[Senate Hearing 109-833]
[From the U.S. Government Printing Office]



                                                        S. Hrg. 109-833
 
ROUNDTABLE ON ``CRISIS IN THE ER: HOW CAN WE IMPROVE EMERGENCY MEDICAL 
                                CARE?''

=======================================================================

                                HEARING

                               BEFORE THE

                SUBCOMMITTEE ON BIOTERRORISM AND PUBLIC 
                          HEALTH PREPAREDNESS

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                                   ON

 EXAMINING MEASURES TO IMPROVE EMERGENCY MEDICAL CARE, FOCUSING ON THE 
 NEED FOR CHANGE TO CONTINUE PROVIDING QUALITY EMERGENCY MEDICAL CARE 
                     WHEN AND WHERE IT IS EXPECTED

                               __________

                           SEPTEMBER 27, 2006

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                   MICHAEL B. ENZI, Wyoming, Chairman

JUDD GREGG, New Hampshire            EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee                CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
RICHARD BURR, North Carolina         BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia              JAMES M. JEFFORDS (I), Vermont
MIKE DeWINE, Ohio                    JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada                  PATTY MURRAY, Washington
ORRIN G. HATCH, Utah                 JACK REED, Rhode Island
JEFF SESSIONS, Alabama               HILLARY RODHAM CLINTON, New York
PAT ROBERTS, Kansas

               Katherine Brunett McGuire, Staff Director

      J. Michael Myers, Minority Staff Director and Chief Counsel

                               __________

      Subcommittee on Bioterrorism and Public Health Preparedness

                 RICHARD BURR, North Carolina, Chairman

JUDD GREGG, New Hampshire            EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee                CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
MIKE DeWINE, Ohio                    BARBARA A. MIKULSKI, Maryland
JOHN ENSIGN, Nevada                  JEFF BINGAMAN, New Mexico
ORRIN G. HATCH, Utah                 PATTY MURRAY, Washington
PAT ROBERTS, Kansas                  JACK REED, Rhode Island
MICHAEL B. ENZI, Wyoming (ex 
officio)

                     Robert Kadlec, Staff Director

                David C. Bowen, Minority Staff Director

                                  (ii)

  




                            C O N T E N T S

                               __________

                               STATEMENTS

                     WEDNESDAY, SEPTEMBER 27, 2006

                                                                   Page
Burr, Hon. Richard, Chairman, Subcommittee on Bioterrorism and 
  Public Health Preparedness, opening statement..................     1
Isakson, Hon. Johnny, a U.S. Senator from the State of Georgia, 
  opening statement..............................................    27
Blum, Frederick, M.D., F.A.C.E.P., Associate Professor of 
  Emergency Medicine, Pediatrics, and Internal Medicine at West 
  Virginia University and President, American College of 
  Emergency Physicians...........................................     3
    Prepared statement...........................................     5
Bonalumi, Nancy, R.N., M.S., C.E.N., Director of Emergency 
  Nursing, The Children's Hospital of Philadelphia, and President 
  of Emergency Nurses Association................................    11
    Prepared statement...........................................    13
VanAmringe, Margaret, M.H.S., Vice President for Public Policy 
  and Government Relations at the Joint Commission on 
  Accreditation of Healthcare Organizations......................    17
    Prepared statement...........................................    19
Bass, Robert, M.D., F.A.C.E.P., Executive Director for Maryland 
  Institute for Emergency Medical Services and President of 
  National Association of EMS Officials..........................    22
    Prepared statement...........................................    24
Haley, Leon, Jr., M.D., M.H.S.A., F.A.C.E.P., Associate Professor 
  of Emergency Medicine and Vice Chair of Clinical Affairs for 
  Grady Health Systems...........................................    27
    Prepared statement...........................................    30

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Prepared statements of:
        American Academy of Pediatrics...........................    50
        Advocates for EMS........................................    57

                                 (iii)

  


ROUNDTABLE ON ``CRISIS IN THE ER: HOW CAN WE IMPROVE EMERGENCY MEDICAL 
                                CARE?''

                              ----------                              


                     WEDNESDAY, SEPTEMBER 27, 2006

                                        U.S. Senate
            Subcommittee on Bioterrorism and Public Health 
             Preparedness, Committee on Health, Education, 
                                       Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:33 p.m. in 
Room SD-430, Dirksen Senate Office Building, Hon. Richard Burr, 
chairman of the subcommittee, presiding.
    Present: Senators Burr and Isakson.

                   Opening Statement of Senator Burr

    Senator Burr. Let me call to order this official 
roundtable. Let me take this opportunity to apologize, with all 
the Hill--there are many things going on, on the Senate side 
today, that I know we're going to have some members that are in 
and out of the room. We're going to make sure, by unanimous 
consent, we leave the record open for those members who would 
like to make opening statements and any members that would like 
to extend to you questions because of their inability to be 
here. And I hope all of you will open yourself up to that.
    Again, I want to thank you for coming to this HELP 
Subcommittee on Bioterrorism and Public Health Preparedness 
member roundtable to discuss the crisis patients face every day 
in emergency departments across the country: overcrowding.
    I'd like to welcome our panelists and to thank you for 
taking the time to travel to Washington to share your 
knowledge, your lessons learned, and recommendations from your 
firsthand experiences in emergency medical care. It's my hope 
that this roundtable begins what I believe is a very important 
national dialogue on the state of emergency medical care in 
this country. Your testimony will help us better understand the 
crisis that our Nation's emergency rooms are facing each and 
every day. This knowledge of the challenges facing emergency 
medical care will help us as we consider how we can better 
improve patient care throughout our health delivery system.
    I'd like to also thank Chairman Enzi and Ranking Member 
Kennedy for their continued support, confidence, and latitude 
in where this subcommittee chooses to invest its time and the 
members' times. Unfortunately, they're unable to be with us 
today, but both of them certainly have a tremendous amount of 
interest in the information that we hear today, and, 
ultimately, how that guides us, as a Congress, as to how we 
begin to address this crisis.
    Let me share a few stories, if I could. I'm sure we will 
hear more as we hear some of the testimony, but there are ones 
that I've been personally exposed to as individuals have either 
visited my office or I've seen in an emergency room or I've had 
the opportunity to see in a public setting, and they shared 
their story.
    A 49-year-old woman arrives at the ER with the symptoms of 
a heart attack, and dies in the waiting room after waiting 2 
hours to see a doctor. A 9-year-old boy with a broken elbow is 
transferred to three different emergency rooms, and waits 24 
hours to receive the pediatric orthopedic care he needs. A 
physician reports that every single bed in an emergency room is 
used by patients admitted to the hospital, patients who could 
not be moved to beds in the hospital inpatient wards, because 
they are all booked. A little girl with abdominal pain leaves 
the emergency room, because there is literally no room for her 
to lie down. She comes back by ambulance after her appendix 
bursts.
    Now, these are just a few stories, and they're certainly 
not indicative of every emergency room in this country. This is 
not to suggest, in any way, shape, or form, that the function 
of these facilities is, in fact, deficient. I think that as we 
see investments made, we see those investments, not because 
hospitals like ``bigger and better,'' but because hospitals see 
lines, and they're not able to deliver the care in a timely 
fashion.
    The challenge for all of us is to make sure that as we are 
challenged with redesigning the healthcare delivery system in 
this country, that, in fact, we take into account what it is 
that emergency rooms are there to do, who it is they are there 
to serve, and that we learn from, in some cases, those 
experiences that were not done necessarily right, to make sure 
in the future, we don't do them that way again.
    The Institute of Medicine has recently issued three ground-
breaking reports about the system of emergency care in this 
country. The reports explored the system's strength, its 
limitations, and its future challenges; described a desired 
vision for the system; and recommended the strategies for 
achieving this vision.
    I, personally, look forward to hearing from each and every 
one of you regarding your experiences. I know all of you have 
different experiences to share. Please know that what you tell 
this subcommittee today really will start our review of where 
we should go legislatively and how this fits in with what I 
think will be a very challenging time as we define what the 
delivery system for healthcare in the future looks like for 
every American.
    At this point, let me take the opportunity to do a brief 
introduction for our witnesses today.
    Our first witness is Dr. Richard Blum, from West Virginia 
University School of Medicine, where he is an Associate 
Professor of Emergency Medicine and Pediatrics. Dr. Blum is 
also the President of the American College of Emergency 
Physicians. He also served on the college's pediatric 
committee.
    Next, we will hear from Nancy Bonalumi. She's the Director 
of Emergency Nursing at Children's Hospital of Philadelphia. 
She is also the President of the Emergency Nurses Association. 
Welcome.
    Margaret VanAmringe is the Vice President for Public Policy 
and Government Relations with the Joint Commission on 
Accreditation of Healthcare Organizations, where she's 
responsible for developing strategic opportunities for the 
Joint Commission in both the public and in private sectors. 
Thank you, Margaret.
    Dr. Robert Bass is the Executive Director for the Maryland 
Institute of Emergency Medical Services Systems, and is 
President of the National Association of EMS Officials. Doctor, 
welcome.
    And finally, Dr. Leon Haley is the Chief of Emergency 
Medicine for Grady Health Systems, and Associate Professor of 
Emergency Medicine at Emory University.
    We anticipate, with some degree of accuracy, that Senator 
Isakson will be here for a much longer introduction of you, and 
probably one richly deserved. But, on behalf of the committee 
and the Chairman and Ranking Member, let me once again say how 
pleased we are with your willingness to be here, how valuable 
the testimony that you're going to give will be to our process 
as we move forward.
    And, with that, I'd like to recognize you, in the order 
that I introduced you, for the purposes of any statement.
    Dr. Blum.

   STATEMENT OF FREDERICK BLUM, M.D., F.A.C.E.P., ASSOCIATE 
   PROFESSOR OF EMERGENCY MEDICINE, PEDIATRICS, AND INTERNAL 
 MEDICINE AT WEST VIRGINIA UNIVERSITY, AND PRESIDENT, AMERICAN 
                COLLEGE OF EMERGENCY PHYSICIANS

    Dr. Blum. Thank you, Senator.
    America's emergency departments are underfunded, 
understaffed, overcrowded, and overwhelmed, and, in many 
places, are on the brink of collapse. In the past few years, 
the United States has faced unprecedented threats, such as 
terrorist attacks, and now one of the largest natural disasters 
in our history. During such events, Americans have rightly come 
to rely on the Nation's emergency departments.
    My name is Rick Blum, and, as was said, I'm President of 
the American College of Emergency Physicians, which represents 
24,000 emergency physicians nationwide. Thank you for giving me 
the opportunity to address you and the members of your 
committee today to discuss the vital role emergency departments 
play in our Nation's healthcare system, not only on a daily 
basis, but especially during those times of national 
catastrophe.
    My testimony today comes from my own experiences as an 
emergency physician for 23 years, and also as a representative 
of thousands of emergency physicians, but it also comes from 
some recent landmark studies, such as the Institute of Medicine 
Report, in June, looking at hospital-based emergency care, ``At 
the Breaking Point,'' and our own national report card on the 
state of emergency medicine, which was released in January.
    For several years now, ACEP and its emergency physician 
members have been working to raise awareness of lawmakers and 
others of a looming problem in the Nation's emergency 
departments. As was said, they are overcrowded. We currently 
have no surge capacity to be able to deal with the next big 
thing that comes along in the way of a terrorist attack or a 
natural disaster. And until we address these issues, we're not 
going to be prepared, as a country. These issues threaten our 
ability to provide high-quality medical care when and where 
it's needed.
    You know, some of my friends frequently, kind of, assume 
that emergency medicine is a stressful job and that I, you 
know, sometimes am stressed out by it. And that is actually 
true. But it's not true because of the reasons they think. They 
think the job is what's stressful. But that's not at all 
stressful for emergency physicians. What's stressful is knowing 
how to do the job, and not being able to do it, because you 
don't have the capacity and you don't have the personnel to 
support you in that job. You don't have the space to put 
patients. You don't have, literally, gurneys to put patients 
on. That, ladies and gentlemen, is a very, very stressful 
thing. Taking care of sick people is what we do, and all of us 
take that job very seriously. And that's not the issue at all. 
But knowing how to do a good job taking care of sick people, 
and not being able to do it, is very, very disturbing for our 
members.
    How have we gotten into this situation? Well, 
unfortunately, it's not a simple answer to that. Emergency-
department visits have gone up by about 22 percent in the last 
10 years. During that same period of time, the number of 
emergency departments in the country has dropped by almost 500. 
So, we are seeing more and more patients in fewer and fewer 
emergency departments.
    We also have seen situations develop where we have a lack 
of on-call specialists in many hospitals. So, once the patient 
gets to the emergency department and we evaluate them and find 
they need specialized care, we are often unable to find someone 
to provide that care, sometimes requiring transfers hundreds of 
miles to get that care.
    We have a lack of inpatient beds. We have--in a time of 
unprecedented growth in demand for healthcare, we have 
decreased the number of inpatient beds in this country by 
200,000 in recent years. We have a population time-bomb that 
really is just hitting the healthcare market in the baby-
boomers. Right now, the baby-boomers are a pretty healthy 
generation, but pretty soon they're going to hit the healthcare 
market in a very, very big way. And I can tell you, without any 
doubt at all, that they are going to stress the system to the 
breaking point.
    We have significant shortages of nurses, both in numbers 
and in experience. One of the things that has occurred because 
of our nursing shortage is that a number of experienced 
emergency nurses have left the field of emergency nursing, 
because they've been asked to do more and more, again, with 
less and less, and simply have made the decision to go 
elsewhere, to take jobs in less stressful parts of the 
healthcare market.
    In addition to having an absolute--you know, a problem with 
absolute numbers of nurses, we have had--and this all is really 
a symptom of declining reimbursement for emergency care in this 
country. Emergency physicians, emergency nurses, bear the 
disproportionate burden of the care of 47 million uninsured 
people within this country. The result is that over 50 percent 
of emergency care in this country is unreimbursed. That's 
simply not a business model that is sustainable, and that is 
the reason why emergency departments are closing. If you have 
this kind of demand, and, you know, there was money to be made 
in emergency medicine, we would be building new emergency 
departments. But we are not. And I think you would have to go 
no further to find out, you know, where the problems are with 
regard to reimbursement for emergency care than to look at that 
factor.
    We have some specific recommendations. We need to increase 
our surge capacity by ending the practice of boarding admitted 
patients in the emergency department, which is one of our 
problems across the country. We have several pieces of 
legislation that go a ways to do just that. We want to promote 
protocols and information systems that collect realtime data on 
capacity and diversion, and syndromic surveillance so that we 
can do more with what we have.
    We need to recognize the role of emergency departments as 
first responders in natural disasters and in terrorist attacks. 
The role of public health in EMS is critical in such events, 
but let's not forget that, in some events, up to 75 or 80 
percent of the patients will come directly to the emergency 
department. They will not use public health, they will not use 
EMS, they will come directly to the emergency department. And 
we really are a part of the first response. I think that's 
something that often gets left out of the equation.
    We want to specifically mention two particularly vulnerable 
populations that we think need to be given some attention. The 
IR report addressed the pediatric population fairly 
comprehensively, but I would also like to add that the 
geriatric population didn't get as much attention, and is at 
least as vulnerable, as events around Katrina really suggest. 
During the next catastrophe, the Nation's emergency physicians 
will be there to do their jobs. The question is, Will they have 
the space? Will they have the support to do it well?
    I was at a committee meeting earlier this year with 
Homeland Security and was asked, How can we engage your members 
in their responsibility for a natural disaster? And I said,

          ``You don't have to. We know our responsibility. We'll be 
        there. We were there in Katrina, we were there in the other 
        natural disasters. What you have to do is support us and give 
        us the capacity to do our job well, and we'll be there.''

    Every day, we save countless lives. Please give us the 
capacity and the tools we need to be there for you and the 
country, when and where you need us. The country should be able 
to take the emergency department for granted, but our 
policymakers cannot have that luxury. You need to be able to 
help us solve some of these problems now.
    Thank you, Senator, for your leadership on this.
    [The prepared statement of Dr. Blum follows:]

  Prepared Statement of Frederick C. Blum, M.D., F.A.C.E.P., F.A.A.P.

                              INTRODUCTION

    America's emergency departments are underfunded, understaffed, 
overcrowded and overwhelmed--and we find ourselves on the brink of 
collapse.
    Mr. 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 the subsequent Senate companion legislation, S. 2750); 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 a 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 3 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 
later, he called an orthodontist who fortunately agreed to see her 
right away. By then, it was 12 a.m.

    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 1 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 3 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 3-
        hour delay.

                                 EMTALA

    ACEP has long supported the goals of the ``Emergency Medical 
Treatment and Labor Act'' (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.

                                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 nonclinical 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 2 hours and 
nearly 20 percent of hospitals reported an average boarding time of 8 
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 canceled 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 1 in 10 hospitals reported being 
on diversion 20 percent of the time (more than 4 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 S. 
2750/H.R. 3875, 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 10 
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 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 decisionmaking.
     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.

    Senator Burr. Thank you, Doctor.
    Nancy.

