Welcome to the latest issue of EMS on the Hill, a newsletter representing the work of a broad group of EMS organizations dedicated to achieving positive change and recognition for emergency medical services at the state and federal levels. In July 2007, this group of organizations met to review the recommendations of the 2006 IOM Crossroads report and develop priorities and action items to help make these recommendations reality. This newsletter will provide updates on those action items, plus discuss other critical industry issues.

NEMSAC GETS DOWN TO BUSINESS

A flurry of motions emerge from the EMS Advisory Council’s fall meeting

The National EMS Advisory Council (NEMSAC) met last October in Arlington, VA, adopting several motions in furtherance of its mission to offer advice and recommendations to the National Highway Traffic Safety Administration’s Office of EMS.

Twenty-one of the council’s 25 members attended the first day’s meeting, and 20 the second. Also present were key members of the NHTSA and the Department of Homeland Security. NEMSAC’s meetings are open to the public, and public attendance
included representatives of the International Association of Fire Chiefs, International Association of Fire Fighters, National Volunteer Fire Council and Advocates for EMS.

The first day began with a presentation and discussion concerning implementation of the EMS Education Agenda for the Future. Vermont EMS director Dan Manz, on behalf of the National Association of State EMS Officials, presented “A New Day in EMS: Education, Challenges and Opportunities With the EMS Education Agenda for the Future: A Systems Approach.” Manz stressed the amount of work still required to implement the agenda, and the group discussed existing gaps in EMS education.

Committee chairs then provided overviews of their groups’ activities and recommendations. These included the Systems; Safety; Analysis, Oversight & Research; Education & Workforce; and Finance committees.

Day two included a motion from member Kurt Krumperman, on behalf of the Finance Committee, requesting that NHTSA seek from FICEMS (the Federal Interagency Committee on EMS) the highest priority in implementing the Institute of Medicine’s recommendation that the Centers for Medicare and Medicaid Services (CMS) assemble an ad hoc working group with expertise in emergency care, trauma, and EMS systems to evaluate EMS reimbursement and make a recommendation with regard to including readiness costs and permitting payment without transport. All members were in favor, and the motion passed.

On behalf of the Analysis, Oversight & Research Committee, Ritu Sahni offered a resolution proclaiming that, in the interests of providing the most appropriate quality healthcare to patients, NEMSAC adopt “Establishing a Culture of Safety: A National Strategy,” with the development of a National Strategic Consensus Project. Again, all were in favor, and the motion passed.

NHTSA EMS director Drew Dawson noted recent changes in leadership at FICEMS. Dr. Jeff Runge, the previous chair, is no longer in federal service, and Dr. Jon Krohmer was elected as chair for the remainder of 2008. The committee’s vice chair, Dr. Kevin Yeskey, was to take over as chair in December. Dawson explained the FICEMS Technical Working Group (TWG), whose members meet monthly to assess implementation of FICEMS’ guiding Work Plan and determine strategies for collaboration, and highlighted two recent FICEMS position statements:

1. Systems receiving federal EMS grant funding must have medical oversight. If they don’t, they can use some of these funds to develop it.
2. EMS systems nationwide should be encouraged to adopt the National EMS Information System (NEMSIS).
   As well, Cathy Gotschall, of NHTSA’s Office of EMS, provided an overview of the “From Evidence to EMS Practice: Building the National Model” conference held in September. For more on that, see Washington Watch on page 4.

Under new business, discussion turned to the air medical crash increase of the past 1–2 years. LifeFlight of Maine’s Tom Judge suggested there should be a way to classify emergencies and guide decisions pertaining to mode of transport, and moved that NEMSAC ask NHTSA to identify opportunities to develop national guidelines around the topic of mode of transport. All members were in favor, and the motion passed.

The group’s next meeting was planned for January, with a teleconference to follow in April and another meeting in June.

—Heather Caspi, EMSResponder.com

NATIONAL REPORT CARD ON EMERGENCY CARE PAINTS AN OMINOUS PICTURE

‘People are dying in waiting rooms because there are no beds available.’

Every child knows a bad report card means trouble and possible punishment. But the report card released in December by the American College of Emergency Physicians calls for more extreme measures than just being grounded.

