Crossroads: Report calls for EMS standards of care

Article Outline

• Call for a federal EMS agency
• Trauma transfers or triage by wallet

Nearly every American takes for granted that a call to 911 will yield an immediate response. But most probably couldn’t say who the arriving paramedics arrive work for, or even if they’re being paid.

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

“There is this delusion out there (that) this is all taken care of,” 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 thinks they have an EMS system. And then they find out the truth when they spend 18 hours in an emergency department or they find themselves in an ambulance driving around on diversion.”

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

“While today’s emergency care system offers significantly more medical capability than was available in years past, it continues to suffer from severe fragmentation, an absence of system-wide coordination and planning, and a lack of accountability. To overcome these challenges and chart a new direction for emergency care, the committee envisions a system in which all communities will be served by well planned and highly coordinated emergency care services that are accountable for their performance.”

Responsibility for oversight of EMS nominally falls to the National Highway Traffic Safety Administration (NHTSA), which is perhaps a little odd as EMS is a medical discipline and NHTSA has as its primary goal the reduction of motor vehicle crashes. To address the fragmentation issue, the subcommittee recommended that Congress establish a lead agency, housed within 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 emergency medical dispatch.

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Call for a federal EMS agency 

The report calls upon Congress to create such an agency within 2 years in hopes that it will draw increased focus on the problems facing EMS and emergency departments.

“Undoubtedly a lead federal agency is going to be a key step in 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 at the University of Texas Medical School and medical director of the emergency center at Lyndon B. Johnson General Hospital in Houston. “I’m pretty confident there will be one. The IOM has developed a terrific report. I have a lot of respect for people on the panel who developed this report, and I think our elected leaders are going to understand that this is a crisis that we have to address.”

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

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

To address this problem, the subcommittee recommended that the Centers for Medicare and Medicaid Services convene a work group with EMS and emergency care expertise to evaluate the present reimbursement for EMS and consider including readiness 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 directing injured patients to the facilities with the personnel, resources and quality of care to meet their needs. The report recommends that HHS and the NHTSA convene a panel of emergency care experts to develop an evidence-based categorization system for EMS, EDs and trauma centers based upon their capabilities. Such a system could help guide ambulances to the most appropriate hospitals.

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Trauma transfers or triage by wallet 

But 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 of Emergency Physicians. “In many communities around the country patients are transferred, often great distances, based on economic criteria under the guise that they are going to the trauma center.”

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

“Other hospitals need to play an equal role,” he said. “A regional approach helps ensure that there’s equal distribution, that everyone’s doing their proportionate share. In saying this I realize that all hospitals are doing yeoman’s work in emergency services, but having a regional approach to EMS must help us do a better job of balancing than we already are.”

In statements released by HHS and NHTSA, the federal agencies promised to carefully review the IOM panel recommendations and consider implementing them.

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

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