 STATEMENT OF NANCY BONALUMI, R.N., M.S., C.E.N., DIRECTOR OF 
EMERGENCY NURSING, THE CHILDREN'S HOSPITAL OF PHILADELPHIA, AND 
           PRESIDENT OF EMERGENCY NURSES ASSOCIATION

    Ms. Bonalumi. Good afternoon. Thank you for convening this 
roundtable.
    My name is Nancy Bonalumi. I'm the Director of Emergency 
and Trauma Nursing at the Children's Hospital of Philadelphia, 
and the President of the Emergency Nurses Association (ENA).
    ENA, with nearly 32,000 members, is the only professional 
nursing association dedicated to defining the future of 
emergency nursing and emergency care. And on behalf of ENA, I 
appreciate the opportunity to engage with this subcommittee to 
explore options that Congress might implement to improve 
emergency care by reducing crowding in our Nation's emergency 
departments.
    Let me state right up front that ENA does not support 
holding or boarding patients in the emergency department. This 
is not in the best interest of our patients.
    The emergency nurse is on the forefront of care in your 
hospitals. We perform multiple tasks, including assessment and 
prioritiza-
tion, planning and implementation, crisis intervention, 
stabilization, and resuscitation. In these roles, we experience 
with our patients the all-too-real effects of hospital crowding 
that we experience every day.
    Crowding is a systems issue. It is not confined to the 
emergency department. Its causes often originate outside of the 
immediate control of the ED. Some of these causes include an 
inadequate number of beds in the hospital that have the right 
kind of equipment to care for the sickest of patients, an 
inadequate number of nurses who can provide proper monitoring, 
and elective-surgery patients that occupy beds that are needed 
by emergency patients. On any given day, each of these factors 
affects access to emergency care and threatens patient safety 
and patient outcomes.
    Meaningful change for this system demands examination and 
problem solving at the institutional level, as well as the 
local, State, and national levels. We need measures to promote 
systems thinking and coordination that includes forming a 
national-level forum to facilitate effective communication and 
coordination related to emergency care. We saw this as a 
recommendation in the Institute of Medicine Report. To this 
end, ENA has supported the recent authorization of the Federal 
Interagency Committee on Emergency Medical Services, or FICEMS 
that will help to address regional, State, and local EMS system 
needs. But to enhance the effectiveness and create two-way 
communication between FICEMS and the outside world, ENA 
supports Government efforts to create a non-Federal Advisory 
Council that will provide input to FICEMS from stakeholders who 
work every day in the emergency-care system.
    Federal leadership toward systems problem solving and 
crowding needs to focus on eliminating regulatory barriers, 
such as those that are associated with EMTALA. EMTALA has had 
the unintentional effect of burdening the emergency department 
with nonemergent patients who we are mandated to treat. And 
despite Federal efforts to overhaul the restrictions regarding 
patients with nonemergent conditions, there is much confusion 
that continues to surround this issue. Hospitals are fearful 
that if they turn away someone who shows up at their doorstep, 
that they will still be held liable under the EMTALA 
regulations, and be subject to severe fines and penalties. What 
we need is reasonable flexibility for clinical judgment by the 
emergency-department practitioners, nurses, and physicians to 
identify those patients who do not meet the EMTALA definition 
that triggers emergency care.
    Nurses are not interchangeable resources. The emergency 
nurse has vital role that's made all the more precious owing to 
the workforce shortage that we are currently in. During the 10-
year span of 2002 to 2012, healthcare facilities will need to 
fill more than 1.1 million R.N. positions. The nursing 
community has been urgently asking Congress to increase funding 
for nursing workforce development programs, especially funding 
for nursing faculty preparation.
    The Federal investment in nursing education is less than 
six-thousanths of 1 percent of the total Federal budget. In 
1974, during the last serious nursing shortage, Congress 
appropriated $153 million for nursing education, which, in 
today's dollars, is worth almost $6 million, or approximately 
four times what our Federal Government is currently spending. 
Applications to nursing programs have been rising--thankfully, 
because we need this workforce shortage to be alleviated--but 
we have to turn away a number of qualified applicants.
    In the academic year 2004-2005, almost 150,000 qualified 
candidates for nursing school were turned away, because there 
was no capacity in those schools of nursing to accept them. 
This is really due to the lack of faculty that we have in our 
nursing schools. We have no surge capacity in our emergency 
departments. We have no surge capacity in our nursing education 
programs. We have done a great effort to really publicize the 
value of nursing, particularly in emergency nursing; and yet, 
we cannot meet this demand. We have a great discrepancy between 
what we have as a workforce need and our ability to fill that.
    Nursing educators are retiring at the rate of about 1,800 
per year. We are only graduating 4,000 doctorally-prepared 
nurses annually. There is a huge discrepancy in what we need.
    Now, these discrepancies are played out in the workforce in 
every emergency department in this country where there are 
short staffing; nurses who are struggling to be able to provide 
the care that their patients require; causing emergency-
department crowding; ambulance diversions. And ultimately it is 
the patients who suffer the consequences.
    The emergency nurses of this country strongly desire to 
provide skilled and compassionate emergency care to our 
patients, and we ask that you support the recommendations that 
ENA has outlined in its written testimony and work with us to 
create a coordinated, regionalized, and accountable emergency-
care system that is staffed, trained, and prepared for our 
communities when they need us. We cannot achieve this national 
expectation by ourselves.
    Thank you.
    [The prepared statement of Ms. Bonalumi follows:]

        Prepared Statement of Nancy Bonalumi, R.N., M.S., C.E.N.

    Good afternoon, Mr. Chairman and members of the subcommittee. Thank 
you for convening this roundtable to examine the current condition of 
emergency care in our Nation. Characterized as ``overburdened, short of 
resources, under funded, and fragmented,'' the present situation is an 
environment where emergency departments are less able to serve as the 
country's safety net in ordinary situations, much less able to 
appropriately handle the extraordinary events of natural and man-made 
disasters.
    I am Nancy Bonalumi, Director of Emergency and Trauma Nursing at 
the Children's Hospital of Philadelphia, and the 2006 President of the 
Emergency Nurses Association (ENA). ENA is the only professional 
nursing organization dedicated to defining the future of emergency 
nursing and emergency care through expertise, innovation, and 
leadership. It serves as the voice of nearly 32,000 members and their 
patients through research, publications, professional development, 
injury prevention, and patient education. Recognized as an authority in 
the discipline of emergency care and its practice, ENA was invited by 
the IOM to share its data and expertise on the current state of U.S. 
emergency departments (EDs). On behalf of the Emergency Nurses 
Association, I appreciate this opportunity to engage with the 
subcommittee and explore options that Congress might implement to 
improve emergency care by reducing crowding in the Nation's emergency 
departments. Let me state right up front, ENA does not support holding 
or boarding in the ED because this practice is not in the best interest 
of patients.
    Crowding is a systems issue, and not confined to the ED. Its causes 
often originate outside of the immediate control of the ED. Some of 
these are: an inadequate number of beds in the hospital with the right 
equipment to care for the sickest patients, an insufficient number of 
nurses who can provide the proper monitoring, and elective surgery 
patients occupying beds needed by emergency patients. On any given day, 
each of these factors affects access to emergency care, and threatens 
patient safety and patient outcomes. Meaningful change for this system 
demands examination and problem-solving at the institutional level, as 
well as at local, regional, and national levels.

                     FRAGMENTATION/REGIONALIZATION

    ENA supports government efforts to create a non-Federal advisory 
council to provide input to FICEMS. Measures to promote systems 
thinking and coordination include forming a national-level forum to 
facilitate effective communication and coordination related to 
emergency care between and among Federal stakeholders. To this end, ENA 
supported the recent authorization of the Federal Interagency Committee 
on Emergency Medical Services (FICEMS) to address the regional, State, 
and local EMS systems needs. To enhance effective two-way 
communications between FICEMS and the outside world, a non-Federal 
advisory council is needed to provide input to FICEMS from stakeholders 
with daily operational experience in EMS.
    ENA supports the IOM's assertion that the U.S. emergency care 
system needs to be coordinated and regionalized. The IOM report 
acknowledges that the Nation's emergency care system is saturated, 
highly fragmented, and variable in the delivery of care. In its 2002 
Mass Casualty Incidents position statement, ENA recommended that 
emergency services be seamless with 911 and dispatch, ambulances, 
emergency medical services (EMS) personnel, hospital EDs, and trauma 
centers and specialists working in a coordinated manner. The ENA 
believes emergency care also must be regionalized to help ensure the 
patient is transported to the right hospital at the right time for the 
right care.
    ENA supports the immediate reinstatement of funding for the HRSA 
Trauma-EMS Program in order to renew the work in the States toward 
establishment of state-wide trauma systems. The Trauma-EMS Program, 
administered by the Health Resources and Services Administration 
(HRSA), provided States with grants for planning, developing, and 
implementing state-wide trauma care systems. Although only eight States 
have fully developed trauma systems, these state-wide health care 
systems could be used as models for full regionalization of care. ENA 
recognizes the necessity of the Trauma-EMS Program, which has been the 
only Federal source available to build a trauma system infrastructure 
in the United States. When it existed, the Trauma-EMS Program, which 
lost its funding in fiscal year 2006, provided critical national 
leadership, and leveraged additional scarce State dollars, to optimize 
trauma care through system integration that offered seriously injured 
individuals, wherever they lived, prompt emergency transport to the 
nearest appropriate trauma center within the ``golden hour.'' The IOM 
report bolsters support for such regionalized models of care by drawing 
on substantial evidence that ``demonstrates that doing so [i.e., 
creating a coordinated, regionalized system] improves outcomes and 
reduces costs across a range of high-risk conditions and procedures.''
    ENA supports the IOM's call for a series of research demonstration 
projects that will put these ideas into practice by testing these 
strategies under various emergency care conditions. Achieving an 
integrated, regionalized emergency care system takes coordination, 
commitment of staff, development and implementation of standards of 
care, a process for designating trauma centers, and evaluation. To this 
end, ENA has advocated a regionalization that gathers together all 
community stakeholders to examine all alternatives for providing 
appropriate patient care and better patient outcomes. Our organization 
supports a best practice of coordinated, community-wide response 
planning, using a common framework that is applicable to all hazards 
and that links local, State, regional, and national resources.

                                CROWDING

    Crowding in our Nation's emergency departments is of increasing 
concern. In our 2005 position statement Crowding in the Emergency 
Department, ED crowding is described as ``a situation in which the 
identified need for emergency services outstrips available resources in 
the emergency department. This situation occurs in hospital emergency 
departments when there are more patients than staffed ED treatment beds 
and wait times exceed a reasonable period.''
    When crowding occurs, patients are often placed in hallways and 
other nontreatment areas to be monitored until ED treatment beds or 
staffed hospital inpatient beds become available. In addition, crowding 
may contribute to an inability to triage and treat patients in a timely 
manner, as well as increased rates of patients leaving the ED without 
being seen. As a result of crowding, hospitals often implement 
ambulance diversion measures.
    An emergency care system that is beyond saturation on a daily basis 
will have limited ability to respond to the surge of patients related 
to catastrophic events. The Federal Government must establish clear 
leadership and directed funding support to coordinate the functions of 
emergency care, as well as assist in providing system incentives for 
nonemergency care that is delivered in areas outside of the ED.
    One aspect of crowding that ENA continues to address concerns the 
interpretation of emergency care's federally mandated regulations. ENA 
wholeheartedly endorses unencumbered access to quality emergency care 
by all individuals regardless of their financial status. However, 
EMTALA, the Emergency Medical Treatment and Labor Act which ensures 
public access to emergency services regardless of ability to pay, has 
had the unintentional effect of increasing unnecessary visits to the ED 
for acute and chronic conditions that do not meet the Centers for 
Medicare and Medicaid Services' (CMS) definition of ``emergency medical 
condition.''
    ENA acknowledges an attempt by CMS to lessen the restrictions 
regarding patients with nonemergent conditions. Despite a CMS 
clarification, much confusion continues to surround this issue, 
grounded in fear of possible reprisals for failure to strictly adhere 
to EMTALA mandates. EMTALA continues to limit an ED's options to manage 
its patient load by limiting its ability to send nonurgent patients 
off-site for clinical care, rather than conducting a full medical 
assessment in the ED. Nurses cannot tell a patient probable wait times 
or suggest alternatives for care under the current rules. With severe 
crowding and ambulance diversions identified as a national crisis, 
compounded by the increase in patients using the ED for primary care, 
some flexibility is needed for clinical judgment by an ED practitioner 
(who has experienced an actual encounter with the patient) to identify 
those patients who do not obviously meet the definition of an emergency 
medical condition.
    Notwithstanding EMTALA regulations, the problem of crowding is not 
confined to the ED, and is considered a systems issue, which can be 
examined at department and institution levels as well as at local, 
regional, and national levels. The factors contributing to ED crowding 
are numerous and varied and have been well documented in the 
literature. The root causes of ED crowding are embedded in the crisis 
of health care in the United States, requiring solutions that may fall 
outside of the ED's control. The ENA believes crowding is caused by:

     Hospital/trauma center closures;
     Lack of inpatient beds, forcing emergency departments to 
hold patients;
     Increased use of emergency departments over the past 
decade; and
     Lack of universal access to primary and preventative 
health care and the use of the emergency department for primary care.
    To address crowding, ENA recommends increased Federal funding to 
support:

     Collaborative research by emergency nurses and physicians 
to develop and implement new flow management solutions for the 
emergency department to both prevent and manage ED crowding;
     Professional and public awareness programs as well as 
legislative efforts to reduce visits to the ED by: (1) strengthening 
capacity for nonemergent care by increasing access to primary care 
providers in the community and teaching when and how to access 
emergency care; (2) reducing the numbers of uninsured and underinsured; 
(3) reducing trauma caused by preventable injuries, violence, and 
substance abuse; and (4) improving prevention, wellness, and disease 
management efforts; and
     Evaluation and prioritized performance incentives that 
increase capacity and efficiency, not only in the emergency department, 
but within hospitals and other patient care facilities in order to help 
reduce the burdens suffered by ED patients when emergency departments 
become too crowded for patients needing specialized care.

            NURSING WORKFORCE AND NURSING FACULTY SHORTAGES

    The IOM report also notes that nursing shortages in U.S. hospitals 
continue to disrupt hospital operations and are detrimental to patient 
care and safety. Because of the unique insight and clinical knowledge 
of an experienced emergency nurse, the nursing shortfalls constitute a 
loss of expertise in the system. Nurses are not inter-changeable 
resources. The expertise of a seasoned ED nurse is critical to achieve 
quality patient outcomes in a dynamic health care system that demands 
competencies for a multitude of situations. Hospital staffing systems 
must acknowledge the need for, and incorporate, training and education 
time and funding for emergency nurses.
    During the 10-year span of 2002 to 2012, health care facilities 
will need to fill more than 1.1 million RN job openings. The nursing 
community has been urgently asking Congress to increase funding for 
HRSA's Nursing Workforce Development Programs, especially to increase 
funding for nursing faculty preparation. Do you know that Federal 
investment in nursing education is less than six hundred-thousandths of 
the total Federal budget? Or that in 1974, during the last serious 
nursing shortage, Congress appropriated $153 million for nurse 
education programs. In today's dollars that would be worth $592 
million, approximately four times what the Federal Government is 
spending now.
    ENA agrees with the IOM's recommendation that Federal agencies must 
jointly undertake a detailed assessment of emergency and trauma 
workforce capacity, trends, and future needs to develop strategies 
meeting these needs in the future. Applications to nursing programs 
have increased but at the same time an estimated 147,000 qualified 
applications were turned away from nursing programs at all levels for 
the academic year 2004-2005 in large part because of the severe faculty 
shortage. The results of the disparities in workforce supply and demand 
are played out in staff shortages in the majority of emergency 
departments across the country--from staff who are struggling to 
provide care, to ED crowding, to ambulance diversions, and to the 
patients who ultimately suffer. The situation is only going to get 
worse as the population ages.
    ENA supports the IOM's assertion that national standards for core 
competencies applicable to nurses and other key emergency and trauma 
professionals be developed using a national, evidence-based, 
multidisciplinary process. To date, the ENA-affiliated Board of 
Certification of Emergency Nursing (BCEN) has credentialed 14,000 
Certified Emergency Nurses (CEN) and more than 1,000 Flight Registered 
Nurses (CFRN). BCEN also recently announced the launch of the 
Certified Transport Registered Nurse (CTRNTM) certification for nurses 
qualified to move patients between medical facilities.
    The ENA is on record advocating increased Federal efforts to 
support:

     Effective strategies for the recruitment, retention, and 
continuing education of registered nurses working in emergency 
departments, providing safe, efficient, quality care, especially during 
crisis situations when the ED is crowded and functioning above 
capacity; and
     New strategies to increase the numbers of individuals 
pursuing nursing careers, as well as initiatives to increase qualified 
nursing faculty, who are vital to addressing the nursing shortage.

                STATUTORY NATURE OF U.S. EMERGENCY CARE

    When the American public is asked about its views on trauma centers 
and trauma systems, large majorities value them as highly as having a 
police or fire department in their community. In addressing the crucial 
nature of regionalized trauma services, the IOM report notes that 
trauma care ``is widely viewed as an essential public service.'' The 
report further states that ``unlike other such services [e.g., 
electricity, highways, airports, and telephone service . . . created 
and then actively maintained through major national infrastructure 
investments] access to timely and high quality . . . trauma care has 
largely been relegated to local and State initiative.''
    The dilemma of emergency care runs deeper than the disparity 
between the perceptions of emergency care as a public service and the 
funding underlying the system. A distinctive policy characteristic of 
emergency care is that emergency care is legislated (e.g., as 
previously suggested in the EMTALA regulations discussion). Of all the 
health care disciplines, emergency care is the one that is mandated by 
the U.S. government. In effect, the government has promised the people 
that emergency care will be a service to which the public has a lawful 
right (not just a discretionary, moral right). This statutory nature 
holds special implications, evoking general questions such as:

     How does Federal support of this public service compare to 
support of other legislated services?; and
     To what degree is the government legally accountable for 
delivery of this right/public service?

    For emergency care nurses, this legal requirement reinforces 
respective professional duties and ethical commitments. As front-line 
providers of emergency care, ENA believes it is essential that every 
person in our country has access to a system that provides definitive 
care as quickly as possible. We ask that you support the 
recommendations that ENA has outlined in its written testimony and work 
with us to create a coordinated, regionalized, and accountable 
emergency care system that is staffed, trained, and prepared for our 
communities when they need us. We cannot achieve it alone.
    Thank you.

    Senator Burr. Margaret.

