[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
EMERGENCY CARE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON WAYS AND MEANS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
JULY 27, 2006
__________
Serial No. 109-80
__________
Printed for the use of the Committee on Ways and Means
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30-453 PDF WASHINGTON : 2006
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COMMITTEE ON WAYS AND MEANS
BILL THOMAS, California, Chairman
E. CLAY SHAW, JR., Florida CHARLES B. RANGEL, New York
NANCY L. JOHNSON, Connecticut FORTNEY PETE STARK, California
WALLY HERGER, California SANDER M. LEVIN, Michigan
JIM MCCRERY, Louisiana BENJAMIN L. CARDIN, Maryland
DAVE CAMP, Michigan JIM MCDERMOTT, Washington
JIM RAMSTAD, Minnesota JOHN LEWIS, Georgia
JIM NUSSLE, Iowa RICHARD E. NEAL, Massachusetts
SAM JOHNSON, Texas MICHAEL R. MCNULTY, New York
PHIL ENGLISH, Pennsylvania JOHN S. TANNER, Tennessee
J.D. HAYWORTH, Arizona XAVIER BECERRA, California
JERRY WELLER, Illinois LLOYD DOGGETT, Texas
KENNY C. HULSHOF, Missouri EARL POMEROY, North Dakota
RON LEWIS, Kentucky STEPHANIE TUBBS JONES, Ohio
MARK FOLEY, Florida MIKE THOMPSON, California
KEVIN BRADY, Texas JOHN B. LARSON, Connecticut
THOMAS M. REYNOLDS, New York RAHM EMANUEL, Illinois
PAUL RYAN, Wisconsin
ERIC CANTOR, Virginia
JOHN LINDER, Georgia
BOB BEAUPREZ, Colorado
MELISSA A. HART, Pennsylvania
CHRIS CHOCOLA, Indiana
DEVIN NUNES, California
Allison H. Giles, Chief of Staff
Janice Mays, Minority Chief Counsel
______
SUBCOMMITTEE ON HEALTH
NANCY L. JOHNSON, Connecticut, Chairman
JIM MCCRERY, Louisiana FORTNEY PETE STARK, California
SAM JOHNSON, Texas JOHN LEWIS, Georgia
DAVE CAMP, Michigan LLOYD DOGGETT, Texas
JIM RAMSTAD, Minnesota MIKE THOMPSON, California
PHIL ENGLISH, Pennsylvania RAHM EMANUEL, Illinois
J.D. HAYWORTH, Arizona
KENNY C. HULSHOF, Missouri
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Ways and Means are also published
in electronic form. The printed hearing record remains the official
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unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
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C O N T E N T S
__________
Page
Advisory of July 20, 2006 announcing the hearing................. 2
WITNESSES
Gail L. Warden, President Emeritus, Henry Ford Health System,
Detroit, Michigan.............................................. 5
Alan Kelly, Vice President and General Council, Scottsdale
Healthcare, Scottsdale, Arizona................................ 12
Alan Levine, President and Chief Executive Officer, North Broward
Hospital District, Fort Lauderdale, Florida.................... 17
Frederick C. Blum, M.D., President, American College of Emergency
Physicians, Morgantown, West Virginia.......................... 21
Larry Bedard, M.D., Senior Partner, California Emergency
Physicians, Emeryville, California............................. 29
SUBMISSIONS FOR THE RECORD
American Academy of Pediatrics, statement........................ 61
Rios, Elena, National Hispanic Medical Association, letter....... 69
Sanger, William, Emergency Medical Services Corporation,
statement...................................................... 69
EMERGENCY CARE
----------
THURSDAY, JULY 27, 2006
U.S. House of Representatives,
Committee on Ways and Means,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:10 a.m., in
room 1100, Longworth House Office Building, Hon. Nancy L.
Johnson (Chairman of the Subcommittee), presiding.
[The advisory announcing the hearing follows:]
ADVISORY
FROM THE
COMMITTEE
ON WAYS
AND
MEANS
SUBCOMMITTEE ON HEALTH
CONTACT: (202) 225-3943
FOR IMMEDIATE RELEASE
July 20, 2006
HL-18
Johnson Announces Hearing on Emergency Care
Congresswoman Nancy L. Johnson (R-CT), Chairman, Subcommittee on
Health of the Committee on Ways and Means, today announced that the
Subcommittee will hold a hearing on emergency care. The hearing will
take place on July 27, 2006, in the main Committee hearing room, 1100
Longworth House Office Building, beginning at 10:00 a.m.
In view of the limited time available to hear witnesses, oral
testimony at this hearing will be from the invited witnesses only.
Witnesses will include representatives from the Institute of Medicine
and the hospital and health care provider community. However, any
individual or organization not scheduled for an oral appearance may
submit a written statement for consideration by the Subcommittee and
for inclusion in the printed record of the hearing.
BACKGROUND:
A recent report issued by the Institute of Medicine suggests that
demand for emergency room services has increased in recent years,
capacity has been reduced, patients are often ``boarded'' until
inpatient beds become available, and diversions to other hospitals
frequently occur. Also, there are concerns regarding the availability
of medical specialists to provide emergency and trauma care.
Hospitals are an important component of the nation's health care
system, particularly with respect to emergency care, and they operate
under various federal requirements. For instance, hospitals with
emergency departments are required to screen and stabilize all
individuals who enter hospital emergency rooms, regardless of their
income level, citizenship, or insurance status.
In announcing the hearing, Chairman Johnson said, ``Recent
information appears to indicate that emergency health care providers,
including the Nation's hospital systems, are experiencing increasing
demands for their services. We need to better understand the demands
placed on the health care provider community, and the reasons for these
demands in order to fully assess any problems and explore potential
solutions.''
FOCUS OF THE HEARING:
This hearing will focus on the status of emergency health care and
administration of health care services within the jurisdiction of the
Subcommittee.
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noted above.
Chairman JOHNSON OF CONNECTICUT. Good morning. Mr. Stark
will be here momentarily, and I'm going to start with my
opening statement and hope that by the time I finish it, he'll
be here. He has been unavoidably delayed, but we're going to
start. I'm very pleased to chair a hearing to consider the
recent Institute of Medicine (IOM) report, ``Hospital-Based
Emergency Care at the Breaking Point.'' We've all known this
was coming. We've all known it as we've visited hospitals and
circulated in our districts, so I welcome this report. I think
it will be very helpful to this Committee and to the
Administration, and I do consider addressing the issues it
raises as very high on our agenda and indeed, an emergency.
Emergency departments play a critical role in our health
care system. They're responsible for urgent care, lifesaving
care, they act as a safety net for those with limited access to
the health care system, and they're the first line of defense
in a public health emergency and in a disaster. Yet today,
emergency departments face unprecedented challenges, and
without attention, I believe they will not be able to fulfill
their responsibilities, and the institutions on which they rely
and which they serve will be at risk. Each year, there are
approximately 114 million visits to emergency departments.
According to the Institute of Medicine's recent report in
2002, almost half of all hospital admissions occurred through
the emergency department. In addition to the critical role
emergency departments play in the health care system, they are
also required to comply with unique legal requirements. In
1986, Congress enacted Emergency Medical Treatment and Active
Labor Act (EMTALA) (P.L. 99-272) to ensure public access to
emergency services, regardless of ability to pay. section 1867
of the Social Security Act (P.L. 108-173) imposes specific
obligations on Medicare participating hospitals that offer
emergency services to provide a medical screening exam when a
request is made for examination or treatment for an emergency
medical condition, including active labor, regardless of an
individual's ability to pay.
Hospitals are then required to provide stabilizing
treatment for patients with emergency medical conditions. If a
hospital is unable to stabilize a patient within its capacity,
or if a patient requests it, an appropriate transfer must be
made. The IOM also found that, as the demand on emergency
services has grown, the nature of how hospitals operate has
also changed. Between 1993 and 2003, there was a net loss
198,000 hospital beds in the United States. This, in part, has
given rise to boarding, which occurs when admitted patients are
required to stay in emergency departments either because of
lack of in-patient beds or because the in-patient beds
available are being reserved for patients not entering the
hospital through the emergency room.
These patients may be cared for in settings that are far
less than optimal and for significant lengths of times.
Emergency departments are not equipped to board such patients,
and it's not in the best interests of the patient, and it
places great strain on the department. Perhaps the most tragic
example of this are adolescents with psychiatric problems. We
should truly be ashamed of where we are with that particular
group needing health care. Additionally, emergency departments
are responsible for treating the whole spectrum of injuries and
diseases and are therefore, required to be able to call a
specialist at any time of day or night to ensure that patients
receive optimal and appropriate care.
However, for a number of reasons, including increased
malpractice premiums, the financial implications of caring for
the uninsured, and the strain of being on call in addition to a
full-time physician, means most emergency departments are
finding it very difficult to have sufficient on-call physicians
to care for their patients. As we will also hear, this
situation has given rise to local and regional coordination
efforts to raise the quality of care within the same resource
base. Today, we'll first hear from Gail Warden, president
emeritus of the Henry Ford Health System in Detroit, Michigan.
I don't believe we will hear from her. Is she here? Oh, Mr.
Warden. Sorry.
Mr. Warden will testify to the findings and recommendations
of the Institute of Medicine's ongoing series of reports on
emergency departments, pediatric care in emergency departments,
and emergency medical services. Additionally, Alan Kelly, vice
president and general counsel of Scottsdale Healthcare in
Arizona, will speak to the challenges of providing emergency
care to a population with a significant number of undocumented
immigrants and the unique challenges hospitals face in caring
for these individuals. Alan Levine is president and CEO of the
North Broward Hospital District in Florida, which is one of the
largest nonprofit public health care systems in the nation. Mr.
Levine will also speak to the stresses being placed upon
emergency departments, the complexity of the causes, and the
need for state and regional flexibility to meet these
challenges.
Finally, Dr. Frederick Blum, associate professor of
emergency medicine, pediatrics, and internal medicine at West
Virginia University School of Medicine, and president of
American College of Emergency Physicians, and Larry Bedard, an
emergency department physician, will provide the physician
perspective on emergency department care in the United States.
I look forward to hearing from all of the witnesses and thank
you for being here today, but I would like to yield at this
time a moment to my colleague from Arizona for the purposes of
an introduction.
Mr. HAYWORTH. Madam Chairman, thank you very much. As you
mentioned, among the witnesses, and I would be remiss if I did
not welcome all of our witnesses today to deal with the
challenges confronting emergency care, but I am very pleased to
have one of my constituents and friends, Alan Kelly, who serves
as vice president and general counsel of Scottsdale Health Care
in my hometown of Scottsdale, Arizona. As one who has not taken
advantage well, no, strike that. Perhaps not personally, but
with kids and athletic accidents, for purposes of full
disclosure, we have availed ourselves of the emergency
facilities at what we used to call Scottsdale North. We've
since changed the nomenclature.
I've seen firsthand the emergency care, and look forward to
hearing Alan document the challenges that we are encountering
in Arizona, and challenges that don't simply come to hospitals
in border states with emergency care to illegal immigrants. So
Alan, we welcome you, as we welcome all of the witnesses, and
Madam Chairman, I thank you very much for the generosity of
your time, and for holding this hearing today. I yield back.
Chairman JOHNSON OF CONNECTICUT. Thank you very much. We
are going to proceed, and Mr. Stark will make some comments
when he arrives. He will be arriving momentarily. Mr. Warden.
STATEMENT OF GAIL L. WARDEN, PRESIDENT EMERITUS, HENRY FORD
HEALTH SYSTEM, DETROIT, MICHIGAN
Mr. WARDEN. Thank you, Madam Chair and Members of the
Subcommittee. My name is Gail Warden. I'm the president
emeritus of Henry Ford Health System in Detroit, Michigan, and
was the chair of the Institute of Medicine's Committee on the
Future of Emergency Care in the United States Health System.
This Committee was formed in September of 2003 to examine the
emergency care system, explore its strengths, limitations, and
challenges to create a vision for the future of the system and
to make recommendations to help the nation achieve that vision.
Over 40 national experts from fields including emergency
care, trauma, pediatrics, health care administration, public
health, and health services research participated as Members of
the Committee or Subcommittee. The study was requested by
Congress and funded through a congressional appropriation along
with additional sponsorship from the Josiah Macy Foundation,
the Department of Health and Human Services, and the Department
of Transportation. In my brief time this morning, I'm going to
basically focus on the findings and recommendations of the
report as they relate to hospital-based emergency care. As far
as the findings are concerned, I think it's fair to say that
beneath the surface, there's a growing crisis in emergency
care.
Many emergency departments today are severely overcrowded
with patients, many of whom are being held in the emergency
department because of no in-patient bed being available. When
crowding reaches dangerous levels, hospital often divert
ambulances to other facilities. In 2003 alone, U.S. hospitals
diverted more than half a million ambulances, which is an
average of one per minute. Each diversion adds minutes to the
time before a patient can be seen by a doctor and these delays
may mean the difference between life and death for some
patients. A second finding, which is important, which, Madam
Chair, you mentioned in your opening statement, is it is
becoming increasingly difficult for hospitals to find
specialists who will agree to be on call.
The rising cost of uncompensated care, the fear of legal
liability for performing risky procedures, and the disruptions
of daily medical practice and home lives have led more surgical
specialists to opt out on taking emergency department (ED)
calls. The resulting shortage of on-call specialists in
emergency departments can have a tragic result. Thirdly,
today's emergency care system is often highly fragmented and
variable. Coordination of emergency care providers on the
ground is often poor. Emergency medical services, hospitals,
and public safety often lack common radio frequencies, much
less interoperable communications systems, and these
technological gaps are compounded by cultural gaps between
public safety providers and emergency care personnel. The
fourth important finding is that there's a lack of preparedness
within the system to care for children.
We have recognized for decades that children require
specialized care, and although children make up 27 percent of
all visits to the emergency departments, a recent study found
only 6 percent of the hospitals have all the supplies deemed
essential for managing pediatric emergencies. We believe the
country can do better. As far as recommendations are concerned
to improve the nation's emergency care system and deal with the
growing demands placed upon it, the Committee described a
vision of the emergency system that we would like to see, in
which we talked about coordination, regionalization, and
accountability: Coordination of all the components of the
system, such as EMS, hospital emergency departments, trauma
centers, local dispatchers working together; Regionalization so
patients are taken to facilities that are best able to address
the needs of each patient based upon their particular illness
or injury; Accountability in that an emergency care system
should be transparent and accountable to the public it serves
and their preferences should be measured.
To achieve that vision, we recommended that Congress
establish a demonstration program to promote that vision
through an $8 million appropriation over 5 years for
demonstrations in 10 states in each phase, Phase 1 and Phase 2.
We recommended the establishment of a lead agency in the
Department of Health and Human Services for emergency and
trauma care, and asked that that lead agency establish a
working group to consolidate the funding and functions. We also
recommended that the Federal agencies establish evidence-based
categorization of systems' pre-hospital protocols and
indicators of system performance.
A second recommendation related to the fact that we felt we
must end the practice of emergency department boarding and
diversion except in the most extreme circumstances, such as
community mass casualty events, and recommended that the tools
developed from engineering and operation research and
information technology that are available be applied in
institutions----
Chairman JOHNSON OF CONNECTICUT. Mr. Warden, could I ask
you to just start back? You've just gone on to recommendation
number one. So, if you would start back with your first
recommendation, that would be useful.
Mr. WARDEN. Back to describing the vision, ma'am?
Chairman JOHNSON OF CONNECTICUT. You may proceed.
Mr. WARDEN. Okay. In the recommendations, there were four
recommendations that I thought we should highlight today. The
first was a vision that we establish, as it relates to what we
thought the emergency system ought to be able to do in this
country. We emphasized coordination among all components of the
system; We emphasized regionalization, where patients are taken
to facilities that are best able to address the needs for each
patient based upon their particular illness or injury;
Accountability, in that an emergency care system should be
transparent and accountable to the public it serves, and their
preferences should be measured.
To achieve that vision, we recommended that Congress
establish a demonstration program to promote a regionalized,
coordinated, and accountable emergency care system over five
years. We also suggested that Congress should establish a lead
agency in the Department of Health and Human Services for
emergency and trauma care, and a working group should be
brought together to consolidate functions of funding which are
now in a multiple number of agencies. We also recommended that
Federal agencies establish evidence-based categorization of
systems' pre-hospital protocols and indicators of system
performance.
The second recommendation was that we must end the practice
of emergency department boarding and diversion except in most
extreme circumstances, such as a community mass casualty event.
We outlined in much detail about the tools that are available
from engineering and operations research and information
technology that would help to accomplish that. We also
suggested that, since there are few financial incentives for
hospitals to reduce crowding, that the Joint Commission should
develop strong standards about emergency department crowding,
boarding, and diversion. The third important recommendation was
really related to increasing funding that could help improve
the nation's emergency care system. Much research is needed.
We also felt Congress should provide greater reimbursement
to the large safety net hospitals and trauma centers that bear
a disproportionate amount of the cost of taking care of
uninsured patients and that there should be greater funding for
disaster preparedness. Finally, as the various improvements are
made to the nation's emergency care system, it will be
important to keep pediatric patients in mind in all aspects of
emergency care, because they have not gotten the attention that
they should. In closing, the Committee believes that the
nation's emergency care system is in serious peril. Strong
measures must be taken by Congress, the state, hospitals, and
others to achieve the level of response that Americans expect
and deserve. Thank you for the opportunity to testify, and I'll
be happy to answer any questions that the Subcommittee might
have.
[The prepared statement of Ms. Warden follows:]
Statement of Gail L. Warden, President Emeritus, Henry Ford Health
System, Detroit, Michigan
INTRODUCTION
Good morning Madame Chair and members of the Subcommittee. My name
is Gail Warden and I am President Emeritus of Henry Ford Hospital in
Detroit, Michigan. I served as chair 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 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. Over 40 national experts from
fields including emergency care, trauma, pediatrics, health care
administration, public health, and health services research
participated on the Committee or one of its subcommittees. 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 U.S.
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
hospital-based emergency care.
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 (EDs)--more than 1 for every 3
people in the U.S. 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 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.
Emergency Department Crowding
The number of patients visiting EDs has been growing rapidly. There
were 113.9 million ED visits in 2003, for example, up from 90.3 million
a decade earlier. At the same time, the number of facilities available
to deal with these visits has been declining. Between 1993 and 2003,
the total number of hospitals in the United States decreased by 703,
the number of hospital beds dropped by 198,000, and the number of EDs
fell by 425. The result has been serious overcrowding. If the beds in a
hospital are filled, patients cannot be transferred from the ED to
inpatient units. This can lead to the practice of ``boarding''
patients--holding them in the ED, often in beds in hallways, until an
inpatient bed becomes available. It is not uncommon for patients in
some busy EDs to board for 48 hours or more. These patients have
limited privacy, receive less timely services, and do not have the
benefit of expertise and equipment specific to their condition that
they would get within the inpatient department.
Another consequence of overcrowding has been a striking increase in
the number of ambulance diversions. Once considered a safety valve to
be used only in the most extreme circumstances, diversions are now
commonplace. Half a million times each year--an average of once every
minute--an ambulance carrying an emergency patient is diverted from an
ED that is full and sent to one that is farther away. Each diversion
adds precious minutes to the time before a patient can be wheeled into
an ED and be seen by a doctor, and these delays may mean the difference
between life and death for some patients. Moreover, the delays increase
the time that ambulances are unavailable for other patients.
Fragmentation
Few systems around the country coordinate the regional flow of
emergency patients to hospitals and trauma centers effectively because
most fail to take into account such things as the levels of crowding
and the differing sets of medical expertise available at each hospital.
Indeed, in most cases, the only time an ED passes along information
concerning its status to EMS agencies is when it formally goes on
diversion and refuses to take further deliveries of patients. As a
result, the regional flow of patients is managed poorly and individual
patients may have to be taken to facilities that are not optimal given
their medical needs.
Adding to the fragmentation is the fact that there is tremendous
variability around the country in how emergency care is handled. There
are more than six thousand 9-1-1 call centers around the country and
depending on their location, they may be operated by the police
department, the fire department, the city or county government, or some
other entity. There is no single agency in the federal government that
oversees the emergency and trauma care system. Instead, responsibility
for EMS and hospital-based emergency and trauma care is scattered among
many different agencies and federal departments, including Health and
Human Services, Transportation, and Homeland Security. Because
responsibility for the system is so fractured, there is very little
accountability. In fact, it is often difficult even to determine where
system breakdowns occur and why.
Shortage of On-Call Specialists
Emergency and trauma doctors can be called on to treat nearly any
type of injury or illness, so it is important for them to be able to
consult with specialists in various fields. It has become increasingly
difficult, however, for hospitals to find specialists willing to be on
call for the ED. The resulting shortage of on-call specialists in EDs
can have dire and sometimes tragic results.
There are many reasons why specialists are often unwilling to be
on-call in EDs. Many specialists find that they have difficulty getting
paid for services provided in the ED because many emergency and trauma
patients are uninsured. Specialists are also deterred by the additional
liability risk of working in the ED. Many of the procedures performed
in EDs are inherently risky and physicians rarely have an existing
relationship with emergency patients. The result is that insurance
premiums for doctors who serve as on-call specialists in the ED are
higher than for those who do not. Finally, many specialists find the
demands of providing on-call services too disruptive to their private
practices and their family lives.
Lack of Preparedness for Disasters
Unfortunately, the nation's emergency care system is very poorly
prepared to handle disasters. The difficulties begin with the already
overcrowded nature of the system. With hospitals in many large cities
operating at or near full capacity, even a multiple-car highway crash
can create havoc in an ED. A major disaster with many casualties is
something that most hospitals have limited capacity to handle.
Much of the problem, though, is due to a simple lack of funding.
Hospital grants from HRSA's National Bioterrorism Hospital Preparedness
Program are small--not enough to equip even one critical-care room.
Although emergency service providers are a crucial part of the response
to any disaster, they received only 4 percent of the $3.38 billion
distributed by the Homeland Security Department for emergency
preparedness in 2002 and 2003. Due to this lack of funding, few
hospital and EMS personnel have received even minimal training in how
to prepare for and respond to a disaster. Few hospitals have negative-
pressure units, for instance, which are crucial for isolating victims
of airborne diseases, such as the avian flu. Nor do many hospitals have
the appropriate personal protective equipment to keep their staffs safe
when dealing with an epidemic or other disaster.
Shortcomings in Pediatric Emergency Care
Children who are injured or ill have different medical needs than
adults with the same conditions. They have different heart rates, blood
pressures, and respiratory rates, and these change as children grow.
They often need equipment that is smaller than what is used for adults,
and they require medication in much more carefully calculated doses.
They have special emotional needs as well, often reacting very
differently to an injury or illness than adults. Unfortunately,
although children make up 27 percent of all visits to the ED, many
hospitals and EMS agencies are not well equipped to handle these
patients.
IOM RECOMMENDATIONS
To improve the nation's emergency care system and deal with the
growing demands placed on it, the Committee recommends a broad strategy
for reform, beginning with a new vision for the future of emergency
care.
