the greatest opportunities we will have that will come out of thisreport,” Kellermann said. “It is low-hanging fruit. We can makean enormous impact very quickly with a very focused researchagenda. . . . About $95 billion, that’s billion with a B, dollarsare spent on research in the federal government every year onhuman health. If you take that number, probably less than 1-

10th of 1% is being devoted now to emergency care. That ispretty astounding.”

Maryn McKenna contributed to this article.

doi:10.1016/j.annemergmed.2006.06.022

CROSSROADS: REPORT CALLS FOR EMS STANDARDS OF CAREEric Berger

Special Contributor to Annals News and Perspective

Nearly every American takes for granted that a call to 911will yield an immediate response. But most probably couldn’tsay who the arriving paramedics arrive work for, or even ifthey’re being paid.

Such is the fragmented nature of modern emergency medicalservices in which multiple EMS agencies–be they volunteer,paid, fire-department-based, hospital or privately-operated –frequently serve a single metropolitan area, often with littlecohesion.

“There is this delusion out there (that) this is all taken careof,” said Dr. A. Brent Eastman, chief medical officer and N.Paul Whittier Chair of Trauma for ScrippsHealth, San Diego.“Everybody thinks they have a trauma center; everybody thinksthey have an EMS system. And then they find out the truthwhen they spend 18 hours in an emergency department or theyfind themselves in an ambulance driving around on diversion.”

This situation, as well as other problems such as a lack ofmetrics to measure EMS quality of care and poor preparednessfor disasters, led the IOM panel to devote a subcommittee toEmergency Medical Services at the Crossroads. The report states:

“While today’s emergency care system offers significantlymore medical capability than was available in years past, itcontinues to suffer from severe fragmentation, an absence ofsystem-wide coordination and planning, and a lack ofaccountability. To overcome these challenges and chart a newdirection for emergency care, the committee envisions a systemin which all communities will be served by well planned andhighly coordinated emergency care services that are accountablefor their performance.”

Responsibility for oversight of EMS nominally falls to theNational Highway Traffic Safety Administration (NHTSA),which is perhaps a little odd as EMS is a medical discipline andNHTSA has as its primary goal the reduction of motor vehiclecrashes. To address the fragmentation issue, the subcommitteerecommended that Congress establish a lead agency, housedwithin the US Department of Health and Human Services(HHS), to have primary programmatic responsibility for

EMS, emergency and trauma care, as well as 911 and emergencymedical dispatch.

CALL FOR A FEDERAL EMS AGENCYThe report calls upon Congress to create such an agency

within 2 years in hopes that it will draw increased focus on theproblems facing EMS and emergency departments.

“Undoubtedly a lead federal agency is going to be a key stepin helping us through this problem, to work out funding issues,navigate us through changes and coordinate research,” said Dr.Richard Bradley, associate professor of emergency medicine atthe University of Texas Medical School and medical director ofthe emergency center at Lyndon B. Johnson General Hospitalin Houston. “I’m pretty confident there will be one. The IOMhas developed a terrific report. I have a lot of respect for peopleon the panel who developed this report, and I think our electedleaders are going to understand that this is a crisis that we haveto address.”

A member of the subcommittee, Dr. Arthur Kellermann,Professor and Chair, Department of Emergency Medicine andDirector, Center for Injury Control, Emory University Schoolof Medicine, Atlanta, said it was important to locate the agencywithin HHS because of its sizable budget.

“That’s where the money is, and that’s where the overarchingfederal responsibility for human health is,” he said. EMSservices also face a funding crunch. Medicare reimburses EMSonly when a patient is transported, regardless of the costsincurred by maintaining the capability to respond immediately,24-hours a day, 7-days a week.

To address this problem, the subcommittee recommendedthat the Centers for Medicare and Medicaid Services convene awork group with EMS and emergency care expertise to evaluatethe present reimbursement for EMS and consider includingreadiness costs to reflect the true cost of patient transport.