The results of a two-year survey of all 50 states present a picture of an emergency care system in serious trouble, with an overall grade across five categories of C-. The five areas analyzed were access to emergency care, patient safety environment, medical liability environment, public health and injury prevention, and disaster preparedness. Although some states did better in some categories, the strong D- for access to care brought the overall average down.

“Last year, emergency providers took care of approximately 120 million people, which is about two out of every five,” says ACEP spokesperson Andrew I. Bern, MD, FACEP. That, he says, has resulted in an ambulance diversion every minute of every day, 365 days a year.

“The National Report Card on the State of Emergency Medicine is really focusing on the systems support structure, legislation and regulatory environment,” Bern says. “It doesn’t speak to what individual hospitals or ED physicians are doing, but rather about the environment in which the whole system is operating. Is it favorable or not? Is there good access to care or not? Is the quality and patient safety environment good or not, and why? Is the medical liability environment supportive for the emergency patient, or is it a toxic environment that’s encouraging physicians to retire or leave, thereby reducing patient access to specialty care?”

According to Bern, a bill will be introduced in the next Congress calling for a bipartisan commission to evaluate all the factors involved in delivery of emergency care and, where problems can be identified, make specific recommendations to help.

“One of the problems is that it’s hard to get our hands on all the necessary information,” says Bern, also a member of ACEP’s board of directors. “For example, there’s no national tracking of diversions, so we don’t know who’s being diverted from which hospitals, what patients they’re carrying and with what problems, and why they were diverted. One reason no action has been taken is that there hasn’t been a public outcry saying, ‘Look, we have a problem here.’ Emergency departments have become the safety net, and they’re facing increasing volumes and a reduction in number across the country, and it’s resulted in reduced capacity to take care of patients.”

States received the highest overall score, a C+, in the category of Quality and Patient Safety Environment, with seven states receiving an A and five others an A-. For Medical Liability, however, the national score was a mediocre C-, and Public Health and Injury Prevention came in just a bit higher with a C. This category includes an infant mortality rate across the United States that’s listed as 6.9 per 1,000 live births—twice the rate of six other countries and only 28th-best worldwide.

Although this was a national report card, local agencies need to be concerned and start getting involved in their communities by making the public aware of what’s happening and how their own care might be impacted, says Bern.

“In some states, the prehospital community is joining with emergency physicians, medical staff and organized hospital associations and approaching their state legislatures about the problem,” Bern says. “Numbers matter, and they need to build those alliances, mobilize the civilian population, and let individual lawmakers know that people are dying in waiting rooms because there are no beds available to treat them in. That their own family member might have injuries that require the skills of a neurosurgeon and there might not be one available, and that’s unconscionable in the United States. Watching the financial crisis in the U.S., we have to point out that the healthcare industry is also being critically affected, and we need to let local, state and federal lawmakers know this is an important issue we can no longer afford to ignore.

“The real problem is that we in the emergency medical community have been making it work with fewer and fewer resources, and it’s becoming more and more difficult,” Bern adds. “It’s like a being in a pressure cooker, where the system is churning and boiling, and we’re just waiting for it to hit the pressure release valve. It’s a great credit to the prehospital care providers, physicians and hospital personnel who are holding this safety net together, but we’re almost at the point where the string will break and the whole thing will melt down. We need to correct that, because a lot of lives are at stake.”

CDC HONORS MODEL COMMUNITIES

The Centers for Disease Control and Prevention identified seven model communities for 2008 as part of its TIIDE (Terrorism Injuries: Information, Dissemination and Exchange) project, which recognizes excellence in linking emergency medical services to other safety and public health agencies in times of disaster.

The 2008 model communities were Orlando, Fla.; Minneapolis/St Paul, Minn.; Indiana Co., Penn.; Aurora, Colo.; Danbury, Conn.; Southern New Jersey; and Kalamazoo, Mich. These locales, the CDC says, benefit from strong public health and medical partnerships that work together to respond to large-scale incidents.

Objectives of the TIIDE project include partnership building, learning lessons from previous terrorist events, and disseminating information. It’s designed to meet the need to develop and exchange information about injuries from terrorism, including community strategies to improve public safety, public health, clinical management and healthcare system preparedness for mass-casualty incidents.