A Vision for the Future of Emergency Care
The Committee believes the challenges that exist in the system
today can best be addressed by building a nationwide network of
regionalized, coordinated, and accountable emergency care systems. They
should be coordinated in the sense that, from the patient's point of
view, delivery of emergency services should be seamless. To achieve
this, the various components of the system--9-1-1 and dispatch,
ambulances and EMS workers, hospital EDs and trauma centers, and the
specialists supporting them--must be able to communicate continuously
and coordinate their activities. When an ambulance picks up a patient,
for example, the EMS personnel gather information on the patient, and
the information is automatically passed on to the ED before the
ambulance even arrives.
The system should be regionalized in the sense that neighboring
hospitals, EMS, and other agencies work together as a unit to provide
emergency care to everyone in that region. A patient should be taken to
the optimal facility within the region based on his or her condition
and the distances involved. In case of a stroke, for example, a patient
might be better served by going to a hospital that is slightly farther
away but that specializes in treatment of strokes.
Finally, the system should be accountable, which means that there
must be a way of determining the performance of the different
components of the system and reporting that performance to the public.
This will require the development of well-defined standards and methods
to collect data and measure performance against those standards.
To promote the development of these systems, the Committee
recommends two important roles for Congress. First, Congress should
establish a federally funded demonstration program to develop and test
various approaches to regionalize delivery of prehospital and hospital-
based emergency care. Second, Congress should 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 at the local
and regional level 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.
Improving Efficiency and Patient Flow
Tools developed from engineering and operations research have been
successfully applied to a variety of businesses, from banking and
airlines to manufacturing companies. These same tools have been shown
to improve the flow of patients through hospitals, increasing the
number of patients that can be treated while minimizing delays in their
treatment and improving the quality of their care. For example,
smoothing the peaks and valleys of patient admissions has the potential
to eliminate bottlenecks, reduce crowding, improve patient care, and
reduce cost. Another promising tool is the clinical decision unit, or
23-hour observation unit, which helps ED staff determine whether
certain ED patients require admission. Hospitals should use these tools
as a way of improving hospital efficiency and, in particular, reducing
ED crowding.
At the same time hospitals should increase their use of information
technologies with such things as dashboard systems that track and
coordinate patient flow and communications systems that enable ED
physicians to link to patients' records from other providers. Such
increased use of information technologies will not only lead to greater
hospital efficiency but will increase safety and improve the quality of
emergency care.
Since there are few financial incentives for hospitals to reduce
crowding, the Joint Commission on the Accreditation of Healthcare
Organizations should put into place strong standards on ED crowding,
boarding, and diversion. In particular, the practices of boarding and
ambulance diversion should be eliminated except in the most extreme
circumstances, such as a community mass-casualty event.
Increasing Resources for Emergency Care
Increased funding could help improve the nation's emergency care
system in a number of ways. More research is needed, for instance, to
determine the best ways to organize the delivery of emergency care
services, particularly prehospital EMS. And, given that many closings
of hospitals and EDs can be attributed to financial losses from the
delivery of emergency and trauma services, Congress should provide
additional funding to large safety-net hospitals and trauma centers
that bear a disproportionate amount of the cost of taking care of
uninsured patients.
Another area in which more funding is needed is disaster
preparedness. To date, despite their importance in any response to
disaster, the various components of the emergency care system have
received very little of the funding that Congress has dispensed for
disaster preparedness. In part this is because the money tends to be
funneled through public safety agencies that often consider medical
care to be a low priority. Therefore, Congress should make
significantly more disaster-preparation funds available to the
emergency system through dedicated funding streams.
Paying Attention to Children
Finally, as these various improvements are made to the nation's
emergency care system, it will be important to keep pediatric patients
in mind in all aspects of emergency care. The needs of pediatric
patients should be taken into account in developing standards and
protocols for triage and transport of patients; in developing disaster
plans; in training emergency care workers, to ensure that they are
competent and comfortable providing emergency care to children; and in
conducting research to determine which treatments and strategies are
most effective with children in various emergency situations.
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? Strong measures must be
taken by Congress, the states, hospitals, and other stakeholders to
lead the emergency care system into the future. The Committee's
recommendations provide concrete recommendations for action.
Thank you for the opportunity to testify. I would be happy to
address any questions the Subcommittee might have.
Chairman JOHNSON OF CONNECTICUT. Thank you very much, Mr.
Warden. Mr. Kelly. I should have mentioned to begin with, your
entire testimony will be included in the record. You each have
5 minutes. Mr. Kelly.
STATEMENT OF ALAN B. KELLY, VICE PRESIDENT AND GENERAL COUNSEL,
SCOTTSDALE HEALTHCARE, SCOTTSDALE, ARIZONA
Mr. KELLY. Good morning, Chairman, and Members of the
Committee, and thank you for the find introduction, Congressman
Hayworth. Again, my name is Alan Kelly. I am vice president and
general counsel for Scottsdale Healthcare. I'm greatly honored
to be here today. Scottsdale Healthcare is a three-campus
health care system located in Scottsdale, Arizona. A full
description of our hospitals is in the submission given to the
Committee, but I would like to emphasize a few things.
Our Osborn facility is the only Level 1 trauma center for
the Greater Eastern Phoenix area serving over 2.5 million
people. We provide over 51,000 emergency room visits with over
3,200 trauma cases. Our Shea facility provides over 50,000 ER
visits, and our new Thompson Peak facility, which is expected
to open in 2007, we expect around 20,000 ER visits. On the
issue of overcrowding, this has existed many years in ERs, the
origins I think being the increase in the number of uninsured
and the EMTALA Act. Now, we have new pressures that I would
like to focus this Committee's attention on, and if the
Committee will indulge me, I am passionate about these two
issues.
The first is the inflow and the influx of illegal
immigrants which section 1011 tries to address but really does
not. An example can best be illustrated by telling you about a
man with many names, and this is a story that recently actually
transpired in our facility. This is a 63-year-old Hispanic male
who came into our trauma center via ambulance on January 18th
of this year. He had sustained a laceration on the neck from a
branch after falling from a tree, obviously picking fruit. He
also suffered a stroke. After being treated in our trauma unit,
the patient was transferred from the ER into our intensive care
unit.
As a result of the stroke, he had difficulty swallowing and
the patient required a feeding tube. On January 31st, the
patient was considered stabilized and ready for transfer to a
skilled nursing facility, but as all of the Members of this
Committee know, no facility would accept him due to a lack of a
payer source or place or origin. He was turned down from
coverage from the Arizona Medicaid program, and the Social
Security number found on his personal belongings was determined
to be completely invalid. His employer's name was also found in
his personal belongings. When contacted, however, the employer
denied knowledge of his name. The next day when we called, the
phone number was disconnected.
The Mexican Consulate in Phoenix was contacted, but office
staff requested information which is impossible for even us to
get. The Mexican Consulate is extremely difficult and little
help in these matters. On January 24, 2006, the patient was
transferred to a medical unit within our facility, and sitter
care had to be maintained 24 hours, 7 days per week, because
the patient attempted to get out of bed multiple times. Our
case management department continued to explore skilled nursing
care facilities, but was able to make a transfer because of the
payer issue.
The Scottsdale Police Department fingerprinted the patient
for identification purposes, and I authorized the hiring of a
private investigator to determine the patient's identification.
The private investigator uncovered several police reports
indicating that this patient had used at least 10 different
names, had used at least 10 different date of birth, and at
least six different Social Security numbers. The private
investigator's final report also indicated that the patient had
been arrested 10 times over three decades, released, and
deported. The arrests included three felony convictions in this
country, one for aggravated assault, and one for distribution
of drugs.
The total investigator's report was finally faxed to the
Mexican Consulate in Phoenix on April 17, 2006 of this year,
and I think, Committee Members, they were basically shamed into
finally giving us the necessary transport papers in order for
us to get this patient back to Sonora, Mexico, at Scottsdale
Healthcare's cost, of course. Scottsdale Healthcare incurred
costs of over $260,000 for this patient's 93-day length of stay
and $4,000 for ambulance transport to Mexico. Our system
additionally incurred expenses for the numerous hours and
clinical staff, including case managers, legal. A 93-day stay
speaks for itself.
Unfortunately, this is only one example of the massive
challenge to treat and care for the undocumented crisis
patients in this country, just not in border states. The second
other biggest problem that I face on a weekly basis is the
shortage of on-call physicians, that my colleague has talked
about. Scottsdale Healthcare spent over 13 million on stipends
for surgical specialists to ensure their on-call attention in
2005. Whatever the Committee's position is on specialty care
providers, whatever it is, the fact is that physicians have
many other alternatives to practice, the ER being the least,
since this cohort of patients are typically high in uninsured
and under-insured.
We must, however, provide the coverage, as EMTALA requires,
and therefore, have to pay handsomely for it. Now, I ask the
Committee Members, what physician, given the practice choices
now available, want to cover at difficult hours with little or
no chance of getting collected for insurance, and with the
exposure of being sued, what physician would like to take that
type of coverage? In conclusion, more than 46 percent of the
patients who are admitted in Arizona hospitals are emergency
department patients. The cascading impact of ever tightening
regulations, the flood of undocumented immigrants, and the
spiraling costs of providing specialty physician coverage is
foreboding. It is stressing a system that is already under
considerable pressure.
Section 1011 is a blunt instrument. Although well-intended
to help finance illegal alien health services, what we are
really talking about is the distribution of expensive talent
and existing resources to provide to our own citizens. Filling
out the forms section 11 requires, it is almost impossible.
Committee Members, look at the form yourself. Moreover, it
turns our registration clerks into immigration officials.
Members of this Subcommittee, 93-day stays in an in-patient
setting is becoming more common, more common for illegal
immigrants because of the special problems I have identified
today, and therefore profoundly affects overcrowding throughout
hospitals. section 1011 does not solve our shared
constitutional obligations to protect our borders. It only
seeks to help finance it, but it's not the answer to this
problem.
Prompt action is necessary to avoid a health care
catastrophe that will shut the doors of emergency departments
nationwide and further stress scare in-patient resources.
Again, Chairman, it has been a pleasure to be here today, and I
look forward to your questions. Thank you.
[The prepared statement of Mr. Kelly follows:]
Statement of Alan Kelly, Vice President and General Council, Scottsdale
Healthcare, Scottsdale, Arizona
Good morning, Madam Chairwoman and members of the Committee, my
name is Alan Kelly, Vice President and General Counsel for Scottsdale
Healthcare. I am very pleased to be here today, on behalf of Scottsdale
Healthcare and discuss issues related to emergency care. Scottsdale
Healthcare is a three-campus health system located in Scottsdale
Arizona. Our hospitals were founded in 1962 as a non-for-profit
provider, led by a volunteer board of local residents.
The Scottsdale Healthcare Osborn campus is our original hospital
facility. Expanded numerous times since 1962, it is a 337-bed hospital
offering the only Level 1 Trauma Center for the eastern portion of the
greater Phoenix metropolitan area, serving a population of
approximately two and a half million people. The hospital recently
expanded it emergency services and conducts the first community-based
military trauma training program in the United States. Osborn's
emergency department annually provides care for over 51,000 patient
visits with over 3,200 trauma cases.
Scottsdale Healthcare Shea is a 405-bed hospital which opened in
1984. Also located on the Shea campus is the Virginia G. Piper Cancer
Center. The Cancer Center combines the talents of community
oncologists, faculty from the University of Arizona, and genomic
researchers in one location to serve our cancer patients. Through these
collaborations, we are able to offer Phase I and Phase II Clinical
Trials of new cancer therapies. Shea's emergency department provides
care for over 50,000 emergency department patient visits per year.
Our third hospital, Scottsdale Healthcare Thompson Peak, will open
in late 2007. Now under construction, the hospital will initially open
with 60 beds, expanding to 184 beds with ten dedicated to emergency
care to meet the needs of our growing community.
Overcrowding
The Institute of Medicine's June 2006 report on the Future of
Emergency Care in the United States Health System highlights the
challenges hospitals and health systems face in providing emergency
care to our communities. The report correctly indicates that emergency
departments are the first place patients turn to address illness and
immediate health care needs. Many of those patients visits could be
provided by primary care physicians in another care setting. Often,
insured patients use emergency departments when their physician is not
available to address their needs. Another cause of is the increasing
number of uninsured patients who use emergency departments as their
primary care setting. All of this utilization stretches emergency
facilities beyond their capability. Many hospitals will divert incoming
patients from their emergency department to another hospital emergency
facility. The consequence is a domino effect moving the burden from one
emergency department to another.
Nearly five years ago, Scottsdale Healthcare began the discussion
of reorganizing its patient ``throughput'' processes. The development
and implementation took three years, with a $1.4 million dollar
investment and annual commitment in increased staff. The intent was to
improve patient care and provide for more efficiency through the
Emergency Department to an inpatient bed or to discharge. The outcome
was significant reductions in wait times. Scottsdale Healthcare
averages a turn-around times of two to four hours, from entering the
Emergency Department to either discharge or a patient bed. Yet, as
Scottsdale Healthcare has improved its internal patient throughput
process, we continue to experience increased emergency department
volumes.
EMTALA
The Emergency Treatment and Labor Act (EMTALA) directs hospitals to
provide a medical screening examination to people, regardless of their
ability to pay, for the purpose of identifying an emergency medical
condition. There is a provision within EMTALA that requires a hospital
to accept a transfer from another hospital's Emergency Department if
the accepting hospital provides the necessary higher level of care for
that patient, and the hospital has sufficient resources to accept the
patient (beds, equipment, and personnel, including on-call
specialists). While the objectives of this Act goes to the heart of
healthcare's desire to provide all patients with quality care, the
ramification is a burgeoning patient population flow through Emergency
Departments and Trauma Centers.
Aggravating this growth is the population of undocumented
immigrants, who do not qualify for emergency Medicaid services. Section
1011 of the Medicare Modernization Act of 2003 targets this population
with supplemental resources. Unfortunately, access to the funding is
contingent upon the hospital completing a Provider Payment
Determination questionnaire. The process to receive reimbursement is
cumbersome and required additional financial services personnel to
manage and coordinate the implementation of Section 1011. Additionally,
hospitals must gather from the patients complicated immigration
documentation, which is time consuming and rarely forthcoming. We need
to avoid turning healthcare professionals and hospital financial
services personnel into immigration experts.
One undocumented patient from Scottsdale Healthcare's Trauma Center
serves as a case example of the challenges that healthcare facilities
face in treating undocumented persons. This patient was a 63 year-old
Hispanic male brought to the Trauma Center via ambulance on January 18,
2006 as a Level I emergency. He had sustained a laceration on the neck
from the branch of a small tree after falling off a ladder. He had a
stroke secondary to traumatic carotid artery dissection. After being
treated, the patient was transferred from the Emergency Department and
admitted to the Intensive care unit. As a result of the stroke and
difficulty swallowing, the patient required a feeding tube for
nutritional intake.
On January 31, 2006, the patient was considered ``stabilized'' and
ready for discharge to a skilled nursing facility. However, no facility
would accept the patient due to lack of payor source. He was turned
down for coverage from Arizona Health Care Cost Containment System,
Arizona's Medicaid program, since he had no proof of residency. The
Social Security number found in his personal belongings was determined
to be invalid. His employer's name was also found in his personal
belonging. When contacted, however, the employer denied knowledge of
the patient's name. The following day, the employer's phone number was
disconnected. The Mexican Consulate in Phoenix was contacted, but
office staff requested information on where the patient was born in
order to assist in locating family members.
On January 24, 2006 the patient was transferred to a medical unit
and assigned ``sitter care'' for 24 hours, 7 days a week, due to
repeated attempts to get out of bed unaccompanied. The result of the
stroke rendered his body unable to support his own weight without
assistance. Case management continued to explore skilled nursing
facility options, but were unable to make a transfer due to the lack of
payor source.
The Scottsdale Police Department finger-printed the patient for
identification purposes. Scottsdale Healthcare authorized the hiring of
a private investigator to determine the patient's identification. The
private investigator uncovered several police reports indicating that
the patient had several different names (10 on record). The patient had
five different dates of birth and at least six different Social
Security numbers. The private investigator's final report also
indicated that the patient had been arrested 10 times over three
decades, released, and deported.
The investigation report was faxed to the Mexican Consulate in
Phoenix on April 17, 2006. A representative from the Consulate visited
the patient on April 19, 2006 and issued a temporary Mexican ID for
travel. The patient was transfer by ambulance to Hospital Integral in
Agua Prieta, Mexico, to the services of an accepting physician.
Scottsdale Healthcare incurred costs of over $260,000 for the
patient's 93-day length of stay. In addition to the cost for inpatient
care, which totaled over $230,000, there was a cost of $31,920 for 24
hour/7 day sitter care, and $4,000 for ambulance transport to Mexico.
Our system additionally incurred expenses for the numerous hours above
the clinical care staff, including case managers, legal and government
relations departments to facilitate the appropriate discharge.
Unfortunately, that is only one example of the massive challenge to
treat and care for the undocumented crisis in our country's health care
system. We have many more examples at Scottsdale Healthcare, including
the following:
------------------------------------------------------------------------
Date of
Citizenship Cost Stay
------------------------------------------------------------------------
Mexico $118,151 (including Nov 5, 2006
$13,519 for air
ambulance, and
$12,240 for
respirator)
------------------------------------------------------------------------
Mexico $166,138 (including Oct 26,
$20,565 for air 2004
ambulance)
------------------------------------------------------------------------
San Salvador $87,359 (including July 11,
$18,500 for air 2004
ambulance)
------------------------------------------------------------------------
Belize $107,203, including May 8, 2004
$19,140 for air
ambulance
------------------------------------------------------------------------
Egypt $377,827 (including Nov 25,
$32,700 for nursing 2003
home sitter care)
------------------------------------------------------------------------
Shortage of On-Call Specialists
Scottsdale Healthcare spent $13 million on stipends for surgical
specialist to ensure their on-call attention to patients in 2005 ($10
million in 2005 and $8 million in 2004. However, other hospitals in the
region do not pay for specialist care. As such, patients are
transferred to Scottsdale Healthcare for services rendered by
specialists such as those in hand surgery.
The deficit in specialist care within Emergency Departments is
directly correlated to the proliferation of specialty hospitals.
Arizona is one of seven states with more than five specialty hospitals.
The impact of the new genre of limited service hospitals is
devastating. The emergence of limited service providers--hospitals that
limit their scope of service to profitable specialties like orthopedic
surgery and cardiac care--has exacerbated Arizona's shortage of on-call
specialty physicians. These hospitals primarily do not provide a full
range of emergency services cater to a commercially insured and
Medicare population, and tend not to treat Medicaid or uninsured
patients. The deadline for the extended moratorium on limited service
providers is quickly approaching. While the Centers for Medicare and
Medicaid Services are working to change the reimbursement systems for
all hospitals including acute care and specialty, implementation will
take the next two years. The opportunity exists for limited services
providers to enter the market when the moratorium expires and carve out
a service niche from community hospitals. Physician owned limited
service providers will continue to have an advantage with physician
self referrals.
Pediatric Care Shortages
In Maricopa County, there are only three hospitals that provide
specialty pediatric emergency treatment. Hence, the region is severely
lacking in terms of being able to handle emergency care for children.
Fragmentation
Complicating the overcrowding and specialist shortages in the
Emergency Departments is the absence of a communication technology that
would permit the seamless prioritization and transfer of patients from
the field. Prehospital agencies are unable to rapidly communicate vital
signs, scene details, and other information that would expedite
Emergency and Trauma Center preparations for incoming patients.
Scottsdale Healthcare has supported the Arizona Department of
Health Services on its efforts to integrate an automated diversion
notification and management program, called the EMSystem. The program
is web-based and coordinated by dedicated dispatch sites throughout the
State. A linked program, called the EMTrack, is a patient tracking
device that employs patient banding in the field. PDA-inserted
information supplements patient data bases. The data is transmitted to
Emergency Departments to understand patient movement and final
destinations. What is obviously lacking from the technology is an
aligned program that conveys critical patient data.
Scottsdale Healthcare has been working closely with the academic
research scientists at Arizona State University's BioDesign Institute
for three years on a device that would automate vital signs and other
patient information for communication from prehospital agencies to the
Emergency Department. The technologies for vital sign assessment and
collection of supplemental information are already available in the
research arena. Yet, there exists no funding to integrate the
technologies into a single and usable platform.
In addition, Scottsdale Healthcare has joined with General
Dynamics, the Arizona National Guard, and the Fire and Police
Departments of Scottsdale Healthcare on development an Internet-based
chat room format for connecting ``command centers,'' or key
communication centers, together. Developed for a disaster drill in
Scottsdale, this chat room communication methodology has proven to be
effective for the military in battlefield settings. The initial phase
of the communication strategy was tested in April of 2006 (during the
Coyote Crisis Campaign, the disaster drill). The permits communication
and coordination across the organizations as well as within them, on a
secured and confidential patient management system. This technology,
would also enable partners to address critical resource challenges
immediately during a disaster (e.g., water, generator, staffing, and
other resource problems). Yet, again, there is no funding available to
advance this program.
Lack of Disaster Preparedness
A major disaster, with many casualties, is an event that many
hospitals will not be able to manage well. Whether man-made, a disease
outbreak, or a terrorist attack, Emergency Departments cannot
accommodate the influx of patients due to facility and staff surge
capacity deficits.
The bioterrorism funding available to hospitals for disaster
preparedness is so minimal that it tends to generate only superficial
disaster response equipment purchases and mediocre disaster program
planning. The table-top drills that are generally being conducted by
states with Homeland Security funding do not test for human error, nor
do they coherently, comprehensively, or rapidly coordinate players.
Exacerbating this problem is a grave shortage of medical professionals
to handle surge increases in the Emergency Departments.
Scottsdale Healthcare and its community partners have accepted a
leadership role in defining the future for disaster readiness in the
nation, focusing on a practical, integrated, and proactively
coordinated approach to regional disaster readiness. The grass-roots
and groundbreaking program leverages and blends the resources of the
Arizona National Guard, the state Air Force medical units, General
Dynamics, and the City of Scottsdale with Scottsdale Healthcare. In
April of 2006, the Coyote Crisis Campaign partnership launched its
first drill to test new technologies and the medical and prehospital
manpower merged to respond to a terrorist disaster. In 2007, the drill
will focus on a Pandemic Flu theme. Yet, there exists no funding to
plan and execute the drills. This is because Homeland Security funding
is not available for healthcare programs to work on surge capacity
enhancements with the military. And, there are no dollars to build with
premier corporate experts the necessary command center technologies for
resource identification and movement, field triage and transfer of
large volumes of patients, or other disaster response needs. Homeland
Security funding is meager, disjointed, and supportive of highly
fragmented programming. Perhaps the only glimmer of light is found
within the Department of Defense budget, which could generate 1) cross
department coordination, 2) support for getting military assets to
hospitals in a crisis, and 3) strengthen training between the military
and the civilian worlds.
Concluding Comments:
More than 46 percent of the patients who are admitted to Arizona's
hospitals are Emergency Department patients. The cascading impact of
ever-tightening regulations, the flood of undocumented immigrants, and
the spiraling of specialty hospitals is foreboding. While funding can
ameliorate many of the consequences, congressional action offers even
more hope. Prompt action is necessary to avoid a healthcare catastrophe
that will shut the doors of Emergency Departments nationwide.
Chairman JOHNSON OF CONNECTICUT. Thank you very much, Mr.