 STATEMENT OF MARGARET VANAMRINGE, M.H.S., VICE PRESIDENT FOR 
PUBLIC POLICY AND GOVERNMENT RELATIONS AT THE JOINT COMMISSION 
          ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

    Ms. VanAmringe. Thank you. The Joint Commission welcomes 
the opportunity to add our voice to this important issue.
    We accredit over 15,000 healthcare organizations across a 
continuum of care in approximately 95 percent of the hospital 
beds in this country. We recently had an expert roundtable on 
the issue of emergency-department overcrowding, and the 
discussions that came from that roundtable, as well as our 
experience with onsite evaluations, really serve as the basis 
for my statement today.
    Many EDs are in trouble across the country, as we've 
already heard. It's no surprise, however, that this is the 
case. We have been building toward this situation for many 
years, starting far before the altering events of 9/11, the 
outbreak of SARS, and the threat of avian flu, all of which are 
making us far more attentive to the capacity in the healthcare 
system to respond to challenges of all sorts.
    In the 1990s, funding policies, as well as stiff marketing 
competition, led to a wringing-out of many excesses in the 
healthcare system. This is not to say that those were bad 
things to have happened at the time, but, when combined with a 
dwindling base of essential professional staff needed in 
hospitals and now a burgeoning demand for medical services, we 
are left with a critical situation. The only guaranteed access 
to medical care in the United States is through the ED. All 
persons who present to the ED must be provided with medical 
screening, exam, stabilization. And no one can be turned away 
because of their inability to pay. Whereas, EDs were once meant 
for treating trauma and urgent illness, they are now the safety 
net for the safety net.
    ED demand is driven by an aging, higher acuity population, 
as well as an increasing number of mentally-ill patients who 
have no other care option. Community health centers, 
specifically created to provide safety-net care to Medicaid, 
underinsured, or uninsured, are typically underfunded and 
overwhelmed by demand. And community mental-health services are 
especially lacking and very problematic, as the ED is one of 
the first places the police take disruptive citizens or 
mentally-ill, homeless individuals.
    Unfortunately, this overall increased demand is coupled 
with reduced capacity. And I won't go through that, as we've 
already heard. But we must recognize, if we are to successfully 
tackle the problems facing EDs today, that what we have is a 
systems problem, as Nancy very well pointed out, and systems 
problem requires systems solutions, not piecemeal approaches. 
We need to look at broad community solutions while we also 
focus on what is happening within the hospital, such as 
available community resources to keep citizens out of the ED or 
the ability to discharge patients into the community. The 
emergency department is clearly affected by the adequacy of 
nursing home, home care, mental health, and other community 
services to receive patients.
    The ED is also part of a smaller system. It's a microsystem 
of the hospital itself, and thus, the ED can be greatly 
affected by what goes on in the rest of the organization, 
including staffing, because an unstaffed bed is an unavailable 
bed.
    Although it is true that EDs have the capacity to deliver 
an array of medical services for acutely ill and injured 
patients, emergency departments also depend upon a number of 
ancillary services, such as laboratory, diagnostic imaging, and 
skilled nursing, to make that delivery happen. The failure of 
any one of these services could bring the ED to a halt, thus 
supporting the notion that the ED is not necessarily the cause 
of the backlog, but, rather, it is the unit most vulnerable to 
it. For example, lack of hospital efficiency in areas such as 
the throughput of patients, surgical scheduling, and management 
of inpatient care can cause backups in the ED. So can lack of 
HIT resources or poor triaging system. To underscore this 
point, it has been shown that hospital leadership, use of 
hospitalist bed czars, and smoothing of surgical schedules can 
have dramatic effects in ED backups.
    So, what can Congress do? Again, there's no single magic 
bullet. But Congress, of course, can play an important role to 
address certain aspects of the problem. First, attention 
continues to need to be given to the issue of the uninsured, 
because they serve a large population of the ED. Nevertheless, 
and contrary to public perceptions of the uninsured's impact, 
the most frequent visitors to EDs are Medicaid beneficiaries, 
followed by Medicare beneficiaries. A major percentage of these 
patients are visiting the ED because of a severe illness that 
could have been prevented by proper intervention in the 
community. Therefore, Congress should also support, and work 
with States, as appropriate, to increase the availability of 
primary care and other community health services, especially 
mental-health services.
    The current environment around pay-for-performance provides 
an opportunity for Congress to ensure that appropriate 
incentives are placed into reimbursement programs that can 
affect how care is delivered. So, another recommendation would 
be that, as part of the pay-for-performance framework, Congress 
should consider a number of incentives to improve the 
emergency-care processes, such as rewarding an institutional 
culture that drives improvements in ED quality and efficiency 
and implements hospital-wide solutions while rewarding HI---
health information technology that can bring realtime 
laboratory and other information to the bedside in the ED, and 
not have staff in the ED have to search for information.
    Another recommendation is that Congress should act on 
proposals that will lessen litigation and improve the medical 
liability system.
    A fifth recommendation is that Congress should continue to 
invest in title VIII programs to address the critical nurse 
shortages in the country, but Congress should also consider how 
to invest in other health professions education programs in an 
effective manner, starting with qualified laboratory personnel 
for hospitals.
    And here, I would just like to add that some of these 
investments need to be targeted. We need to make sure that our 
leaders of tomorrow, whether we're talking about our medical 
leaders, our nursing leaders, or our hospital administrative 
leaders, have schooling in the disciplines of systems 
engineering and human factors analysis. If we don't have this 
put into the curricula and have incentives to have this into 
the curricula of health professionals that--we will not solve 
the problems, because we will not have the knowledge and skill 
base we need in hospital care to do so.
    So, I'd like to end by just mentioning something about 
communitywide preparedness. It's clear that we do not have the 
capacity to address a mass-casualty event, and we will have--we 
will suffer, I think, with these consequences unless we take 
some additional action. The Joint Commission, for a long time, 
has been encouraging communitywide preparedness. So, two 
recommendations we have for Congress in this area is that it 
should encourage communitywide, realtime healthcare systems 
capacity monitoring that gives continuous information on 
available beds, ED capacity, and other characteristics of the 
medical system. And if we have that in place on a day-to-day 
basis, then we will be much prepared, should we have a large-
scale disaster.
    And last, I would say, in the same area of mass casualty 
and preparedness, that Congress should also develop concrete 
expectations for communities that accept emergency preparedness 
funding and fund a program of objective evaluation for 
assessing the effectiveness of these emergency preparedness 
efforts across all players. The Joint Commission has standards 
for emergency preparedness for hospitals that include the ED. 
HRSA has its own checklist of hospital preparedness--
requirements for hospitals. The homeland security has targeted 
capabilities list. All these lists need to be harmonized in a 
manner that there are clear expectations for hospitals for 
community preparedness. And if we don't have third-party 
independent evaluation of those metrics that we have all agreed 
upon that includes looking at the interconnectivity of the 
medical and healthcare capabilities with the community, we will 
not know whether or not we're truly prepared. This will require 
funding, but we believe that critical effort on this regard 
needs to take place.
    Thank you very much.
    [The prepared statement of Ms. VanAmringe follows:]

           Prepared Statement of Margaret VanAmringe, M.H.S.

    I am Margaret VanAmringe, Vice President for Public Policy and 
Government Relations at the Joint Commission on Accreditation of 
Healthcare Organizations. I appreciate the opportunity to submit 
comments on the current state of emergency and trauma care in U.S. 
emergency departments (ED). Founded in 1951, the Joint Commission is 
the Nation's oldest and largest standard setting and accrediting body 
in healthcare. The Joint Commission accredits approximately 15,000 
healthcare facilities along the entire spectrum of services. Our 
mission is to continuously improve the safety and quality of care 
provided to the public. We are an independent voice that is derived 
from both the multitude of expert opinion that we bring together on 
tough issues facing the healthcare system, and from our more than 50 
years gathering daily information on quality and safety from the front 
lines of care delivery.
    On behalf of the Joint Commission, I would like to take this 
opportunity to thank the Senate subcommittee members for their 
dedication to improving the quality and safety of emergency care in the 
United States. We are especially grateful because we realize the 
subcommittee has jurisdiction over a very wide array of public health 
issues: BioShield, the Centers for Disease Control and Prevention 
(CDC), immunizations, infectious diseases, pandemic flu, and vaccines. 
Your specific focus on EDs and emergency care, strongly linked with the 
aforementioned issues, is both important and germane.
    The Joint Commission agrees with the subcommittee's statement that, 
``ambulances are on diversion, stretchers line ED hallways, ambulances 
idle waiting to off-load patients, [and] patients leave EDs without 
being seen.'' Because the Joint Commission accredits most hospitals, 
these emergency care issues are of great concern. The Joint Commission 
recently sponsored an expert roundtable to discuss ED overcrowding. The 
issues raised in that session, in conjunction with the work we do with 
providers across the United States, serves as the basis for our 
responses to the questions the subcommittee has posed in its letter of 
invitation.

             WHY ARE EMERGENCY DEPARTMENTS SO OVERCROWDED?

    Bolstered by the Emergency Medical Treatment and Labor Act of 1986 
(EMTALA), the only guaranteed access to medical care in the United 
States is through the ED. All persons who present to the ED must be 
provided with a medical screening exam and stabilization, and no one 
can be turned away because of their inability to pay. Whereas EDs were 
once meant for treating trauma and urgent illness, they are now the 
``safety net for the safety net.'' Many patients wait hours, even days, 
in the ED because they have no other care option. Others, however, view 
the ED as a convenient choice to receive same-day service without 
lengthy appointment waits. ED demand is driven further by an aging, 
higher acuity patient population, as well as an increasing number of 
mentally ill patients who have no other care option. EDs also have 
disproportionately high Medicare and Medicaid patient populations.
    Additionally, a growing number of uninsured is overwhelming 
community health centers and other public ``safety net'' providers. 
Community health centers specifically created to provide safety net 
care to Medicaid-insured or uninsured patients are typically under 
funded and overwhelmed by demand. Community mental health services are 
especially lacking and very problematic as the ED is one of the first 
places that police take disruptive citizens or mentally ill homeless 
individuals.
    Unfortunately, this overall increased demand is coupled with 
reduced capacity. Hospitals are short of available beds and workers, 
particularly registered nurses. Rising demand for hospital-based care 
comes at a time when there are fewer hospitals and still fewer EDs. 
From 1988 to 1998, the number of EDs decreased by 1,128. This 
diminution of hospital capacity was a planned ``benefit'' of managed 
care and federally administered financial constraints designed to 
control costs and rid the healthcare system of excess and inefficiency. 
Another factor driving demand involves high medical liability insurance 
rates in some States, especially for physician specialists. At the same 
time, many specialists are in short supply and increasingly unwilling 
to agree to take on-call duties from hospitals.
    Overcrowding is clearly a systems problem, not just an emergency 
department problem. This is even true within the hospital itself. The 
lack of inpatient beds is the most commonly cited reason for crowding 
in the ED. When patients are ``boarded'' in the hallway, they take up 
treatment space, equipment, and staff time, straining an already 
overwhelmed unit. Overcrowding may also involve the inability to 
appropriately triage patients, forcing patients into the ED waiting 
area while they await ED treatment spaces. Although it is true that 
emergency departments have the capacity to deliver an array of medical 
services for acutely ill and injured patients, it is also dependent 
upon a number of ancillary services such as laboratory, diagnostic 
imaging, and skilled nursing to make that delivery happen. The failure 
of any one of these services could bring the ED to a halt--thus 
supporting the notion that the ED is not necessarily the cause of the 
backlog; but rather is the unit most vulnerable to it.
    Last, the emergency department is affected by the number and type 
of community services that can receive its patients, and the ease at 
which patient transfer can take place. There must be adequate nursing 
home, home care, mental health and other community services to receive 
patients that can be discharged to these other venues, and good service 
support and collaboration to make these transfers work efficiently.

                          WHAT CONGRESS CAN DO

    Complex problems with multiple contributing factors require 
multifaceted solutions. Therefore, there is no one magic bullet, or 
single recommendation that will solve the problem. Many stakeholders 
have a part to play and a full list of strategies for all players would 
be quite long. The Congress, of course, can play an important role in 
addressing certain aspects of the problem.

     First, Congress should continue to address the issue of 
the uninsured. Unfortunately, a major source of healthcare for this 
underserved population is the ED. Thus, in order to properly address 
the subcommittee's first inquiry of why EDs are so crowded, the 
uninsured must be acknowledged as a significant demand on the system.
    Nevertheless, and contrary to public perceptions of the uninsured's 
impact, the most frequent visitors to EDs are Medicaid beneficiaries, 
followed by Medicare beneficiaries. A major percentage of these 
patients are visiting the ED because of a severe illness that could 
have been prevented by proper intervention in the community, either by 
having a relationship with a primary care physician or by having 
available community-based services.
     Congress should support and work with States as 
appropriate to increase the availability of primary care and other 
community health services, especially for publicly insured populations. 
One area that needs particular attention in the community is the 
creation and funding of more mental health services to meet a range of 
behavioral health needs.

    The current environment around pay-for-performance provides an 
opportunity for Congress to ensure that appropriate incentives are 
placed into reimbursement programs that can affect how care is 
delivered.

     As part of a pay for performance framework, Congress 
should consider a number of incentives to improve emergency care 
processes, such as rewarding: an institutional culture that drives 
improvement in ED quality and efficiency; fast-track and intervention 
programs to help ensure patients are receiving care where it can be 
most effective and efficiently delivered; healthcare information 
technology solutions to improve occupancy and capacity monitoring; 
dedicated personnel for quicker bed turnover and streamlining discharge 
policies and procedures; the use of hospitalists to provide more 
inpatient care, and specific provisions for treating psychiatric 
patients in the ED.

    Certain bills introduced in 2005 and 2006, like the Access to 
Emergency Medical Services Act (H.R. 3875 or S. 2750), provide a model 
for addressing some of the problems and the standards contained within 
should be vetted with the private sector in order that the standards 
have broad-based support.
    Finally,

     Congress should act on proposals that will lessen 
litigation and improve the medical liability system.
     Congress should continue to invest in title VIII programs 
that are aimed at addressing the critical nurse shortages in this 
country and consider effective funding programs aimed at growing 
shortages in other essential hospital staff, such as qualified 
laboratory personnel.
   federal options for enhancing system coordination and integration
    From a systemwide coordination and integration perspective, 
Congress should help to alter public perceptions, encouraging all 
healthcare stakeholders to view ED crowding as a collective problem. 
Because so many trauma centers and large hospitals report that their 
emergency departments are operating at or over capacity, it may be 
difficult or impossible to gain the surge capacity needed to sustain 
the health care system in a community during a mass casualty event. 
Community planning for emergency care is essential and should be part 
of ongoing community and regional efforts. If effectively done on a 
routine basis, such planning will position the community/region for 
large-scale disasters.
    The Joint Commission has been promoting more community integration 
and coordination as a means to disaster preparedness. Recent 
publications have been produced to help guide communities in this 
regard. For example, the Joint Commission has published:

     Are You Prepared? Hospital Emergency Management Guidebook 
(2006)
     Standing Together: An Emergency Planning Guide for 
America's Communities (2005)
     Managing Patient Flow: Strategies/Solutions for Addressing 
Hospital Overcrowding (2004)

    Despite the years of post 9/11 funding, there are still many more 
efforts which need to be made to ensure that communities are prepared.

     Congress should encourage community-wide real-time 
healthcare system capacity monitoring systems.
     Congress should also develop concrete expectations for 
communities that accept emergency preparedness funding, and fund a 
program of objective evaluation for assessing the effectiveness of 
these emergency preparedness efforts across all players.

                               CONCLUSION

    If considered crowded today, EDs promise to become busier in the 
not-too-distant future. A large cohort of aging Baby Boomers are 
beginning to live longer, the ranks of the uninsured continue to grow, 
and a growing number of providers are less willing to treat Medicaid- 
and Medicare-covered patients. In short, more and more patients will 
enter a diminished number of EDs. Increased demand will be met with 
reduced capacity. It is the Joint Commission's contention that neither 
patients nor healthcare providers are well served by the current 
emergency care system in the United States. The central question is how 
emergency care services can be restructured to actively encourage 
providers to implement new policies. Redesigning the emergency care 
system will be a long-term endeavor, one that addresses larger/national 
social and economic issues.

    Senator Burr. Thank you very much.
    Dr. Bass.

STATEMENT OF ROBERT BASS, M.D., F.A.C.E.P., EXECUTIVE DIRECTOR 
   FOR MARYLAND INSTITUTE FOR EMERGENCY MEDICAL SERVICES AND 
       PRESIDENT OF NATIONAL ASSOCIATION OF EMS OFFICIALS

    Dr. Bass. Thank you, Mr. Chairman. Good morning.
    My name is Robert Bass. I'm the Executive Director of the 
Maryland Institute for EMS Systems--that's the State EMS agency 
in Maryland--and I did serve as a member of the Institute of 
Medicine's Committee on the Future for Emergency Care in the 
U.S. Health System. I am an emergency physician who specializes 
in pre-hospital care, which, by the way, was a skill I learned 
while I was a police officer in Chapel Hill, North Carolina, in 
the early 1970s. That's a whole 'nother story.
    Senator Burr. Did you graduate from Chapel Hill?
    Dr. Bass. I did, sir.
    Senator Burr. Having two sons there, you have picked up my 
day, knowing there's somebody that graduates from Chapel Hill.
    [Laughter.]
    Dr. Bass. I understand, Senator.
    [Laughter.]
    Dr. Bass. I'm going to briefly summarize the IOM 
Committee's findings and recommendations regarding pre-hospital 
EMS. I'm going to focus on that area, giving particular 
attention to those that relate to the impact of ED 
overcrowding, emergency preparedness, and the need for greater 
and more effective Federal coordination.
    As you've heard, many emergency departments today are 
seriously overcrowded with patients, many of whom are being 
held in the ED because no inpatient bed is available. The 
widespread practice of holding admitted patients in the ED, 
also known as ``boarding,'' ties up precious space, equipment, 
and staff that cannot be used to handle and manage the needs of 
incoming patients. While there are other factors contributing 
to ED overcrowding, hospital inpatient crowding and boarding of 
patients in the ED are believed to be major players.
    When EDs are overcrowded, EMS personnel may not be able to 
transfer patients to an ED bed or turn over care to the staff. 
This situation can delay definitive care by hospital personnel, 
as well as delay ambulances from returning to service and 
responding to the next emergency.
    Data from a recent study of ED overcrowding in Baltimore 
indicated ambulance delays in EDs are increasingly having an 
adverse impact on the availability of ambulances to respond in 
that community.
    The committee offered three recommendations to address 
emergency-department overcrowding. No. 1, hospitals should 
reduce crowding by improving hospital efficiency and patient 
flow and using operational management methods and information 
technologies. No. 2, the Joint Commission on the Accreditation 
of Healthcare Organizations should re-instate strong standards 
for ED boarding and diversion. And, No. 3, the Centers for 
Medicare and Medicaid Services should develop payment and other 
incentives to discourage boarding and diversion.
    With many hospitals and EMS services already operating at 
or above capacity, it is difficult to envision how they would 
absorb a surge of casualties from a disaster or major act of 
terrorism. Regardless of whether the disaster is a result of 
terrorism, human error, a natural disaster, or epidemic, our 
Nation's emergency-care system simply lacks the capacity to 
mount an effective response today.
    Disaster response capabilities are also hindered by poor 
communications and a lack of coordination. EMS, hospitals, and 
public safety often lack common radio frequencies, much less 
interoperable communications systems. These technological gaps 
are compounded by cultural gaps between public-safety providers 
and emergency-care personnel. Fragmentation of local efforts is 
mirrored by a lack of coordination at the Federal level. 
Federal responsibility for emergency care is spread across 
multiple agencies and departments. For example, there are 52 
centers for public-health preparedness with Federal funding to 
access--excuse me--to address various aspects of bioterrorism, 
but not one federally-funded center focusing on the civilian 
consequences of terrorist bombings, even though explosives are 
the most common instrument of terrorism worldwide.
    The committee made a number of recommendations to address 
these issues. First and foremost, and most important, the best 
way to ensure an effective response in the event of a disaster 
is to create an emergency-care system that effectively 
functions on a day-to-day basis. The committee believes that 
this can best be accomplished by building a nationwide network 
of regionalized, coordinated, and accountable emergency-care 
systems. The committee recommends that Congress establish a 
federally funded demonstration program to develop and test 
various approaches to regionalize delivery of pre-hospital and 
hospital-based emergency care. And, second, designate a lead 
agency for emergency care in the Federal Government.
    There are many compelling reasons for creating a new lead 
Federal agency for emergency care that are cited in the report. 
They include creating unified accountability for performance, 
optimizing allocation of resources, a single point of contact 
and better coordination of programs, more consistent Federal 
leadership on policy issues, increased visibility, identity, 
and stature for emergency-care providers and the system, and 
greater multidisciplinary collaboration to improve integration 
of services.
    On the other hand, there are significant questions and 
challenges regarding the location, structure, and function of 
the new lead agency, the impact this will have on existing EMS-
related Federal programs and funding; the difficulties in 
combining agencies with different missions and cultures, as was 
experienced in the formation of DHS, that could lead to--result 
in enhanced fragmentation.
    In closing, 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 achieve a level of 
response that Americans expect and deserve.
    I'd like to thank you both for your leadership on this 
issue, and thank you for the opportunity to allow me to testify 
today.
    [The prepared statement of Dr. Bass follows:]

         Prepared Statement of Robert R. Bass, M.D., F.A.C.E.P.