Model communities honored in 2007 were Chouteau Co., Mont.; Pinellas Co., Fla.; San Diego Co., Calif.; the Palm Beach County, Fla., Healthcare Emergency Response Coalition; and the Southeast Region 7 Wisconsin Hospital Emergency Preparedness Plan. Those recognized in 2006 were Boston, Mass.; Eau Claire Co., Wisc.; Erie, Livingston and Monroe counties, NY; Louisville, Kent.; and the Southern Nevada Health District.

These honorees, the CDC says, have successfully improved collaboration and relationships between the emergency care and public health communities to better daily operations and disaster preparedness. Their common features include strong medical oversight for both public health and emergency care; efforts to educate both communities about each other’s roles and responsibilities; maintenance of relationships through regular meetings, planning and team-building exercises; stakeholder involvement in planning processes; disaster plans developed locally with broad involvement and repeated drilling; and aggressive pursuit and acquisition of funding. For more, see www.bt.cdc.gov/masscasualties/modelcommunities.asp.

Advocates for EMS: Successes in 2008 Lay Foundation for More Progress in ’09

By Lisa Meyer

As the EMS community begins a new year, Advocates for EMS is not only in the process of setting its agenda for 2009 but also reflecting on a very successful 2008. Advocates implemented an aggressive advocacy agenda and believes it’s important to highlight a number of successes to show the organization’s ever-growing presence on Capitol Hill.
Those successes include:

• We developed consensus policy positions among the EMS community that protected funding for vital programs that support EMS across the federal landscape.

• We supported S. 1873 and H.R. 3173, the Improving Emergency Medical Care and Response Act of 2007, respectively introduced by then-Sen. Barack Obama (D-IL) and Rep. Henry Waxman (D-CA). This legislation would create four multiyear grants to support demonstration programs aimed at designing, implementing and evaluating a regionalized, accountable emergency care system and provide additional support for EMS research at the federal level.

• We added nine members of the House of Representatives to the Congressional EMS Caucus.

• We conducted EMS policy summits at the industry’s major conferences/trade shows, EMS EXPO in Las Vegas and EMS Today in Baltimore. Representatives from various federal agencies participated in a panel that provided attendees updates on activities at the federal level that impact EMS providers and answered questions from audience members.

• We successfully advocated for the creation of a $30 million grant program in the 2008 Farm Bill for equipment and training for rural firefighters and EMS providers.

• Advocates successfully worked with members of Congress to secure $750,000 in fiscal year 2008 funding for the National EMS Information System (NEMSIS). This money was included in the Senate version of the Transportation appropriations bill, and the final appropriation will be determined when the 111th Congress and President-elect Obama take office and remaining bills are passed and signed into law.

  Additional funding for NEMSIS remains a top priority for FY 2009.

• We worked with the National EMS Memorial Bike Ride to coordinate an event in Washington’s Upper Senate Park, next to the Russell Senate Office Building, honoring EMS providers who died in the line of duty and promoting H.R. 3822, legislation broadening the Public Safety Officer Benefit program to include nongovernmental and volunteer firefighters, ground and air ambulance crew members, and first responders.We facilitated communication with representatives and senators on Capitol Hill for Advocates members by adding an online advocacy tool to the Advocates for EMS website (www.advocatesforems.org).

• Advocates convened monthly conference calls with national EMS organizations and coordinated advocacy actions, including sending out action alerts to partners to engage in grassroots advocacy on appropriations and authorizing legislation.

• Other legislation Advocates supported or monitored that did not make it through the legislative process before members departed to campaign in their home states and districts included the Improving Emergency Medical Care and Response Act, reauthorization of the Emergency Medical Services for Children program, the Veterans to Paramedics Transition Act and the Stroke Treatment and Ongoing Prevention (STOP) Stroke Act. These bills will have to be reintroduced in 2009 when the 111th Congress convenes.

• Advocates partnered with the International Association of Fire Fighters, International Association of Fire Chiefs, National Volunteer Fire Council and National Association of Government Employees in advocating for the reinstatement of a provision in the Ryan White CARE Act that will be renewed by Congress in 2009. The provision, which was eliminated during the bill’s last reauthorization, would require emergency response employers to have a designated officer for infection or exposure control to field calls from employees regarding exposures to communicable diseases, and to obtain the disease statuses of source patients in those exposures from the medical facilities providing treatment to those patients.