Kelly. Mr. Levine.
STATEMENT OF ALAN LEVINE, PRESIDENT AND CHIEF EXECUTIVE
OFFICER, NORTH BROWARD HOSPITAL DISTRICT, FORT LAUDERDALE,
FLORIDA
Mr. LEVINE. Thank you, Madam Chair, Representative Stark,
and Members of the Committee. I'm the president of the North
Broward Hospital District, one of the largest non-profit,
public systems in the nation, located in Broward County,
Florida. We consist of four hospitals, two trauma centers, the
Chris Everett Children's Hospital, and we serve over 200,000
emergency department visits a year. I'm also formerly the
secretary of health care administration for the State of
Florida under Governor Bush. In Florida. the percentage of our
population over 65 is nearly 40 percent higher than the
national average and our over-85 population is almost double
the national average.
This offers a perspective of what America is going to look
like in the coming decades and provides insight on how we
should prepare. Consistent with national trends, emergency
department visits to Florida's hospitals reached 7.2 million in
2004, up 50 percent from 1994, while in-patient admissions grew
34 percent. Hospital capacity during this period has actually
decreased, with the ratio of beds per 1,000 population
decreasing from four in 1994 to three in 2005, again mirroring
a national trend and those numbers don't include and swelling
of tourists that we have during the season, as well.
This decreasing capacity was not an accident. Federal and
state policies implemented two decades ago were focused on cost
containment, and hence capacity has been constrained. Indeed,
the capacity constraints have helped the system become more
cost effective, with hospital length of stay decreasing from an
average of 10.2 days in 1981 to as low as 4 days today. On the
issue of emergency department volume, however, growth in visits
cannot be solely attributed to population growth, as the use
rate per 1,000 increased from 348 visits in 1994 to 410 a
couple years ago, thus demonstrating what could be the impact
of an aging, more chronically ill, and also increasingly
uninsured population.
The contributors to this crisis are numerous and complex
and the capabilities of our system are being tested to a degree
that could raise questions not only about our surge capacity in
a mass emergency, but whether we can sustain the demand we face
with our aging and more chronically ill population. From an
operational standpoint, the more substantial causes for ER
backup and unavailability of services are staffing shortages,
substantial unavailability of call physician specialists, a
less than optimal number of critical care and telemetry beds,
the use of the emergency department as a safety net for routine
or non-emergent visits which hospital are required by Federal
law under EMTALA to treat, and the increasing influence the
uninsured are having on hospital operations.
Only a decade ago, the average age of a practicing nurse
was 35, and today it's 45. Vacancy rates for telemetry nursing
is 13 percent, critical care nurses are 10 percent, and one in
five emergency nursing positions are vacant. Florida alone will
need 61,000 additional nurses by 2020, and this is a very
relevant cause for this crisis. As the population has aged and
become more chronic, the demand for critical care and telemetry
beds has increased. Clearly, an inability to staff these beds
requires hospitals to keep patients boarded in the emergency
department, or worse, to divert ambulances once the ER beds are
full.
Sadly, less than 6 percent of the nursing population is
male, and only 13 percent represent minorities. I believe that
represents a huge opportunity for us to draw new people into
the nursing profession. This shortage does transcend other
allied health care professions, including EMS, where in
Florida, 61 percent of the more than 3.2 million EMS calls
require transport to an emergency department. While new
hospitals require regulatory approval in Florida, as in most
states, Governor Bush approved allowing existing hospitals to
add an unlimited number of beds without seeking state approval.
We can certainly build more hospital beds, but unless we
can staff these beds, we only compound the shortage by creating
additional capacity and demand for staffing, which will have
the unintended consequence of increasing cost without any
identifiable means for reimbursement. The issue of medical
liability, an increase in non-hospital alternatives for
specialists, and an impending physician shortage overall are
major contributors to this crisis. Imagine being a neurosurgeon
at Broward General Medical Center in Fort Lauderdale. Every
time you get called for an emergency, there is a 55 percent
likelihood the patient is charity, uncompensated, or Medicaid,
and since most of the community hospitals in Broward County and
neighboring Palm Beach County, two of the most populous
counties in Florida, do not have 24/7 emergency neurosurgery
coverage, there is a good chance this patient's care has been
delayed because he or she is being transferred from another
hospital, perhaps one at least 30 miles away.
At what point as a physician, given the likelihood of
litigation and a lack of payment, do you say that you've had
enough? Many, if not a majority and by the way, there are many,
many more issues related to the liability issue that we can
talk about if you choose to ask. Many, if not a majority of the
specialists have gone bare, and they've opted to limit their
coverage only to low-risk services within their specialty,
often leaving many services without any coverage at all. In
many cases, hospitals are paying enormous call fees in order to
entice physicians to cover the emergency department, without
any source of revenue to offset the cost, and are in fact left
wondering if they will, at some point be accused of violating
anti-referral or kickback laws.
Federal EMTALA requirements leave hospitals with no choice
but to succumb to whatever short-term measures are necessary to
cover call at any given time, whether or not these measures are
even rational. Also, given the substantial opportunity for
physicians to earn income outside the hospitals, their reliance
on staff privileges and ER coverage has decreased for many
subspecialties. Another problem on the horizon is the fact that
one in four physicians in Florida is over the age of 65, and
another 16 percent are between the ages of 55 and 65. Medical
school enrollment combined with that fact, medical school
enrollment has been flat for 10 years now, and new applications
for 2005-2006, while increasing by 4.6 percent, still remain 21
percent below 1995 levels.
The supply of practicing physicians is expected to slow
considerably after 2010, reflecting the aging physician
population and the level enrollment in medical schools.
Intuitively, the demand for physicians will increase as our
population ages, and by 2015, the rate of population growth
will exceed the rate of growth in the number of physicians. By
2020, it's estimated the United States will have a shortage of
about 96,000 physicians. Many of the Institute of Medicine
suggestions are plausible and merit our support. While I do not
agree we need a new national bureaucracy, it is appropriate to
have national standards with state flexibility, transparency
using consistent measurement, a review of antitrust laws which
would allow hospitals to regionalize call coverage, and
enhanced use of information technology.
Addressing these issues and seeking resolutions to the
other concerns I mentioned in my testimony I believe will move
us toward a goal of an agile and prepared emergency system. I'm
proud to come from Florida where we've demonstrated we have the
best, in our opinion, emergency response system in the nation.
We're proud of that, but we know it's been tested, and we're
concerned about that. We look forward to answering your
questions, and I do thank you for this opportunity, Madam
Chair.
[The prepared statement of Mr. Levine follows:]
Statement of Alan Levine, President and Chief Executive Officer, North
Broward Hospital District, Fort Lauderdale, Florida
Madam Chair, Representative Stark and Members; thank you for taking
the time to inquire about the crisis of access to emergency care. I am
currently the President of the North Broward Hospital District, one of
the largest non-profit, public hospital systems in the nation, located
in Broward County, Florida, and I am formerly the Secretary of Health
Care Administration for the State of Florida. I will do my best to
highlight the contributory factors to this crisis as I see them, and I
will answer any questions you may have. In Florida, the percentage of
our population over 65 is nearly 40 percent higher than the national
average and our over-85 population is almost double the national
average. Perhaps this offers a perspective of what America will look
like in the coming decades and provide insight on how we should
prepare. Consistent with national trends, Emergency Department visits
to Florida's hospitals reached 7.2 million in 2004, up 50 percent from
1994, while inpatient admissions grew 34 percent. Hospital capacity
during this period has actually decreased, with the ratio of beds per
1,000 population decreasing from 4 in 1994 to 3 in 2005--again,
mirroring a national trend. This decreasing capacity was not an
accident. Federal and state policies implemented two decades ago were
focused on cost-containment and hence capacity has been constrained.
Indeed, the capacity constraints have helped the system become more
cost-effective, with hospital length of stay decreasing from an average
of 10.2 days in 1981 to as low as 4 days today. On the issue of
Emergency Department volume, growth in visits cannot be solely
attributed to population growth, as the use rate per thousand increased
from 348 visits in1994 to 410 in 2004--thus demonstrating what could be
the impact of an aging, more chronically ill, and also, increasingly
uninsured population. The contributors to this crisis are numerous and
complex and the capabilities of our system are being tested to a degree
that could raise questions not only about our surge capacity in a mass
emergency, but whether we can sustain the demand we face with our aging
and more chronically ill population.
From an operational standpoint, the more substantial causes for ER
backup and unavailability of services are; nursing, allied health and
EMS staff shortages; substantial unavailability of on-call physician
specialists, a less than optimal number of critical care/telemetry
beds, the use of the Emergency Department as a safety net for routine
or non-emergent visits which hospitals are required by federal law to
treat, and the increasing influence the uninsured are having on
hospital operations.
Only a decade ago, the average age of a practicing nurse was 35;
today it is 45. Vacancy rates for telemetry nurses are 13 percent,
critical care nurses 10 percent, and one in five emergency RN positions
are vacant. Florida alone will need 61,000 additional nurses by 2020.
As the population has aged and become more chronic, the demand for
critical care and telemetry beds has increased. Clearly, an inability
to staff these beds requires hospitals to keep patients boarded in the
Emergency Department, or worse, to divert ambulances once the Emergency
Department beds are full. Sadly, less than 6 percent of the nursing
population is male, and only 13 percent represent minorities. This
shortage transcends other allied health professions, including EMS,
where, in Florida, 61 percent of the more than 3.2 million EMS calls
require transport to an ED. While new hospitals require regulatory
approval in Florida, Governor Bush approved allowing existing hospitals
to add an unlimited number of beds without seeking approval. We can
certainly build more hospital beds, but unless we can staff these beds,
we only compound the shortage by creating additional capacity and
demand for staffing--which has the unintended consequence of increasing
cost without any identifiable means for funding.
The issue of Medical Liability, an increase in non-hospital
alternatives for specialists, and an impending physician shortage
overall are major contributors to the problem. Imagine being a
neurosurgeon at Broward General Medical Center, in Fort Lauderdale.
Every time you get called for an emergency, there is a 55% likelihood
the patient is charity, uncompensated or Medicaid. And since most of
the community hospitals in Broward County and neighboring Palm Beach
County do not have 24/7 neurosurgery coverage, there is a good chance
this patient's care has been delayed because he or she is being
transferred from another hospital--perhaps one 30 miles away. At what
point, as a physician, given the likelihood of litigation and lack of
payment, do you say you have had enough? Many--if not a majority--of
specialists have gone bare, so while the data may show they take call,
they have opted to limit the coverage to only low-risk services within
their specialty, often leaving many services without any coverage at
all. In many cases, hospitals are paying enormous call fees in order to
entice physicians to cover the Emergency Department--without any source
of revenue to offset the cost, and are in fact left wondering if they
will, at some point, be accused of violating anti-referral or kickback
laws. Federal EMTALA requirements leave hospitals with no choice but to
succumb to whatever short-term measures necessary to cover call at any
given time--whether or not these measures are rational. Also, given the
substantial opportunity for physicians to earn income outside the
hospitals, their reliance on staff privileges and Emergency Department
coverage has decreased for many subspecialties, including orthopedics,
gastroenterology, otolaryngology, cardiology and plastic surgery.
Another problem on the horizon is the fact that one in four physicians
in Florida is over the age of 65, and another 16 percent are between
the ages of 55 and 65. Medical school enrollment has been flat for ten
years and new applications for 2005-06, while having increased by 4.6
percent, still remain 21 percent below 1995 levels. The supply of
practicing physicians is expected to slow considerably after 2010,
reflecting the aging physician population and the relatively level
medical school enrollment over the past two decades. Intuitively,
demand for physicians will increase, and by 2015, the rate of
population growth will exceed the rate of growth in the number of
physicians. By 2020, it is estimated the United States will have a
shortage of about 96,000 physicians.
Many of the IOM suggestions are plausible and merit our support.
While I do not agree we need a new national bureaucracy, it is
appropriate to have national standards with state flexibility;
transparency using consistent measurement; review of anti-trust laws
which would allow hospitals to regionalize call coverage; and enhanced
use of information technology. Addressing these issues and seeking
resolutions to the concerns I mentioned in this statement will, in my
opinion, move us toward our goal of an agile and prepared Emergency
System. I look forward to answering your questions, and I thank you for
this opportunity.
Chairman JOHNSON OF CONNECTICUT. Thank you very much for
your testimony, Mr. Levine. Dr. Blum.
STATEMENT OF FREDERICK C. BLUM, M.D., ASSOCIATE PROFESSOR OF
EMERGENCY MEDICINE, PEDIATRICS AND INTERNAL MEDICINE, WEST
VIRGINIA UNIVERSITY SCHOOL OF MEDICINE AND PRESIDENT, AMERICAN
COLLEGE OF EMERGENCY PHYSICIANS
Dr. BLUM. Thank you, Madam Chairman. My name is Rick Blum.
I am the president of the American College of Emergency
Physicians. I'm a practicing emergency physician in West
Virginia. I'm here to deliver a simple message. Mr. Kelly asked
the question, what physician, if given the options of
practicing and treating the patients with the problems and in
the setting that he described would take that option? Well,
that would be me and the 24,000 people that I represent as the
American College of Emergency Physicians. We take that
challenge every day.
You don't have to have money. You don't have to be clean or
smell good. You don't even have to be nice to me. You just have
to come to the emergency department and need what I have to
give, which is care. I'm very proud of that. I'm here to
deliver a really simple message today, which is that America's
emergency departments are underfunded, they're understaffed,
they're overcrowded, and in fact, they're overwhelmed.
I'm glad to address the issues raised by the Institute of
Medicine Report, because they're an independent body that
confirmed what we've been saying for a long time. Emergency
physicians are proud of the fact that they could ramp up or
ramp down as the circumstances allow. We are traditionally the
most elastic part of any hospital operation. Frankly, we're
sometimes too good at it, because I think I get the impression
that people think we have the infinite ability to ramp up and
ramp down.
I'm here to tell you that anything that's elastic
eventually reaches the point where it breaks, and when it does,
it does to catastrophically, and that's where we are today.
This Subcommittee has a long history of promoting quality
health care for the citizens of the U.S. Your leadership on
EMTALA my associates welcome. EMTALA simply put into law what
we had long practiced and the values that we hold that I just
described to you. The original intent of EMTALA we have not a
single problem with, because we believe what is embodied within
that law, but the challenges are still there.
It is a gigantic unfunded mandate for American health care,
and it's an escalating mandate that has no end in sight, and
that mandate is increasing in the face of overall declining
reimbursement from all payers, both in the private and public
sectors. As other parts of the health care system fail, those
failures are felt in the emergency departments, and so the
result is our departments are overcrowded, we have no surge
capacity to deal with the next big thing that happens with
regard to natural disasters or terrorist attacks.
We have an ambulance diverted in this country every minute
of every hour of every day, and that probably under-represents
the problem, because many communities have said, ``Well, we're
not going to divert,'' but yet the ambulance crew will
sometimes wait in the hallway of the emergency department for
hours waiting for a bed to open up to offload their patient.
Patients wait hours for admission. There are millions of
Americans that come to the emergency department, and we
determine they need to be admitted to the hospital, who wait
hours, if not days, to move upstairs to hospital beds that
don't exist. There's a huge on-call crisis that has already
been, I think, very, very aptly described. None of this is new
to emergency physicians. Why has this occurred? Well, we have
reduced resources. Fifty percent of all emergency care in this
country is now un-reimbursed.
We have a lack of in-patient beds that's been described.
We've tried to control health care spending in this country by
controlling the number of beds that we've had. I think we now
believe that that's a flawed public policy. We have a growing
demand, and by the way, the baby boomers are still pretty
healthy. They're yet to get sick. When they start getting sick
in large numbers, I frankly don't know what we're going to do.
We have a shortage of nurses and a looming shortage of
physicians. We've already seen it in parts of the country, like
Phoenix, but in most parts of the country, that is still a
looming crisis, but I can tell you, the crisis we have right
now is a shortage of nurses. As was said, we can't staff the
beds that we have, and we don't have enough beds. From 1993 to
2003, the number of ED visits have gone up 26 percent in this
country.
At the same time, the population only went up 13 percent.
During that same period of time, 425 emergency departments in
this country closed. So, we're seeing more and more patients in
fewer and fewer emergency departments with less and less
resources. Ladies and gentlemen, that's not sustainable. The
on-call crisis we talked about already. We did a study a while
back with Johns Hopkins that showed that 73 percent of ED
medical directors report regular lack of coverage in their on-
call panels. We have the surgeons who are talking about the
fact that fewer and fewer specialty surgeons, like
neurosurgeons and orthopedists, are now taking call to the
emergency departments, so you have a smaller and smaller number
of specialists caring for a larger and larger number of people
again, not sustainable.
What can we do about all this? We have proposed several
recommendations. We have included at least three of them in a
bill that we proposed and have asked for your support for. It's
House Bill 3875, which includes three provisions. One would
provide incentives for hospitals to move patients upstairs more
quickly. Those incentives currently do not exist. They would
provide some professional liability protection for EMTALA-
mandated services that would basically treat our EMTALA mandate
the way any other federalized health care worker would be
treated with regard to professional liability.
It would provide a 10 percent add-on for Medicaid payments
to the emergency department to acknowledge this gigantic
unfunded mandate that we have. Every day we have the privilege
of impacting and saving people's lives. I guess what I'm here
to ask for today is your help in allowing us to do that,
because, quite frankly, it's getting to the point where I
cannot. Thank you.
[The prepared statement of Dr. Blum follows:]
Statement of Frederick C. Blum, M.D., President, American College of
Emergency Physicians, Morgantown, West Virginia
Introduction
America's emergency departments are underfunded, understaffed,
overcrowded and overwhelmed--and we find ourselves on the brink of
collapse.
Madame Chairman and members of the subcommittee, my name is Rick
Blum, M.D., F.A.C.E.P., F.A.A.P., and I would like to thank you for
allowing me to testify today on behalf of the American College of
Emergency Physicians (ACEP) to discuss the current state of emergency
medical care in this country. In particular, I will address issues
raised by ACEP's ``National Report Card on the State of Emergency
Medicine'' and the Institute of Medicine (IOM) reports on the ``Future
of Emergency Care,'' which must be resolved to ensure emergency medical
care will be available to the American public during a public health
disaster.
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 of the Institute of Medicine (IOM) report ``Hospital-Based
Emergency Care: At the Breaking Point,'' which was just released on
June 14. I would like to say that these findings are new to 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's emergency departments could be alleviated;
sponsoring 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, 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. Grades were 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's 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.
Emergency Department Overcrowding
As the frontline of emergency care in this country, emergency
physicians are particularly aware of how overcrowding in our nation's
emergency departments is affecting patients. Here are two true patient
stories that have been anonymously shared with ACEP that illustrate
this point:
I am at a level one trauma center, and we are so overcrowded that
people are waiting up to 11 hours to be seen, patients are on
stretchers lined up against the walls waiting for beds for three or
more hours, and we are filled with patients being held for ICU beds. I
am only able to see four to six patients in a 6--hour shift because
there just are not beds to put the patients in to see them. We go on
diversion, but so do the other hospitals in the area.
A teenage girl was hit in the mouth playing softball, causing
injury to her teeth. She arrived in the emergency department, which was
full, at 6 pm and sat in a waiting room, holding a cloth to her face,
bleeding for 2 hours. Finally, when a bed opened for her, the doctor
saw she had significant dental injures, including loose upper front
teeth. He ordered an x-ray. Once he had the results several hours to
obtain later, he called an orthodontist who fortunately agreed to see
her right away. By then, it was 12 midnight.
The root of this problem exists due to overcrowded 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, but we are stretched
beyond our means on a daily basis as well.
Every day in emergency departments across America, critically ill
patients line the halls, waiting hours--sometimes days--to be
transferred to inpatient beds. This causes 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 reduced hospital resources; a lack of hospital
inpatient beds; a growing elderly population and an overall increase in
emergency department utilization; and nationwide shortages of nurses,
physicians and hospital support staff.
On-Call Shortage
ACEP and Johns Hopkins University conducted two national surveys,
one in the spring of 2004 and another in the summer of 2005, 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. Nearly three-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).
As indicated by the IOM 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 premiums; and relaxed Emergency Medical Treatment and Labor
Act (EMTALA) requirements for on-call panels.
Two anonymous reports on emergency crowding explain the on-call
shortage well:
A 23 year-old male in Texas arrived unconscious with what turned
out to be a subdural hematoma. We were at a small hospital with no
neurosurgical services. Ten minutes away was a hospital with plenty of
neurosurgeons, but that 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 was FINALLY
accepted by a hospital many miles away, with a 90-minute Life flight
helicopter transfer. The patient died immediately after surgery there.
A 65 year-old male in Washington State came to an emergency
department at 4:00 a.m. complaining of abdominal pain. The ultrasound
showed a six-centimeter abdominal aortic aneurysm (AAA) and he was
unstable for CT scanning. We had no vascular surgeon available within
150 miles; a general surgeon was available, but he refused to take the
patient out-of-state. We reversed the Coumadin and transferred the
patient in three hours to the nearest Level I trauma center, but he
died on the operating table. He probably would have had a better
outcome without a three-hour delay.
EMTALA
This committee has a long history of promoting quality health care
for the citizens of this country, including its role leading the way to
the enact EMTALA in 1986. We are pleased that the Congress, and your
committee in particular, have begun a focused examination of emergency
care in this country and thank you for your efforts to create an EMTALA
Technical Advisory Group (EMTALA TAG) as part of the ``Medicare
Prescription Drug, Improvement and Modernization Act of 2003'' (P.L.
108-173), which is looking at important issues facing emergency
medicine.
ACEP has long supported the goals of EMTALA as being consistent
with the mission of emergency physicians. While the congressional
intent of EMTALA, which requires hospitals with emergency departments
to provide emergency medical care to everyone who needs it, regardless
of ability to pay or insurance status, was commendable, the
interpretation of some EMTALA regulations have been problematic.
When CMS issued its September 2003 EMTALA regulation, uncertainty
was created regarding the obligations of on-call physicians who provide
emergency care that could potentially increase the shortage of on-call
medical specialists available and multiply the number of patients
transferred to hospitals able to provide this coverage. Under this new
rule, hospitals must continue to provide on-call lists of specialists,
but they can also allow specialists to opt-out of being on-call to the
emergency department. Specialists can also now be on-call at more than
one hospital simultaneously and they can schedule elective surgeries
and procedures while on-call. Without an adequate supply of specialists
willing to take call, some hospitals may choose not to provide
emergency care at all, which would only shift the burden to the already
strained hospital emergency departments that remain open.
Reimbursement and Uncompensated Care
The patient population can vary dramatically from hospital to
hospital and the differences in payer-mix have a substantial impact on
a hospital's financial condition. Of the 110 million emergency
department visits in 2004, individuals with private insurance
represented 36 percent, 22 percent were Medicaid or SCHIP enrollees, 15
percent were Medicare beneficiaries and another 16 percent were
uninsured. These numbers demonstrate the large volume of care provided
in the emergency department to individuals who are underinsured or
uninsured. According to an American Hospital Association (AHA)
statement from 2002, 73 percent of hospitals lose money providing
emergency care to Medicaid patients while 58 percent lose money for
care provided to Medicare patients. Even private insurance plans still
frequently deny claims for emergency care because the visit was not
deemed an emergency in spite of the ``prudent layperson standard''
which ACEP has strongly advocated for years.