                              INTRODUCTION

    Good morning, Mr. Chairman and members of the subcommittee. My name 
is Robert Bass. I am Executive Director of the Maryland Institute of 
EMS Systems and I served as a member of the Institute of Medicine's 
Committee on the Future of Emergency Care in the U.S. Health System. I 
am an emergency physician who specializes in prehospital care.

                 THE MARYLAND INSTITUTE FOR EMS SYSTEMS

    The Maryland Institute for EMS Systems (MIEMSS) is the independent 
State agency that oversees and coordinates the emergency medical 
services and trauma system in Maryland.

                                THE IOM

    The Institute of Medicine, or IOM as it is commonly called, was 
established in 1970 under the charter of the National Academy of 
Sciences to provide independent, objective, evidence-based advice to 
the government, health professionals, the private sector, and the 
public on matters relating to medicine and health care.

                               THE STUDY

    The Institute of Medicine's Committee on the Future of Emergency 
Care in the U.S. Health System was formed in September 2003 to examine 
the full scope of emergency care; explore its strengths, limitations 
and challenges; create a vision for the future of the system; and make 
recommendations to help the Nation achieve that vision. The committee 
consisted of 40 national experts from fields including emergency care, 
trauma, pediatrics, health care administration, public health, and 
health services research. The committee produced three reports--one on 
prehospital emergency medical services (EMS), one on hospital-based 
emergency care, and one on pediatric emergency care. These reports 
provide complimentary perspectives on the emergency care system, while 
the series as a whole offers a common vision for the future of 
emergency care in the United States.
    This study was requested by Congress and funded through a 
congressional appropriation, along with additional sponsorship from the 
Josiah Macy Jr. Foundation, the Agency for Healthcare Research and 
Quality, the Health Resources and Services Administration, the Centers 
for Disease Control and Prevention, and the National Highway Traffic 
Safety Administration.
    I will briefly summarize the committee's findings and 
recommendations regarding prehospital EMS, giving particular attention 
to those that relate to the impact of ED overcrowding, emergency 
preparedness, and the need for greater and more effective Federal 
coordination.

                            GENERAL FINDINGS

    Many emergency departments (EDs) today are severely overcrowded 
with patients, many of whom are being held in the ED because no 
inpatient bed is available. The widespread practice of holding admitted 
patients in the ED ties up precious space, equipment, and staff that 
cannot be used to meet the needs of incoming patients.
    When crowding reaches dangerous levels, hospitals often divert 
ambulances to other facilities. In 2003, U.S. hospitals diverted more 
than 500,000 ambulances--an average of one per minute. Diversion may 
provide a brief respite for a beleaguered staff, but it prolongs 
ambulance transport times and disrupts established patterns of care. It 
also creates ripple effects that can compromise care throughout the 
community. Because crowding is rarely limited to a single hospital, 
decisions to divert ambulances can prompt others to do the same. When 
this happens, a community may experience the health care equivalent of 
a ``rolling blackout.'' Everyone's access to care is affected--insured 
and uninsured alike.
    When EDs are overcrowded EMS personnel may not be able to transfer 
patients to an ED bed or turn over care to ED personnel in a timely 
manner. This situation can delay definitive care of the patient by 
hospital personnel as well as delay ambulances from returning to 
service and responding to the next emergency. Data from a recent study 
of ED overcrowding in Baltimore indicate that ambulance delays in the 
EDs are increasingly having an adverse impact on the availability of 
ambulances.

    SHORTCOMINGS IN THE EMERGENCY CARE SYSTEM'S CAPACITY TO RESPOND 
                              TO DISASTERS

    With many hospitals and EMS services already operating at or above 
capacity, it is difficult to envision how they could absorb a surge of 
casualties from a disaster or major act of terrorism. A sustained 
outbreak of disease, whether triggered by an emerging strain of 
influenza or intentional release of a bioterror agent, would be even 
more problematic because casualties would keep arriving for days, 
weeks, or months. But regardless of whether a disaster is the result of 
terrorism, human error, a natural disaster, or epidemic, our Nation's 
emergency care system simply lacks the capacity to mount an effective 
response. In light of these concerns, the IOM committee's 
recommendations have a special urgency.
    Training for EMS personnel and hospital staff in disaster 
procedures is limited. Despite the self-evident fact that mass-casualty 
events produce mass casualties, only 4 percent of Department of 
Homeland Security first responder funding in 2002 and 2003 was directed 
to emergency medical services. As a result, few EMS personnel have 
received adequate training in how to respond to chemical, biological, 
radiological, nuclear, and explosive (CBRNE) terrorism, much less 
natural disasters.
    Protecting hospital and EMS personnel from secondary contamination 
in the event of biological or chemical events poses extraordinary 
challenges. The outbreak of severe acute respiratory syndrome (SARS) in 
Toronto was triggered, in part, by a young man who spent his first 
night in a crowded Toronto ED with what was thought at the time to be a 
simple case of pneumonia. In the process, he infected two nearby 
patients, both of whom subsequently died of SARS (as did the first 
patient), but not before they infected scores of others, some of whom 
also died. EMS personnel that were utilized to transfer patients were 
some of the earliest victims.
    If a patient with SARS called 911 or walked into an American 
emergency department tonight, the effect would be like tossing a 
lighted match into a tinder-dry forest.
    Disaster response capabilities are also hindered by poor 
communications and lack of coordination. EMS, hospitals, and public 
safety often lack common radio frequencies, much less interoperable 
communication systems. These technological gaps are compounded by 
cultural gaps between public safety providers and emergency care 
personnel. In many communities, emergency management and homeland 
security meetings are held without a single health care professional in 
the room, even though, (in the words of one of my fellow committee 
members), ``Sometimes, in a disaster, people get hurt.''

                          FEDERAL COORDINATION

    Fragmentation of local efforts is mirrored by a lack of 
coordination at the Federal level. Federal responsibility for emergency 
care is spread across multiple agencies and departments. This may 
explain, in part, why large amounts of funding are directed toward some 
priorities, but not others. For example, Federal spending on 
bioterrorism and emergency preparedness in the Department of Health and 
Human Services (DHHS) rose from $237 million in fiscal year 2000 to 9.6 
billion in fiscal year 2006. During this same time period, the Congress 
eliminated the Trauma/EMS Systems Program at DHHS from the Federal 
budget. There are presently 52 Centers for Public Health Preparedness 
with Federal funding to address various aspects of bioterrorism, but 
not one federally funded center focusing on the civilian consequences 
of terrorist bombings. Explosives are the most common instrument of 
terrorism worldwide.
    The current level of funding received by EMS and hospitals is 
inadequate to enable them to develop needed surge capacity for 
disasters, much less a major flu epidemic.
    The needs of children have been largely overlooked, especially in 
disaster scenarios. Children are far more vulnerable to the 
consequences of disasters than adults, both physiologically and 
psychologically. For example, if children sustain burns, they have a 
greater likelihood of life-threatening fluid loss and susceptibility to 
infection. If they sustain blood loss, they develop irreversible shock 
more quickly. Because they are closer to the ground, and have a faster 
metabolic rate, they are more vulnerable to the effects of toxic gases. 
Additionally, if separated from their caregiver, they lose their 
protection and support system. In spite of this, the needs of children 
are often overlooked in disaster planning. Many States do not address 
pediatric needs in their disaster plans, and disaster drills frequently 
lack a realistic pediatric component. Presently few sheltering sites 
ensure the availability of resources for children, including formula, 
diapers, and cribs.

                       COMMITTEE RECOMMENDATIONS

    The committee offers several recommendations to address these 
inadequacies.
    First, and most important, the best way to insure an effective 
response in the event of a disaster is to create an emergency care 
system that effectively functions on a day-to-day basis. The committee 
believes that this can best be accomplished by building a nationwide 
network of regionalized, coordinated, and accountable emergency care 
systems. To promote the development of these systems, the committee 
recommends that Congress: (1) establish a federally funded 
demonstration program to develop and test various approaches to 
regionalize delivery of prehospital and hospital-based emergency care, 
and (2) designate a lead agency for emergency care in the Federal 
Government to increase accountability, minimize duplication of efforts 
and fill important gaps in Federal support of the system.
    The committee recommends that States actively promote regionalized 
emergency care services. This will help insure that the right patient 
gets to the right hospital at the right time, and help hospitals retain 
sufficient on-call specialist coverage. Disaster planning would take 
place within the context of these regionalized systems so that patients 
get the best care possible in the event of a disaster. Integrating 
communications systems would improve coordination of services across 
the region; not only during a major disaster but on a day-to-day basis.
    In addition to offering these general recommendations for 
strengthening the emergency care system, the committee developed 
specific recommendations to enhance disaster preparedness. For example, 
to address concerns about lack of surge capacity, inadequate training, 
and insufficient protection of hospital and EMS personnel, the 
committee recommends that Congress significantly increase preparedness 
funding in fiscal year 2007 for hospitals and EMS in a number of key 
areas--surge capacity; trauma care systems; EMS response to explosives; 
training programs; availability of decontamination showers, standby ICU 
capacity, negative pressure rooms, and personal protective equipment; 
and research on response to conventional weapons terrorism. In 
addition, the committee recommends that EMS be brought to a level of 
parity with other public safety entities in disaster planning and 
operations.
    The committee further recommends that disaster response topics be 
included as essential elements in the training, continuing education, 
and credentialing of emergency care professionals (including medicine, 
nursing, EMS, allied health, public health, and hospital 
administration).
    To address the special needs of pediatric patients in preparing for 
disasters, the committee made a number of specific recommendations: 
minimizing parent-child separation; enhancing the level of pediatric 
expertise on organized disaster response teams; including pediatric 
surge capacity in disaster planning; improving access to pediatric-
specific medical, mental health, and social services in disasters; and 
developing policies that ensure that disaster drills include a 
meaningful pediatric component.
    Finally, the committee concluded that the Veterans Affairs (VA) 
hospital system is an underutilized resource for emergency preparedness 
at the local level. Therefore, there should be greater integration of 
VA resources into civilian disaster planning.

      REFLECTIONS OF THE RECOMMENDATION FOR A LEAD FEDERAL AGENCY

    There are many compelling reasons for creating a new Federal lead 
agency for emergency care that are cited in the report. They include 
creating unified accountability for performance; optimizing allocation 
of resources; a single point of contact and better coordination of 
programs; more consistent Federal leadership on policy issues; 
increased visibility, identity, and stature for the emergency care 
system and providers; greater multidisciplinary collaboration to 
improve integration of services.
    On the other hand, there are significant questions and challenges 
regarding the location, structure and function of the new agency; the 
impact on existing EMS-
related Federal programs and funding; the difficulties in combining 
agencies with different missions and cultures as was experienced with 
the formation of DHS that could lead to enhanced fragmentation.

                                CLOSING

    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 achieve the level of 
response that Americans expect and deserve. The IOM committee's 
recommendations provide concrete actions that can, and should lead to 
an emergency care system that is capable of providing safety and 
security for all Americans.
    Thank you for the opportunity to testify. I would be happy to 
address any questions that you might have.

    Senator Burr. Thank you, Robert.
    I'm going to turn to my colleague, Senator Isakson, who, as 
I promised you, probably had a more thorough introduction of 
Dr. Haley.

                  Opening Statement of Senator Isakson

    Senator Isakson. Well, I thank you, Chairman Burr, not only 
for allowing me this privilege of introducing Dr. Haley, but I 
commend you on all the work you're doing on bioterrorism and 
this important hearing regarding emergency medical services.
    And it's really with a great deal of pride that I introduce 
Dr. Leon Haley, of Grady Memorial Hospital, in Atlanta. It is 
an almost 1,000-bed hospital serving 22 counties in North 
Georgia and more than 5 million people in the metropolitan 
Atlanta area. And it is the designated coordinating hospital 
for emergency for the region.
    There is nobody more qualified to talk about that than Dr. 
Haley. He's the Deputy Chief of Staff, the Deputy Senior Vice 
President, and the Chief of Service of the emergency medical 
delivery system for Grady Memorial Hospital. And to let you 
know what that impact means and what he oversees, Grady 
averages 130,000 emergency visits a year. So, nobody is more 
capable to testify before us and give us some ideas of ways we 
can improve responding to emergencies and the way we can plan 
for those tragedies that may or may not come in the future.
    It's an honor for me to introduce a great Georgian, and a 
good friend, Dr. Haley.

   STATEMENT OF LEON HALEY, JR., M.D., M.H.S.A., F.A.C.E.P., 
  ASSOCIATE PROFESSOR OF EMERGENCY MEDICINE AND VICE CHAIR OF 
           CLINICAL AFFAIRS FOR GRADY HEALTH SYSTEMS