Advocates looks forward to building on those successes in 2009 by working with the 111th Congress and new administration. Priorities include continued funding for NEMSIS; adding members to the Congressional EMS Caucus; reinstating the first responder worker protection provision eliminated in the Ryan White CARE Act; supporting legislation broadening the Public Safety Officer Benefit program to include nongovernmental and volunteer firefighters, ground and air ambulance crew members, and first responders; and seeking support and new sponsors for the Improving Emergency Care and Response Act, among others.

Please visit www.advocatesforems.org to join and for updated information on our advocacy efforts.

WASHINGTON WATCH

NIMS Revision for 2009

Just in time for Christmas, emergency officials received an updated version of the National Incident Management System (NIMS) from FEMA and the Department of Homeland Security. The revised version of NIMS—which sets standardized processes, protocols and procedures for emergency responses—clarifies some concepts, better incorporating preparedness and planning and improving overall readability. For more, see www.dhs.gov.

NTSB Wish: Safer EMS Flights

The National Transportation Safety Board cited safer EMS flight operations as one of its Most Wanted improvements for 2009.

The NTSB made a series of recommendations concerning EMS air safety in 2006, but the FAA has not mandated them under law, and crash and death numbers have increased in recent years. Between December 2007 and October 28, 2008, when the NTSB’s list was issued, there were nine EMS accidents, killing 35 people.

Areas addressed by the NTSB include runway safety, safety in icing conditions, requiring flight image recorders, and providing Crew Resource Management training. See www.ntsb.gov.

Major Fire Groups Argue for Keeping FEMA Under DHS

Major fire-service groups are asking the Obama administration to keep FEMA within the Department of Homeland Security.

The International Association of Fire Fighters, International Association of Fire Chiefs and Congressional Fire Services Caucus sent a letter to the president-elect earlier this month, noting recent media discussions of restoring FEMA’s independent status. The fire groups cited improvements made since Hurricane Katrina and FEMA’s successful responses to flooding and hurricanes in 2008 as reasons to keep it where it is.

EMS Managers: Budget Cuts Would Endanger Lives

A third of EMS and fire managers surveyed by the National EMS Management Association (NEMSMA) and Best Practices in Emergency Services believed cuts to their budgets in these lean times would put lives at risk, and almost half thought the public should be concerned about their emergency services in the near future.

More than 450 managers took the groups’ voluntary online survey in December. For more results, see www.nemsma.org. NEMSMA also sent a letter to President-elect Barack Obama and Health and Human Services Secretary-nominee Tom Daschle making 11 recommendations for better federal support of EMS.

Experts Tackle Improving the Evidence Behind EMS

Experts in EMS and evidence-based medicine came together in Washington, DC, late in 2008 to begin devising a process to remedy the lack of evidence-based guidelines for EMS care.

Cosponsored by the Federal Interagency Committee on EMS (FICEMS) and National EMS Advisory Council (NEMSAC), the “From Evidence to EMS Practice: Building the National Model” conference featured ideas and recommendations in support of a national, consensus-based process to develop better evidence to support EMS interventions. Experts considered how such a process would be created and executed, and how guidelines would be developed, then translated into practice.

Their ultimate proposal was to be submitted to FICEMS and NEMSAC, then opened for public comment. For more, including links to conference presentations, see www.ems.gov.

Too Little Being Done to Track Nonfatal Public Safety Injuries

We have a pretty good idea what hurts public-safety providers on the job, but we don’t track such injuries sufficiently or do enough to prevent them, a study from the RAND Corp. found.

Nonfatal injuries to EMS providers, firefighters and police officers are far more common than fatal injuries, the study determined, and create more costs. Yet less is done to track their incidence and causes. “This makes the lack of good data on these kinds of injuries a serious gap,” lead author Tom LaTourrette said.

For more: www.rand.org.

THE DOCTORS WILL SEE YOU NOW

Telemedicine’s arrival, in homes and at jobs, means changes for EMS

By John Erich, Associate Editor

The Ameya Preserve housing development, near Bozeman, MT, won’t be finished until 2011. But already it may represent a dramatic evolution in the future of emergency medical care in the U.S. Under a first-of-its-kind agreement, each of the development’s 300 homes will be telemedicine-equipped and provide residents around-the-clock access to physician advice and consultation.