While emergency physicians stand ready to treat anyone who arrives
at their emergency department, uncompensated care can be an extreme
burden at hospitals that have a high volume of uninsured patients,
which now exceeds 51.3 million Americans and continues to rise.
Hospital emergency departments are the provider of last resort for many
people, including undocumented aliens, who have no other access to
medical care. As such, emergency departments experience a high-rate of
uncompensated care.
As pointed out in the IOM report, the estimated annual cost to
emergency care providers nationwide for undocumented aliens is $1.45
billion and the cost to the 28 counties along the border in Texas, New
Mexico, Arizona and California is $232 million. Congress attempted to
alleviate some of this burden by including a provision in the
``Medicare Prescription Drug, Improvement and Modernization Act of
2003'' (P.L. 108-173) that provided $1 billion ($250 million per year)
between FY 2005--FY 2008 to help pay for unreimbursed emergency health
care services provided to undocumented aliens and other specified
aliens. While ACEP strongly supported this provision to help provide
relief for this uncompensated burden, this program has been
underutilized due to the overly burdensome and impractical regulations
that were implemented by CMS in 2005.
Boarding
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 beds are available for admissions from
the emergency 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 IOM report 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
1 hour (Weiss et al., 2004; Bradley, 2005).''
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. I have 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
arriving by ambulance, and that 70 percent of those patients had urgent
conditions that required care within an hour. A companion study found
ambulance diversions in Los Angeles more 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. 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.
Congress can begin to address these problems today by enacting H.R.
3875/S. 2750, the ``Access to Emergency Medical Services Act.'' This
legislation provides: (1) limited liability protections for EMTALA-
related care delivered in the emergency department to uninsured
individuals; (2) additional compensation for care delivered in the
emergency department; and (3) incentives to hospitals that move boarded
patients out of the emergency department in a timely manner. As noted
in my testimony, and supported by the findings of the GAO and IOM,
these are three of the most critical issues facing emergency medicine.
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. If no 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-term solution to a surge of patients,
ultimately we need long-term 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 best interest of the American public.
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.
Attachment
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 Healthcare 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. In short,
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. In an
environment where emergency departments 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
(MA).
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 solve the crowding crisis that
are in the 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. If 20 patients are waiting for 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 pay or 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.
Chairman JOHNSON OF CONNECTICUT. Thank you very much, Dr.
Blum. Dr. Bedard.
STATEMENT OF LARRY BEDARD, M.D., SENIOR PARTNER, CALIFORNIA
EMERGENCY PHYSICIANS, EMERYVILLE, CALIFORNIA
Dr. BEDARD. Good morning, Madam Chair and Members of the
Committee. I'm Dr. Larry Bedard. I'm an emergency physician, a
pit doctor. I really appreciate the opportunity to share with
you my perspectives on the growing crisis facing the emergency
care system in this country. I'm not going to talk about the
problems. I'm assuming that you agree that there are
significant problems. I would like to congratulate Mr. Warden
on the excellent report that came out from IOM. I agree with
virtually all of their findings.
What I would like to spend my time on is talking about some
of the solutions. In my written testimony I submitted to you a
copy of a ``Top 10 List,'' ``Dr. Bedard's Top 10 List,'' in
order to try to deal with this crisis. First and foremost, I
think we need to enforce EMTALA prospectively, not
retrospectively. I believe hospitals should be surveyed and
certified that they meet and comply with the EMTALA rules and
regulations. We've heard 75 percent of emergency department
directors have a problem with on-call physicians. Seventy-five
percent of these hospitals do not comply with EMTALA, yet the
number of investigations and violations is only a handful.
There are many reasons why physicians are intimidated or
reluctant to report or deal with this issue. Secondly, I think
we need to have a different organization than Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) certifying
hospitals or certifying the emergency care system. Last year,
our hospital went through a JCAHO survey. We passed with
glowing colors. What happened is, the night before the surveyor
showed up, we took all the gurneys and the patients we board
and hid them elsewhere in the hospital. Immediately after the
surveyors left, the gurneys were back in the hallways and
patients were being boarded in our emergency department. The
fact that 75 percent of ED directors have problems with on-
call, I'll guarantee you, every one of those medical directors
practices at a hospital that JCAHO has certified.
It is obvious to me, and I think that the certification
process is in effective as currently conducted by JCAHO. Number
three, I agree that regionalization is one way of helping with
the on-call problems and you need to get the patient to the
right hospital, to the right doctors, at the right time.
However, in order to regionalize emergency care, I believe
Congress is going to have to enact some antitrust legislation
which would allow competing hospitals and health systems to get
together to coordinate and regionalize care. Perhaps, my most
controversial solution is the way I would reimburse physicians
for serving on call. I refer to it as the ``play or pay
system.''
Every physician in the United States who went to medical
school here, who has done residency training in the United
States has been heavily subsidized by the taxpayers. A common
approach of professional associations, for example, the
American College of Surgeons, says, ``Gee, give us tax
deductions or tax credits for the charity care that we
provide.'' I believe before physicians are given tax credits or
tax deductions, that they should pay back the debt to the
taxpayers for our education. In order to do this, you would
have to do two things: One, Centers for Medicare and Medicaid
Services (CMS). You do an actuarial study to determine the
amount of taxpayer subsidy that went into physicians' education
and training.
We then have CMS work with American Medical Association's
Reimbursement Update Committee to set a value or in essence, a
payment for what it's worth to be on call for 24 hours. Then
physicians would have the opportunities, say over 20 years, to
pay back their taxpayer subsidy by serving on call. If you were
a neurosurgeon who was netting $500,000 a year, you might want
to take the other option, which is to pay at the going rate,
say $1,000, so you don't have to take call. You could pay one
of your other colleagues to provide that service for you. Six.
I think we do need to come up with some meaningful malpractice
reform. Physicians should not have to pay an extra premium for
agreeing to serve on call.
I think the Congress also needs to support and incentivize
hospitals to have information technology so we can coordinate,
we can regionalize emergency care. I think the ultimate
solution is Congress needs to create a system of universal
basic health care for all citizens of the United States. I look
forward to answering any of your questions.
[The prepared statement of Dr. Bedard follows:]
Statement of Larry Bedard, M.D., Senior Partner, California Emergency
Physicians, Emeryville, California
Chair Nancy Johnson and Members of the House Ways and Means
Subcommittee on Health. I want to thank for the opportunity to share my
perspective and views about the worsening crisis in the emergency care
system of the United States.
In particular, I want to thank, Congressman Pete Stark who invited
me to testify. In 1985 Congressman Stark introduced legislation, the
``Emergency Medical Treatment and Active Labor Act'' (EMTALA). When
President Ronald Regan signed EMTALA into law on April 6, 1986 it
answered the question for once and for all: ``Is medical care a right
or privilege?'' EMTALA made emergency care a legal right. Before April
1986 the only people who had a legal right to health care were
prisoners. After April 1985 all people had a right to go a hospital
emergency facility and be evaluated and treated for an emergency
medical condition. It is difficult to underestimate the impact that the
passage of EMTALA had on the development and practice of emergency
medicine in the United States. We needed EMTALA in 1986 and we need a
strengthened EMTALA in 2006.
However, from the perspective of Emergency Physicians, the 1986 law
was fatally flawed. EMTALA defined a responsible physician as one who
``was employed by or contracted with a hospital.'' Since the vast
majority of emergency physicians contract with hospitals, we were
clearly responsible physicians. The California Medical Association's
position however, was that EMTALA did not apply to on-call physicians.
California law prohibits hospitals from employing physicians so clearly
on-call physicians were not employees. The CMA did not consider medical
staff privileges a contract. In 1987 the California Chapter of the
American College of Emergency Physicians (CAL/ACEP) working with a
broad coalition of health care organizations passed SB12 which defined
on-call physicians as responsible physicians under California transfer
law.
In 1988, as an individual, I met with Congressman Stark and two
aides. I explained to the congressman how EMTALA was fatally flawed.
Emergency physicians can not stand alone! We and our patients need the
availability and access to many on-call specialists if we are to
provide high quality emergency care. In 1989, much to his credit,
Congressman Stark successfully amended EMTALA to define on-call
physicians as responsible physicians.
EMTALA, however, did not solve the access and availability of on-
call physicians to back up hospital emergency departments. Indeed, many
physicians refuse to take call, sighting the EMTALA unfunded mandates
and threats of significant fines.
In 2005, nearly three quarters of emergency department medical
directors indicate they had a problem with on-call back up.
The issue in 1985 was availability and access to on-call
specialists.
The issue in 1989 was defining the role and responsibility of on-
call physicians.
The issue in 2006 is the availability and access to on-call
physicians.
I view the Institute of Medicine's Committee on the Future of
Emergency Care in the United States Health System report ``Hospital-
Based Emergency Care At the Braking Point'' from two perspectives.
First, from the perspective of someone who has been involved in medical
politics for more then 25 years. I have engaged in policy discussions
as a Delegate to the American Medical Association and a Trustee of the
California Medical Association As President of ACEP, my national
professional association and CAL/ACEP, my state professional
association, I represented the views and interests of emergency
physicians in Washington DC. and Sacramento. Locally, I was an elected
public official, serving on the Marin Hospital District Board. I just
completed my tenure as President of the county medical society. Today,
I'm glad to say I represent none of theses organizations!
Today, I speak from the perspective of an individual emergency
physician. A pit doctor! A patient advocate. And believe me, when you
present to the ER with a significant illness or injury you need your
emergency physician to be your advocate. Your ER doc needs to help you
navigate the chaotic and difficult world of emergency medicine. You're
my patient, I'm your doctor.
I would like to share with the committee a recent experience I had
in the ER. A mid 60ish Asian male got up from the dinner table,
complained of a severe headache and collapsed. 911 was called and the
patient was brought to the nearest hospital, our overcrowded ER. You do
not need to a rocket scientist or a brain surgeon to know that an
intracerebral bleed was the most likely diagnosis. The CAT obtained and
read by the radiologist within 45 minutes did in fact reveal a large
bleed. Since we had no neurosurgeon or neurologist on--call at our
hospital, I contacted the neurosurgeon on call at the premier private
hospital in San Francisco. When I asked for him to accept the patient
in transfer, he informed me that he was not on call for my hospital and
then hung up the phone. I next phoned San Francisco General Hospital, a
nationally renowned trauma center. I was informed that they were
holding their neurosurgeon in reserve for any trauma cases. At that
time I thought maybe I should have told them the patient tripped and
hit his head. I next called the University of San Francisco Medical
Center, one of the premier academic centers in the country. The
neurosurgery fellow indicated that he needed to talk with the
neurosurgery attending and the hospital admissions staff. He promised
to get back to me shortly. A half hour latter I received his call:
``This is the kind of patient we would like to accept but we are
boarding patients in the ED for 2 days. We will be happy to accept him
in 2 days.'' At that time I called the patients personal physician, the
ED Medical Director and the Chief of Staff of the Hospital to apprise
them of the situation and seek their assistance in arranging an
appropriate transfer. Hopefully, one of these physicians could call in
a favor from a colleague. I next called Stanford University Hospital
but their ICU was full and they were also boarding patients in their
ER. Four physicians worked for more then 4 hours but we failed in our
attempts to arrange a safe transfer for this patient. The emergency
physicians guardian angel came to my and the patients rescue. The man's
daughter, who worked for an internist, called her boss for help. This
internist asked a neurosurgeon, who was not on call to accept the
patient in transfer. After nearly 5 hours the patient was transferred
to the premier private hospital for neurological care. What is wrong
with this picture? How ironic that the patients daughter could arrange
for a transfer when four physicians could not. This situation occurred
in San Francisco, everybody's favorite city. In San Francisco, a city
with one of the highest physician to patient ratios in the country.
This single situation epitomizes many of the problems revealed in
the IOM report. ``Hospital Based Emergency Care At the Breaking
Point.'' A fragmented system was unable to provide, coordinated
effective emergency care. The ER was overcrowded, hospitals were on
diversion, and boarders jammed up other ERs preventing transfer and the
necessary on-call specialists were not available.
I want to congratulate the IOM's Committee on the Future of
Emergency Care in the United States Health System for a comprehensive,
thought provoking report on the current state of emergency care. I
agree with virtually all their key findings. I believe they did an
excellent job of evaluating and diagnosing the afflictions of the
emergency care system. In my comments I will offer additional or
alternative treatments or solutions to cure the problems identified in
the IOM Report. Hopefully, my comments will help the committee to take
appropriate actions in solving some of the problems that we face.
I applaud and share the committee's ``vision for the future of
emergency care that centers around three goals: coordination,
regionalization, and accountability.''
REGIONALIZATION: ``The committee recommends that hospitals,
physician organizations, and public health agencies collaborate to
regionalize critical specialty care on-call services.'' I strongly
support this recommendation.
Take the patient to the doctor, instead of taking the doctors to
the patients. Take the patient to the right hospital with the right
doctors the first time. If a hospital doesn't have a readily available
on-call neurologist they should not receive stroke patients.
Regionalization makes a lot of sense.
However, when such a regional system was proposed for the
Sacramento area by the 1998-1999 CMA,CAL/ACEP,CHA ``On-Call'' Task
Force, lawyers from Sutter, Kaiser and Catholic Health Care West (CHW)
immediately cautioned their hospital systems that regionalizing
emergency care may violate federal anti-trust law. They advised them
against sitting down with competitors to allocate and divide market
share. If we are to implement regionalized on-call services Congress
needs to amend, federal anti-trust laws to expressly permit competing
hospital and health care systems to regionalize emergency care.
ACCOUNTABILITY: ``Accountability is perhaps the most important of
the three goals of the emergency care system envisioned by the
committee because it is necessary to achieving the other two. Lack of
accountability has contributed to the failure of the emergency care
system to adopt needed changes in the past. Without accountability,
participants in the system need not accept responsibility for failure,
and can avoid making changes necessary to avoid the same outcomes in
the future.'' IOM Pg 73
``We don't need new laws, we just need to enforce the ones already
on the books.'' Is a well worn cliche in Washington In the case of the
emergency care system this is probably true.
I believe that we could address and solve many of the problems
confronting the emergency care system if we proactively audited and
enforced the EMTALA rules and regulations and interpretative
guidelines. Under current law, EMTALA is only reactively enforced. The
only times there is an investigation is when some one complains. Isn't
it a little strange that when 73% of ED medical directors have problems
with on-call coverage there are only a handful of EMTALA
investigations? ``To get along, go along'' is often an essential
requirement for a medical director. Working on a contract that can be
cancelled in 90 days is another inducement to go along. I believe that
a proactive enforcement of EMTALA many years ago would have helped us
address, mitigate and solve some of the problems facing us.
The IOM request that ``The federal government should support the
development of national standards for: emergency care performance
measurement; categorization of all emergency care facilities; and
protocols for the treatment, triage, and transport of prehospital
patients''
The question arises: Who should do the certification, monitoring,
and auditing of emergency care facilities and pre-hospital systems?
``The committee recommends that the Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO) reinstate strong
standards that sharply reduce and ultimately eliminate ED crowding,
boarding, and diversion. Pg 122
I disagree with this recommendation. I believe that JCAHO is not
the appropriate organization to accredit and certify emergency care
systems. I am disappointed but not surprised to learn that JCAHO
``under pressure from the hospital industry'' withdrew requirements for
hospitals ``to take serious steps to reduce crowding, boarding and
diversion'' IOM pg 122. In some respects, having JCAHO regulate the
emergency care system is like having the proverbial fox guarding the
hen house.
In my career, I have participated in several JCAHO inspections both
as the Medical Director of the Emergency Department and as an attending
emergency physician. We passed a recent inspection with glowing colors.
What a joke. We moved the gurneys and the patient boarders from the
hallways the night before JCAHO came and immediately returned them the
moment they left. JCAHO had no interest in looking at the on-call
schedule. If they saw the numerous holes for specialty coverage,
perhaps they would have to do something about it.
In a 2005, ACEP study, 73 percent of EDs reported problems with on-
call coverage, in contrast to 67 percent the year before. How many of
these EDs and hospitals did JCAHO refuse to certify? How does JCAHO
address and resolve the ``problems with on-call coverage.''? I think
the committee should have answers to these questions before deciding
which agency should certify and regulate the emergency care system.
Lead agency. ``The federal government should consolidate functions
related to emergency care that are currently scattered among multiple
agencies into a single agency in the Department of Health and Human
Services (OHHS).'' I believe that there should be such a lead agency. I
believe that the lead agency should monitor, audit, accredit and
certify emergency care facilities The federal government should not
outsource the regulation of the emergency care system, a vital national
interest, to JCAHO.
TRANSPARENCY Make the system transparent to patients. Educate the
public about the access and availability of on-call specialists and
hospital capability. Require hospitals to post in the daily paper, on
TV or on the internet which on-call specialists are available. This
would save tourists in San Francisco from bringing their sick kid to a
hospital that did not have a pediatric department or service.
Make the system transparent to EMS pre-hospital providers.
Ambulance destination guidelines should take into consideration the
availability of on-call specialist. Dispatchers and paramedics need to
know in real time what on call physicians are available.
Boarding and diversion. ``Current CMS payment policies should be
revised to reward hospitals that appropriately manage patient flow.
Conversely, hospitals that fail to properly manage patient flow should
be subject to penalties'' IOM Pg 121
The IOM recommendation is both a carrot and stick. I recommend
trying the carrot first. Have The Centers for Medicare and Medicaid
Services (CMS) s develop Pay For Performance (P4P) (P$P) incentives to
award hospitals for improving efficiency in admitting patients from the
ED. It would be relatively easy to monitor, record and audit admission
times--the time from the moment the emergency or other admitting
physician writes the admit order until the time the patient arrives in
their hospital room or surgical suite.
Disaster Management: The IOM notes: ``With many EDs at or over
capacity, there is little surge capacity for a major event, whether it
takes the form of a natural disaster, disease outbreak, or terrorist
attack.'' The truth be told that in many metropolitan area in the U.S.,
the emergency care system is not equipped to handle a busy Saturday
night this weekend. One of the scariest aspects of the IOM report was
how poorly we are prepared for a major disaster.
ON-CALL Specialist: ``One of the most troubling aspects of the
current emergency and trauma care system is the lack of available
specialists to provide on-call services to hospital EDs and trauma
centers. This is particularly true for highly skilled specialties such
as neurosurgery, interventional cardiology, and orthopedic surgery.''
IOM Pg 17
Critical specialists are often unavailable to provide emergency and
trauma care. This is a chronic and increasing problem in emergency
medicine. Nothing is more painful, frustrating and depressing for an
emergency physician then to have a patient suffer or die because there
is no on-call specialist to back you up. Solving the on-call crisis is
a dilemma with no easy solutions. However, I don't believe that you can
solve boarding or ambulance diversion without solving the on-call
problem.
One promising solution is to regionalize the services of certain
on-call specialties, so that every hospital need not maintain on-call
services for every specialty.''
IOM 8
Another issue that needs to be addressed is the malpractice
liability exposure and costs for being an emergency physicians and an
on-call specialist. You can not expect a physician to pay a 25-50%
premium on their malpractice insurance because they have volunteered to
serve on-call. for the ER.HR 3875, the Access to Emergency Medical
Services Act of 2006 is a vehicle to address the malpractice issue.
A common approach and request is to throw more money at the
problem. Physicians are resentful of EMTALA's unfunded mandate.
Personally, I would welcome this solution but I realize that this is
unlikely. The projected Medicare shortfall in 2040 is $63 trillion
dollars. Society security is a relatively easy fix at $8 trillion.
dollars. Medicare and Medicaid are much, much bigger problems.
Another approach is to ask the federal government to provide tax
credits or tax deductions for charitable or uncompensated care. This is
the policy of the American College of Surgeons.
Increasingly, physicians have responded to the on-call issues by
demanding and receiving stipends from hospitals for agreeing to serve
on-call. In essence, we are witnessing a transformation from an
``implicit social contract'' whereby physicians voluntarily provided on
call services to their communities and hospitals to an ``explicit
financial contract'' whereby physicians demand and receive significant
stipends from hospitals for providing on-call services to their
communities. On-call stipends which vary from a few hundred dollars to
several thousands of dollars a day can only be afforded by some
hospitals. These hospitals tend to be located in more affluent areas
with good payer demographics. Hospitals located in areas with poor
payer demographics cannot afford such stipends and are in danger of
losing their on-call panels.
Congress created an EMTALA Technical Advisory Group (TAG) to review
the interpretation and implementation of EMTALA. The EMTALA tag is very
limited in scope. It can only recommend regulations or interpretative
guidelines to the Center on Medicare and Medicaid Services (CMS). At
one of the TAG's earliest meeting the American Hospital Association
proposed requiring physicians to serve on-call as a condition of
Medicare participation. This proposal was quickly rejected when it was
pointed out that physicians would stop participating in or possibly
boycotting Medicare. I have very little optimism that the EMTALA TAG it
will develop necessary and creative solutions to the on-call crisis.
I offer the following Play or Pay system as a possible solution.
``Play or Pay'' is a policy whereby an organization or group is
required to participate in activities or programs or pay into a fund to
support such activities or programs. For example, a ``Play or Pay''
policy has been advocated by many national specialties to require small
businesses to either ``play'' by providing health insurance for their
employees or ``pay'' into a fund that would then be used to purchase
health insurance for their employees.
The On-Call Play or Pay system would requires physicians to
``play'' by serving on a hospitals on-call panel or ``pay'' into a fund
that would be used to compensate physicians for serving on-call.
Every physician who graduates from an American medical school or
who trains in a specialty residency program is heavily subsidized by
the taxpayers. The tuition paid to attend medical school pays only a
small proportion of the total cost to educate that physician. The
difference between the total educational costs and the student's
tuition is the amount of the of the taxpayers subsidy.
Implementation of an On Call Play or Pay system requires that the
following issues be addressed.
EDUCATION/TRAINING ACCOUNT: An actuarial study would determine the
amount of tax subsidy provided for medical school and residency
training. Such actuarial studies could be done for individual medical
schools and training programs or the average cost for medical school
and residency could be used to determine each physician's tax subsidy.
The tax subsidy would vary by specialty. Some specialties such as
neurosurgery or cardiovascular surgery which are longer then family
practice probably receive a larger taxpayer subsidy. Upon completion of
their education and residency training each physician would be assigned
their individual education/training account. The physician could then
payoff their taxpayers' subsidy by ``playing'' by serving the community
by being on-call at a local hospital or the physician could ``pay''
into a fund which would be used to pay for physicians who serve on-
call. Another possibility would be for a physician to have a colleague
serve on-call on their behalf. Each physician could pay off their
individual education/training account over a 20-30 year period. For
physicians who do not have hospital privileges, a Domestic Peace Corp
for Health Care or some other public service could be established
PAY RATES: A system needs to be developed to determine the monetary
value of serving on-call. One process would be to use the AMA's
Reimbursement Update Committee (RUC) to determine the relative value of
being on-call. The RUC use a consensus process to develop
recommendations for CMS to assign relative value to new or modified
physician services. CMS, although not required to, usually accepts the
RUC's recommendations for assigning relative values to the Common
Procedural Terminology (CPT) codes.