    Dr. Haley. Thank you, Senator. I appreciate it. And, again, 
I want to thank you both for your leadership on this important 
initiative.
    I would like to take the opportunity to thank the U.S. 
Senate Subcommittee on Bioterrorism and Public Health 
Preparedness for inviting me today. I'm honored by the 
opportunity to participate in a roundtable discussion.
    As has been stated in the recent IOM report on the future 
of emergency care, the emergency care system is but one 
component of a larger healthcare system and an even larger 
social safety-net system. Moreover, this crisis is augmented by 
fragmented local, regional, and national leadership, which led 
to inadequately coordinated and integrated systems of care.
    In addition, unrealistic expectations of daily service 
performance, disaster-response capability, and surge capacity 
have become an additional burden for the emergency-care system 
to shoulder.
    Unfortunately, the reasons why emergency departments are 
crowded are complex and multifactorial, and, like in many 
things in healthcare and in life, they have tremendous local 
and regional variation.
    On a macro level, a simplistic reason for emergency-
department crowding is a rise in emergency-department visits 
across the country, from 90 million visits in 1996 to over 113 
million visits in 2003, while, during the approximate same 
timeframe, the number of emergency departments in this country 
fell by almost 500. There are reports of emergency departments 
closing weekly across the country, with little or no 
commensurate options for patients and their families to choose.
    A more complex but more microrealistic deal is when 
emergency-department crowding is best viewed by the Asplin 
conceptual model of the emergency-department crowding that 
involves input, throughput, and output.
    The input phase represents the entrance point into the 
emergency department. It's composed of those patients who are 
truly seriously ill and injured, and require emergency care. 
They may arrive on their own, by ambulance, or by other 
emergency vehicle, or they may have been sent from another 
healthcare environment because their condition outstrips the 
capability of the referring location. This phase also captured 
the unscheduled urgent care, which is typically a function of 
the lack of capacity of the current ambulatory-care system to 
support this component of healthcare. This has increasingly 
been shown to be a part of an individual's desire for immediate 
care, secondary to job conflicts, family, or inconvenience. 
This phase, however, captures individuals where the ED 
represents the safety net. This group is composed of the 
vulnerable populations of our society--the chronically ill, the 
uninsured, the underinsured, prisoners, mental health, and 
those suffering from substance abuse.
    The drivers of this phase are many. They include EMTALA, 
which has been spoken about before, which mandates that all 
patients who present to a hospital ED must at least receive a 
hospital screening exam to ensure that an emergency does not 
exist. The proof and responsibility is ultimately on the 
provider, but may include diagnostic testing and specialists to 
reach that conclusion. While some patients have a level of 
awareness of EMTALA, all healthcare providers do. This means if 
they opt not to see a patient in their office and send them to 
the emergency department, they know the ED must do the 
screening exam, at the very least. Many EDs and emergency 
physicians, because of the level of work and responsibility 
associated with medical screening exams, just go ahead and 
complete the patient's evaluation.
    Another driver in this phase are the difficulties in 
accessing primary and urgent care in a timely fashion in many 
communities, especially when evenings and weekends are taken 
into consideration. Components of this driver range from 
decreased reimbursements for primary-care physicians from 
Medicare, Medicaid, and managed-care, to the uninsured, who 
have no other choice but to seek the emergency department, to 
the fact that physicians treating patients in the ED have 
access to a wide range of medical technology and equipment, 
consultants, and other evaluation tools. In other words, 
emergency departments have become one-stop shopping for 
patients and healthcare providers. And in many States the 
effect of illegal or undocumented citizens compounds the 
problem.
    The throughput phase, as has been spoken on before, 
represents that triage phase, which includes nursing 
assessment, physician assessment, diagnostic treatment, and 
consultative needs. Crowding drivers in this phase include 
several operational issues. One of the most significant 
problems is with ancillary services. Derlet & Richards 
conducted a survey for the Emergency Nurses Association in 
which respondents felt that 50 percent of their ED service 
delays were due to wait times for laboratory and radiology 
results. Shortages in health-professional staffing also make 
significant contributions to this crowding in this phase.
    While there are certainly shortages in radiology, lab, and 
pharmacist, a major contributor is nurse staffing. From 1995 to 
2000, there was a 26-percent decrease in the number of new 
nursing graduates in this country. And when compounded with the 
fact that the average age of a nurse is now 47 and that the ED 
workload for nurses is generally more complex and more 
challenging, with worse ratios, it's no surprise that this 
continues to be a problem.
    Another crowing driver in this phase is the increasing 
problem in the ED with on-call coverage for specialty 
physicians. In many hospitals and many communities, there's 
limited or no neurosurgery coverage, limited or no orthopedic 
coverage, and other specialties are challenged, as well. 
Reasons for this lack of coverage range from reimbursement 
issues to malpractice concerns, all of which create incredible 
challenges.
    The final phase is that of output. It represents the 
options for the ED once the ED patient's care has been 
completed. It ranges from discharge from the ED with primary- 
or ambulatory-care followup, transfer to another facility, to 
hospital admission. As has been stated, the hospital admission 
has proven to be the most complex and the most challenging, 
because when hospitals reach their inpatient capacity, there's 
no place for the admitted patient wait but the ED. It is not 
unusual for emergency departments to have 25 to 50 percent or 
more of their emergency departments filled with admitted 
patients who do not have a bed; hence, these patients become 
boarders. Having ED spots used by admitted patients means there 
are no new options for new patients that arrive in the ED. 
This, in turn, leads to problems with throughput, ultimately 
affects input, ultimately leads to ambulance diversion. And in 
many locales, admissions for pediatric and mental health become 
increasingly complicated, and also contributes to extended 
delays.
    There are a lot of ideas, but there are two overarching 
themes for Congress to address the ED crowding: opportunities 
and incentives. A major opportunity exists for Congress to 
create the appropriate incentives--primarily positive, but 
negative, as well--to reduce the ED crowding. One might be such 
as to address EMS to develop payment initiatives and other--
possibly others, to encourage hospitals and health systems to 
reduce the hospital boarding problem by finding ways to 
facilitate patient movement in the inpatient setting.
    A second incentive, that would encourage primary-care 
providers to engage with the urgent-care patients is by 
receiving patients in their offices or finding alternative 
sources of care beyond the emergency department.
    We must also evaluate the effective DRG payments on the 
current system. It has been well-described that patients 
admitted from the ED are more costly than elective admissions 
for the same surgical DRG. As such, hospitals are more inclined 
to focus on elective admissions than those from the emergency 
department. And we also encourage the Joint Commission to re-
instate strong standards that sharply reduce and ultimately 
eliminate ED crowding, boarding, and diversion.
    Another great opportunity for Congress is to examine and 
augment the existing research in emergency medicine. I'm 
currently a member of the board of directors of the Society for 
Academic Emergency Medicine, the largest organization in the 
country whose mission is to promote research and education in 
emergency medicine. There is currently no NIH study section 
with a specific on emergency care, and there exists a great 
opportunity to create such a section or institute with that 
focus.
    Finally, there exists a great opportunity for Congress to 
create a coordinated, accountable system that is both a 
function of opportunity and incentives. The system would be 
technologically advanced and efficient, would be seamless, with 
multiple entities, and would be supported with the appropriate 
advanced research.
    I thank you for this opportunity to talk to you today, and 
we look forward to the continuation of the discussion.
    [The prepared statement of Dr. Haley follows:]
    Prepared Statement of Leon L. Haley, Jr., M.D., M.H.S.A., C.P.E.
    I would like to take the opportunity to thank the U.S. Senate 
Subcommittee on Bioterrorism and Public Health Preparedness for 
inviting me today. I am honored by the opportunity to participate in 
the roundtable discussion on Crisis in the ER: How Can We Improve 
Emergency Medical Care? As has been stated in the recent IOM report on 
The Future of Emergency Care, the emergency care system is but one 
component of the larger health care delivery system and of the even 
larger social safety net system. Moreover, this crisis is augmented by 
fragmented local, regional and national leadership which has lead to 
inadequately coordinated and integrated systems of care. In addition, 
unrealistic expectations of daily service performance, disaster 
response capability and surge capacity have become an additional burden 
for the emergency care system to shoulder.
    Why are emergency departments (ED's) crowded and what can Congress 
do to improve the situation: Unfortunately, the reasons why ED's are 
crowded are complex and multifactorial and like much in healthcare and 
in life, have tremendous local and regional variation. On the ``macro'' 
level, a simplistic reason for ED crowding is the rise in ED visits 
across the country from approximately 90 million visits in 1996 to 
close to 113 million in 2003 while during approximately that same time 
period, the number of ED's across the country fell from 4,547 in 1994 
to 4,177 in 2000. There are reports of ED's closing weekly across the 
country with little to no commensurate options for patients. A more 
complex, but more ``micro'' realistic view on ED crowding is best 
described by the Asplin conceptual model of ED crowding. This model 
breaks the component of the ED visit into three phases: input, 
throughput and output; it serves as one of the best models to 
understand the complexity of the problem and will serve as the basis of 
my thoughts.
    Input: This phase represents the entry point into the ED. It is 
composed of those patients who are truly seriously ill or injured and 
require emergency care. They may arrive on their own, by ambulance or 
other emergency vehicle or they may be sent from another healthcare 
environment because their condition outstrips the capability of the 
referring location. This phase also captures unscheduled urgent care 
which is typically a function of the lack of capacity of the current 
ambulatory care system to support this component of health care. This 
has increasingly been shown to be a function of an individual's desire 
for immediate care potentially secondary to job conflicts, family and/
or convenience. Finally, this phase captures individuals where the ED 
represents the ``safety net.'' This group is composed of the vulnerable 
populations in our society: the chronically ill, the uninsured, the 
underinsured, prisoners, mental health and those suffering from 
substance abuse. The drivers of ED crowding in this phase are multiple 
and many ED's suffer from not just one of these factors, but many of 
them. One primary crowding driver in this phase is EMTALA which 
mandates that all patients who present to a hospital ED (in a hospital 
that receives Medicare/Medicaid funding) must at the very least receive 
a medical screening exam to ensure that an emergency does NOT exist. 
The proof and responsibility is ultimately on the provider, but may 
include diagnostic testing and specialists to reach that conclusion. 
While some patients have a level of awareness of EMTALA, all healthcare 
providers do. This means if they opt not to see a patient in their 
office and send them to an ED, they know the ED must do the screening 
exam at least. Many ED's and many emergency medicine physicians, 
because of the level of work and responsibility associated with medical 
screening exams, just go ahead and complete the patient's evaluation. 
Another driver in this phase are the difficulties in accessing primary 
and urgent care on a timely fashion in many communities, especially 
when evenings and weekends are taken into the equation. Components of 
this driver range from decreasing reimbursements for primary care 
physicians from Medicare, Medicaid and Managed Care, to the uninsured 
who often have no other choice but to seek care in the ED, to the fact 
that physicians treating patients in the ED have access to a wide range 
of medical technology and equipment, consultants and other evaluation 
tools--all in environment. In other words, many ED's have become ``one-
stop shopping'' centers for patients and healthcare providers. Another 
driver in many parts of the country, but not all, is the influx of 
undocumented individuals into the system. Border States tend to be most 
affected, but because of limited options for the healthcare needs of 
undocumented individuals, the ED becomes a place of choice.
    Throughput: This phase represents the actual treatment component of 
the ED visit. This includes the actual triage process by which we 
ascertain patient acuity, the nursing assessment, the physician 
assessment and any diagnostic, treatment and consultative needs. 
Crowding drivers in this phase include several operational issues. One 
of those is significant problems with ancillary service delays. Derlet 
and Richards conducted a survey for the Emergency Nurses Association in 
which respondents felt that 50 percent of their ED service delays were 
due to wait-times for laboratory and radiology process and results. 
Shortages in health professional staffing also makes significant 
contributions to crowding in this phase. While there are certainly 
shortages in radiology and laboratory technicians and pharmacists, a 
major contributor is nurse staffing. From 1995 to 2000, there was a 26 
percent decrease in the number of new nursing graduates in this country 
and when compounded with the fact that the average age of a nurse is 
now 47, and that the ED workload for nurses is generally more complex 
and with worse staffing ratios, then it should come as no surprise that 
ED's have challenges with nurse staffing. Another crowding driver in 
this phase is the increasing problem with ED on-call coverage for 
specialty physicians. In many hospitals and in many communities, there 
is limited or no neurosurgery coverage for the ED, there is limited or 
no orthopedic coverage and other specialties are challenged as well. 
Reasons for the lack of coverage range from reimbursement issues to 
malpractice concerns which may or may not be legitimate, but certainly 
create challenges for many ED's.
    Output: This phase represents the options for the ED once the 
patient's ED care has been completed. This ranges from discharge from 
the ED with primary or ambulatory care followup, to transfer to another 
care facility to hospital admission. It is the hospital admission that 
has proven to be the most complex and the most challenging because when 
hospitals reach their inpatient capacity, there is no place for the 
admitted patient to wait, but the ED. It is not unusual for many ED's 
to have 25-50 percent (or more) of their ED's filled with admitted 
patients who do not have a bed; hence these patients become 
``boarders'' in the ED. Having ED spots being used by admitted patients 
means there are no options for the new patients that arrive in the ED. 
This in turn leads to problems with throughput as described above and 
ultimately affects the input phase as well which can lead to ambulance 
diversion. Moreover, in many locales, admissions for pediatric and 
mental health patients is even more complicated and also contributes to 
extended stays in the ED.
    Options for Congress: While there are a lot of ideas, I think there 
are two overarching options for Congress to address ED crowding: 
Opportunities and Incentives. A major opportunity exists for Congress 
to create the appropriate incentives--primarily positive, but negative 
ones as well--necessary to reduce ED crowding. One such incentive might 
be for the Centers for Medicare and Medicaid Services to develop 
payment incentives (and possibly others) that encourage hospitals and 
health systems to (a) reduce the hospital boarding problem by finding 
ways to facilitate patient movement to the in-patient setting; (b) 
incentives that encourage primary care providers to engage with urgent 
care patients by either seeing patients in their offices or finding 
alternative sources of care beyond the ED; (c) to evaluate the effect 
DRG payments have on the current system. As well described in the IOM 
report, there is research from Munoz-1985 and Henry-2003 that suggests 
patients admitted from the ED are more ``costly'' than elective 
admissions for the same surgical DRG. As such, hospitals are more 
inclined to focus on elective admissions than those from the ED; and 
(d) to encourage the Joint Commission on the Accreditation of 
Healthcare Organizations (JCAHO) to reinstate strong standards that 
sharply reduce and hopefully ultimately eliminate ED crowding, boarding 
and diversion. As the primary accreditation organization for hospitals 
and health systems, JCAHO, under a mandate from Congress, is in the 
appropriate position to force hospitals to meet their crowding demands. 
Congress can also intervene on the crowding issue by ``creating'' 
opportunities. One such opportunity proposed by the IOM would be the 
development of a demonstration program to encourage States and local 
regions to identify and test alternative strategies to address crowding 
on a system level than leaving it strictly to the behavior of 
individual hospitals. Another great opportunity for Congress is to 
examine and augment existing research in Emergency Medicine. I 
currently am a member of the Board of Directors of the Society for 
Academic Emergency Medicine, the largest organization in the country 
whose mission is to promote research and education in Emergency 
Medicine. There is currently no NIH study section with a specific focus 
on emergency care and there is a great opportunity to create such a 
section or institute with that focus.
    Who is leading the charge to improve emergency care at the Federal 
level and what options exist for enhancing system coordination and 
integration. Unfortunately, there is no lead organization addressing 
emergency care at the Federal level. In fact, that concept is a 
specific recommendation from the IOM report which states that the 
Federal Government should consolidate functions related to emergency 
care, currently scattered among multiple agencies, into a single agency 
in the Department of Health and Human Services. There are agencies 
responsible for disaster preparedness, bioterrorism, public health and 
emergency services for children, but they are all acting independently 
and not under a single umbrella.
    In any existing locale, there is the potential for several ED's and 
several EMS providers not to mention fire and police. Unfortunately, 
these organizations do not communicate well together, both 
philosophically as well as logistically. They operate under different 
leadership structures, often have different missions and visions and 
almost always have different technologies that prevent adequate 
coordination on a daily basis, yet alone during the events of a 
disaster. There are over 6,000 9-1-1 systems across the country and 
they are frequently under different jurisdictions and the standards by 
which they and EMS providers operate are not under a Federal or 
national standard.
    Congress has several options and opportunities to enhance system 
integration and coordination. One, technology coordination. As 
mentioned earlier, different ED's, EMS providers, fire and police are 
frequently using different technology and even if the first responders 
are on the same frequencies, the hospital ED is often the forgotten 
link and is not included. Through grants, demonstration projects or 
awards, Congress can encourage system integration, by awarding locales 
or regions that agree to work together money for technology 
integration. For example, we should envision a system that allows an 
EMS provider to pick up a patient from any location, look at a 
computerized screen in the truck that allows them to see the ED status 
of all the ED's in their region, select the most appropriate ED based 
upon patient condition and acuity, ED status and the other cases that 
are currently in route to the ED's in that region. Two, system 
accountability. Unfortunately the number of service providers (ED, EMS, 
etc) means that there is no one system of accountability of care, there 
is no centralized database to assess EMS or emergency department care 
and without a lead organization/agency, there is no one to monitor the 
process or progress. There has been suggestion that creating a lead 
agency, composed of the appropriate mix of legislators, physicians, EMS 
providers and government officials would be an appropriate entity for 
congress to create and develop.

                                SUMMARY

    Many hospital emergency departments are crowded and the reasons are 
multifactorial. The problem can best be viewed through both a ``macro'' 
assessment of the issues as well as the ``micro'' events that actually 
occur at the emergency department level. Moreover, problems with ED 
crowding are inadequately addressed at the Federal level. There is 
currently no lead agency in the Federal Government that has the 
responsibility to assess and monitor emergency services and while 
challenging, there is opportunity for the Federal Government to step up 
to the challenge and change emergency services for our future. It is 
clear that ED crowding is really a function of ``hospital and system'' 
crowding and solutions should reflect that reality.
    There are many issues that affect ED's on the ``macro'' level. 
There are shifting demographic trends in emergency care as ED visits 
across the country have been rising in the past decade; over 113 
million patients were seen in the Nation's emergency departments in 
2003, up from 90 million one decade ago. In addition, the number of 
emergency departments across the country has fallen by over 400 during 
this same time period. Also on the macro level, emergency departments 
must comply with EMTALA which mandates that all patients presenting to 
hospital ED's must at least provide a medical screening exam for 
patients. ED's are also often the first option for care for patients 
who are uninsured or underinsured, but increasing, even the insured 
population has come to view the ED as a viable first alternative for 
care. ED's have become ``one-stop shops'' where advances in technology, 
access to consultants and specialists and diagnostic testing is 
available of a 24/7/365 basis. Finally, ED's have become the safety net 
for the vulnerable populations in our society including the mentally 
ill.
    On a ``micro'' level, hospital ED crowding can be broken into three 
phases: (a) input, (b) throughput, and (c) output, where problems in 
any one of these phases will lead to crowding. Input is composed on 
legitimate emergencies, but more importantly patients who are 
vulnerable and those who were unable to access the urgent or ambulatory 
care system leaving them no other option but the hospital ED. 
Throughput represents the actual treatment and care phase of the ED 
visit. Factors that lead to problems with throughput range from 
staffing inadequacies, particularly nursing, to delays in ancillary 
testing to problems with on-call specialty/consultant coverage. Output 
represents that phase where a disposition decision has been made. In 
most cases, that represents a discharge from the ED. However problems 
arise when admitted patients, or ED Boarders, remain in the ED when the 
inpatient units are full.
    Unfortunately, there is a no lead Federal agency that directs 
emergency care services; there are instead several agencies, in several 
departments where emergency care is currently scattered. Unfortunately, 
this leads to fragmentation, lack of accountability and inadequate 
monitoring. There exists the opportunity for Congress to create a 
coordinated, accountable system that is both a function of opportunity 
and incentives. This system would be technologically advanced and 
efficient, would be seamless between multiple entities and would be 
supported with advanced research.

