Riding Off into the Sunset' Where do we go from here

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Riding Off into the Sunset.Where do we go from
here

• Thomas J. Esposito, MD, MPH
• Medical Director, REMSTTAC
• Professor of Surgery, Loyola University Medical
  Center
• Maywood, IL

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Major Paradigm Shift

• EMS pre-hospital issues
• EMS Services needed to address the needs of all
  patients who present with an emergency condition
  throughout the continuum of the health care
  system, i.e. prevention rehabilitation

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Major Paradigm Shift

• BT Bioterrorism
• BT Bomb Terrorism
• gt funding directed toward trauma systems and
  care of multisystem physical trauma and burns

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Major PI E Efforts

• Public
• Elected Government Officials

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The Public Good Model

• The 4th public service
• Police
• Fire
• Pre-hospital EMS
• Post-hospital EMS

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There is public support
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Almost all Americans feel it is extremely or very
important to be treated at a trauma center in the
event of a life-threatening injury (after hearing
a description of a trauma center).
indicating how important it would be to be
treated at a trauma center if they or a family
member had a serious or life-threatening injury
Trauma centers are selected hospitals that
provide a full range of care for severely injured
patients 24 hours a day, seven days a week. This
trauma care includes ready-to-go-teams that
perform immediate surgery and other necessary
procedures for people with serious or
life-threatening injuries, for example, due to a
car accident, burn, bad fall, or gunshot.
Q605 If you or a family member had a serious of
life-threatening injury, how important would it
be to be treated in a trauma center? Base All
respondents (N1000)
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About nine in ten Americans think it is extremely
or very important for an ambulance to take them
to a trauma center in the event of a
life-threatening Injury, even if it is not the
closest hospital.
indicating how important it would be taken by
ambulance to a trauma center even if it were not
the closest hospital
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Q610 If you or a family member had a serious of
life-threatening injury, how important would it
be to be that an ambulance be instructed to take
you to a trauma center able to handle your
specific injury, even if it is not the closest
hospital? Base All respondents (N1000)
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Nine in ten Americans feel that having a trauma
center nearby is equally or more important than
having a library.
indicating that compared to a having a public
library, a trauma system is
Q617 Is having a trauma center within easy reach
of where you live more important, equally
important, or less important that having a public
library? Base All respondents (N1000)
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Nearly eight in ten Americans would be willing to
pay a dime or more per year to have trauma
centers and systems in their state. Over half
would be willing to pay 25 or more.
indicating how much they would be willing to
pay per year to have trauma centers and a trauma
system in their state ready to provide care if
they or their families were seriously injured
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Q735 How much would you be willing to pay per
year to have trauma centers and a trauma system
in your state ready to provide care to you and
your family if you were seriously injured?
Base All respondents (N1000)
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The Public Good Model

• Under the public good model of all encompassing
  EMS, public funding would be available for system
  wide use not just the pre-hospital Side

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Technology

• The 4 Es of Prevention
• Engineering (Technology)
• Education
• Enactment/Enforcement (Laws)
• Economic Incentives/Disincentives

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Technology

• The quickest, best fix
• Generally thought to apply to
• Transportation systems
• Vehicles
• Communication

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Technology

• . Also applies to
• Clinical care
• Telemedicine
• Distance/virtual surgery (Robotics)
• Rehabilitation (Prostheses, assist devices)
• Medical education (Delivery/evaluation)
• Data collection and management

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Consider the need..

• Aging population
• Special needs of the elderly

EMSO

• EMS for old people
• Patterned after EMSC

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Research and Evaluation Issues

• More Paradigm Shifts
• Data
• Data elements data sets relevant
  questions question sets to be answered by data
• Outcome Research
• Beyond mortality and morbidity
• Financial outcomes
• Educational outcomes
• Primary prevention outcomes
• System process/practice behavior outcomes

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CAUTION..

• Pre-hospital EMS outcomes
• Analysis STOPS at the ED Door!
• Good pre-hospital care can be negated by poor
  hospital care
• Poor hospital care can be hidden/reversed by good
  subsequent care
• Valid long term outcome conclusions
• Data needed from the entire spectrum of care to
  control for various confounding factors

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Needs Assessments/System Evaluations

• Key to the process of performance improvement
• The tools and methods exist
• REMSTTAC Community Assessments
• American College of Surgeons
• Trauma system evaluation planning program
• Trauma system benchmarks, indicators standards

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Workforce Issues

• Identify incentives and disincentives to
  participation in emergency care
• Professional lifestyle
• Personal lifestyle
• Across the continuum of providers
• Prehospital
• ED
• Surgeons
• Nurses
• Rehabilitation

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Address Identified Incentives/Disincentives

• Direct strategies
• Indirect strategies
• Work around the problem

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Potential Strategies to AddressWorkforce Issues

• Scholarships to facilitate recruitment
• Loans and loan forgivement programs for EMS
  education and practice in underserved areas or
  for undersubscribed provider types
• Cross training (eg Paramedics in the ED)
• Expanded scopes of practice
• Pre-hospital
• Community health ( dressing changes, I.V.
  antibiotics, chemotherapy, etc.)
• Prevention/Health Promotion (immunizations,
  teaching, counseling, etc.)
• Hospital
• Advance practice nurses
• Physicians assistants
• Acute care surgeons
• Emergency general surgery
• Emergency neurosurgery
• Emergency orthopedics
• Surgical critical care

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More Strategies

• Regionalization
• Up triage
• Down/back triage (repatriation)
• Credentialing /Education
• Distance learning
• Paradigm shift
• CME AMC
• Continuing Medical Education Assuring
  Maintenance of Competency

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IOM ReportSpecific Issues

• Best Practices Recommendation
• Evidence may already exist
• NHTSA EMS Assessments
• ACS TSEP consultations/BIS
• REMSTTAC Community Assessments
• Dont re-invent the wheel
• Review and use whats already out there

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IOM ReportSpecific Issues

• Demonstration Projects
• Caution
• ? Capability of states
• ? Desire of states
• ? Resources of states
• ? Better strategy
• Establish Technical Assistance Centers in every
  federal region
• Mandated relationship and participation in
  collaborative pertinent projects
• Highway and other federal funding contingent upon
  state collaboration with TAC

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Sunset. or
..Sunrise
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Where Do We Go From Here?Not marching off into
the Sunset but rather sitting here marveling at
the Sunrise
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Dont miss the opportunity to seize the new day