CMS then uses the CPT codes to reimburse physicians for providing
necessary services to Medicare patients. Since the Medicare system is a
`zero sum game' if some codes increases in value all other codes
decrease in value. This is a strong incentive for the RUC not to
overvalue codes.
Currently on-call stipends are based upon the ability of physicians
to negotiate such stipends. Specialties in short supply such as
neurosurgeons have used the EMTALA mandate to leverage on-call stipends
of large and in some cases exorbitant amounts. The use of the RUC to
establish on-call fees would probably result in more fair, equitable
and reasonable stipends.
Disproportionate Share Hospitals: Currently the federal government
has a policy whereby some hospitals are classified as disproportionate
share hospitals (DSH). DSH hospitals by definition provide excess
amounts of uncompensated or charity care. Because of their poor payer
demographics physicians may avoid seeking medical privileges at such
hospitals. Physicians who serve on-call at such hospitals should have a
significantly higher ``On call Pay Rate'' in order to attract
physicians to serve on call at these DSH hospitals. In addition, the
money paid by physicians to pay off their education/training debt could
be used to pay physicians for serving on call at DSH hospitals.
The lack of availability and access to on-call physicians backing
up our ERs is a chronic and worsening problem. The transformation from
an implicit social contract whereby physicians voluntarily served on
call for the benefit of hospital privileges to an explicit financial
contract whereby physicians receive stipends for serving on call is a
solution that can only used by some hospitals and communities.
Community hospitals that cannot afford to provide such solutions as
paying large stipends require new creative solutions. Taxpayers in all
communities have paid both federal and state taxes to educate and train
physicians in the United States. The ``On-call Play or Pay'' program
whereby physicians either play by serving on-call or pay off their
education/training debts is a solution to the on-call problem.
The ultimate solution to the on-call crisis is to develop a
universal basic health care system. The vision of Dr. John Kitzhaber,
the former two term governor of Oregon is to ``maximize the health of
the population by creating a sustainable system which reallocates the
public resources spent on health on health care in a way that ensures
universal access to a defined set of effective health services.''
Governor Kitzhaber is working on a legislative approach to bring such a
system to Oregon. His policies and perspectives can be viewed on the
Archimedesmovement.org web site. Perhaps the committee should study
this as a possible solution for providing universal care for the
country.
I hope I have given you some ideas and solutions to think about.
Thank you listening to the voice of this emergency physician. I will
conclude by where the IOM report begins.
``Knowing is not enough, we must apply.
Willing is not enough; we must do''
Goethe
I urge you; Do reform the emergency care system. It is desperately
needed.
Larry A. Bedard, MD FACEP
Chairman JOHNSON OF CONNECTICUT. Thank you. Now, I'd like
to yield to Mr. Stark.
Mr. STARK. Thank you, Madam Chair for holding this hearing,
and I apologize for being late. Mr. Warden, I'm sorry I missed
the beginning of your testimony. Had I been here on time to
charm you with my opening remarks, Madam Chair, I would have
reviewed the experience of a New York Times reporter in
Washington, D.C. recently who died--was attacked, robbed on the
street, mugged. They thought he was drunk, so there was a
failure on the part of the first responders.
Then the ambulance driver took him to a hospital--well,
took him to Howard, because it was closer to his home and he
was going to go home after he dumped this guy off, when Sibley
was much closer. Then he sat around in the emergency room
because they said he was a drunk, and evidently had massive
brain trauma. A guy beat him up, hit him over the head. He
died. A lot of failures on a lot of people's part. I'm not sure
that we don't have those same problems in every branch of
medical care.
We can hear the horror stories all the time about the wrong
the pharmacist giving you the wrong pill, somebody else cutting
off the wrong leg, and I think that the emergency room
physicians take a bad rap for a system that perhaps the
population at large has failed to address. I think our entire
medical care delivery system really is the fault. You guys are
a critical part of it. If we had universal coverage, a great
portion, I suspect, of the work you do in the emergency room
would be handled by nighttime pediatrics or a ``doc in the
box,'' or clinics that would get reimbursed for preventive care
and treatment of minor aches and pains, whereas people today
don't go, because they don't have the money.
They know if they go and take their kid with an earache to
the doc in the box nighttime pediatrics it's going to cost them
65 or 70 bucks and their insurance may or may not cover it if
they have insurance, and they ain't got $65 or $70 bucks, so
they come and wait 2 or 3 hours in the emergency room for you
to see the child and give them the antibiotics they need for
their earache.
I do, as I would have suggested in my opening remarks,
think that if we had a system where people could pay and high
deductible insurance isn't going to be the answer. I would love
to have the Institute of Medicine or the emergency room, Dr.
Blum, your organization, tell us how many people show up with
high deductible policies, but you guys hit them in the first
$1,000 bucks, and they don't have the cash to get over that
deductible amount, so you still end up treating them for free.
I'd be curious to know what percentage you see there.
Mr. Kelly, his description of the patients that come into
Phoenix as Larry Bedard knows, you've just described nine out
of 10 people who come to Highland Hospital in Alameda County,
only they have a longer rap sheet than this poor guy from
Mexico. We treat them all the time. We can only send them back
to county jail. That's standard procedure in our neighborhood
for the people coming to our emergency rooms, and I don't
know--as that's any I can just tell you a story.
We have an emergency at a classroom, at an elementary
school. We have lockdown. It isn't a fire drill. This is a gun
drill. You never heard of gun drills, but our teachers have
learned when they heard a gunshot outside the elementary
school, they put the kids under the desk, lock the doors, pull
the blinds, and wait until the cops come. Two cars come to the
intersection. One guy gets out of the car, starts shooting at
the other guy. One guy gets shot up and gets hauled away.
The cops come. They aren't going to chase the cars. They're
just going to wait for them at the emergency room. They're
going to show up at Dr. Bedard's office, and that's where
they'll haul the guy that got shot. This is part of a system
wherein the rest of us are paying, and I don't think that cost
shifting in the hospital system is going to do it. I think we
have to, I think what you bring to us today is a problem that
goes all through our delivery system, and I hope that at some
point we can deal with how every resident, not necessarily
citizen, but every resident if you go to Canada, you'll get
treated as an American whether you got the money to pay or not,
and they won't drive you home in an ambulance, they'll treat
you. They may try and collect later, but they won't send bill
collectors into America to do it.
I think the underlying system in both Dr. Blum and Dr.
Bedard, in their remarks for how to correct the system have
suggested that universal payment system or universal access is
one of the critical parts. So, I hope that we can find a way. I
like Larry's idea of a code, which I think the physicians to
develop, under resource-based scale (RBS), as to what do you
pay the neurosurgeon who is sitting at home in Arinda waiting
to drive into Oakland because he's on call for an emergency
room. $3,000 a night? I don't know.
There's got to be some kind of a system, and I think you
guys should work it out, and we should, because we do pay you,
for better or for worse, under Medicare and Medicaid. It's
those people who are uninsured that you don't collect from, and
how are we going to do that? I don't know. I certainly
appreciate all of you being willing to be here, particularly
Larry, who came at his own expense, to bring his expertise to
this. As the--I hate to admit it, Madam Chair, as the author of
EMTALA some 20 years ago, I'd still like to continue to work to
get it right, and with your help, maybe we can. Thank you.
Chairman JOHNSON OF CONNECTICUT. Thank you, Mr. Stark. I
think one of the reasons that we're here today is that most of
the laws we wrote 20 years ago no longer work, just because of
the explosion of knowledge in medicine, the explosion of
technology, the explosion of diagnostic and treatment
capabilities, and a variety of other things. If you look at the
physician payment law, it doesn't work; you look at the
hospital payment law, it doesn't work; and it's not surprising
that our EMTALA doesn't work. I just want to ask a few
questions and then go on to the other Members, and then we can
come back for a second round if we have time.
First of all, as you know from the proposed changes in the
in-patient rule, we are moving from the system we invented in
the eighties of diagnosis-related groups (DRGs) toward a system
that is much more, going to be much more directly aligned with
the cost of care, so as we adopt the International
Classification of Diseases (ICD-10), we will have a more
granular system by which to look at what we're going to pay for
and to align cost and payment. As we do that, the ability of
hospitals to shift the cost of emergency room care across all
other categories will be diminished.
Are you prepared to help us understand exactly what the
cost of emergency room care is, what the base cost of an
emergency room facility is, what the base cost facility is,
what the base cost of a trauma capability is, and how we should
look at more accurately reimbursing for emergency care? Are you
capable of working with us yet, you know, at this time, on that
issue? Because right now, the hospitals are not capable of cost
reports that honestly or uniformly allocate costs to categories
all across America. We have a lot of difficulty in
understanding ourselves and I need to know, is our first work
to begin understanding how you cost emergency room care and
whether it is consistent across the country and what's the
relationship between the cost to you and the payment you get?
Mr. Warden.
Mr. WARDEN. Madam Chair, the Institute of Medicine
Committee spend considerable time talking about that topic, and
one of the things that we concluded was that we do not have the
data that you're suggesting is needed, and it reflects the fact
that very little money has been put into research and studies
to really document what's going on in emergency medicine, other
than the clinical side; and secondly, that if we're going to be
able to address those issues, we're going to have to set some
performance standards, we're going to have to have a much
better understanding of what the cost is.
Chairman JOHNSON OF CONNECTICUT. Well, I want you all to
think about, I don't want to dwell on this, because there's so
many other questions, but I want you all to think about this,
because it may be that even this year we could develop a
requirement that at least we start the process of finding out,
because emergency room care costs now, just because of all the
diagnostic equipment you're capable of, and years ago, are
completely different, and not only do we not have any real
understanding of that nor does the payment system reflect that,
but we haven't developed any criteria for appropriateness.
I recently learned that one of my hospitals is seeing
Magnetic Resonance Imagining (MRIs) for every appendectomy.
Now, this is nice, because in court, it's absolute proof, but
we cannot afford MRIs for appendectomy. So, I ask you to think
with this Subcommittee about what we do do now to find out what
it does cost, because as changes in hospital payment move
forward, we're going to need to know, and if we don't pay you
more accurately, you won't be there. Then two other questions,
and you can fold back in. You're dealing with a lot of
uncompensated care, for whatever reason. How do we honestly
recognize that? What is the spectrum of your payments from
Medicaid, Medicare, real cost, non-payers? We need to better
understand that piece of it.
Then we need to better understand what we can do to change
EMTALA law so that those who are just who could be using
regular facilities use the community health center system,
because we pay for that, too. We need to think, where is our
money going, and what incentives do we need to put in place so
people get to the point where we already pay for care. So,
that's one issue. Then on this malpractice, I think if we don't
do something about that, you will not survive, and what we did
about that in the community health center, because I passed
that law, was we took that liability onto the Federal
Government, period, the community health centers pay if they
get sued. We would need to know how many of the uninsured that
come through emergency rooms end up suing. Probably not a lot
of them. Yet, we're paying huge premiums for that possibility.
Okay. Those are the things I need to know, because we need
to pick out which portions of this problem we need information
about and we need to start that aggressively now, which portion
of these problems we could at least for a year or 2 years
absorb malpractice costs or such and such, and what are the
incentives for flow management, because I need to know why we
can't do more of this through enlightened management and why we
can't do more of this through regional planning. Mr. Levine.
Mr. LEVINE. Yes, ma'am. You asked a lot of questions there.
Let me start with the last one first, related to liability, and
some of the nuances of how this actually plays out and how it
relates to the first question you asked about cost and coming
up with a true cost. We stand absolutely ready. I think the
weakness in our health care system generally has been a lack of
transparency in understanding the cost structure and the inputs
to what the actual cost of care is. For example, in the
emergency department, in the last few years, the costs have
changed so dramatically, being able to pin those down is very
difficult. Let me explain. For example, the cost of paying for
on-call coverage can exceed $1,000, $2,000, $3,000 a day
sometimes for certain specialists. That's a new cost that isn't
built into any of the reimbursement structures.
Number two, what do you do about the fact for example,
we're a public system, and as a result, we have sovereign
immunity. So, perhaps the only tool we have at our disposal is
to employ physicians, and we employ over 200 physicians, for
the purpose of trying to deal with, to extend our sovereign
immunity to those doctors. Think about the thousands of other
doctors in the community who are not employees of our health
system. Here's what happens to us. We're the public safety net
system. More than half of our ER visits are charity,
uncompensated, or Medicaid. What happens when they show up in
our emergency department?
For a specialist in the community, who is a private doctor,
who has insurance of their own, because we're public and we
have sovereign immunity, now that doctor is the deep pocket.
So, the doctors don't want to cover the safety net hospitals
for that reason, so they go to the private hospitals and
they'll cover those hospitals, but not ours. So, that creates,
you know, a really interesting wrinkle for us. The other
problem is, and what I've seen really from our physicians, is
now the incentive is to go bare, because for example, if you
have a patient that has multiple system problems and they have
four specialists taking care of that patient, if only one of
the doctors has coverage and the other three doctors don't have
any insurance, they're bare, the doctor that has insurance all
of a sudden is the only target. They have a big bullseye on
their back. So, they don't take the consults.
So, this contributes to the ER problem, in that that
patient may be sitting in an in-patient bed needing a consult,
but we can't get a doctor to see the patient, so the patient
occupies a bed and that disrupts the flow of patients. Those
things are interwoven, and those costs what winds up happening
in those cases, we will sometimes have to pay a specialist to
come see that patient in the hospital. So all of those costs
are built into the system that we don't have a way right now of
disclosing to the Federal Government. As far as EMTALA, you
know, the hammer does work. As the secretary of health care
administration for the State of Florida, it was our
responsibility to administer EMTALA, and what we found was it
was becoming increasingly difficult.
On top of EMTALA, the State of Florida has a law that says
if you offer us an elective service like orthopedics, and you
don't cover the emergency department for that specialty, then
you can't offer the elective service. On the surface, that
sounds great, except here's what can happen. What happens when
an elderly patient falls in the hospital? If the ER didn't have
full orthopedic coverage, and you don't offer the elective
service, you now have no doctor to take care of the in-patient
who needs the service. These are all interwoven problems that
are, I think, relevant.
Now, in terms of EMTALA, and I have to disagree a little
bit with what the doctor at the end said with regard to forcing
doctors to pay, when you're40 percent of the doctors in south
Florida are foreign medical graduates. Twenty-five percent of
the doctors in our country are foreign medical graduates. We've
got to get more people to go into medicine, and putting hammers
over their head and telling them they're going to be punished
is not the right way to do it, though I do think EMTALA needs
to take into consideration if we have a patient that's in our
emergency department, and a doctor, we can't get a doctor to
cover, how does EMTALA apply to the medical community?
That's part of the issue for the hospitals. When we go out
and we survey hospitals for EMTALA violations, we fine them
$10, $20, $50 thousand dollars an incident. We publish it in
the newspaper. We embarrass the heck out of them. Then, really,
the hospital isn't the one that wasn't covering the ER. Even
though they were willing to pay for it, they didn't have a
doctor to cover it. So, who do you punish in that circumstance?
I think that's a relevant issue to talk more about.
Chairman JOHNSON OF CONNECTICUT. Dr. Blum, I think that is,
Mr. Levine, a very relevant issue, and when I look at JCAHO, to
some extent, how can you impose on institutions standards they
couldn't possibly meet because we've been unable to deal with
the underlying problems? Dr. Blum.
Dr. BLUM. There were a lot of questions.
Chairman JOHNSON OF CONNECTICUT. Incidentally, you know, my
time has expired, so let's do this. Let's go on to the others
and we'll come back. I wanted you to know what my concerns are,
because we need to pick out and see what's the first step we
can take on as many fronts as possible. My colleague from
Arizona.
Mr. HAYWORTH. I thank the gentlelady from Connecticut, our
Chairman, and again, to our witnesses, thank you. Perhaps,
Madam Chairman, it's just with the appointment to the Health
Subcommittee, but I find myself, this merger of public policy
and medicine almost involved I guess offering political
diagnoses, and to hear the array of maladies in terms of public
policy confronting emergency rooms, it sounds as if the case is
almost terminal, that the sclerosis, the inertia of public
policy, and the failure to deal with a variety of competing
interests, and the inability to enforce laws have contributed
to a state of crisis that is very troubling.
Mr, Kelly, since you hail from the Fifth Congressional
District of Arizona, and for obvious purposes, I have more than
a casual interest in what transpires in that geopolitical
subdivision, let's talk more about what transpired at the
Osborn facility with the illegal immigrant. As I recall from
your testimony, Scottsdale Healthcare incurred over $260,000 in
costs. Can you describe the lengths to which your hospital
system has had to go to ensure that these patients are returned
safely to their home country and to ensure they are receiving
proper care once they get there?
Mr. KELLY. Yeah. In many instances, the consulate will not
permit transport papers to be issued unless we can arrange for
a facility, let's say in Mexico or in another country to accept
that patient, and will not provide transportation. So, we have
in the past also provided certain equipment for the care of
that patient. For example, I believe, I have some figures here
where we have given hospitals in Mexico and in other areas
ventilators and other equipment and provided the transportation
necessary along with the arrangements, the very complicated
arrangements to get that patient from our facility to that
foreign country.
Mr. HAYWORTH. So, on one hand, the Republic of Mexico
oftentimes refuses to be involved in extradition of suspected
murderers back to the United States, and yet the transfer of
patients I guess we wouldn't call it extradition, medical
extraditionists as if they say, ``No, we're to set
preconditions upon you in the United States to ensure the
health care once they return to the sovereign nation.'' That's
been something else that's happened recently within Maricopa
County, Arizona, where we live, in Scottsdale. There have been
threats by the Mexican Consulate to get involved in court
action----
Mr. KELLY. Yes.
Mr. HAYWORTH. To ensure what I don't believe again, I'm not
a lawyer, don't even play one here in Congress, much less on
TV, but what I believe we would have to accurately describe not
as rights, but as privileges, privileges they assume illegals
should have in the United States. In your course of discourse
in negotiations with the Mexican Consulate, were there any
threats of legal action against Scottsdale Healthcare during
the course of this episode or any others?
Mr. KELLY. Indirectly, Congressman, yes. ``You cannot
definitively prove that, that we will take whatever action is
necessary, including court action, to ensure that, you know,
you are not going to transport this person back. We will not
issue transport papers.'' Yes, sir, that is correct. In
furtherance of your point, though, I'd like to point something
out, and it's just not relative to Mexico. In my submission to
this Committee, there is an Egyptian there. The cost of
transportation, special air transportation back to Egypt was in
excess of $8,000. That patient came through our emergency room.
That patient sued us. That patient sued the physician, the
patient sued the hospital. The physician paid over $400,000 and
the hospital paid over $70,000 with both $100,000 in defense
costs with the physician paying over $120,000 in defense costs.
These are just not Mexicans that we're dealing with.
Mr. HAYWORTH. No, indeed. It is a problem almost
encyclopedic in scope.
Mr. KELLY. My colleague here has even some more shocking
length of stay statistics that just blew me away in this chair
right now.
Mr. LEVINE. Madam Chair, we have awe actually have cases
in-house now, patients on ventilators from several South
American countries. We have one case, a patient who needed a
liver transplant, from another country, in the hospital for 85
days, ran up $800,000 worth of charges. We have another patient
that was in the hospital for 373 days, came in through the ER
as a gunshot wound. Actually, the consulate from Guatemala
called an attorney to try to delay the patient's discharge from
the hospital. So, these are cases where they've cost us in
excess of millions of dollars, just at our one trauma center in
Broward County.
Mr. HAYWORTH. Madam Chair, you've been generous with the
time. I look forward to the second round of questioning.
Suffice it to say now, just as you're preparing your thoughts,
panelists, again, a merger of medical and public policy terms,
what do we do in terms of public policy triage to be reasonable
and compassionate, and yet not bled dry financially by the
abuse of our system? Think about that and we'll get back, I'll
yield back, because you've been very generous with the time.
Chairman JOHNSON OF CONNECTICUT. Thank you. The gentleman
from California.
Mr. THOMPSON. Thank you, Madam Chair. Thanks for having
this hearing. This is a problem that I think that we all
experience, irrespective of where we live, and I would
certainly hope that we get an opportunity, Madam Chair, to work
on this, even if it's incrementally trying to bring about some
of the changes that may in the big picture not fix it all, but
would certainly deliver some relief to folks who are having to
deal with these problems every day in real life. Thank you all
for being here to make presentations. I appreciate it very
much. Mr. Warden, in your testimony you talked about the lack
of surge capacity and what could happen if there was a big car
crash and how that could really impact things.
I live in a district that is a rural district, and it has a
whole set of problems just because of that, but in addition,
we've had all kinds of natural disasters. We have earthquakes
and wildfires and floods, and we've even had a tsunami in my
district that wiped out an entire town. There's one building
standing today that was standing in 1964. So, the whole issue
of surge capacity is of great concern to the people that I
represent. Given the propensity for natural disasters across
sequence of events of the different areas, is there one thing
that you would recommend that Congress could do to improve our
disaster preparedness?
Mr. WARDEN. Yes, sir. I think that one of the biggest
challenges is that there's been very little funding available
for disaster preparedness in hospitals, or for that matter, the
health care system, and when you look at the amount of money
that has been appropriated for those kinds of things, it just
doesn't filter down to the level of the hospital and the
hospital emergency room, and consequently, we're put in a
situation where we have to react. Every hospital has an
emergency preparedness plan, but at the same time, it's not as
sophisticated as it should be, and they don't have the funding
to do the kinds of things and get the equipment they need to be
able to do it; and I think that's where it has to start.
Mr. THOMPSON. I would appreciate it, I don't know if it's
appropriate to ask that it be shared with the whole Committee,
I don't know what the rest of my colleagues' level of concern
is in this regard, but if you could, I'd like to see some ideas
that you might have, not just we need more money, but, you
know, what we could--what we actually need to do and how we
would go about doing that. I'd find that very helpful.
Mr. WARDEN. There is information in the report, and we can
see that that's provided to you.
Mr. THOMPSON. If you could get that to me, I would really
appreciate it.
Mr. WARDEN. Yes, sir.
Mr. THOMPSON. Two of the witnesses, I think Mr. Levine and
Dr. Blum both talked about the nursing shortage issue that
faces us. In my home state, in California, it's projected that
by 2010 we're going to have over a 100,000 nurse shortage, and
it affects, I suspect, every place around the state. I see it
at home. My wife is a nurse practitioner, and she's worked more
in the last year on an on-call basis than she has probably in
the last 5 years. So it's a real problem. I suspect that it has
a real impact in regard to backups in emergency departments
across there in every hospital. I'd like to know what your
thoughts might be as to how we could help reduce that by doing
a better job recruiting nurses.
Mr. LEVINE. Sir, you hit the problem right on the head. You
know, you have to make nursing more attractive to a broader
population. Historically, nursing has been a population and by
the way, this isn't limited just to nursing. It's EMS
professionals, it's allied health professionals, pharmacists,
therapists, and so forth. You know, like I said in my
testimony, only 5 percent of nurses are male and only 13
percent are minority, which is not reflective of the
population. So, I think trying to make nursing more attractive
as a profession for non-traditional populations is very
critical. We can't do it without them, frankly. So, more
recruitment, more incentives through the Federal and state
government. I also think more faculty is a problem. There's not
enough faculty to train the additional nurses.
