BUILDING A 21st CENTURY OF EMERGENCY AND TRAUMA CARE SYSTEM

Hospitals are part of a continuum of emergency care services that includes 9-1-1 and ambulance dispatch, prehospital emergency medical services (EMS) care and transport, hospital-based emergency and trauma care, and inpatient services. 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 systemwide coordination, and a lack of accountability. These shortcomings diminish the care provided to emergency patients and often result in worsened medical outcomes. To address 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 performance and serve the needs of patients of all ages within the system.

In this new system, 9-1-1 dispatchers, EMS personnel, medical providers, public safety officers, and public health officials will be fully interconnected and united in an effort to ensure that each patient receives the most appropriate care, at the optimal location, with the minimum delay. From the patient’s point of view, delivery of services for every type of emergency will be seamless. All service delivery will also be evidence based, and innovations will be rapidly adopted and adapted to each community’s needs. Hospital emergency department (ED) closures and ambulance diversions will never occur, except in the most extreme situations, such as a hospital fire or a communitywide mass casualty event. Standby capacity appropriate to each community based on its disaster risks will be embedded in the system. The performance of the system will be transparent, and the public will beactively engaged in its operation through prevention, bystander training, and monitoring of system performance.

While these objectives will require substantial, systemwide change, they are achievable. Early progress toward the goal of more integrated, coordinated, regionalized emergency care systems became derailed over the last two decades. Efforts stalled because of deeply entrenched interests and cultural attitudes, as well as funding cutbacks and practical impediments to change. These obstacles remain today, and represent the primary challenges to achieving the committee’s vision. However, the need for change is clear. The committee calls for concerted, cooperative efforts at multiple levels of government and the private sector to finally achieve the objectives outlined above.

Communications are a critical factor in establishing systemwide coordination. An effective communications system is the glue that can hold together effective, integrated emergency care services. It provides the key link between 9-1-1/dispatch and EMS responders and is necessary to ensure that on-line medical direction is available when needed. It enables ambulance dispatchers to tell callers what to do until help arrives and to track a patient’s progress following the arrival of EMS responders. An effective communications system also enables ambulance dispatchers to assist EMS personnel in directing patients to the most appropriate facility based on the nature of their illness or injury and the capacity of receiving facilities. It links the emergency medical system with other public safety providers—such as police and fire departments, emergency management services, and public health agencies—and facilitates coordination between the medical response system and incident command in both routine and disaster situations. It helps hospitals communicate with each other to organize interfacility transfers and arrange for mutual aid. And it facilitates medical and operational oversight and quality control within the system.
The objective of regionalization is to improve patient outcomes by directing patients to facilities with optimal capabilities for any given type of illness or injury. Substantial evidence demonstrates that doing so improves outcomes and reduces costs across a range of high-risk conditions and procedures, including cardiac arrest and stroke . Not all aspects of regionalization are positive. If not properly implemented, regionalizing key clinical services may adversely impact their overall availability in a community. For example, regional allocation of patients with suspected acute myocardial infarction could result in the closure of a cardiac unit or even an entire hospital, particularly in rural areas. The survival of small rural facilities may require identification and treatment of those illnesses and injuries that do not require the capacities and capabilities of larger facilities, as well as repatriation to the local facility for long-term care and follow-up after stabilization at the tertiary center. A systems approach to regionalization considers the full effects of regionalizing services on a community. Determining the appropriate metrics for this type of analysis and defining the process for applying them within each region are significant research and practical issues. Nonetheless, in the absence of rigorous evidence to guide the process, planning authorities should take these factors into account in developing regionalized systems of emergency care.

The committee believes communities will best be served by emergency care systems in which services are organized so as to provide the optimal care based on the patient’s location and condition. To the extent that the movement toward specialty hospitals impacts the configuration of services and therefore the ability of the system to optimize emergency services, it is an appropriate subject for the committee to address. While the committee does not advocate for or against the further development of specialty hospitals, it does believe that their development would potentially impact emergency care and that this impact, which in some cases could be adverse, should be considered in the regionalization of emergency care  Once the basic classification system proposed above is understood, it can be used to determine the optimal destination for patients based on their condition and location. However, more research and discussion are needed to determine the circumstances under which patients should be brought to the closest hospital for stabilization and transfer as opposed to being transported directly to the facility offering the highest level of care, even if that facility is farther away. A debate remains over whether EMS  should perform ALS procedures in the field, or rapid transport to definitive care). It is likely that this answer depends, at least in part, on the type of emergency condition. It is evident, for example, that whether a patient will survive out-of-hospital cardiac arrest depends almost entirely on actions taken at the scene, including rapid defibrillation, provision of cardiopulmonary resuscitation (CPR), and perhaps other ALS interventions. Delaying these actions until the unit reaches a hospital results in dismal rates of survival and poor neurological outcomes. Conversely, there is little that prehospital personnel can do to stop internal bleeding from major trauma. In this instance, rapid transport to definitive care in an operating room offers the victim the best odds of survival. For example, a recent study showed that bypassing a level II trauma center in favor of a more distant level I trauma center may be optimal for head trauma patients 