Residents—who will live 45 minutes from the nearest healthcare facility—will connect by phone, Internet and/or bidirectional video to doctors from SwiftMD, a New York-based telemedicine provider now offering similar services in that state.

Under the company’s model, subscribers call a toll-free number or seek help through www.SwiftMD.com. A doctor contacts them back to gather information and ask questions, referring to their individual electronic health record, which both parties can securely access. Patients then get a diagnosis and course of treatment without having to leave their home or office.

This works, CEO Elliott Justin, MD, says, because the vast majority of what people go to doctors for is minor stuff—aches, pains, sprains, sniffles, etc.—that can be safely and easily treated remotely.

“Most people who come to ERs and primary care offices really just need advice or a prescription, and that’s the only way they can get it,” Justin says. “We inconvenience people, and make them come to us, because that’s how we make money. This business is an attempt to address that deficiency.”

With this growing realization and advances in technology, telemedicine is spreading rapidly. Another New York service, Hello Health, offers a similar model to SwiftMD’s, with physician consultations by e-mail, text message, IM or video, but with in-person appointments also available. And for casual users, even places like ubiquitous retail giant WalMart are getting into the game—some of its locations now go beyond “minute clinics” to offer full telemedicine links.

“When you combine that with $4 generic prescriptions and a desire to get people into your store to buy other stuff,” observes Don Jones, an EMS veteran who now leads Qualcomm’s efforts to incorporate wireless technologies into the healthcare and medical device markets, “you’re actually changing the face of how medicine’s delivered.”

The doctor could also come to your place of employment: SwiftMD is working with vendors of healthcare kiosk technology who can offer companies one-stop employee healthcare facilities, with information like vital signs streamed directly to clinicians. And while users currently get that information to their docs verbally or by e-mail, other advances will soon make it simple to send electronically.

A Pennsylvania-based company, CardioNet, now offers mobile cardiac outpatient telemetry that allows heartbeat-by-heartbeat remote ECG monitoring, analysis and response 24/7. Arrhythmias are detected automatically, expediting intervention. BiancaMed, from the U.K., makes products for the contact-free sensing of heart rate and respiration for groups like babies and athletes. And San Diego’s Triage Wireless is working on “smart” bandages—peel-and-stick biosensors that noninvasively transmit seven vital signs, including blood pressure.

As products and services like these and more come into wider use, it portends a lot of change for EMS. A lot of minor, nonemergency ambulance calls may be prevented, relieving stressed systems and congested EDs. And EMS, having more data gathered with less effort, may be better informed and better prepared to treat patients. Those patients will have more information at their disposal as well, potentially including metrics like their own vitals, feedback from professionals and even care programs tailored to their own risks and medical profiles.

How it all looks, exactly, will be determined over time. But for EMS, know that change is coming.

“We’re liberating healthcare from traditional brick and mortar—that’s the 21st century solution to the increasing demands on our ill-supplied healthcare sector,” says Justin. “With telemedicine, we can take the exam rooms to where people are. It’s a powerful tool for a system that’s crashing.”

LOOKING OUT FOR RESPONDERS” FAMILIES WHEN DISASTER STRIKES

In the event of a disaster, public safety personnel are expected to respond quickly and remain on duty until the catastrophe is over. But while they’re looking after the needs of others, their own families are often left to fend for themselves.

Until now: In partnership with the Department of Homeland Security, the Gulf States Regional Center for Public Safety Innovations (GSRCPI) is in the final stages of developing a training program that will provide planning tools for agencies and corporations to better provide for the safety and security of first responder employees and their families.

GSRCPI director Daphne Levenson had the idea for the program after a personal experience during Hurricane Katrina. While she was working at headquarters in Baton Rouge, a call came in from the wife of a police officer from a small department in south Louisiana. The wife had evacuated with her three children to Dallas.

“Her credit cards were maxed out, she had no way to write a check or get money, she was about to be put out of her hotel, and she didn’t know if her husband was alive or dead,” says Levenson. “One of the kids needed a prescription, but she couldn’t reach the doctor, and her cell phone didn’t work because the entire 504 area code was out of service.”