In fact, what was antithetical for me was the fact that we
actually had waiting lists of people applying for nursing
programs, but there's just not enough faculty to train them. To
your question, if I may, on emergency preparedness, one of the
best tools that we've got, and we used them for the eight
hurricanes in Florida, at the Department of Health and Human
Services is the use of the Disaster Medical Assistance Team
(DMAT), and it is a tremendous it relieved a tremendous burden
for the state and for the hospitals when we needed that surge
capacity. Unfortunately, in a large-scale disaster, I don't
think that there's enough resources there for those teams, but
those are terrific tools that we made great use of during those
disasters.
Dr. BLUM. On the nursing issue, I'm probably not the best
person to ask about recruiting nurses, but I can tell you
another aspect of the nursing shortage from the emergency
medicine standpoint is not only the fact that we have not
enough nurses in the entire hospital, therefore impacting the
emergency department, but because the emergency department is
asked to be infinitely elastic, we've asked our nurses to be
infinitely elastic, and we've simply burnt them up and burnt
them out.
I've lost hundreds of years of emergency nursing experience
in my emergency department in the last few years. I have nurses
with 25 and 30 years experience in emergency nursing who in the
last couple years have decided, ``I can't do this anymore, I'm
going to take a lesser-paying job working in radiation therapy
or somewhere else in the hospital.'' Many of them have not left
the hospital, but they've left the emergency department. So,
our workforce now in emergency medicine is much younger than it
has been relative to the past. It used to be that you had to
have several years of critical care experience before you could
even work in the emergency department. That's not true anymore.
Mr. THOMPSON. Thank you very much.
Chairman JOHNSON OF CONNECTICUT. Thank you. We'll start the
second round of questions. Mr. Stark.
Mr. STARK. Thank you, Madam Chair. I just want to put in a
plug for my bill, which eliminates mandatory overtime for
nurses. There's 500,000 nurses in this country who are not
working, principally, we understand, because they don't want
the mandatory overtime. So, we have that resource out there if
we could somehow encourage them to come back into the system
with a more friendly workplace. That might help somewhat. I
want to get back to the payment thing for the on-call
physicians. Just help me a little bit. I don't know whether,
Mr. Warden, you remember. I mean, your former hospital system
used to staff Kieren Mountain where I once went. They had
doctors, all they had to know is how to pick fishhooks out of
people, and that was a plum assignment for the Henry Ford
physicians in the summer.
Recently, we had a guy from Indiana who ran a bunch of
hospitals in Indiana, and it turned out that in this hospital
system, the not-for-profit hospital system, so he could see the
990, the five highest-paid people in the hospital system were
radiologists. It ran from $600,000 bucks a year for the lead
guy to $490 thousand for the next lowest. Is that we can't do
that in California. It's against the law to hire, for a
hospital to hire a physician. Do any of you, Mr. Warden,
anybody who runs a hospital, know, what say, neurosurgeons do,
any hospitals hire neurosurgeons, teaching hospitals? If so,
what do they earn? Larry?
Dr. BEDARD. Our hospital had an incident where we did not
have a neurosurgeon. I live and practice in Marin County, one
of the wealthiest counties. They were outraged. So, the
hospital administrator started to pay. It was $1,000 a day.
Once you paid the neurosurgeons, you had to pay the surgeons,
the orthopedists. Now, we're paying $10 million a year to get
on call. The going rate for neurosurgeons now is $3,000 per
day.
Mr. STARK. Where they're hired--what I'm trying to get at
is, when they're hired by the year, on salary.
Dr. BEDARD. No, they were contracted, so----
Mr. STARK. What does Kaiser pay, do you know?
Dr. BEDARD. I'm not sure what Kaiser pays----
Mr. STARK. Do you know what----
Mr. KELLY. I know what I pay neurosurgery, Congressman
Stark. It's $3,000 per day.
Mr. STARK. Does anybody have a hospital, Mr. Levine, Mr.
Warden, where they hire, where the hospital hires a
neurosurgeon on salary? It
Mr. WARDEN. I think in university teaching hospitals,
medical centers----
Mr. STARK. Okay.
Mr. WARDEN. Or institutions like ours, which has an
organized medical group, all the specialists are on salary, and
they are expected to cover the emergency room. If you have a
trauma center, you have to have that coverage----
Mr. STARK. Can you give me to the nearest $50 or $100
thousand bucks what a neurosurgeon would make?
Mr. WARDEN. In our system, a neurosurgeon makes about
$350,000.
Mr. STARK. Okay.
Mr. KELLY. In my previous experience at Jefferson, I would
concur with that.
Mr. STARK. Okay. So, I guess what I'm getting at is, it
doesn't seem to me unreasonable, though maybe there aren't
enough of them, to increase that salary or to expect that
person on salary to be available one or two nights a week when
they're on salary. I just, I'm just trying to, I'm sure that we
find that many of these people have a high income and they
don't want to sit around for a couple hundred bucks. That seems
wrong. Mr. Levine.
Mr. LEVINE. I don't know that you can--I don't know that
you can make an accurate comparison in academic medicine
salaries, because in academic medicine they don't cover ER call
themselves. They have residents and interns that do it. So----
Mr. STARK. I'm just trying to, and I want to kick this back
to the, you know, onto the AMA and the people who do the
resource-based relative value scale (RVRVS), and say, as I
think you recommended, Dr. Bedard and Dr. Blum, we ought to
figure out whether there's we can't make Blue Cross do that. If
we had a code under Medicare, it pretty soon trickles down to
the other insurers, and say, ``Look, here's what we pay.'' I
would hope, and I would hope the chair would join with me, that
we could encourage the medical societies to come up with a
resource-based charge that we would then institutionalize
through Medicare and say, ``Okay, this is the way to do it.''
Perhaps, we could get that problem solved for you, and I would
ask any of you who are involved in this if you would have any
other ways that we could do it, but one of you in your
testimony said that's what we should do, is go back and find a
code to reimburse for this. Dr. Blum.
Dr. BLUM. Well, first of all, I explained the mindset of my
colleagues and myself. To us, paying for on-call services is
kind of antithetical. We believe a better solution is to remove
the barriers that keep physicians like neurosurgeons and
orthopedists from taking call in the hospital. That makes much
more sense to us. We believe being on call is part of as part
of being on the medical staff of a hospital is a
responsibility. What has happened is there have been
significant barriers to being on call for those folks, and if
we remove those, I think that would solve the problem.
If we could ensure, you know that they get some payment for
what they do, if we could ensure they have some protection from
unreasonable liability, I think that that would help them.
Quite frankly, part of the issue is that it's very uneven. You
have some of those specialists that are willing to take call
and others who are not, and so again, fewer and fewer
specialists are caring for more and more patients, and I can
tell you, in a busy trauma center, a neurosurgeon may be up all
night caring for the emergency department patients, and then he
can't do his regular, you know, operating room (OR) schedule
the next day.
Mr. STARK. I would come back to you guys and the
neurosurgeon. You don't want us to define that for you, believe
me. If you all would come up, as you did with the RVRVS or
others, something that the physicians are comfortable with, and
come back to us, I think we could move ahead. I warn you that
having us design that system, you wouldn't be very comfortable
with it. I'm over my time, Madam Chair, but maybe Mr. Levine
and Dr. Bedard could respond----
Mr. WARDEN. Can I just speak one comment?
Mr. STARK. Go ahead.
Mr. WARDEN. I think, just two comments, Madam Chair and Mr.
Stark. Number one, I think that one of the issues that is
silent, that we're not recognizing, in some of the specialties
where there's a shortage, it's because the specialists are not
being turned out because they have basically limited the number
of education or training positions and residencies in the
particular specialties, so we're never going to catch up as
long as that occurs.
The second thing is that in the report, in our discussion
on regionalization, we talk about the regionalization of
specialty coverage, and, you know, in a community like Detroit,
there's no reason why every institution has to offer every
specialty, and if we regionalized it and had a coordinated
plan, we could solve a lot of the problems, and I think that's
one of the other things that has to be considered.
Mr. LEVINE. I think that would, the second part of what the
doctor just said is accurate, in that one thing that the
Congress could do is look at the antitrust issues related to
hospitals----
Mr. STARK. Could antitrust help solve that?
Mr. LEVINE. I believe so. We have hospitals in Palm Beach
County, for example, that have been trying to do that, but are
afraid to move forward for fear of antitrust. Also, too, I
don't think you have to reinvent the wheel, if we look at
what's been tried and has worked. For example, in Texas, they
implemented reforms in 2003. Since they implemented their
reforms in 2003, their medical liability reforms, they've
brought 4,000 new doctors to Texas, including neurosurgeons,
pediatric surgeons, obstetricians and gynecologists (OB/GYNs).
It's been a huge, huge change, a sea change in Texas, and
they've gone from a net exporter of physicians to they're
bringing them back in the state.
Mr. STARK. Even in the summer?
Dr. BEDARD. I served on the AMA's RUC, the Reimbursement
Update Committee, and there's about 50 different organizations
of specialty represented. The interesting thing, it's a zero-
sum game. So, if we increase the fees of one physician
specialist, the other ones take a slight cut. That has a very
mild effect on the overall, I think, cost of health care. In
California, I know where neurosurgeons are getting $3,000 a day
for being on call from three separate hospitals, so they're
getting $9,000 for being on call. So, regionalization makes a
lot of sense. Have them at one hospital. Take the patient to
where the neurosurgeon is. Don't allow them to be on three
different hospitals. They use EMTALA as a tremendous leverage
in any negotiation with the hospital, and I think that's one of
the reasons why there are such high rates and somewhat
exorbitant costs.
It's also, I think, interesting to note, the physicians
with the highest income neurosurgeons, orthopedic surgeons,
ear-nose-and throat (ENT) surgeons are the ones that are most
difficult to get to serve on call. The lowest-paid specialty is
pediatrics, and in my career, I've never had a problem getting
a pediatrician to come in, smile on his face, taking care of a
little kid. So, it's kind of paradoxical that neurosurgeons,
who may be making, you know, $500,000 a year, or $9,000 a
night, want to complain about the fact that they're going to
have to take care of somebody who has no insurance and they may
be uncompensated.
Chairman JOHNSON OF CONNECTICUT. The gentleman from
Arizona.
Mr. STARK. Can we do that, Madam Chair?
Chairman JOHNSON OF CONNECTICUT. Well, we'll certainly look
at it.
Mr. STARK. I'm not sure it's our jurisdiction.
Chairman JOHNSON OF CONNECTICUT. I think we can, you know,
ask the Judiciary Committee to look at it with our staff over
the break and see what comes out. The gentleman from Arizona.
Mr. HAYWORTH. Thank you, Madam Chair. Gentlemen, as we
listen to this, I return back to the dynamic I presented at the
conclusion of our first round. What do we do, specifically, as
we talk about patients from foreign nations, wherever they may
come from, receiving a quality type of care I mean, it seems
that undergirding western jurisprudence, and what we've done in
the United States is the basic test of what is reasonable, and
to hear the cases brought forward today, reasonableness went
out the window. Mr. Kelly and others on the panel, what should
we do? Should we set in statute and maybe it goes back to the
way EMTALA was drafted or the threat of legal action.
What parameters could we set in terms of what is reasonable
that certainly wouldn't be like triage in the wake of a
disaster, but something that's reasonable to get people up and
then get their on their way back to their home country without
continuing to ask American taxpayers to foot the bill?
Mr. KELLY. That's an excellent question, Congressman. Let's
treat these people and stabilize them, and the cost of their
transport should be met by the government which they're a
citizen of. We cannot afford this type of what's causing the
backlog, the overcrowding, the length of stay, just not from
the ER, but from the transport from the ER into the in-patient
setting, because we can't get that foreign country or that
foreign government or that person to cooperate with us. So, we
should be able to treat and stabilize and that person should be
taken back to their country at their country's expense. The 93-
day length of stay, the 200-day length of stay that you heard
from my colleague to my left here, this is what's causing
tremendous amount of backlog and an enormous amount of expense.
So, let's treat to stabilize in a humanitarian way, these
illegal immigrants, and let's get them back to their country of
origin.
Mr. LEVINE. There is nowhere, once they are in our
emergency department, and we've identified they need treatment,
even once we're done treating them, unless they can be
discharged to the street, basically, there's nowhere for them
to go. No post-op, post-acute facility will take them, so
they're stuck in the hospital until we can find somebody. I
think that my colleague is right on target. Stabilizing and
transferring back and having some requirement that the foreign
government take responsibility. In fact Canada does that. You
know, when they come down from Canada, they either pay for the
treatment or they pay to return them back, and that's exactly
what other governments ought to do.
Mr. HAYWORTH. Dr. Blum?
Dr. BLUM. Well, I don't know that----
Mr. HAYWORTH. Excuse me, Dr. Blum, could you----
Dr. BLUM. I'm sorry. I'm not sure I'm the best person to
answer how best to transfer them back once they're stabilized.
I can tell you what does not work for emergency physicians is
denying people care that need it, no matter what they are. You
know, they could be, you know, felons in other countries, but
if they need our care, you know, we don't want to be put in the
position where we have to deny care. Neither one of these
gentlemen have said that, but that has been proposed by some
people, actually, in some cases. So, I just want to be real
clear about that.
Mr. HAYWORTH. Likewise, let me be clear, doctor. I think
perhaps the best way, not to put words in your mouth, but I
think we're describing compassion and our sense of humanity.
When the question is asked of me, and we'll get into political
theater, because it's inevitable as people try to draw
distinctions and perhaps exaggerate distinctions, the law
should deal in humane fashion. Medical ethics is not a
contradiction in terms, as perhaps political ethics might be,
and you obviously have responsibility as a physician to treat
people, and indeed the law caught up with your sense of ethos,
but the question becomes how then do we deal in a humane manner
and also show some compassion in terms of public policy for
those who get stuck with a bill that continues to drain your
system and deny care to the mom and dad with a youngster who is
waiting three and four and five hours, not just in border
states, and I don't know anecdotally what happens in West
Virginia where you practice there at the university, Dr. Blum,
but all these things are interrelated. I think the point is
well taken. Yes, sir.
Dr. BLUM. It's a very complex problem. It's not even just
the patients that get admitted. I'm aware, I do not practice in
a border state, but I'm aware from my colleagues in the
specialty of patients that come and present to the emergency
department a couple times a week for dialysis. You know, they
get treated, they get dialyzed, they go back across the border,
and then they repeat the whole process again, you know, later
in the week, which isn't that person doesn't even necessarily
need admitted to the hospital, but they present with an acute
problem, which is the need for dialysis, and we treat them.
So,----
Mr. HAYWORTH. Is it fair to call that serial abuse of our
medical system, because that comes not with malice
aforethought, with gaming our system, taking advantage of our
laws?
Dr. BLUM. I do want to say something. This is not directly
related to this. But several comments now have alluded to this.
One of the important points that I want to make today is to
correct what I believe to be a widespread misconception that
the nation's emergency departments are crowded with people who
do not need to be there. Our waiting rooms sometimes are
crowded with people who do not need to be there, but our
emergency departments are usually crowded with people that need
to be there. They often are there because they can't get
primary care somewhere else and their medical condition
advances to the point where they need emergency care. It would
be a great misconception to say, ``If we could just remove all
the patients that are inappropriately using the emergency
department, we could solve this problem.'' That would not be
the case.
Mr. HAYWORTH. Dr. Bedard, with your indulgence, Madam
Chair?
Dr. BEDARD. First of all, the current law under EMTALA only
requires treatment up to the point of stabilization, so I think
it is compassionate and I think it addresses the issue. When
that person was stabilized, his right to any future medical
care ended. So, the issue, though, how do you repatriate that
person to Nicaragua or Mexico, is obviously something that the
medical profession can't do or deal with; that's something,
whatever, treaty or an agreement to send them back. Also, with
Dr. Blum, we have to take care of these people. You can't deny
them care. We're not going to let them bleed to death on the
street. But once they're stable, we can discharge them.
Mr. HAYWORTH. Again, just one point about this. The root
cause, however, as you say, law simply stipulates we stabilize.
What is the exterior threat? Is it lawsuit? Why over and above?
Is that it, the threat of lawsuit?
Mr. KELLY. It's the threat of lawsuit of abandonment, that
is correct. When they go from the emergency room, there's
nowhere else to go. There is no long-term care facility that
will take them.
Dr. BLUM. It goes way beyond that. I mean, oftentimes, they
have medical conditions that simply do not allow you to send
them out. You know, we talk about patients that require long-
term ventilation or long-term feeding tubes. You know, you
can't take a patient on a ventilator and roll them up to the
border and say, you know, ``There, take them back.'' I mean,
that doesn't work unless you have a receiving facility with the
ability to care for the kind of problems that patient has. So
no medical professional, I don't care who he is, whether it's
an emergency physician or whatever, is not going to discharge
that patient to an inappropriate environment, whatever that
might be. So we all kind of suck it up and, you know, try to do
the best we can. What these gentlemen have described is just
that.
Mr. LEVINE. The practical reality is just what you said,
sir. The fact is, if we have a woman in the hospital who needs
a liver transplant and, you know, she's stable, we could
certainly discharge her, but practically speaking, it would be
she would die. So, you know, we hold her until we figure out
what we're going to do, and in that particular case, that
patient stayed, in that case, it was over 300 days, over a
year, actually, in the hospital, because and to the dialysis
issue, as well. If other states, if other governments, rather,
don't do dialysis for people over the age of 55, they show up
in our emergency department, and at that point, they may not be
stable, and we have to dialyze them.
Mr. HAYWORTH. Madam Chair, you have been very indulgent
with the time, and I'm grateful for that. As you and the
Ranking Member were talking about jurisdictional issues perhaps
beyond the purview of this Committee, I'd certainly take a look
at international relations, at not so much treaties, but the
whole establishment of diplomatic relations. I'd take a look at
the funds we spend on international Committees dealing with
health. Certainly, there is a cross-jurisdictional challenge to
prioritize the payment of these bills and to ensure that there
is more than a diplomatic exchange, that there is
responsibility on the part of nations with whom we have
diplomatic relations to likewise be accountable.
The failure to see that, and the dynamic of the threat of
lawsuits adding to what is obviously the ethos of the
profession to care for people, and understanding that this is
not just a simple cut-and-dried matter, all of this combines,
and it's going to require some thought, and even into the whole
realm of foreign relations and diplomacy with foreign nations,
as we're dealing with the question. It's really, it's
interesting the inter-relatedness of all these different topics
coming to bear today in this hearing before our Health
Subcommittee. Madam Chair, I thank you, and gentlemen, again,
thanks to all of you for your thoughts.
Chairman JOHNSON OF CONNECTICUT. Thank you very much. The
advantage of having one panel is that you do get a chance to
allow Members to pursue their questions and the panelists to
contribute. There is one other issue that I want to raise that
we haven't had a chance to plumb, that is important as we begin
to think in this area. Mr. Warden, the Institute of Medicine
report recommends that we establish an office of emergency
care, emergency and trauma care. That certainly has some appeal
when you see the chaos and mess of that service. However,
establishing offices in the Federal Government has not always
assured progressive, thoughtful, and effective law or
management. A number of other things you recommend remind us
that regional performance, institutional performance is really,
in the end, what matters.
I want you each to make comment on what do you think. The
recommendation to coordinate regional EMS and emergency room
care is very logical. We certainly have to remove the legal
barriers, and maybe even require that, as a condition of
Medicare eligibility, you have to have in place a regional
system that can bring a neuro patienta patient needing a
neurologist to the emergency room that has a neurologist on
call and a bed available, I mean, that we could do a lot about
the many problems we've talked about if we could bring patients
where there is space for them and expertise available for their
care. So, that's a kind of simple example. Mr. Levine, in your
testimony, you referred to things that you've done in Florida
to better manage the resources of an institution so you don't
have some of the problems that we've talked about.
Now, putting malpractice aside because we've discussed that
a lot, and I think a solution to that is absolutely essential
both in regard to the illegals and in regard to the liability
of the individual physician. I was shocked the last time I was
in Florida to see how many of the physicians there are just
going bare, bare. People in America don't know that. So, it's
ludicrous to say that somehow malpractice insurance provides
you with some inalienable right when it is now so expensive
that you have no right at all. So, putting malpractice kind of
off to the side, and the problem of the illegals off to the
side, just looking in terms of Federal structure because after
all, in Medicare, we have a lot of leverage to pull. We can
require that you do certain things.
So, whether we establish an office versus what has the
institutional aspect of this, what can be done institutionally,
what can be done regionally, and do you or do you not, each one
of you, think some of you may have heard this idea for the
first time and want to get back to us? We really need your
thinking on the structure of not only responsibility but
oversight. Mr. Warden, maybe you'd like to start with a clearer
explanation of the Institute of Medicine's recommendation.
Mr. WARDEN. The Institute of Medicine's recommendation
about the lead agency really stems from the fact that as we did
the study and sought testimony from all the stakeholders, it
was very clear that there were eight or 10 different agencies
that were coming to bear on the issues that we've been talking
about this morning. Each one of those agencies, in their own
right, has contributed a lot, and a good example is NHSTA, the
National Highway Safety and Traffic Administration. Yet at the
same time, no one of those agencies had enough reach to be able
to influence things sufficiently in any integrated fashion.
We're not suggesting that we create a huge bureaucracy. We're
suggesting that there needs to be an agency that takes
responsibility for basically leading the coordination among
these various organizations, establishing work groups,
stimulating demonstrations that will begin to address the kinds
of things----
Chairman JOHNSON OF CONNECTICUT. So, for example, a lead
office within CMS, since both Medicare and Medicaid are located
there, is that----
Mr. WARDEN. Well, we actually suggested that a lead office
be within HHS, and were kind of silent on CMS, but----
Chairman JOHNSON OF CONNECTICUT. We'll have to look at
that, because there are some advantages and some disadvantages
to not being, right, working with the people who are running
these two big systems.
Mr. WARDEN. It's really kind of beyond----
Chairman JOHNSON OF CONNECTICUT. Yeah, okay----
Mr. WARDEN. It's not just payment. The second point in
terms of your question about regionalization, we believe that
regionalization, wherever possible, ought to be accomplished at
the state and local level, but that there ought to be some
guidelines for making that happen. If we can do that, we don't
need a large bureaucracy over seeing it if we can get these
various organizations and the providers and all the
stakeholders to buy into it. We really think that if we can get
the regionalization and coordination and accountability
developed at the state and local level and we can have
basically a seamless experience for the patient, then it will
solve a lot of the problems that we've been talking about.
Chairman JOHNSON OF CONNECTICUT. Mr. Levine.
Mr. LEVINE. I think my first reaction when I read that was
at first to say I didn't like the idea of a national
bureaucracy. I'm encouraged to hear that wasn't what they had
in mind. I'm going to borrow a little bit from our emergency
disaster experience in Florida and how we've handled the
emergency system, because I think, I view the safety net in
that from that perspective. It's bottom up. I think probably
the one word that we want to use to describe our emergency
system is we want it to be agile. We want there to be agility
in the system. For example, after several of our hurricanes,
dialysis centers became a problem. They didn't have water and
they didn't have power.