EMS responders who provide stabilization before the patient arrives at a critical care unit are sometimes subject to criticism because of a strongly held bias among many physicians that out-of-hospital stabilization only delays definitive treatment without adding value; however, there is little evidence that the prevailing “scoop and run” paradigm of EMS is always open). For example, in cases of out-of-hospital cardiac arrest, properly trained and equipped EMS personnel can provide all needed interventions at the scene. In fact, research has shown that failure to reestablish a pulse on the scene virtually ensures that the patient will not survive, regardless of what is done at the hospital .On the other hand, a scoop and run approach makes sense when a critical intervention needed by the patient can be provided only at the hospital (for example, surgery to control internal bleeding).

Decisions regarding the appropriate steps to take should be resolved using the best available evidence. The committee concludes that there should be a national approach to the development of prehospital protocols. It therefore recommends that the National Highway Traffic Safety Administration, in partnership with professional organizations, convene a panel of individuals with multidisciplinary expertise to develop evidence-based model prehospital care protocols for the treatment, triage, and transport of patients (3.2).The transport protocols should also reflect the state of readiness of given facilities within a region at a particular point in time. Real-time, concurrent information on the availability of hospital resources and specialists should be made available to EMS providers to support transport decisions. Development of an initial set of model protocols should be completed within 18 months of the release of this report. Treatments may require modification to reflect local resources, capabilities, and transport times; however, the basic pathophysiology of human illness is the same in all areas of the country. Once in place, the national protocols could betailored to local assets and needs. The process for updating the protocols will also be important because it will dictate how rapidly patients receive the current standard of care.

The 1966 report Accidental Death and Disabilityanticipated the need to categorize care facilities and improve transport decisions:

The patient must be transported to the emergency department best prepared for his particular problem…. Hospital emergency departments should be surveyed …to determine the numbers and types of emergency facilities necessary to provide optimal emergency treatment for the occupants of each region…. Once the required numbers and types of treatment facilities have been determined, it may be necessary to lessen the requirements at some institutions, increase them in others, and even redistribute resources to support space, equipment, and personnel in the major emergency facilities. Until patient, ambulance driver, and hospital staff are in accord as to what the patient might reasonably expect and what the staff of an emergency facility can logically be expected to administer, and until effective transportation and adequate communication are provided to deliver casualties to proper facilities, our present levels of knowledge cannot be applied to optimal care and little reduction in mortality and/or lasting disability can be expected Once the decision has been made to transport a patient, the responding ambulance unit should be instructed—either by written protocol or by on-line medical direction—which hospital should receive the patient. This instruction should be based on developed transport protocols to ensure that the patient is taken to the optimal facility given the severity and nature of the illness or injury, the status of the various care facilities, and the travel times involved. Ideally, this decision will take into account a number of complex and fluctuating factors, such as hospital ED closures and diversions and traffic congestion that hinders transport times for the EMS unit. In addition to the use of ambulance units and the EMS system to direct patients to the optimum location for emergency care, hospital emergency care designations should be posted prominently to improve patients’ self-triage decisions. Such postings can educate the public about the types of emergency services available in their community and enable patients who are not using EMS to direct themselves to the optimal facility.

FIGURE 3-1 Service configuration in a regionalized system. The figure illustrates some potential transport options within a regionalized system. The basic structure of current EMS systems is not altered, but protocols are refined to ensure that patients go to the optimal facility given their type of illness or injury, the travel time involved, and facility status (e.g., availability of ED and intensive care unit [ICU] beds). For example, instead of taking a stroke victim to the closest general community hospital or to a tertiary medical center that is farther away, there may be a third option—transport to a community hospital with a stroke center. Over time, based on evidence on the effectiveness of alternative delivery models, some patients may be transported to a nearby urgent care center for stabilization or treated on the street and released. Whichever pathway the patient follows, communications are enhanced, data collected, and the performance of the system evaluated and reported so that future improvements can be made

,   protocols to ensure that the patient is taken to the optimal facility given the severity and nature of the illness or injury, the status of the various care facilities, and the travel times involved. Ideally, this decision should take into account a number of complex and fluctuating factors, such as hospital ED closures and diversions and traffic congestion that hinders transport times for the EMS unit .