    Senator Burr. Dr. Haley, thank you very much.
    What I'd like to do is spend just a few minutes on some 
initial questions, if I can, and then recognize Johnny for some 
questions before he has to leave. And then I'll spend the 
balance of the time, maybe until 4 o'clock, in an exchange of 
questions, and hopefully a little further mining of some of 
your thoughts, not just on the problems that exist that I think 
we find pretty wide consensus on, but where those solutions 
are.
    And, I guess, first and foremost, I want to go to Margaret 
and Nancy, because I think both of you raised, actually 
everybody raised, the nursing shortage in some fashion. And I 
remember, about 5 years ago, we passed the Nurse Reinvestment 
Act, targeted at underserved areas, from the standpoint of 
nursing. It dealt with scholarships, loan repayments, and 
faculty loan repayments. I don't question that there's a 
nursing shortage. It's real. I see it in every community I 
represent. My question to you two would be, Is this program 
working? If it is, is it just not producing enough? Or, if we 
mine down, do we find that we have shortages on clinical 
facilities for nursing programs to expand and the clinical side 
of their studies can't be completed? Are there additional 
shortages, as in professors, that don't allow the class sizes 
or the multiple classes in the 24-hour period to take place? 
And, if you would, rank the issues in importance, from the 
standpoint of how we solve this.
    Ms. VanAmringe. Well, you're probably the expert, Nancy, 
but I'll put my 2 cents in anyway. I think the Nurse 
Reinvestment Act was very, very important, but there still are 
a number of issues.
    First of all, it takes a long time between the initial 
investment in a nurse going through the training for us to 
actually see the results out in the field. So, it's going to 
take a number of years anyway. And we're certainly trying to 
pull together the data to show: for every X number of dollars 
one puts into the Nurse Reinvestment Act, how many nurses we 
get out. But a critical stumbling block we have right now is 
the faculty issue. So, many qualified applicants to nursing 
schools are being turned away, because there isn't enough 
sufficient faculty to teach these students. That is a real 
problem. So, I think we have that.
    We also have an issue, in that we need to have, I think, a 
consideration of almost a residency or type of training program 
for nurses, postschool, to make sure that they have the 
expertise to go into these high-pressured situations, as 
opposed to just being put into the hospital, kind of, cold, 
with just the hospital's own training courses. So, I think we 
need some additional funding in that area, as well.
    Ms. Bonalumi. I do want to express my gratitude for the 
Nurse Reinvestment Act that was passed in 2002. The unfortunate 
part of it is that the appropriations are not adequate to meet 
the demand. We have only been able to fund approximately 18 
percent of the loan repayment requests that have come in, and 
about 6 percent of the scholarship applications that have come 
in, in the years that have passed since the Reinvestment Act 
was launched.
    And, as our colleague has said, the nursing faculty 
shortage is critical. We are turning people away who want to 
become registered nurses. We're making them go through 
extensive periods of time before they can begin their education 
to become an R.N. And then, indeed, once they graduate--and as 
a director of an emergency department, we hire nurses right out 
of their education into the emergency-department setting. We 
really try to screen for the most qualified candidates from the 
best schools so that we have the best and the brightest coming 
to work in our department, but we still can't fill all the 
positions that we have, even with taking in brand-new nurses. 
They require an extensive period of time before they're really 
comfortable taking care of patients on their own, especially in 
my department, where our patient population is really very 
vulnerable. They're very small children, and they have--they 
come in very critically ill, and it requires a great deal of 
expertise to care for them. So, we make our nurses go through a 
minimum of 4 to 6 months of, kind of, tutored education before 
we let them work independently in our department, and that is a 
very--that is a long time. Some hospitals don't grant that much 
protected time to get oriented to the work and are put in their 
new jobs and are working on their own, independently, within a 
matter of a few weeks. That is a very stressful situation.
    So, I think the recommendation of a--kind of a residency 
program, or sort of a tiered approach to education, would be 
something that would be very prudent.
    But, clearly, the funding, in and of itself, is a part of 
the root cause of why we cannot create enough nurses. There is 
interest; we just can't meet the demand. Some of it is physical 
space in schools of nursing, that they don't have enough 
classroom, but it is really the allocation of how many students 
a faculty person can have in their classes. And I've worked as 
faculty in a school of nursing. I'm only able to carry a 
responsibility for seven or eight nursing students when they're 
in their clinical practice. You can't supervise more than that 
and expect them to be able to practice safely. So, there's a 
huge issue with being able to generate enough people who want 
to train the next generation of nurses in our country.
    Nursing faculty positions are very poorly paid compared to 
positions in a hospital. So, the salary of a person who has a 
doctorate in nursing, who is teaching at a school of nursing, 
may be one-half of what a staff nurse who is working in a 
hospital setting could receive. So, there's a great disparity 
in the amount of education they need and the expense they incur 
to do that. Combined with poor salaries, really doesn't make it 
a very attractive combination for people to move into that 
role.
    But through additional funding from Congress to the Nurse 
Reinvestment Act, I think that we can make a difference. And it 
won't be something that will happen overnight, you're 
absolutely right. It takes 4 years for a nurse to go through a 
college program, and then another year to really feel 
comfortable in their practice. So, even if we increased funding 
in the fiscal year 2007 budget, it would be, you know, perhaps 
fiscal year 2012 before we would really see the full effect of 
what that increased funding could do to help schools of nursing 
and help the nursing workforce shortage.
    Senator Burr. Clearly, this won't be the last time we go 
into this area, from the standpoint of trying to figure out 
what we do.
    I want to recognize Senator Isakson.
    Senator Isakson. I want to thank the panel. I want to 
apologize. I just got--my BlackBerry went off, and I've got to 
go back to another hearing, but--I was very intrigued by Dr. 
Haley's testimony, particularly in the section entitled 
``Options for Congress,'' talking about positive and negative 
incentives to accomplish some things to reduce the pressure on 
emergency rooms.
    And I guess this is both a statement and a question. I hope 
you will follow that with some specific recommendations on what 
those incentives might need to be. Particularly, I was 
intrigued when you talked about incentives that encourage 
primary-care providers to engage with urgent-care providers by 
either seeing patients in their office or finding alternative 
sources of care beyond the emergency room. Anything you can get 
to us that we might do as a policy, that, through incentives, 
could cause those types of things to happen, would be a 
tremendous help. You list five specific categories there we 
could address. I would just say, on behalf of the Chairman, 
here, and myself, any of those suggestions you have, we would 
love to see.
    Dr. Haley. Thank you. I think--and we listed a few of 
those--I think the opportunity does exist to create the 
appropriate options and incentives. And, obviously, form 
follows finance, as--oftentimes for the healthcare community, 
as well, and making it financially feasible for primary-care 
physicians to keep extended office hours, to be specific, or 
weekends, or whatever the options may be. Right now, there's no 
incentives for them to see more patients. In fact, it may be 
more stressful, and depending upon their cost structure, it may 
actually cost them to stay open. So, making sure we have those 
options for people and whatever freestanding urgent-care 
centers or options for people exist, I think, is important, as 
well.
    And then, sort of, dovetailing it with some of the hospital 
initiatives, making sure that we create whatever financial 
incentives are appropriate to reduce that boarding problem, to 
help get patients upstairs, will then give us options, in terms 
of seeing urgent-care population in the ED setting.
    Senator Isakson. Just one, following up on that. A lot of 
people--and I'm not a medical person, but a lot of people talk 
about--when you referenced that the cost of treating a 
emergency-room referral in the hospital for the same illness or 
problem is oftentimes much more expensive than the person that 
does not refer from the emergency room, I would assume that's 
because those nonemergency-room folks probably have better 
access to normal healthcare, normal physician services, than 
one who shows up in the emergency room. Is that correct?
    Dr. Haley. That's one way of thinking about it. I think the 
challenge we have, of course, is sometimes the perspective that 
we bring. So, we're obviously trained, from a physician and 
nursing standpoint, to think emergency first and making sure 
the patient doesn't have an emergency. So, we tend to think 
from one different perspective.
    The other option is, we have standby costs; and so, if 
we're going to be--or use our emergency departments to help us 
with surge capacity, emergency preparedness, we do have a lot 
of standby costs that are built into it. In that regard, by 
getting people to an appropriate setting of care, means that we 
can probably do it from a lower-cost perspective.
    Senator Isakson. Thank you, Doctor.
    Senator Burr. Thank you, Johnny.
    Johnny actually headed where I was going next. I'm going to 
spend a little bit of time here, because--I think it started 
with Dr. Blum's comment, which I thought was very appropriate, 
``Our job is taking care of sick people. That's what we do.'' 
So, I'm going to ask a similar question in a different way. How 
many people that you treat are not sick?
    Dr. Blum. Well, sir, it's probably a bit of a misconception 
that we try to address that our Nation's emergency departments 
are full of people that don't need to be there. Certainly, 
there are some of those. We sometimes joke that nonemergent 
patients crowd our waiting rooms, but they don't necessarily 
crowd our emergency departments. Because we take the worst 
patients first, you know, people that aren't very sick go, kind 
of, to the back of the line. And so, there are certainly people 
that have no access to care anywhere else, that have minor 
problems, that come to the emergency department, but that's not 
the root cause of this problem.
    Now, it would be safe to say that people with minor 
problems end up in the emergency department because of lack of 
care of their minor problems. If the patient with asthma 
doesn't get regular care, they will eventually have an asthma 
attack that appropriately lands them in the emergency 
department. A patient with diabetes that doesn't have regular 
access to care for that diabetes will end up with a diabetic 
emergency that lands them in the emergency department. But, 
Senator, it's a misconception to believe that if we could just 
get nonemergent patients out of the emergency department, we 
would solve our problems. That will not do it, trust me. In my 
emergency department, the people that are lining my hallways 
and filling my beds all need to be there. Many of them need to 
be upstairs after I've done my job and treated them, but they 
all need to be in a healthcare facility. My waiting room may be 
full of people that don't necessarily need to be there.
    Senator Burr. Is there any distinction between the 
individuals that are uninsured and individuals that might be 
Medicaid-
covered, relative to how they access the ED?
    Dr. Blum. Only in that it affects their access to primary 
care. We are blind to that. As an emergency physician, I have 
no idea what kind of insurance they may have. I mean, I could 
make speculation about someone being uninsured or whatever, but 
we are appropriately blinded to that. We take people on the 
basis of their illness and not on their insurance or 
medication. Now, having said that, if you have a Medicaid 
system in the State that provides very limited access to 
patients to primary care, they're going to use the emergency 
department in increased volumes. Certainly, the uninsured have 
no other option. There are 47 million people out there that 
have no option.
    And even the Medicare population--you know, physicians in 
this country are facing 37-percent pay cuts under Medicare over 
the next 8 years. Many primary-care physicians are already 
operating at the margin on Medicare patients. You know, as 
those cuts go into effect, primary-care physicians are going to 
have a limited ability to see more and more Medicaid patients--
Medicare patients, I'm sorry. And we know the Medicare 
population is burgeoning. And so, what's going to happen to 
those patients when they can't get their primary care? They're 
going to come to the emergency department.
    And so, all of those--all of those payor types have reasons 
to use the emergency department. And all those issues need to 
be addressed if we're going to truly create a system that has 
the kind of capacity that we need.
    Senator Burr. Dr. Haley, you raised the issue of--I think, 
in response to Senator Isakson, as well as in your testimony--
that we need to focus on creating some incentives so that 
people choose the right delivery point to get access to care. 
If it is not an emergency case, then--even if it's not many in 
your settling, it may be more in somebody else's where patients 
actually access the emergency department for primary care--but 
there needs to be an incentive to sort that out so we don't 
have to deal with it.
    I think Walgreen is headed into some type of primary-care 
delivery in their stores. Is that right, is the private sector 
now attempting to do what you're talking about, creating an 
option that, No. 1, is on a predictable schedule and No. 2, 
predictable from the standpoint of cost, if they prove that the 
quality can be delivered there? Is that now in competition with 
not just the emergency room, from the standpoint of whether 
somebody goes for a nonemergency visit, but also isn't that, in 
essence, going to compete with the private docs, as well?
    Dr. Haley. Well, I think the----
    Senator Burr. And do you see it as a help or a hindrance?
    Dr. Haley. I think--a couple of issues. Certainly, the 
patients who present to the mini-clinic concept of the 
Walgreen's--and we're seeing some of that in Georgia, as well--
for a sector of the patient population, that might be a 
reasonable option for them to choose. But, obviously, that 
group is not going to take the uninsured, they're not going to 
take the underinsured, and they're certainly not going to take 
the vulnerable. So, for a very small segment of the patient 
population, that may be a reasonable option for them, and we'll 
just have to see. Now, many of those clinics, of course, are 
not staffed by physicians; they're using nurse practitioners. 
So, there's a limitation in the amount of care they can 
provide. Obviously, there are timeframes. So, for a very small 
segment, that's going to be an option. For some of the segments 
that Dr. Blum was talking about, in our emergency department, 
you've got a different group of patients. And he described it 
very well. The emergency department is very crowded with very 
sick and injured patients. The waiting room is very crowded, in 
our case, with patients who have urgent-care options. The 
patients are making their own individual choices about how to 
access the system. And, yes, ultimately we can think through a 
better payor system. We may be able to think about how to 
create the appropriate patient incentives. But right now we 
don't even have the appropriate healthcare provider incentives, 
so there are no, or very limited, incentives for healthcare 
providers to provide extra ambulatory or extra care, there are 
very little incentives. In fact, in many States, as Medicaid 
managed care continues to be rolled out, particularly in our 
State, there's even less of an incentive to do that, because 
they're getting challenged by some of the payment mechanisms, 
that they don't even want to be able to participate in the 
system, if possible.
    So, it gets back to, I think, what was addressed by some of 
the earlier speakers about really making sure we think about 
how we address the system. We keep trying to get to, sort of, 
one element of--one silo, and another silo, and another silo. 
We've got to really think, from a systems perspective, about 
how to address, sort of, that bigger problem.
    Senator Burr. Dr. Bass.
    Dr. Bass. Senator, I was going to say that the IOM report 
actually spent a fair amount of time on this issue. And the 
figure I want to throw out is that--you've heard me refer to 
the growth in the number of patients coming in the ER over a 
10-year period was from about 90,000 to 110 to 114--million, 
excuse me. And the bottom line there is, if you look at those 
patients, the majority of the new patients coming to the ER, in 
fact, were insured. And there are probably a number of reasons 
for that. One is that, even though they were insured, they had 
difficulty accessing care. It might be because their physicians 
don't have convenient hours. It might be because they're 
enrolled in an HMO that has very tight scheduling, and, when 
unscheduled demand for care comes, they turn to the ER. But 
there was another big factor, which is that the perception in 
the public right now is that there's quality care in the 
emergency departments, and they view that as a safe, good place 
to go for care. So, that is a factor.
    I also wanted to point out that there was a recent study in 
the Annals of Emergency Medicine that, sort of, looked at this 
issue of the folks who aren't too sick coming to the ER, and 
whether they were plugging up the ER. In fact, if you look at 
it in the study, it strongly indicates that it's not the 
patients with minor complaints that are plugging up the ER; 
it's the sick patients that come in, that need to be admitted, 
that are tying up the staff. And, in fact, they've looked at 
some areas where they, sort of, try to take these minor 
illnesses out of the equation; and, in fact, it has no impact 
on crowding.
    Other research, up in Massachusetts, looked at the issue of 
trying to correlate what was happening in the hospital with 
ambulance diversion. They found out that the number of folks 
coming to the ER had almost no impact on ambulance diversion, 
but the percentage of beds occupied in the hospital had a very 
high impact on ambulance diversion.
    Senator Burr. I agree. And I think Margaret alluded to the 
fact that having the ability to upgrade health technology, the 
ability to, in realtime, know where the vacancy exists, know 
where the backlog isn't, so that, in fact, we can direct 
patients to the right entry point, the better off the entire 
system is. Without that, you're blind. If there's a delay, the 
delay gets worse with everyone that comes in.
    Nancy, you said--and I just want to explore this a little 
bit more--EMTALA was burdening ERs with nonemergency cases. 
Now, the good news is, I think the data exist for us to figure 
out how many of the overall emergency-room visits are, in fact, 
nonemergencies. It's a little bit more difficult, because of--
not your interpretation of EMTALA or his interpretation of 
EMTALA or my staff's interpretation--who just reminded me, in 
2003, CMS tried to clarify EMTALA to say ``only need to do 
screening''--the only interpretation that's important is the 
lawyer of the hospital, because his interpretation will not be 
``screening only,'' it will be ``do everything you need, to 
make sure that, from a liability standpoint, we are covered.'' 
Therefore, it is not as much what the percentage is of 
nonemergency folks, it's ``Should we be treating nonemergency 
folks? Should we be delivering primary care in an emergency 
department?'' Maybe it's not the degree of it, but, based upon 
the legal interpretation of ``exposure,'' what lengths does an 
ED doc, what lengths does an ED nurse, what lengths does an 
administrator then require the system to go to?
    And, ultimately, we know that the majority of the system is 
only going to reimburse a certain amount. And if they're 
uninsured, the likelihood is the collection rate is less than 
10 percent, and few, but some, pay out of pocket. But the 
reality is that, in some cases, we're delivering $50 worth of 
care and charging $1,100 because of the legal interpretation 
that has nothing to do with the healthcare professionals.
    And I want to mine down just a little bit further, if I 
can. How much of the challenge is with individuals who either 
come to the ER, who should have never been an emergency-room 
case, or who might be Medicaid and end up there, or are 
uninsured and end up there, end up in the ER because they have 
no relationship with a healthcare professional?
    Ms. Bonalumi. I think that would be information that would 
be really helpful, because I think, as you heard, the emergency 
departments have become primary-care centers, and that many of 
these patients who come in, when you say, ``Who's your family 
doctor?''--because that's information we, as triage nurses, 
will ask them, because we want to forward a report to them--``I 
don't have one,'' period, especially the uninsured, who have, 
really, no other access point.
    Emergency departments have really become the Ellis Island 
of healthcare, in terms of what we are expected to provide to 
our communities. And I think, Margaret, you talked about the 
safety net. We are the safety net to the safety nets now for 
communities at large. And so, the fact that these patients are 
coming into our hospital, and we really are still very limited 
in our ability to say, ``You have had a cold for 2 weeks, and 
we would like you to go to this clinic tomorrow morning and 
have an examination over there, where it will cost you, 
incrementally, you know, a very small percentage of what we 
will charge you for an emergency-department visit,'' there is 
still great concern that that's a liability for the hospital, 
because we haven't really proved, or ruled out, that a medical 
emergency really exists.
    So, the recommendation I would make is that Congress really 
have CMS clarify those very finite pieces of the EMTALA 
regulation. They have used it, but it still creates--I think, 
Rick, you, as a practicing ER doc, know it's very conflicting, 
and we feel very caught in the middle.
    You know, there was a point in time, with the immigration 
bill, that hospitals were going to be asked to identify and 
report illegal aliens that came for care in the ER. That's in 
direct conflict to the EMTALA regulation, which says, 
regardless of who you are----
    Senator Burr. We have never said we were consistent.
    [Laughter.]
    Ms. Bonalumi. We would like some consistency. That's my 
recommendation.
    Rick.
    Dr. Blum. I'm, unfortunately, old enough to have practiced 
before EMTALA, so I can give the perspective of pre-EMTALA 
versus post-EMTALA. And I can tell you, for me and the 
colleagues that are in my generation of older emergency 
physicians--or getting there, anyway--EMTALA didn't make much 
difference in our day-to-day practice at all. We still saw 
everybody that came in the door, and treated them 
appropriately.
    With regard to the screening exam, it's an interesting 
feeling for that. You know, there's this concept, ``Well, if we 
could just screen them and get them out of the emergency 
department, that would solve our issues,'' but once you've 
screened them, as an emergency physician, you're 90 percent 
done. You know, it would be like fixing your transmission and 
not putting the last bolt in to not give them that prescription 
and send them on their way. So, most of us just do that. 
Because that--quite frankly, you know, it's hard to look a 
patient in the eye and say, ``Well, I've evaluated you, and you 
have an earache, and maybe you really don't need to be in the 
emergency environment, but you need this antibiotic; but I'm 
not going to give it to you, because, you know, this was just a 
screening exam.'' It's an unreasonable kind of position to 
take. So, most of us just go ahead and complete the treatment, 
at that point, because we're 90 percent there by the time----
    Senator Burr. Let me suggest to you that I think you do put 
the last bolt in. But what that person needs to hear is, ``A 
transmission is not designed to go from reverse to drive while 
you're still in motion.'' Therefore, without that education, 
the likelihood is they're going to come back for another 
transmission. And my point is that we could probably talk all 
day about the makeup of the patient that you see, and I think 
we'd all agree it's probably different everywhere that you go. 
But when you talk about the patient that likely could have been 
prevented from being a visitor, when you focus on where that 
problem is, I think what we're going to find out is, that 
without a relationship with a healthcare professional, there is 
no education. You're not designed to be an educational 
component to somebody who walks into the ED. You're there to 
treat sick people. A healthcare relationship is one that's 
there to begin to educate somebody about disease management, 
takes that asthmatic and makes sure that they learn to avoid an 
exacerbation--where they're going to the ER.
    And to some degree--I know we hate to admit it, but the 
practice of medicine has changed since EMTALA came into place, 
because we no longer have the ability after 5 o'clock to call 
and all of a sudden have our primary-care doc, or any doc, 
necessarily say, ``Let me come by and see you.'' That's the 
realities of what we're dealing with. And we're challenged with 
trying to make this work, understanding that some changes are 
irreversible, as well.
    Margaret.
    Ms. VanAmringe. I couldn't agree with you more. I think you 
said it very well. The issue we found at our roundtable is that 
there's significant belief that the lack of having primary-care 
relationships is contributing to the problem. And, as you said, 
the issue isn't just that they come to the ED. If they get that 
prescription and they leave, if they have any problem with that 
prescription, understanding the dosage, anything at all, 