So the emergency response system, the way it's established
is locally they're responsible for coming up with a regional
plan that the local emergency operations centers have to
approve on an annual basis. There needs to be more
regionalization and more coordination locally at that level for
deciding, what we re going to do in the event there's a problem
with dialysis, what are we going to do in the event one of our
trauma centers is knocked out of commission or we don't have
water? It's always better to have it be bottom up rather than
top down, because each state is so different and each community
is so different in unique.
I think if you have national standards for what the
expectations are of our emergency system that are transparent,
and then incentivizing states to implement those standards
because typically states will look to the local leadership and
encourage local leadership through grants or even financial
incentives to participate. To me, then you get the right bottom
up approach, as opposed to a Federal office that grows a life
of its own and then develops its own mechanisms for us to have
to follow, and d I think that would be additive and not
necessarily constructive.
Chairman JOHNSON OF CONNECTICUT. Yes, Mr. Kelly.
Mr. KELLY. Yes. At Scottsdale, with the lead of the City of
Scottsdale, our hospital, and the National Guard, we have one
of the largest disaster drills in the country, at least west of
the Mississippi, and it's called the Coyote Crisis. It has been
a very successful drill, in bringing about all of the
components necessary for everyone to talk to each other,
whether it be the police departments, highway patrol, other
hospitals, specialists, physicians, emergency rooms. I would
hate to see it to be federalized or a specific office. I think
that this can be done cooperatively among the various hospitals
and states, and done on a regional basis. It's been done very
successfully in Arizona. I think part of that has been placed
in my report to the Committee. It is called the Coyote Crisis.
It is really a fantastic partnership between the city, state,
the medical profession, and it's worked.
Chairman JOHNSON OF CONNECTICUT. Thank you. Dr. Bedard.
Dr. BEDARD. First of all, I would support the concept of a
lead agency, emergency medicine is really an essential public
service. I think we provide a vital function for the country
and I think it deserves to be carved out, looked at, standards
set. As I mentioned, JCAHO, when they come to a hospital, the
ER is frequently almost virtually ignored. I mean, I ask them,
gee, I hope they ask me to show them the on-call list, because
half the days are blank. They never ask the question.
So, if you had a lead agency, I think it would also be
effective in proactively surveying hospitals' health care
system. I think regionalization and coordination is critical. I
think medicine is one of the more inefficient, wasteful
services that we provide. I mean, I'm still astounded. Somebody
has a Computerized Axial Tomography (CAT) scan done at a
hospital 2 days ago because they had a seizure, I can't get
that information. So, I think to regionalize and coordinate,
you're going to have to have much more investment in
information technology, have electronic medical records or some
way for patients to carry their records with them, but I think
to do that, you're really going to be it's essential to have
superb information technology.
Chairman JOHNSON OF CONNECTICUT. Dr. Blum.
Dr. BLUM. I would cautiously support the idea of a lead
agency. It depends on what that lead agency is charged with
doing. I think it makes sense for a lead agency to do things
like coordinate national response to disasters, and so forth,
and so forth, things of national scope. I think to overdo that
bureaucracy, though, does not make sense to a system that has
so many fundamental flaws. The analogy that I would use is it
would be like putting a sophisticated computer control module
on a car that has no gas in the tank; and in emergency medicine
right now, we have no gas in the tank, you know, and someone
stole the engine, so that control wouldn't really help us very
much.
We have much more fundamental problems, quite frankly. You
alluded to costs earlier. You talked about costs earlier. You
know, we currently pay for the uninsured by cost shifting, but
that's becoming increasingly difficult. No payer wants to have
costs shifted to them, including the Federal Government. Yet we
still have to figure out a way to care for these people. We
could call it a single payer system, but quite frankly, that's
cost shifting. Anytime you provide care to a bunch of people
who cannot pay for it, that's cost shifting, and you could call
it a single payer system, you could call it taxes, you could
call it whatever you want to, or you could call it what we call
it now, which is cost-shifting, charging people more to pay for
the people who can't pay at all.
I don't run away from cost-shifting. Quite frankly, it's
the way we've figure out how to provide care under this kind of
strange sort of system that we're in. Let's recognize it for
what it is. You could call it something else, but it's still
the same thing. It's those people who can pay paying for those
people who can't.
Chairman JOHNSON OF CONNECTICUT. Thank you. Thank you all
for your--Mr. Stark?
Mr. STARK. Can I just take another slice of the apple here,
Madam Chair?
Chairman JOHNSON OF CONNECTICUT. All right. While I hold no
brief for the state of the art of medical care in Mexico, we
did get from the Mexican Embassy the laws there about treating
people who were either in Mexico legally or illegally, and all
I can suggest to you, I'd make these part of the record.
Mr. STARK. Madam Chair, they're very generous. In other
words, basically, they say, regardless of why you're there,
you're treated. I would make those rules part of the record. I
did want to ask, particularly Dr. Bedard, Dr. Blum, I guess
everybody but Mr. Warden, who may not have a horse in this
race, but one of the issues that we've been talking about, and
initially this hearing was designed to talk about, the burden
placed on you all by immigration, by immigrants. That was
changed for some reason.
Nonetheless, in the House bill that we're talking about,
there's a question whether the possibility that providers of
care to people who are here illegally would criminalize them,
they would be subject to felony charges if that came about.
Also, that would, I suspect, put your emergency departments
somewhat in the position of being de facto immigration agents.
I wanted to ask each of you if you think that's a good idea for
you to you have enough trouble figuring out whether they may
what their blood type is. Do you think it's a good idea for us
to impose on Medicare emergency medical care providers the need
to certify a citizenship? Just, I'll start with Doctor Bedard,
go down the line.
Dr. BEDARD. Absolutely not. I'm a physician. I'm there to
help people. I'm not an Immigration and Naturalization Service
(INS) agent.
Mr. STARK. Dr. Blum?
Dr. BLUM. Absolutely not. Physicians have a contract with
the patient to do what's in their best interests, and that
would violate that.
Mr. STARK. Now, as the representative of a kindly
bureaucracy, Mr. Levine, what would you feel from an
administrative standpoint?
Mr. LEVINE. Let me clarify the question. Are you asking if
we would support our staff or physicians being criminalized if
they treat someone who is----
Mr. STARK. And/or the fact that they would have to somehow
certify if investigate the people who came in were in fact
citizens or here legally.
Mr. LEVINE. Well, we would not support that. Indeed, we
don't even ask that question until we've started treatment,
because of EMTALA requirements.
Mr. STARK. Mr. Kelly.
Mr. KELLY. Congressman Stark, we believe that that would
have an extremely chilling effect upon our health care workers.
You know, we can't do that now. We can't even ask that question
on Form 1011. So, we would be very, very opposed to that.
Mr. STARK. As I say, I have no quarrel with the fact that
people who can't pay, wherever they come from, are a burden to
the system, but I'd like to think that there are better ways to
resolve that than putting you all in the position of having to
be law enforcement people. Thank you, each of you, for your
interest and efforts and I hope you won't want not that the
Chairman won't have another hearing, but I hop you won't wait
until she does to offer us suggestions as to what we might do
to help solve this problem by minor adjustments. I'm not sure
we're going to run around and immediately have universal health
care.
For example, the antitrust thing might be something that we
could move on more quickly, and we really would appreciate, I'm
sure I know that I don't want to speak for the chair, but I
know that she is very receptive to these ideas from the
providers, and I would join with her in asking for your
assistance. Thank you all.
Chairman JOHNSON OF CONNECTICUT. Thank you. I certainly
join with Mr. Stark in his last comments. We won't have another
hearing until we have something to say or we see that there's
some part of it we didn't hear, but you've laid out all aspects
of the problem pretty completely, and we do invite you to share
your thoughts, having listened to one another, you know, as to
what are one or two things we could do now, what are the big
issues that we ought to be laying a more substantial record
knowledge base?
For instance, we really do have to get into medical
education. We all know that. How do we fund it? But also, what
do we teach? I mean, to what extent is our current medical
education system going to prepare the doctors that are going to
serve us in the future for a very different environment? It's
got to be one based entirely in health information technology.
It's got to be capable of absorbing new medical knowledge more
rapidly, delivering it more accurately, providing necessary but
not unnecessary care. It is going to be a different world that
we're moving into, and we want the base of law that we lay in
the next round of shaping our medical education system to
understand that. That's going to be a big challenge just in and
of itself.
It's clear that our old legal system doesn't work now with
the way medicine is moving in America. It doesn't work partly
because the state of the art is moving so rapidly you can't
hold physicians liable for knowledge that wasn't available 2
months ago. So, we're having a lot of problems. Failure to
diagnose is a terrible threat to the medical profession, and so
on and so forth. I just want to say the problems are big. We
understand that. You've done a very good job for us today. We
appreciate that.
If you want to follow up with specific recommendations as
to what steps need to be taken in what order, that would be
very helpful to us. I'm going to submit for the record two
things that Mr. Stark asked me to submit. One is the District
of Columbia Inspector General Report on the assault of David
Rosenbaum. I'm submitting that for the record.
[The information follows:]
GOVERNMENT OF THE DISTRICT OF COLUMBIA OFFICE OF THE INSPECTOR
GENERAL SUMMARY OF SPECIAL REPORT: Emergency Response to the Assault on
David E. Rosenbaum
CHARLES J. WILLOUGHBY INSPECTOR GENERAL OIG No. 06-I-003-UC-FB-FA-
FX June 2006 This Summary describes the D.C. Office of the Inspector
General's review of the emergency response efforts provided by District
agencies and-hospital personnel in light of applicable policies and
procedures. The OIG is providing this Summary in lieu of the full
report in accordance with the exemptions provided in the District of
Columbia Freedom of Information Act (D.C. Code 2-531-539 (Supp.
2004)) to preserve the privacy interests of Mr. Rosenbaum and other
individuals mentioned in the full report.
Background and Perspective
``Man Down.'' On January 6, 2006, at approximately 9:20 p.m., a
resident of Gramercy Street, N.W. went to his car to retrieve an item
and found an unknown man lying on the sidewalk in front of his home.
The resident's wife called 911, and the Office of Unified
Communications dispatched emergency responders to the scene for a ``man
down.'' The fire (first responders), police, and ambulance (second
responders) personnel who were at the scene did not detect serious
injuries, illness, or evidence that the then-unknown man had been
physically attacked. He had no identification in his pockets, but was
wearing a wedding band and a watch. Stereo headphones were found near
him on the grass. Because he was vomiting, and because one or more
responders thought they smelled alcohol, the man was presumed to be
intoxicated. Consequently, the man was classified as a low priority
patient and transported to the Howard University Hospital (Howard)
Emergency Department where, after lying in a hallway for more than an
hour, medical personnel discovered that he had a critical head injury.
At approximately 11:31 p.m., Rosenbaum's wife reported to the
Metropolitan Police Department (MPD) that her husband, David E.
Rosenbaum, had gone for an after-dinner walk at approximately 9 p.m.,
but had not returned. The police broadcast a descriptive lookout, and a
police officer who had responded to the Gramercy Street ``man down''
call realized that the description of the missing person matched that
of the man who had been found lying on the sidewalk. It was later
determined that the ``man down'' was David Rosenbaum.
Mr. Rosenbaum's head injury was discovered at Howard in the early
morning hours of January 7 and reported to MPD. MPD officers then
returned to the Gramercy Street scene to look for evidence that might
indicate the cause of the head injury. Later, on January 7, the
Rosenbaum family was alerted by credit card companies to unusual
activity on Mr. Rosenbaum's credit cards. MPD subsequently linked Mr.
Rosenbaum's injuries, his missing wallet, and the unusual credit card
activity, and initiated an assault and robbery investigation.
Despite surgery and other medical interventions to save him, Mr.
Rosenbaum died on January 8, 2006. The autopsy report issued on January
13, 2006, by the Office of the Chief Medical Examiner concluded that
Mr. Rosenbaum was a victim of homicide due to injuries sustained to his
head and body.
Scope and Methodology
Following Mr. Rosenbaum's death, numerous questions were raised and
complaints made by both citizens and District government officials
about the emergency medical services provided to him by D.C. Fire and
Emergency Medical Services Department (FEMS) and Howard personnel.
Questions were also raised regarding the delayed recognition by MPD
officers that a crime had been committed.
In a letter to the Inspector General dated January 19, 2006, City
Administrator Robert C. Bobb requested that the Office of the Inspector
General conduct a review of the response to David E. Rosenbaum's
assault and subsequent death. Mr. Bobb indicated that he and Mayor
Anthony A. Williams wanted the review ``to ensure the maintenance of
public confidence in the emergency services provided by the District
government.'' In his letter to the Inspector General, Mr. Bobb asked
that the Office of the Inspector General's review specifically include
answers to the following questions: ? Did the Office of Unified
Communications properly handle, dispatch, and monitor the incident? ?
Did FEMS employees follow all rules, policies, protocols, and
procedures? ? Did first responders properly assess the patient? ? Were
FEMS written reports and oral communication adequate? ? Did MPD
responders properly assess the situation at the scene, and were steps
taken by MPD responders prior to opening an investigation adequate? ?
Did the second responders arrive with all due and proper haste? ? Did
the second responders properly assess the patient? ? Did the second
responders select an appropriate hospital? ? Are there any identifiable
improvements to FEMS rules, policies, protocols, and procedures? ? Did
Howard properly triage and assess the patient upon his arrival at the
hospital? ? Did the Office of the Chief Medical Examiner promptly and
completely discharge its review and report of the death?
In addition to Mr. Bobb's questions, the Office also received
inquiries from Councilmembers Phil Mendelson and Kathy Patterson
regarding issues of concern with respect to this matter. Finally, the
Rosenbaum family requested that the Office of the Inspector General
answer questions they posed ``so that errors [they] experienced are not
repeated in the future. . . .'' We believe that this report is
responsive to many of the questions that have been raised. The scope of
the Inspector General's review included the entire emergency response
provided to Mr. Rosenbaum on January 6, 2006, and the review conducted
by the Office of the Chief Medical Examiner.2 To conduct the review,
the Inspector General appointed a team of inspectors and investigators
to examine the circumstances surrounding the January 6, 2006 incident.
The team members have training and experience in law enforcement,
firefighting, medical, and pre, 1 FEMS and MPD also conducted inquiries
into the actions of their responders to the Gramercy Street emergency.
In addition, the District's Department of Health conducted a
``complaint investigation'' into Howard University Hospital's response.
2 The care and treatment provided to Mr. Rosenbaum at Howard University
Hospital subsequent to the discovery of his head injury, and the MPD
assault and robbery investigation that was opened on January 7, 2006,
were not part of the Inspector General's review. hospital care.3 The
team reviewed policies, procedures, protocols, General and Special
Orders, personnel files, patient care standards, hospital and ambulance
medical records, certification and training records, and reports issued
by FEMS, MPD, the Office of the Chief Medical Examiner, and the
Department of Health. The team also interviewed all District government
and Howard personnel involved in Mr. Rosenbaum's emergency care and
autopsy. Upon conducting its review, the OIG team noted multiple
discrepancies in statements made by interviewees. (See Appendix 1)
Findings and Recommendations
Office of Unified Communications
The Office of Unified Communications properly handled,
dispatched, and monitored the Gramercy Street call. The call taker and
dispatchers who handled the 911 call carried out their duties
appropriately.
Recommendation None.
Fire and Emergency Medical Services Department Engine 20
Engine 20 personnel did not follow all applicable rules,
policies, protocols, and procedures. The firefighter in charge of the
Engine 20 crew on January 6 did not have a current CPR certification as
required. In addition, the firefighter/Emergency Medical Technician
(EMT) with the highest level of pre-hospital training did not take
charge of patient care during the Gramercy Street call.
Firefighter/EMTs did not properly assess the patient.
None of the firefighter/EMTs performed a complete assessment of the
patient, and not one of the patient's vital signs4 was recorded at the
scene. Once the firefighter/EMTs perceived an odor of alcohol coming
from the patient, they did not focus on other possibilities as the
cause of his altered mental status such as stroke, drug interaction or
overdose, seizure, diabetes, head trauma, or other injury.
Oral communication and standard reports were not
adequate. Firefighter/EMTs did not pass on key information to the
ambulance crew such as observing blood on the patient and detecting the
patient's constricted pupils. Engine 20 personnel did not prepare a
written report on the Gramercy Street incident because the FEMS form
for such purpose is being revised.
3 Emergency response by fire and ambulance personnel. 4 Heartbeat,
breathing, and blood pressure. Recommendations
1. That FEMS ensure all personnel have current required training
and certifications prior to going on duty.
2. That FEMS immediately implement a reporting form for
firefighter/EMTs who respond to medical calls so that first responder
actions and patient medical information can be documented.
3. That FEMS develop and implement a standardized performance
evaluation system for all firefighters. The Office of the Inspector
General team determined that FEMS employees are not evaluated on a
regular basis, in the manner that other District government employees
are evaluated. Consequently, FEMS lacks standards to guide
firefighters' performance and for use in evaluating their performance.
4. That FEMS assign quality assurance responsibilities to the
employee with the most advanced training on each emergency medical
call. The designated employee should: (a) have in-depth knowledge of
the most current protocols, General Orders, Special Orders, and other
management and medical guidance; (b) monitor compliance with FEMS
protocols by all personnel at the scene; and (c) provide on-the-spot
guidance as required.
Metropolitan Police Department Responders
MPD officers did not properly assess the situation upon
arrival. The three responding MPD officers did not secure the scene,
did not conduct an adequate preliminary investigation in accordance
with MPD General Orders, and did not take adequate steps to determine
if a crime had been committed. They also did not complete a report on
the incident pursuant to the relevant MPD General Order.
Recommendations
1. That MPD immediately review and reissue the pertinent General
Orders relating to officer responsibilities at emergency incidents. In
addition, MPD should consider implementing or revising as necessary a
quality assurance program that includes supervisory review of required
reports, and a tracking system to ensure that reports are written and
retrievable for every call.
2. That MPD assign quality assurance responsibilities to the senior
officer responding to each call.
Fire and Emergency Medical Services Department Ambulance 18
EMTs did not follow applicable rules, policies, and
protocols. The highest-trained EMT, an EMT-Advanced, was not in charge
of the patient as required by protocol. The EMT-Advanced did not assess
the patient, or help her partner assess him. Neither EMT adequately
questioned the first responding firefighter/EMTs about the patient's
vital signs, or other care and treatment. The patient's low Glasgow
Coma Scale results were disregarded, and not brought to the attention
of Howard Emergency Department personnel.
The ambulance did not arrive on the scene expeditiously. The
ambulance driver got lost after being dispatched from Providence
Hospital, and then did not take a direct route to Gramercy Street. This
error added 6 minutes to the trip. (See Appendix 2)
EMTs did not thoroughly assess the patient. The EMT who
assessed the patient failed to conduct all of the required assessments,
and did not fully document his assessment and treatment on the FEMS 151
Run Sheet. (See Appendix 3)
Transport of the patient to the hospital did not follow
FEMS protocol. EMTs are required to transport patients to the ``closest
appropriate open facility.'' Although Ambulance 18 was closest to
Sibley Hospital, the EMT in charge, for personal reasons, decided to
transport the patient to Howard. Howard is 1.85 miles further from
Gramercy Street than the Emergency Department at Sibley Hospital. (See
Appendix 4)
EMTs did not properly document actions. The EMT who cared
for the patient did not completely fill out the FEMS 151 Run Sheet. For
example, the form shows no times when treatment, care, or testing was
provided or performed. An entire page of the form relating to patient
care was left blank.
Recommendations
1. That FEMS ensure all personnel have current required
certifications prior to going on duty.
2. That FEMS take steps to comply with its own policy on evaluating
EMTs on a quarterly basis.
3. That FEMS promptly reassign, retrain, or remove poor performers.
4. That FEMS assign quality assurance responsibilities to the most
highly-trained pre-hospital provider for each incident. This individual
should: (a) have in-depth knowledge of the most current FEMS protocols
and other management guidance; (b) monitor compliance with protocols
and other guidance by all personnel at the scene; and (c) include the
results of on-scene compliance monitoring in all reports required by
management.
5. That FEMS consider installing global positioning devices in all
ambulances to assist EMTs in expeditiously reaching their destinations
on emergency calls.
Howard University Hospital
Nurses did not properly triages and assess Mr. Rosenbaum.
The triage nurse did not perform basic assessments and did not
communicate an abnormal temperature reading. The patient was
incorrectly diagnosed as intoxicated, but employees did not follow
triage policy on treating an intoxicated patient. Howard's Patient Care
Standards--including monitoring airway and breathing, assessing for
trauma, conducting routine lab tests, and monitoring vital signs every
15 minutes--were not followed.
Recommendations
1. That Howard develop a system in the Emergency Department that
will allow staff to readily identify patients' priority level while
they are awaiting care.
2. That Howard consider adopting a patient records system that
would enable nursing and medical staff to review documents when they
are at a patient's side. The current system prevents staff access to
such information in a timely manner.
Office of the Chief Medical Examiner
The Office of the Chief Medical Examiner conducted the
Rosenbaum autopsy expeditiously and promptly issued a report.
Recommendation
That Office of the Chief Medical Examiner consider using digital
camera technology to photograph all autopsies. The Office of the
Inspector General was unable to review requested autopsy pictures
because of photo processing delays and mislaid slides.
5 The process of sorting out and classifying patients to determine
the priority of needs and where a patient should be treated.
Conclusion
The OIG team concludes that personnel from the Office of Unified
Communications properly monitored the 911 call from Gramercy Street and
immediately dispatched adequate resources to respond to the emergency.
However, FEMS, MPD, and Howard personnel failed to respond to David E.
Rosenbaum in accordance with established protocols. Individuals who
played critical roles in providing these services failed to adhere to
applicable policies, procedures, and other guidance from their
respective employers. These failures included incomplete patient
assessments, poor communication between emergency responders, and
inadequate evaluation and documentation of the incident. The result,
significant and unnecessary delays in identifying and treating Mr.
Rosenbaum's injuries, hindered recognition that a crime had been
committed.
On January 6, 2006, David E. Rosenbaum consumed alcohol, both
before and during dinner prior to leaving home for a walk. Neighbors
discovered Mr. Rosenbaum lying on the sidewalk in front of their home
and called 911. Upon assessment, emergency responders concluded that
Mr. Rosenbaum's symptoms, which included poor motor control, inability
to speak or respond to questions, pinpoint pupils, bleeding from the
head, vomiting, and a dangerously low Glasgow Coma Scale, were the
result of intoxication. Hospital laboratory and other tests, however,
confirmed that Mr. Rosenbaum's symptoms were caused by a head injury.
Emergency responders' approach to Mr. Rosenbaum's perceived
intoxication resulted in minimal intervention by both medical and law
enforcement personnel.
FEMS personnel made errors both in getting to the scene and in
transporting Mr. Rosenbaum to a hospital in a timely manner. Ambulance
18 did not take a direct route from Providence Hospital to the Gramercy
Street incident. In addition, for personal reasons, the EMTs did not
take the patient to the nearest hospital. As a result of that decision,
it took twice as long for Ambulance 18 to reach Howard than it would
have taken to get to Sibley Hospital. Once FEMS personnel at the
Gramercy Street scene detected the odor of alcohol, they failed to
properly analyze and treat Mr. Rosenbaum's symptoms according to
accepted pre-hospital care standards. Failure to follow protocols,
policies, and procedures affected care of the patient and the
efficiency with which the EMTs completed the call. In addition, FEMS
employees' failure to adequately and properly communicate information
regarding the patient affected subsequent care givers' abilities to
carry out their responsibilities.