Eventually, says Levenson, the Dallas Fraternal Order of Police helped the woman find a room and a doctor and located her husband, who was alive and equally worried about his family. “It was frustrating to me that responders are out there putting their lives on the line with no support systems for them and their families, and it became obvious that these people need the same type of support we give military families,” she says. From that frustration came the idea for the Critical Employee Emergency Planning course.

“We’re approaching the issue from two perspectives,” says program manager Joel Bolton. “What the agency can do to care for their employees during a catastrophic event, and what employees and their families need to do to be prepared, from what they need to have on hand to the mental and emotional preparation.”

The eight-hour course will begin with an overview of the frequency and unpredictability of disasters and catastrophic events and encourage local agencies to think about what could happen in their areas, says Bolton. The second module talks about local agency-level planning, potential reactions to various scenarios, evacuation and loss of shelter, the impact on dual-responder couples and who will care for their children, making communication plans and knowing how families will stay in touch.

“In the next module, we try to make employees and their families aware of what might happen so they can be better prepared emotionally for what a catastrophe can do,” says Bolton. “The last section deals with actual planning: how to take the information back to the agency and what to do to get prepared.”

Three pilot projects have been completed, and final approval is expected from DHS this month, says Bolton. “Even though we haven’t done any promotion, we have a waiting list of 40 agencies that want to host the course,” he says. “The genesis of this is keeping employees on duty when you most need them and not having them distracted about whether their families are safe. Just a little bit of preplanning can go a long way to make that happen.”

For more information, go to www.gsrcpi.org/ceep.asp.

SEVEN YEARS AFTER 9/11, TERROR REMAINS THREAT

It’s been seven years and counting since 9/11, with no new attacks on U.S. soil. But if Americans needed a refresher about the bloody horrors small groups of determined terrorists can inflict, November events in India provided a graphic one.

In a series of 10 coordinated attacks launched Nov. 26 in Mumbai, militants linked to a radical Pakistani group killed at least 164 people using grenades and automatic weapons. A siege at the Taj Mahal lasted until the 29th. Just one terrorist was ultimately captured alive.

In the attack’s aftermath, the official response was derided in The Times of India as “shockingly lax.” Blaming a lack of disaster planning even after previous attacks, The Times reported confusion and lack of communication between state authorities and hospitals during the response, including ambulances being turned away from facilities unprepared to receive bodies.

It goes without saying that such an assault could still happen in the U.S. In December, the bipartisan Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism (www.preventwmd.gov) warned that the U.S. should expect a terrorist attack using nuclear or biological weapons within the next five years. “Our margin of safety,” Commission members concluded in their World at Risk report, “is shrinking, not growing.” Also late last year, British intelligence officials warned the U.K.’s National Health Service that al Qaeda operatives had been buying ambulances, fire engines and police vehicles on eBay for possible use in attacks.

Other experts are sounding other alarms. Organophosphorus nerve agents, former New York City emergency management director Jerome Hauer emphasized in an EMS Magazine online exclusive, “are highly toxic and can be obtained relatively easily in quantities sufficient for terrorist attacks.” He called for more PPE and training for first responders who may respond to chemical attacks.

—John Erich, Associate Editor

MINNESOTA PLAN: TRAIN COMBAT MEDICS FOR CIVILIAN EMS

Shortages of EMS providers persist in many areas. At the same time, skilled combat medics are returning from the Middle East. Recognizing an obvious match of resource and need, EMS authorities in Minnesota are developing a program to help turn combat medics into civilian EMS providers.

The plan was introduced a year ago and received enthusiastically by state lawmakers. Money for it was lost, however, as the final budget shook out. Now supporters are trying again, with high hopes of winning funds.

“It’s truly a win-win proposition,” says O.J. Doyle, a lobbyist with the Minnesota Ambulance Association, which would use the funding to help participating agencies and training institutions develop abbreviated programs to bring soldier-medics up to state qualifications. “It helps, in one small way, to pay back our veterans, who have invaluable training and real-life experience. And it also addresses a shortage of qualified ambulance personnel in parts of the state.”

The plan could involve income tax credits for participating providers and agencies, and property tax credits for providers willing to serve in areas with shortages.

At the federal level, Minnesota Sen. Amy Klobuchar last year introduced the Veterans to Paramedics Transition Act, which would serve a similar function. That bill died in committee but could be reintroduced this year.

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