they're going to go back and call the ED or go back to the ED. 
So, what you really want is to have incentives in Medicare and 
Medicaid programs, as well as in other private programs, for 
that relationship so it can be an ongoing coordination 
relationship that allows people to get that education and not 
have to keep bouncing back.
    Senator Burr. Let me dig just a little bit deeper. I don't 
want to be consumed with this issue, but--North Carolina has a 
new Medicaid program that they're rolling out, where they have 
broken the State down regionally. Every Medicaid beneficiary 
will be assigned a primary-care provider, be it a primary-care 
doc, a hospital, a community health center, a nurse, a 
physician's assistant. Somebody is in charge of their 
healthcare. That, in itself, will not change whether they 
choose the emergency room or pick up the phone and call this 
person that was assigned to them.
    If--and this is a big ``if''--if you could change EMTALA to 
reflect that if that person walked into the emergency room and 
was screened and determined not to be an emergency case, the 
hospital then has the right to pick up the phone and call the 
primary-care provider and say, ``Where do you want me to send 
them?'' Is there any objection to that around the table?
    Dr. Bass. I think one of the challenges that we heard was 
that a lot of the patients coming into the ED had primary-care 
relationships, but, when they had a problem that needed to be 
evaluated--perhaps it wasn't a clear emergency, but it seemed 
to be urgent; they were in pain, something needed to be 
addressed--they tried to access care, and couldn't get into 
their primary-care physician, and, in fact, may have been 
directed.
    Senator Burr. Well, I think in many cases they are directed 
to go to the emergency room. It is the safety net, as you said, 
of everybody. And, again, without the parameters established, 
which are sometimes difficult, you won't eliminate that one, as 
well.
    Ms. Bonalumi. I think Dr. Haley's recommendation that there 
be incentives for primary-care physicians to really take this 
workload that really is appropriate for them to do, is really a 
strategy that should be looked at, in terms of the 
reimbursement model. If patients are under the Medicare system 
and Medicare coverage, then I think there is some ability for 
Congress to be able to help direct how those patients get seen 
and to put some incentives in place to help those physicians 
who are taking care of that patient population, feel that 
they're being adequately compensated for the work they're 
doing, especially for after hours.
    Senator Burr. I'm not sure you would find disagreement on 
the Hill. I think you might find frustration on the Hill that 
our past efforts to bring preventive care into the Medicare 
reimbursement system--which has come in very slowly, but has 
made a difference--would include pharmacy reimbursements for 
their aid in monitoring of prescriptions filled and 
prescriptions taken, where the physician can't keep up with 
what patients do after they leave--and our inability to get 
that funding. So, you know, there are some things that are 
limitations that we will not overcome, in its current design.
    Dr. Blum. I think, before we leave this particular issue, I 
would also be remiss if I didn't say what doesn't work in this 
arena, and that is something that we've been exposed to for a 
number of years in our practice, which is the practice of 
determining retrospectively that, ``It wasn't an emergency; 
therefore, we're not going to pay you.'' That simply adds to 
the burden of poor reimbursement in the emergency department. 
It provides no disincentive to the patient from using the 
emergency department. And it makes our job more difficult.
    And the other thing is--and this gets lost in this argument 
sometimes--is that the patients don't come in with urgent or 
nonurgent label on them. It is sometimes difficult to tell. 
I've admitted a patient, with an ankle sprain, to the ICU for 
her toxic shock syndrome because of my observation of her skin 
condition when she came in for her sprained ankle. And that--
all of us could tell you those stories, you know, that have 
happened a number of times over the years, where seemingly 
nonurgent things have become urgent or emergent because of our 
intervention. And so, it's sometimes very, very difficult to 
tell. And, until we do our evaluation--which, like I said, once 
we have done it, we're almost home--you know, it's very 
difficult to determine who meets that criteria and who doesn't.
    Senator Burr. Dr. Haley, Atlanta was the site of the 1996 
Olympics. And we had a terrorist act at the Olympics. Let me 
ask you. Today, if you had a similar incident in Atlanta--and 
let's say, hypothetically, there were a hundred bomb-blast 
injuries--could Atlanta handle that?
    Dr. Haley. I think we would be significantly challenged. 
And let me give you some stats that prove that.
    When I was boarding the plane this morning to come here, I 
got my daily e-mail from our bed czar who manages all of our 
beds in the hospital as we try and address these problems, and 
today we started off with two ICU beds for the entire Grady 
Health System. And that is pretty much how we start every day. 
In fact, most of the time it's closer to zero.
    And so, I think the challenge you have with a terrorist act 
in our city, or any city, would be, we would be significantly 
stretched to provide the care, once we got past some of that 
initial emergency-department evaluation. I have a number of 
emergency physicians and nurses who would be very capable of 
providing that front level of care, but then once we got past 
that initial resuscitation phase, what do we do with them? We 
have that challenge every day.
    We looked at our trauma referral statistics over the past 
year, and we received about 430 requests from around the State 
of Georgia for patients to be sent in for our level-one trauma 
center. We had to turn down 190 of those during a 1-year 
timeframe. It's almost--so, almost 40 percent of that group, or 
more, had to be turned down--42 of those were turned down 
because there were no beds at all in the hospital; 74 were 
turned down because there were no ICU beds at the hospital; and 
21 were turned down because we were on some form of diversion. 
So, the challenge is, we have the EMS providers who provide 
front-level care, we've got great ED personnel who can do that, 
but then we're stuck. And that's the challenge. And if you add 
more to that patient population--if it were 1,000 patients, or 
10,000 patients--then you can see the concerns that all of us 
have.
    Senator Burr. Margaret, the Federal Interagency Commission 
on Emergency Medical Services is administered by NHTSA and 
housed within the Department of Transportation. Why?
    Ms. VanAmringe. I don't know the answer to that, Senator. I 
do think we need to have much more collaboration at the Federal 
level between those who are concerned with emergency response, 
in terms of police, fire, transportation, and those who have 
responsibility in the medical-care and public-health systems. 
We're just not all working as well together, I think, as we 
need, to do that.
    As I said in my testimony, I think we need to have some 
better metrics of what community preparedness is, because this 
is--the community--it's all interconnected. I just heard the 
Doctor talk about how few ICU beds you have and so forth. So, 
every community has to, obviously, have a plan to figure out 
how to use all of its medical resources--the nursing homes, the 
home care, the hospices, everything within its system to come 
together.
    So, we need, I think, at the Federal level, a better 
understanding of what needs to be done at the local level and 
have the agencies work well together, in terms of deciding what 
are the metrics that we want to measure in the community to 
decide whether that community has properly paid attention to 
preparedness. And then we have to have an independent 
evaluation of whether or not that community has actually done 
that. But we have all these different expectations, at the 
Federal level, because, as I mentioned, we have--HRSA has its 
checklist, DHS has its checklist and targeted capabilities, the 
Joint Commission has its checklist. We need to harmonize those 
and come up with a common set of metrics for the community.
    Senator Burr. I think you'll find almost complete consensus 
on the belief that we need to streamline our assessments and 
our response. I would suggest to you that, at least as it 
relates to pandemic threats and bioterrorism, it's been our 
assessment that the Federal Government should not be the lead, 
it should be the State; that it's more appropriate for the 
State to incorporate into their plan, whether it's Atlanta or 
Athens, what that response should be, and that the Federal 
Government should be the reviewer of the plan, and that our 
role should be to supplement what they've designed and to be 
there as that logistic resupply at the end of 72 hours with 
whatever the need is, be it supplies or medicines. And I don't 
think that's out of sync with what you just said, but I think 
that I've learned, as we've gone through the last 2 years, we 
have to state this much more clearly than we ever have in the 
past if we, in fact, want to begin to move this somewhere.
    Ms. VanAmringe. I think that's true. I think, though, what 
the Federal Government can do is help with those metrics that 
allow the States to go and do their planning, but they need 
some kind of guideposts, sometimes, just to help them 
understand what is good preparedness, and then they can 
organize their communities and regions in accordance with some, 
at least, guidance, if you will.
    Senator Burr. Robert, I would love to hear from you. EMS: 
Is it housed within the Department of Transportation?
    Dr. Bass. It is. And I'll briefly try to tell you that 
story. The EMS program at the Department of Transportation 
began about 1967. It was about a year after the original IOM 
white paper, called ``Accidental Death and Disability,'' and it 
was really focused on--initially, on providing care to folks 
who were injured in vehicle accidents, which was a terrible 
problem, and remains a problem, but a more significant problem, 
in terms of the lack of care. IOM reported out that we need a 
system of EMS. We need a system of emergency medicine. And, 
actually, it was DOT that came out of the chute the following 
year, in 1967, and set up that program, which has been with us 
ever since.
    In 1972, Congress passed the Emergency Medical Services 
Act, which actually ended up establishing a program within HEW. 
Both of those programs funded EMS development significantly 
during the 1970s. We saw an explosion of EMS, emergency medical 
services, systems around the country. Emergency medicine, as a 
specialty, grew. The trauma program grew. And then, abruptly, 
in 1981, the principal funding for the HEW--well, funding for 
the HEW program went away, the program went away, which left 
NHTSA with a much-reduced funding, and they, in essence, have 
been the lead EMS agency since about 1981, with a relatively 
modest budget, around $2 million a year.
    There is another program at HRSA, EMS for Children, that 
has a little bit better funding. They're around $20 million a 
year. And they partner very closely with NHTSA in trying to 
improve emergency medical services around the country. I mean, 
obviously, the EMS for Children is sort of the seminal 
principle with respect to disasters. If you don't have a good 
EMS system for everybody, you're not going to have a good EMS 
system for kids. So, they have been working very 
collaboratively.
    FICEMS was an effort to try to bring together all of the 
entities that are involved in emergency medical services, and 
then, with the recommendation of the non-Federal advisory body 
to advise FICEMS on issues, and up until the IOM report, that 
was the vision of where we wanted to go with respect to Federal 
coordination. And the IOM report actually looked at that issue, 
but it was felt that a department of emergency care, or 
division of emergency care, that included trauma, EMS, 
emergency medicine--that's hospital-based EMS for children--was 
principally health-based, and recommended that it be at HHS.
    However, as I mention in my testimony, there are a number 
of concerns about how we make that kind of transition. The 
program at NHTSA has worked very well for EMS, even though it's 
modestly funded. And as modest a program as it is, our concern 
is that, in the transition, that we might lose funding, lose 
coordination, etc. So, we have a lot of concern about how this 
would be affected.
    Senator Burr. I would suggest to you that's not a new issue 
up here. Usually anybody's hesitancy about a change in program 
has, first, to do with funding, and, at some point down the 
line, the evaluation of, in fact, whether it fits better. And I 
think the one thing you've seen in the last 2 years is an 
attempt to try to take the healthcare response, be it to 
natural, intentional, accidental events, and to make sure that 
we clearly know, before it happens, who's in charge. And with a 
great degree of reluctance on the part of the Department of 
Homeland Security, we have begun to move some of the health 
responses out of DHS and now back to HHS. We've talked about a 
collaboration that's never existed between HHS and CDC--which 
is odd, that that consultation process has not existed--but not 
necessarily moving things. And I think clearly something we 
ought to look at is whether we take this important ingredient, 
which is our emergency medical capability, and decide whether 
it needs to be under the umbrella with everything else that is 
in healthcare response. I haven't looked at it long enough to 
make an opinion today, but I think it's certainly something 
we'll continue to explore.
    Margaret, the Joint Commission made some strong progress in 
the areas of pay-for-performance, and I want to give you an 
opportunity to talk about how that might improve the quality of 
emergency care, and, more importantly, how Congress can assist 
us in getting there. And, as a side to that, Do we have the 
access today to the data that allows us to make a determination 
about our ability to pay for performance?
    Ms. VanAmringe. Certainly. Well, I think pay-for-
performance poses a number of opportunities, for a couple of 
reasons. First, it can be a good statement to the healthcare 
professions about what other people believe, on a consensus 
basis, are important priorities to pay attention to. And, 
second, financial incentives are very powerful, so it gets 
people's attention when you append money to a particular 
behavior you would like to have.
    I think we do have a lot of information, because there's 
been over a hundred demonstrations on pay-for-performance, to 
show that financial incentives can have a positive effect. Of 
course, we also have to worry about unintended consequences in 
any programs. There always have to be some evaluation of what 
you do to make sure that you haven't changed the situation in a 
way that's also negative. But I think the opportunity here for 
Congress is great, because the Medicaid program, for example, 
must provide to Congress, by 2008, a plan for how it's going to 
move--pay-for-performance. And a number of the things we've 
talked about today could be considered under that framework.
    We've talked about trying to provide incentives for 
hospital leaders to have a more efficient system, and that 
means cultural changes. But it means investing in management. 
It doesn't mean money-investing all the time. But it's time. 
And time, of course, can translate into money. But if hospital 
leaders, for example, could have incentives to pay attention to 
moving patients through to having a bed czar, as was mentioned 
before, for making sure that the physicians write their 
discharge notes early in the morning instead of late in the 
afternoon, that there are ways to smooth the surgical schedule. 
There are so many things, through an operations research type 
of evaluation and through efficiencies, that hospitals could 
do. So, if you put some monetary incentive, and you say that, 
``If you meet these standards for efficiency in your hospital, 
you're eligible for an incentive payment,'' I think we would 
get a lot more attention paid to the management side of things 
that we need to have to make sure that the ED is, again, not 
the victim of all of the problems that are occurring in the 
larger hospital itself.
    Senator Burr. Do you feel confident we know enough about 
the rest of the system to be able to identify those places?
    Ms. VanAmringe. We have a lot of data to show that--what 
some best practices of hospitals have done, how that has 
reduced not only the overcrowding, but ambulance diversion. So, 
we have hard data to show that these practices have a very 
beneficial effect. So, I think we have an opportunity to wrap 
up some of those ends so we don't get caught up with only 
looking at clinical measures under pay-for-performance, that we 
also look at some process measures that we're talking about 
that are problematic today.
    Senator Burr. Nancy, several years ago, the Colorado Nurses 
Association surveyed nurses in seven States. One-third of the 
respondents had been victims of workplace violence in the 
previous year. According to Department of Labor, healthcare 
services led all service industries in nonfatal assaults and 
violent acts resulting in lost workdays. What concerns do you 
have for staff safety, and especially as it relates to the 
crowded ER situation today? And I think it goes without 
saying--we alluded to the first preference of ER drop-points 
for law enforcement on mental health, on substance abuse, and I 
think we could probably all come up with a very lengthy list.
    Ms. Bonalumi. You're absolutely correct. The Bureau of 
Labor Statistics reported that the healthcare industry led all 
other sectors in workplace assaults, at four times the rate of 
any other group within their statistics. And of that workgroup, 
registered nurses represented 46 percent of those people who 
were assaulted. Because we're on the front lines of healthcare 
and we spend probably the most amount of time at the bedside of 
patients and their families, we tend to be the people who get 
into harm's way when things go awry.
    There are a number of factors in the emergency-department 
environment that influence that, starting with the fact that 
emergency departments generally have unlimited access and 
generally low amounts of security because of staffing. We have 
our doors open 24 hours a day. The light is on. And we're there 
for people in our community to come in. We want them to find 
their way to us when they need us. But that also means that 
people can get into the emergency department who might not be 
there for good intention.
    I had an experience in a hospital that I worked in, in 
Pennsylvania, where a patient was brought in by the police to 
be screened before going to jail. He wrestled the gun away from 
the police officer and discharged it in a part of the emergency 
department that was occupied by 10 other patients and a large 
number of staff. The bullet went through the door, skidded 
along the floor, and stopped at the foot of one of my staff. 
And I can tell you, that was an enormous event for our 
department. We were thankful no one was seriously hurt. The 
officer was actually injured by the assault. But had that 
bullet gone to another patient or to a member of our staff, I 
think the consequences would have been phenomenal. But that is 
just the environment that we work in, and we willingly walk 
into that every single day.
    I think that hospitals need to look at the standards that 
were created by OSHA, guidelines for preventing workplace 
violence for healthcare and social-service organizations. Those 
are voluntary guidelines. But I think hospitals need to have 
zero-tolerance policies for violence that occurs in the 
workplace setting. Patients come into the emergency department 
on an unplanned basis. They don't wake up and say, ``Gee, I 
think I'll fall down the stairs and break my ankle at 2 o'clock 
this afternoon.'' So, when they come in, it's always a 
disruption to their lives, and certainly a disruption to them 
and to their families. Compounded with a long wait in a crowded 
space or a very unprivate hallway, anger and frustration begins 
to rise. That, coupled with patients who come in, as we talked 
about, under the influence of drugs, alcohol, and the 
increasing number of patients with mental illness who have 
nowhere to go to receive any community services, is really just 
a place waiting to ignite with violence.
    And so, we see that in the evidence and the statistics of 
who's being hurt in the emergency-department setting, and I 
fear for my staff. We have had two events since January in the 
emergency department I work in, where family members have 
gotten into altercations with other family members, or with 
members of our staff. I work at a trauma center. And if the 
person who came in was a victim of violence, frequently those 
who, kind of, created that violent setting are looking to 
finish the job, and you have to be very careful screening 
people who come in claiming to be the family member of so-and-
so who came in to be--who came in as a result of a gunshot 
wound or a stabbing, because, honestly, they may be in there to 
try and finish that off. They walk in with guns and weapons. In 
most emergency departments we're not patting people down or 
making them go through metal detectors. So, my staff is at risk 
every day that they come to work, and yet they willingly do it, 
because they know their job is to be there, as Rick said, to 
take care of people who are sick. And it is just a consequence 
of the environment we work in. So, I worry about them. And I 
worry, nationally, when I look at these statistics, about how 
unsafe our hospitals really can be and what opportunities we 
can take to help regulate that and at least create safer, 
stronger environments for our healthcare workers.
    Senator Burr. Nancy, thank you. And I want to thank all of 
you. I have to apologize, but they're going to make me go to 
the Senate floor and actually work now. That's the only way I 
can make my wife believe that I actually do something up here, 
if she sees me occasionally on TV.
    Let me end with this. I think Dr. Blum made a statement 
that I think probably displays how difficult this is, because 
it is the way one State or one town looks at it. You said, 
``We're not building new ERs.'' And I'd be willing to bet that 
we are. In North Carolina, in the five urban areas I can think 
of--my hometown of Winston-Salem, two 800-bed facilities, both 
have state-of-the-art ER facilities being built right now--that 
built state-of-the-art ER facilities 5 to 7 years ago. And so, 
I hope you understand that, one, there is a lot of that going 
on. It is not, probably, everywhere that it needs to be done.
    And I also have to look at some of it and ask, Are we doing 
it in places that we shouldn't? And I think that is the tricky 
balance we're trying to establish, that we need to make sure 
the healthcare system, delivery system of the future, that all 
the pieces are designed specifically for what we want to 
deliver there, because we can't afford to deliver what can be 
done more effectively, from a cost standpoint and from a 
quality standpoint, somewhere else.
    I'm not sure we can answer all the questions about 
emergency services without understanding where it is we need to 
go, from an overall standpoint in our healthcare system, and 
that these are all interconnected. And as we design that 
delivery system of the future, and we know which piece of it 
Medicaid plays and which piece of it Medicare plays, and how 
they interact within the delivery system, it suggests to us the 
role of hospitals and emergency rooms and urgent-care 
facilities, and, yes, Walgreen's and the decisions that a Wal-
Mart might make in the future as it relates to our healthcare 
system.
    If there's one thing that disappoints me, it's the lack of 
boldness on the part of Congress to tackle the structural 
changes. We consistently tinker around the edges, but I think 
we would all agree that no longer are you able to get there by 
talking about the changes in reimbursements, and I'm not sure 
that we get there by incentives alone. You have to have a 
system that reflects that type of change. If we're moving to 
performance-based pay and performance-based reimbursements, 
then it is hard for me to believe you can get there if you 
don't have the IT infrastructure in place to collect the data. 
If not, we're trying to find a white shirt in a black closet.
    So, it really is everything in total. This is one that is 
of great urgency because of exactly what it is, and it delivers 
care to the most vulnerable, or to the sickest, or to the ones 
who don't have time to be anywhere else. And I think, for that 
reason, it is important that we start with it, because we want 
to make sure at least the core function of the ED is 
something--that we're able to deliver, and we're not encumbered 
by things that we could change today. But, from the standpoint 
of its overall structure and how it fits, clearly that's a much 
bigger issue that we will deal with.
    The Commission, as it relates to recommendations--I try to 
remind everybody that, as it relates to healthcare, sometimes 
we believe that we have an unlimited pot of money. And the 
reality is, we have a designated pot of money in this country 
that we're going to devote to healthcare. Today, a lot of 
people participate in the funding of that--the Federal 
Government, State government, employers, employees. There are a 
lot of different pieces of it. The pot does not get bigger. The 
way we split the pot up is affected. And when we recognize 
that, we understand just how close to the edge we are. Because 
if it was unlimited money, it would be real simple to handle 
the nurse shortage. We would just pay more. We would, I know. 
But that water balloon, when we allow you to expand, causes a 
real difficult situation to somebody else--that might be the 
ED, it may be some other area of the hospital. So, everything 
has a consequence, whether it was unintended or not. There is 
an effect that it has on the system, and our challenge is, Can 
we redesign it in a way that as much, if not all, profit from 
it. More importantly, the patients are the ones that ultimately 
will be the determining factor as to whether we continue to 
deliver the same level of care.
    So, again, I want to thank each one of you for your 
knowledge that you've shared with us, and, more importantly, I 
hope that you will stay engaged in this as we go through this 
process, trying to find out where it is we need to go short-
term, medium, and long-term.
    Thank you very much. This roundtable is adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

