we will ask that you respond to
those questions in writing, please. The hearing record will be
held open for 10 days. And without objection, this hearing is
closed.
Thank you.
[Whereupon, at 4:01 p.m., the subcommittee was adjourned.]