MPD officers initially dispatched in response to the Gramercy
Street call failed to secure the scene, collect evidence, interview all
potential witnesses, canvass the neighborhood, conduct other
preliminary investigative activities, or properly document the
incident. Both FEMS and MPD failures were later compounded by similar
procedural failures on the part of Howard Emergency Department
personnel, who also initially believed Mr. Rosenbaum's condition to be
the result of intoxication.
Upon Mr. Rosenbaum's arrival at Howard, Emergency Department
personnel failed to properly assess his condition and failed to
communicate critical medical information to each other, thereby
delaying necessary medical intervention, all in violation of Howard's
own patient care standards. Further, a number of Emergency Department
staff members passed Mr. Rosenbaum in the hallway and neglected to
provide clinical and therapeutic care.
The Office of the Inspector General's review indicates a need for
increased oversight and enhanced internal controls by FEMS, MPD, and
Howard managers in the areas of training and certifications,
performance management, oral and written communication, and employee
knowledge of protocols, General Orders, and patient care standards.
Multiple failures during a single evening by District agency and Howard
employees to comply with applicable policies, procedures, and protocols
suggest an impaired work ethic that must be addressed before it becomes
pervasive. Apathy, indifference, and complacency-apparent even during
some of our interviews with care givers-undermined the effective,
efficient, and high quality delivery of emergency services expected
from those entrusted with providing care to those who are ill and
injured.
Accordingly, while the scope of this review was limited, these
multiple failures have generated concerns and perceptions about the
systemic nature of problems related to the delivery of basic emergency
medical services citywide. Such failures mandate immediate action by
management to improve employee accountability. Specifically, we believe
that several quality assurance measures may assist in reducing the risk
of a recurrence of the many failures that occurred in the emergency
responses to Mr. Rosenbaum: systematic compliance testing,
comprehensive and timely performance evaluations, and meaningful
administrative action in cases of employee misconduct or incompetence.
Chairman JOHNSON OF CONNECTICUT. Also this one-page memo on
Mexican medical care for foreigners.
[The information follows:]
ACCESS TO EMERGENCY CARE IN MEXICO
FOR U.S. CITIZENS AND OTHER FOREIGNERS
A foreigner in Mexico is legally entitled to medical care in cases
of emergency, according to the following laws:
Political Constitution of the United Mexican States
Article 1 stipulates that in the United Mexican States, all persons
shall enjoy the fundamental rights recognized by this Constitution,
which may not be abridged nor suspended except in those cases and under
such conditions as herein provided.
Article 4 sets forth that every person has the right to health
protection while in Mexican territory.
Article 33 stipulates that aliens are entitled to the
constitutional rights granted under Chapter I, First Title of this
Constitution.
International Convention on the Protection of the Rights of All
Migrant Workers and Members of Their Families (Ratified by Mexico on
March 8, 1999)
This Convention stipulates that migrant workers and members of
their families shall have the right to receive any medical care that is
urgently required for the preservation of their life or the avoidance
of irreparable harm to their health on the basis of equality of
treatment with nationals of the State concerned. Such emergency medical
care shall not be refused them by reason of any irregularity with
regard to stay or employment.
Convention for the Coalition between the Secretariat of Governance,
through the National Migration Institute, and the Mexican Red Cross.
Signed on April 21, 2006.
The purpose of this Convention is to take joint actions to protect
the physical integrity of migrants, regardless of their nationality or
whether they are documented or undocumented migrants. This is done by
granting prehospital care in cases of emergency, humanitarian
assistance, help, and rescue, if necessary, as well as the equipment
and training to carry out these measures.
Performance standards for the National Migration Institute migration
centers
Chapter X Article 23 stipulates that, whether independently or by
way of other institutions, the National Migration Institute shall grant
medical care to any foreigner who may require it.
Regulation of the General Population Act
Article 209 sections I and VII. Foreigners in migration centers
will receive all necessary medical care while in said migration center.
Chairman JOHNSON OF CONNECTICUT. I would say that a cursory
reading of it means that their standards are roughly ours:
treat and stabilize, and that there is explicitly the right to
receive any medical care that is urgently required. Well, of
course, that's the difficulty. What happens when you provide
urgently required care and then you can't discharge the
patient? So, we do have work to do. There are some difficult
issues to face around what the charge should be in EMTALA.
I hope some of you have had some experience with Health
Resources and Services Administration (HRSA) grants, which have
been very successful in helping communities weed out how can we
get people into the legal/medical systems, and so on and so
forth. So, we look forward to hearing from you. We thank you
for your participation and the excellent of your testimony and
your patience with the individual Members as we have had the
time to question today. Thank you. The hearing is adjourned.
[Whereupon, at 12:08 p.m., the Subcommittee was adjourned.]
[Submissions for the record follow:]
Statement of American Academy of Pediatrics
The American Academy of Pediatrics appreciates this opportunity to
submit testimony for the record of the Ways and Means Subcommittee on
Health's hearing regarding emergency care. The American Academy of
Pediatrics is 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.
BACKGROUND
Emergency medical services are the foundation of our nation's
defense for public health disasters. The emergency care community is
largely 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. 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.\1\ 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. This
testimony focuses on issues concerning pediatric emergency preparedness
so Congress may better understand the unique challenges faced by
emergency medical care professionals as they treat ill and injured
children, as well as the readiness gap in pediatric emergency care.
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\1\ Committee on Pediatric Emergency Medicine. Overcrowding Crisis
in Our Nation's Emergency Departments: Is Our Safety Net Unraveling?
Pediatrics, Vol. 114 No. 3 September 2004.
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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.\2\
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\2\ Committee on Environmental Health and Committee on Infectious
Disease. Chemical-Biological Terrorism and Its Impact on Children: A
Subject Review. Pediatrics, Vol. 105 No. 3 March 2000. (update
scheduled for publication in Pediatrics September 2006.)
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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.\3\ As we all learned from Katrina, children are also
notably vulnerable when they are separated from their parents or
guardians.
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\3\ American Academy of Pediatrics. Children, Terrorism & Disasters
Toolkit. The Youngest Victims: Disaster Preparedness to Meet Children's
Needs. http://www.aap.org/terrorism/topics/PhysiciansSheet.pdf
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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.\4\ Hypothermia can
have a profoundly detrimental impact on a child's survival from illness
or injury.
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\4\ American Academy of Pediatrics. Children, Terrorism & Disasters
Toolkit. The Youngest Victims: Disaster Preparedness to Meet Children's
Needs. http://www.aap.org/terrorism/topics/PhysiciansSheet.pdf
---------------------------------------------------------------------------
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.\5\
---------------------------------------------------------------------------
\5\ 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.
---------------------------------------------------------------------------
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.\6\ 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 a
practice such as a pediatric emergency department located in a tertiary
urban children's hospital and trauma center, providers 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.
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\6\ Markenson D, Reynolds S, Committee on Pediatric Emergency and
Medicine and Task Force on Terrorism. The Pediatrician and Disaster
Preparedness. Pediatrics, Vol. 117 No. 2 February 2006.
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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.
Children with special health care needs \7\ are the fastest growing
subset of children, representing 15 to 20% of the pediatric
population.\8\ 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.
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\7\ MacPherson M et.al. A New Definition of Children with Special
Health Care Needs. Pediatrics, Vol. 102, No. 1, July 1998.
\8\ Van Dyck P et.al. Prevalence and Characteristics of Children
With Special Health Care Needs. Arch Pediatr Adolesc Med, Vol. 158, No.
9, September 2004.
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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.\9\\,\\10\
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\9\ Seidel JS, et al: Emergency medical services and the pediatric
patient: Are the needs being met? Pediatrics, Vol. 73, June 1984.
\10\ Seidel JS, et al.: Emergency medical services and the
pediatric patient: Are the needs being met II. Training and equipping
emergency medical services providers for pediatric emergencies.
Pediatrics, Vol. 78, December 1986.
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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.\11\
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\11\ Durch JS, Lohr KN (eds): Emergency Medical Services for
Children. Report of the Institutes of Medicine Committee on Pediatric
Emergency Medical Services. Washington, D.C., The National Academies
Press, 1993. Available at: http://books.nap.edu/catalog/2137.html.
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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.\12\
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\12\ Institute of Medicine. Future of Emergency Care Series,
``Emergency Care for Children: Growing Pains.'' National Academies
Press, June 2006.
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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.\13\
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\13\ American Academy of Pediatrics Committee on Pediatric
Emergency Medicineand American College of Emergency Physicians
Pediatric Committee. Care of Children in the Emergency Department:
Guidelines for Preparedness. Pediatrics, Vol. 107 No. 4 April 2001.
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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.\14\ Families should also be encouraged to engage in advance
planning for emergencies and disasters.\15\
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\14\ 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.
\15\ Family Readiness Kit. http://www.aap.org/family/frk/frkit.htm.
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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.\16\
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\16\ National Bioterrorism Hospital Preparedness Program FY 2005
Continuation Guidance, HRSA Announcement Number 5-U3R-05-001, http://
www.hrsa.gov/bioterrorism/hrsa05001.htm.
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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.\17\
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\17\ Mace SE and Bern AI. Needs Assessment of Current Pediatric
Guidelines for Use by Disaster Medical Assistance Team Members in
Response to Disaster and Shelter Care. Annals of Emergency Medicine,
44(4): S35.
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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.\18\
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\18\ Committee on Hospital Care. Family-Centered Care and the
Pediatrician's Role. Pediatrics, Vol. 112, No. 3, September 2003.
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It has been a source of great frustration for many pediatric and
emergency medicine providers, including the American Academy of
Pediatrics, 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.\19\ 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.\20\ 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.\21\ 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.\22\
Just last month, the IOM issued its report on the pediatric aspects of
the emergency care system.\23\ Despite all of this, progress in
pediatric preparedness has been slow, fragmented, disorganized, and
largely unmeasured and unaccountable.
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\19\ National Advisory Committee on Children and Terrorism.
Recommendations to the Secretary. Washington, DC: DHHS, 2003.
\20\ Committee on Pediatric Emergency Medicine. The Pediatrician's
Role in Disaster Preparedness. Pediatrics, Vol. 99 No. 1, January 1997.
\21\ AAP Task Force on Terrorism. All related documentation at
www.aap.org/terrorism.
\22\ Pediatric Preparedness for Disasters and Terrorism: A National
Consensus Conference. 2003. http://www.ncdp.mailman.columbia.edu/files/
pediatric_preparedness.pdf.
\23\ Institute of Medicine. Future of Emergency Care Series,
``Emergency Care for Children: Growing Pains.'' National Academies
Press, June 2006.
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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.''\24\
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\24\ Institute of Medicine. Future of Emergency Care Series,
``Emergency Care for Children: Growing Pains.'' National Academies
Press, June 2006.
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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;o 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.\25\
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\25\ Committee on Environmental Health. Radiation Disasters and
Children. Pediatrics, Vol. 111, No. 6, June 2003.
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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.\26\
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\26\ 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
---------------------------------------------------------------------------
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.\27\
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\27\ 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.
---------------------------------------------------------------------------
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 its 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.
National Coalition on Hispanic Health
Washington, DC 20005
August 9, 2006
Dear Members of Congress:
On behalf of the National Coalition on Hispanic Health, an
association of major national Latino associations with extensive
expertise, I write to urge Congress to get the facts about immigrants
and health care. Study after study has proven that immigrants actually
use much less of our nation's health resources than U.S. citizens. This
was first carefully studied and documented by the prestigious National
Research Council, in The New Americans, published in 1997. More recent
reports have only served to reconfirm these findings. For instance, a
recent study in Health Affairs shows that 6.3% of non-citizens used the
emergency room in 2003, compared to 31.8% of the general population in
the total U.S.
It is critical that Congress base decisions about immigration and
health issues upon factual, comprehensive, longitudinal studies of the
type cited above. Rhetorical examples will only serve to divert public
policy from its essential goal of protecting our nation's health and
well-being.
If you have any further questions, please do not hesitate to
contact me.
Sincerely,
Elena Rios, MD, MSPH
President and CEO
Statement of William A. Sanger, Emergency Medical Services Corporation
Emergency Medical Services Corporation (``EMSC'') is pleased to
submit comments to the Health Subcommittee of the House Ways & Means
Committee on the Institute of Medicine (``IOM'') reports on Emergency
Care in America. These reports were the subject of a public hearing
held before the Subcommittee on July 27, 2006.
EMSC has extensive experience in emergency medicine delivery and
emergency care operations. Operating under the recognized brands of
EmCare and AMR, EMSC is a leading provider of emergency medical
services in the United States, serving more than nine million patients
each year. EmCare provides outsourced emergency department staffing and
management services to more than 340 hospitals in 39 states. AMR--
American Medical Response--is America's leading provider of ambulance
services, with local operations serving more than 250 communities in 35
states.
Because of EMSC's unique position in these healthcare sectors, we
are very familiar with the complexities and challenges facing emergency
departments, hospitals, emergency physicians, first responders, EMS and
ambulance service providers, and all others associated with the
delivery of emergency medical services across the nation. As identified
in the IOM reports, some of the key issues facing emergency medical
service providers include regionalization, coordination, the practices
of ``boarding'' and ``parking'' emergency care patients, and patient
flow management. We believe that Congress and others need to take
immediate steps to address these issues in order to improve patient
care delivery and maximize the efficiency of emergency department
operations.
While no one organization can provide answers to the many problems
facing emergency care in America, EMSC believes that our breadth and
depth of experience makes us uniquely qualified to confront the many
issues raised in the IOM reports. We, therefore, would like to share
some of our experiences with the Subcommittee and others involved in
policymaking in this important area. We believe our experiences and
insights will help inform the next phase of deliberation and
consideration of these critical issues.
Regionalization and Coordination
Regionalization of Emergency Services
In today's world, an emergency in one town or one section of a city
can quickly become a much larger incident requiring a response across
jurisdictions and disciplines. The IOM Emergency Medical Services
report makes clear that the objective of regionalization of emergency
medical care services is to ``improve patient outcomes by directing
patients to facilities with experience in and optimal capabilities for
any given type of illness or injury.'' (Emergency Medical Services: At
the Crossroads at p. 58.) Getting the patient to the best provider to
treat their specific medical condition is a primary requirement to meet
this stated goal. Our physicians, EMS professionals, and other
emergency care providers have seen the benefits of regionalization.
This helps ensure that patients receive the best available care with
the result of better outcomes. Unfortunately, we have also experienced
instances where a lack of regionalization has resulted in poor patient
outcomes.
EMSC's unique role in emergency medicine delivery and emergency
care operations has given our team significant ``on the ground''
experience in finding the best ways to make regionalization work to
improve emergency medical care for patients.
The EMS report also noted the concept of an ``inclusive trauma
system'' for the treatment of all illnesses and injuries across the
entire spectrum of emergency care. (Id. at p.58.) We share this vision
for the future of emergency care and are already implementing methods
to achieve this concept. EMSC has worked over the past years to develop
procedures and processes to help our physicians and professionals
ensure top quality emergency medical care to all patients but
especially to those patients in immediate danger of death from
traumatic injury or illness.
The Emergency Medical Services report notes a specific
recommendation for a panel to develop ``evidence-based categorization
systems for EMS, EDs and trauma centers based on adult and pediatric
service capabilities.'' (Id. at p. 59.) We strongly support this
proposal and believe that our depth of experience in delivering
emergency care services would be useful considering ways to develop
such categorization systems. We offer our expertise and experience to
those individuals and organizations committed to this undertaking.
While we believe that regionalization is a positive development in
the improvement of emergency medical care, it is a concept that will
require some changes to current laws to realize its full potential.
Issues like antitrust laws, physician licensure across state lines,
obsolete corporate practice of medicine laws in certain states, and
Good Samaritan laws potentially present certain legal issues that we
and others in the profession will need to consider before
regionalization can be accomplished. We, alongside our professional
societies and fellow health care providers, look forward to working
with Congress to achieve the important goal of regionalization.
Coordination of Emergency Services
The Emergency Medical Services report discussed the current
emergency medical care system's lack of coordination among the
different components of care, including 911 dispatch, pre-hospital EMS,
air ambulance providers, hospitals, and trauma centers. In addressing
this need, the report states that these elements, along with public
safety and public health departments, ``should be fully interconnected
and united in an effort to ensure that each patient receives the most
appropriate care, at the optimum level, with the minimum delay.''
(Emergency Medical Services: At the Crossroads at p. 7.) EMSC fully
agrees with and shares this goal for the future of emergency care.
Coordination of services and emergency care is not just a goal for
EMSC, but is important for all emergency care providers to ensure that
patients receive the highest quality care. The efficiency and
effectiveness of our emergency care delivery depends on how well our
professionals can coordinate their response to an incident, the care
provided to a patient in distress, and the communication with other
providers along the service delivery chain to provide a continuum of
care that achieves the optimum patient outcome.
To date, EMSC has invested several years in our continuing search
for solutions to deliver the best possible emergency care services.
This includes advanced technology to provide the most clinically
appropriate and cost effective level of care to all patients, state of
the art medical transportation software for high performance medical
transportation management, and advanced technology to match physicians
to hospitals' needs.
For example, many hospitals currently utilize software programs to
assist them with bed management issues. When a bed is available, a
nurse will use the software to notify housekeeping that a bed has
become available so they can get the room ready for a new patient. We
have learned, however, for a variety of reasons, nurses do not always
adequately use the software, so empty beds are not filled timely. EMSC
has formed partnerships with software developers, which allows us to
become a part in the process of identifying empty beds. When an EMSC
ambulance arrives to transport a discharged patient in these
facilities, the dispatchers use the software to notify the hospital
that there is an available bed to be filled. This helps hospitals that
use EMSC's ambulances to more timely fill their empty beds, thus
alleviating some of the bed shortage problems faced by these hospitals.
In developing these partnerships, we have gained a number of
insights and new information that we believe will be useful as Congress
explores ways to improve coordination and communications in emergency
care. We stand willing and ready to work with the Subcommittee and
other interested individuals and organizations to provide our expertise
and experience to this very important effort.
Patient Care Issues
Patient ``Boarding'' and ``Parking''
One important area of continuing concern is the practice of
``boarding'' where emergency departments are unable to timely admit
patients into the hospital and must hold the patient in an emergency
department bed or in a non-clinical space, such as an office or
hallway. This practice reduces care capacity and contributes to an
already overcrowded emergency room. The IOM Emergency Medical Services
report urges elimination of the practice of boarding except in extreme
cases, such as a mass casualty event. (Emergency Medical Services: At
the Crossroads at p. 201; Recommendation 4.5.) Similarly, the American
College of Emergency Physicians has cited the negative aspects of this
practice and suggested solutions in testimony before this Subcommittee.
EMSC echoes these concerns and joins our fellow emergency care
professionals in calling for an end to the improper practice of
boarding.
An additional practice that negatively impacts patient care is
``patient parking.'' Some hospitals have significant issues with bed
turnaround and availability and emergency department overcrowding. When
an ambulance arrives at the hospital, the hospital will refuse to
formerly ``accept'' the patient and instead tells the ambulance that
there is inadequate emergency department staff to handle the patient.
If there is not, which occurs in many cases, or the patient needs to be
seen at that specific facility, because of a physician on staff or the
appropriate level of care available at that facility, then the
ambulance is often asked to wait in the parking lot until the patient
can be brought into the facility. This practice not only negatively
impacts the patient care for the individual in the ambulance, but it
also prevents the ambulance from responding to another request for help
since the EMS professionals cannot respond until the first patient is
admitted into the emergency department.
EMSC has proactively acted to address this practice and to improve
patient care by using extra rooms that hospitals make available,
purchasing additional gurneys, and staffing the rooms with
administrative and clinical personnel. For example, when an ambulance
arrives at a hospital that would normally have told the crew to remain
with the patient in the ambulance in the parking lot until adequate
emergency room staff was available to provide care, EMSC personnel have
brought the patient into a room in the hospital set aside for this
purpose and our clinical personnel have monitored the patient until the
hospital could formerly accept the patient. While this innovative
strategy allows EMSC to keep our ambulances in service without having
to call in additional crews to staff units to maintain response time
requirements and provide clinically acceptable care in these areas, it
is a costly procedure and currently, there exists no government or
private payer reimbursement for this practice. We believe that Congress
should work to establish standards on both patient boarding and patient
parking to improve patient flow throughout the emergency medical care
system.
In the IOM report, the committee calls for a panel to develop
evidence-based model pre-hospital protocols for treatment, triage, and
transport of patients. (Emergency Medical Services: At the Crossroads
at p. 60) We believe that the issues of patient boarding and patient
parking should be included in this discussion. Our widespread
experience in treatment, triage, and transport would be useful in the
national debate about how to improve and revamp this aspect of the
emergency care system, and we offer our expertise and experience to
those individuals and organizations committed to this undertaking.
Discharge Resource Rooms at Hospitals
Another area where we have been active in finding new solutions to
overcrowding and congestion in emergency departments is in the
discharge of patients from the emergency department. Many hospitals use
``discharge resource rooms,'' which are essentially ``holding rooms''
for patients who are ready to be discharged, but the mechanics of the
actual discharge still need to occur, such as finding an available bed
for the patient in a skilled nursing facility or rehabilitation
facility, completing the discharge paperwork, and arranging for the
correct level of transportation. These are all things that occur after
the patient has been taken to the discharge resource room. We assist
hospitals with staffing a coordinator that manages the conditions of
patient travel and, in some cases, also help with clinical staffing of
these rooms. This allows a hospital bed to become available for the
next patient.
This is another way in which EMSC has helped develop innovative
solutions to the overcrowding and patient flow issues faced by
emergency departments across the country. We believe that our efforts
in addressing emergency care patient flow issues would be useful in
identifying ways find solutions to these problems.
Summary
To conclude: we believe that EMSC's unique position in the
emergency care healthcare sectors and our familiarity with the wide
range of complexities and challenges facing the many elements involved
in the delivery of emergency medical services make us a valuable
resource in the continuing efforts to improve the delivery of emergency
medical services. EMSC urges Congress and emergency medical health care
organizations to consider and address the issues of regionalization of
care, coordination of care, the practices of ``patient boarding'' and
``patient parking'' of emergency care patients, and other improvements
to overall patient flow management. It is critical that we as a nation
develop permanent solutions to address these problems to improve
patient care and maximize the efficiency of emergency department
operations, so that all patients receive the best quality emergency
care. While EMSC has been innovative in working with hospitals and
other emergency care providers to arrive at temporary solutions to
these problems, it falls far short of the solutions needed to address
the very significant problems facing the delivery of emergency care
across the country.
We believe that the private sector companies in this field should
be included in the working groups and task forces engaged in the next
phase of the IOM's work. EMSC stands ready and willing to assist in any
way we can to offer perspectives, insights, and experience from the
private sector in the range of issues confronting all of us who toil in
the emergency medical services field.
We thank the Subcommittee for its attention to this crisis and for
their actions to chart a course to find solutions and new ideas that
will benefit emergency medical care providers, and most importantly,
patients and our communities.