        Prepared Statement of the American Academy of Pediatrics

    The American Academy of Pediatrics appreciates this opportunity to 
submit testimony for the record of the Health, Education, Labor and 
Pensions Subcommittee on Bioterrorism and Public Health Preparedness 
hearing, ``Roundtable on Crisis in the ER: How Can We Improve Emergency 
Medical Care?'' The American Academy of Pediatrics is a nonprofit 
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. Over the past decade, the Academy has 
engaged in a broad range of activities related to disaster 
preparedness, including policy statements on clinical care and tools 
for pediatricians in crisis situations.

                               BACKGROUND

    Emergency medical services are the foundation of our Nation's 
defense for public health disasters. The Academy expects the hearing's 
panel members to be unified in communicating a concern shared by 
emergency care providers and healthcare consumers throughout our Nation 
regarding the ability of a fragmented, over-burdened and under-funded 
emergency and trauma care system to meet the day-to-day needs of 
acutely ill and injured persons. As you are aware, the Institute of 
Medicine recently released a seminal report which indicates that our 
Nation's emergency care delivery system is in a state of crisis. 
Without a strong emergency medical services system foundation, we will 
never be able to build an effective response for mass casualty events, 
including natural disasters or acts of terror.
    In addition to the many concerns raised within the IOM report 
regarding the overall health of our Nation's emergency medical 
services--issues that impact the day-to-day ability of pre-hospital and 
hospital-based emergency care providers to respond to the needs of all 
Americans--our emergency care systems also bear some specific and 
persistent limitations in their ability to meet the medical needs of 
children.\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. The 
Academy's testimony focuses on issues concerning pediatric emergency 
preparedness so the committee may better understand the unique 
challenges faced by emergency medical care professionals as they treat 
ill and injured children, and so that you may also appreciate the 
readiness gap in pediatric emergency care.

Children Are More Vulnerable Than Adults
    It has been said that children are not little adults, and this is 
especially pertinent in a medical emergency or during a disaster. Their 
developing minds and bodies place children at disproportionate risk in 
a number of specific ways in the event of a disaster or terrorist 
attack:

     Children are particularly vulnerable to aerosolized 
biological or chemical agents because they normally breathe more times 
per minute than do adults, meaning they would be exposed to larger 
doses of an aerosolized substance in the same period of time. Also, 
because such agents (e.g. sarin and chlorine) are heavier than air, 
they accumulate close to the ground--right in the breathing zone of 
children.
     Children are also much more vulnerable to agents that act 
on or through the skin because their skin is thinner and they have a 
larger skin surface-to-body mass ratio than adults.
     Children are more vulnerable to the effects of agents that 
produce vomiting or diarrhea because they have smaller body fluid 
reserves than adults, increasing the risk of rapid progression to 
dehydration or shock.\2\
     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.

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.
     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\
     Children may be developmentally unable to communicate 
their needs with healthcare 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 healthcare 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 percent surviving the event, and with 75 percent 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 percent of all emergency department visits in the United States, 
and 5 to 10 percent of all EMS ambulance patients, the number of these 
children who require this advanced level of emergency and critical 
care, and use of the associated cognitive and technical abilities, is 
quite small. This creates a special problem for pre-hospital and 
hospital-based emergency care providers, as they have limited exposure 
and opportunities to maintain their pediatric assessment and 
resuscitation skills. In my practice, a pediatric emergency department 
located in a tertiary urban children's hospital and trauma center with 
over 50,000 annual visits, we are able to maintain those skills. 
However, over 90 percent of children receive their emergency care in a 
nonchildren's hospital or nontrauma center setting. Emergency care 
professionals in many of these settings, and most pre-hospital 
emergency care providers, simply may not have adequate ongoing exposure 
to critically ill or injured children.
    This vital clinical ability to recognize and respond to the needs 
of an ill or injured child must be present at all levels of care--from 
the pre-hospital setting, to emergency department care, to definitive 
inpatient medical and surgical care. The outcome for the most severely 
ill or injured children, and for the rapidly growing number of special 
needs children with chronic medical conditions, is optimized in centers 
that offer pediatric critical care and trauma services and pediatric 
medical and surgical subspecialty care. As it is not feasible to 
provide this level of expertise in all hospital settings, existing 
emergency and trauma care systems and State and Federal disaster plans 
need to address regionalization of pediatric emergency care within and 
across State lines and inter-facility transport as a means to maximize 
the outcome of the most severely ill and injured children.
    Children with special healthcare needs\7\ are the fastest growing 
subset of children, representing 15 to 20 percent 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.

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\
    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 healthcare 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\
    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 percent of emergency departments across the Nation 
have all of the supplies necessary for managing pediatric emergencies.
     Only half of hospitals have at least 85 percent of those 
critical supplies.
     Of the hospitals that lack the ability to provide care for 
pediatric trauma victims, only half 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\
     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. Last, 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\
    A unique consideration in pediatric emergency care and disaster 
planning is the role of schools and daycare facilities. Children spend 
up to 80 percent of their waking hours in school or out-of-home care. 
Schools and daycare 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\
    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\
    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 healthcare providers 
to calculate dosages quickly and accurately. However, one study showed 
that 46 percent of Disaster Medical Assistance Teams were lacking these 
tapes, in addition to other critical pediatric equipment.\17\
    Training is vital to pediatric preparedness. Many healthcare 
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 healthcare 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 are 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\
    It has been a source of great frustration for many of my pediatric 
and emergency medicine colleagues that our repeated calls for improved 
pediatric emergency preparedness have gone unheeded for the better part 
of a decade. As long ago as 1997, the Federal Emergency Management 
Agency raised the concern that none of the States it had surveyed had 
pediatric components in their disaster plans.\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.

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 healthcare 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 percent.
    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 statewide 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 
policymakers, researchers, providers and professional organizations 
across the spectrum of emergency care, is well positioned to assume 
this leadership role.'' \24\
    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 healthcare 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 healthcare 
facilities to address pediatric preparedness, including maintaining 
surge capacity and creating specialized treatment areas for children, 
such as isolation and decontamination rooms.
     Schools and daycare 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 healthcare 
        professionals;
          Address the care requirements of children with 
        special healthcare 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\
    School and daycare issues: Children spend up to 80 percent of their 
waking hours in school or out-of-home care. Schools and daycare 
facilities must be integrated into disaster planning, with special 
attention paid to evacuation, transportation, and reunification with 
parents.\26\
    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 
healthcare.\27\
    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 
healthcare needs, as well as for the safety and security of all 
children.

                               CONCLUSION

    In conclusion, the American Academy of Pediatrics greatly 
appreciates this opportunity to present our views and concerns related 
to pediatric emergency care and disaster preparedness. While great 
strides have been made in recent years, with many of these improvements 
the direct result of the Federal EMSC program, much more remains to be 
done. America's children represent the future of our great Nation, our 
most precious national resource. They must not be an afterthought in 
emergency and disaster planning. With focused, comprehensive planning 
and the thoughtful application of resources, these goals can be 
achieved. The American Academy of Pediatrics looks forward to working 
with you to protect and promote the health and well-being of all 
children, especially in emergency and disaster situations.

                                ENDNOTES

    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.
    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.)
    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.
    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.
    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.
    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.
    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.
    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.
    11. Durch JS., Lohr KN., (eds): Emergency Medical Services for 
Children. Report of the Institutes of Medicine Committee on Pediatric 
Emergency Medical Services. Washington, DC., The National Academies 
Press, 1993. Available at: http://books.nap.edu/catalog/2137.html.
    12. Institute of Medicine. Future of Emergency Care Series, 
``Emergency Care for Children: Growing Pains.'' National Academies 
Press, June 2006.
    13. American Academy of Pediatrics Committee on Pediatric Emergency 
Medicine and American College of Emergency Physicians Pediatric 
Committee. Care of Children in the Emergency Department: Guidelines for 
Preparedness. Pediatrics, Vol. 107 No. 4 April 2001.
    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.
    16. National Bioterrorism Hospital Preparedness Program Fiscal Year 
2005 Continuation Guidance, HRSA Announcement Number 5-U3R-05-001, 
http://www.hrsa.gov/bioterrorism/hrsa05001.htm.
    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.
    18. Committee on Hospital Care. Family-Centered Care and the 
Pediatrician's Role. Pediatrics, Vol. 112, No. 3, September 2003.
    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_prepared-ness.pdf.
    23. Institute of Medicine. Future of Emergency Care Series, 
``Emergency Care for Children: Growing Pains.'' National Academies 
Press, June 2006.
    24. Institute of Medicine. Future of Emergency Care Series, 
``Emergency Care for Children: Growing Pains.'' National Academies 
Press, June 2006.
    25. Committee on Environmental Health. Radiation Disasters and 
Children. Pediatrics, Vol. 111, No. 6, June 2003.
    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.
    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.

                Prepared Statement of Advocates for EMS

    Chairman Burr, Ranking Member Kennedy, Advocates for EMS, a not-
for-profit organization founded to educate elected and appointed 
officials and the public on important issues affecting EMS providers, 
would like to thank you for holding this important roundtable 
discussion today examining emergency care. Advocates' Board of 
Directors is comprised of members from the National Association of 
State EMS Officials, the National Association of Emergency Medical 
Systems Physicians, the National Association of Emergency Medical 
Technicians and the National Association of Emergency Medical Services 
Educators.
    We would like to address in particular, the Federal Interagency 
Committee on Emergency Medical Services (FICEMS) and the Institute of 
Medicine's (IOM) recommendation of establishing a lead agency for 
emergency medical services at the Department of Health and Human 
Services (HHS). While there is merit to the IOM's recommendation to 
establish a lead agency at HHS, we are concerned that National Highway 
Traffic Safety Administration's (NHTSA) long-standing support of EMS 
systems has not been carefully considered. Never in our Nation's 
history has there been a time when EMS systems need more coordination 
and consolidation of EMS activities. The new, fully-formed FICEMS is 
the ideal body to consider the lead agency issue and fully form a 
consensus on how to best organize and perhaps realign Federal support 
of EMS systems.
    Advocates has long been concerned about emergency medical services 
getting lost in the shuffle at the Federal level. For the past 20 
years, Federal support for EMS has been both scarce and uncoordinated. 
In fact, following the September 11th attacks, when the country focused 
its attention on all terrorism preparedness, first responders were 
described as police, fire, and ``other.'' In conjunction with police 
and fire, EMS is the primary first responder for medical assistance in 
the event of a natural or man-made disaster or public health emergency. 
However, unlike with police, fire and emergency management, there was a 
lack of coordination at the Federal level and no dedicated program to 
support EMS infrastructure or disaster response. Currently, several 
Federal agencies are involved with EMS, though most focus on just one 
segment of the EMS system, such as fire-based EMS, EMS for Children or 
trauma systems.
    In 2001, the General Accounting Office cited in its report, 
Emergency Medical Services: Reported Needs are Wide-Ranging With a 
Growing Focus on Lack of Data, the need to increase coordination among 
Federal agencies as they address the needs of regional, State or local 
emergency medical services systems.
    During the 108th and 109th Congress, Advocates worked closely with 
Senators Susan Collins and Russ Feingold as well as members of the 
Senate Commerce, Science and Transportation Committee to authorize the 
FICEMS that would serve to coordinate the various Federal agencies that 
are involved in EMS, including HHS, the Department of Homeland Security 
(DHS) and NHTSA at the Department of Transportation. On August 10, 
2005, the FICEMS was signed into law as part of H.R. 3, the Safe, 
Accountable, Flexible, Efficient, Transportation Equity Act--A Legacy 
for Users (SAFETEA-LU). The new FICEMS is beginning its work this year.
    Advocates believes the new FICEMS will greatly enhance coordination 
among the Federal agencies involved with the State, local, tribal and 
regional emergency medical services and 9-1-1 systems. The Interagency 
Committee will help assure that Federal agencies coordinate their EMS-
related activities and maximize the best utilization of established 
funding. In addition, the FICEMS is required to submit an annual report 
to Congress to help provide Members of Congress with information on 
emerging Federal EMS issues.
    We worked with Members of Congress to establish the FICEMS at NHTSA 
because of NHTSA's longstanding role in EMS. Since the early 1970's 
NHTSA has been the only agency to consistently focus on improving the 
overall EMS system. NHTSA has been responsible for creating national 
standards for EMS education, operations and system development. NHTSA 
supported the creation of a consensus-based national EMS strategic 
plan, the EMS Agenda for the Future, which united the many professional 
factions of EMS service in a common effort to improve system 
performance.
    As a result of this long-standing leadership, national EMS leaders 
and organizations rely on NHTSA for guidance on a wide range of EMS 
issues. NHTSA is widely considered by the EMS community to be the lead 
Federal EMS agency addressing the overall EMS system that is comprised 
of many different organizational structures, including fire-based (42 
percent), hospital-based (7 percent), other governmental or public 
utility model (21 percent), and private and other configurations (30 
percent). Among these organizations, part are staffed totally with 
career staff (48.5 percent), part totally with volunteers (24 percent) 
or with a combination of career and volunteer staff (27.5 percent).
    At this time, Advocates believes that establishing a lead agency 
for emergency medical services needs careful consideration. The FICEMS, 
in consultation with EMS associations and providers throughout the 
country, should study the issue and make a recommendation as to whether 
there should be a lead agency for EMS and what roles other Federal 
agencies should play in EMS. A rush to judgment would only further 
jeopardize the few EMS programs that currently exist along with their 
funding.
    An emergency medical services system serves as the safety net for 
the local health care system and individuals who call 9-1-1 for an 
emergency medical services transport when all other sources of help are 
exhausted. A comprehensive, coordinated emergency medical services 
system is essential to assure prompt, quality care to persons 
experiencing medical crisis.
    On behalf of the pre-hospital and hospital-based emergency care 
associations and providers that make up Advocates for EMS, we look 
forward to working with you as you consider this issue further.

    [Whereupon, at 4:15 p.m., the hearing was adjourned.]