The EMS subcommittee also sought to move–carefully–toward regionalization of services, with a goal of directinginjured patients to the facilities with the personnel, resources

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and quality of care to meet their needs. The report recommendsthat HHS and the NHTSA convene a panel of emergencycare experts to develop an evidence-based categorization systemfor EMS, EDs and trauma centers based upon their capabilities.Such a system could help guide ambulances to the mostappropriate hospitals.

TRAUMA TRANSFERS OR TRIAGE BY WALLETBut some emergency physicians warned that such a system

could be used to factor in a patient’s financial status.“The unintended consequence of regionalization is that it has

become a surrogate for economically triaging patients,” said Dr.Frederick Blum, president of the American College ofEmergency Physicians. “In many communities around thecountry patients are transferred, often great distances, based oneconomic criteria under the guise that they are going to thetrauma center.”

Bradley said he, too, wanted to ensure that regionalizationdoesn’t mean that county hospitals, like his, end up bearing aneven greater burden of uninsured patients.

“Other hospitals need to play an equal role,” he said. “Aregional approach helps ensure that there’s equal distribution,

that everyone’s doing their proportionate share. In saying this Irealize that all hospitals are doing yeoman’s work in emergencyservices, but having a regional approach to EMS must help usdo a better job of balancing than we already are.”

In statements released by HHS and NHTSA, the federalagencies promised to carefully review the IOM panelrecommendations and consider implementing them.

The EMS subcommittee also called for more standardizationof training and credentialing for EMTs and paramedics. Somestates require as few as 270 classroom hours, while othersrequire as much as 2,000 hours. The report recommends thatstates adopt a common scope of practice for EMS personnel,and that they accept national certification as a prerequisite for astate license.

The report authors hope such measures–from a single federalagency with EMS oversight to more systematic training for itspractitioners–will bring more standardization to the disparatepatchwork of more than 15,000 EMS systems and 800,000personnel that now respond when a 911 call is made.

Maryn McKenna contributed to this article.

doi:10.1016/j.annemergmed.2006.06.023

GROWING PAINS: REPORT NOTES PEDIATRICEMERGENCIES NEED GREATER EMPHASIS

Eric BergerSpecial Contributor to Annals News and Perspective

The Institute of Medicine subcommittee report PediatricEmergency Care: Growing Up released on June 14 called forbetter preparation and training for the special needs ofchildhood emergencies.

The committee’s report stresses several goals for improvingthe quality of care given to children, including a regionalizedapproach in which facilities pool their resources for the deliveryof high-level emergency care, and accountability, theestablishment of evidence-based indicators to measureemergency department (ED) performance.

“Many elements of this vision have been advocatedpreviously; however, progress toward achieving these elementshas been derailed by deeply entrenched political interests andcultural attitudes, as well as funding cutbacks and practicalimpediments to change,” the report’s authors write. “Concerted,cooperative efforts at all levels of government, federal, state,regional, local and the private sector are necessary to finallybreak through and achieve optimum emergency care.”

The report was welcomed by emergency pediatricians whosay their specialty is often an afterthought when efforts are

undertaken to improve EDs or communities seek to readythemselves for disasters.

Dr. Joan Shook, ED Director at Texas Children’s Hospitalin Houston, recalled a 150-page draft plan recently released bythe Texas Department of Health and Human Services fordealing with emergencies.

“The word ‘child’ was not mentioned one time, but they didmention pets 5 times,” Shook said. “I was just blown away. Imean, you’re supposed to be worried about your cat, and notyour kid? But I think that’s pretty typical.”

A member of the subcommittee, Dr. Jane Knapp, ViceChair Graduate Medical Education, Children’s MercyHospital, Kansas City, Missouri, agreed with Shook’ssentiments.

“One thing we are saying is, don’t forget the children,” shesaid. “Anytime you sit down to think about emergency medicalcare, emergency medical response, you have to think about allthose special populations out there.”

The report identified a host of issues faced by emergencyphysicians who treat children.

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