4. Emergency Medical Services and Pediatric Transport

Recommendation 4.1: The President and Congress should clearly designate and appropriately resource a lead Federal agency for emergency medical services (EMS) with primary responsibility for the coordination of grant programs, research, policy, and standards development and implementation. Establish a dedicated Federal grant program under a designated lead Federal agency for pre-hospital EMS disaster preparedness, including pediatric equipment and training.

As stated in the National Health Security Strategy, emergency medical services (EMS) is an integral part of our Nation's emergency services system, alongside police, fire, and emergency management.¹⁷² Numerous Federal programs and entities provide some form of support or policy-making for EMS. These entities include the Federal Interagency Committee on Emergency Medical Services (FICEMS);¹⁷³ the National Highway Traffic Safety Administration's Office of EMS¹⁷⁴ and National EMS Advisory Council;¹⁷⁵ the Health Resources and Services Administration's (HRSA) Emergency Medical Services for Children (EMSC) program;¹⁷⁶ and the Department of Health and Human Services' (HHS) Assistant Secretary for Preparedness and Response's Emergency Care Coordination Center,¹⁷⁷ among others. FICEMS was primarily established to ensure coordination among the Federal agencies and entities involved with State, local, tribal, or regional emergency medical services and 9-1-1 systems.¹⁷⁸ However, FICEMS does not have program management and budgetary authority to provide disaster preparedness grants to EMS providers and ensure accountability for meeting National performance measures.

In 2006, the Institute of Medicine (IOM) reported that "[t]he scattered nature of Federal responsibility for emergency care makes it difficult for the public to identify a clear point of contact, limits the visibility necessary to secure and maintain funding, and creates overlaps and gaps in program funding."¹⁷⁹ Accordingly, IOM recommended that Congress establish a lead agency that has "primary programmatic responsibility for the full continuum of emergency medical services and emergency and trauma care for adults and children,"including pre-hospital care and medical-related disaster preparedness.¹⁸⁰ The Commission finds that Federal agency leadership and oversight for pre-hospital EMS is still unclear and supports IOM's recommendation that Congress clearly designate and appropriately resource a lead Federal agency for EMS.

The Commission also recommends that Congress establish a dedicated Federal grant program to improve EMS disaster preparedness and response. The National EMS Advisory Council released a position statement in June 2009 stating: "Providing core funding specifically for EMS, regardless of delivery model, to ensure surge capacity and response to public health emergencies and natural or man-made disasters is an essential public interest."¹⁸¹ Unlike other first responder entities, including emergency management agencies, law enforcement, fire departments, public health departments and hospitals, the majority of EMS systems in the Nation do not receive Federal grant support for disaster preparedness and response.¹⁸² In addition, the American Recovery and Reinvestment Act of 2009¹⁸³ did not authorize funds for EMS organizations. Grants are necessary to support State-level coordination and disaster planning, field-level staffing, pediatric supply and equipment needs, pediatric-specific training and exercises, and, in general, the expansion of pediatric surge capacity for disasters. A lead Federal agency is also necessary to ensure existing emergency preparedness grant programs establish pediatric EMS performance measures.

Recommendation 4.2: Improve the capability of emergency medical services (EMS) to transport pediatric patients and provide comprehensive pre-hospital pediatric care during daily operations and disasters. Congress should provide full funding to the Emergency Medical Services for Children (EMSC) program to ensure all States and territories meet targets and achieve progress in the EMSC performance measures for grantees, and to support development of a research portfolio. As an eligibility guideline for Centers for Medicare & Medicaid Services reimbursement, require first response and emergency medical response vehicles to acquire and maintain pediatric equipment and supplies in accordance with the national guidelines for equipment for Basic Life Support and Advanced Life Support vehicles.184 HHS and DHS should establish stronger pediatric EMS performance measures within relevant Federal emergency preparedness grant programs. HHS should address the findings of the EMSC 2009 Gap Analysis of EMS Related Research.185

As noted in the Commission's Interim Report, the IOM reported in 2006 that on a daily basis a great disparity exists across the Nation in the quality of adult and pediatric emergency care, which is exacerbated by disasters.¹⁸⁶ EMS requirements regarding coordination among first responders, equipment standards, and emergency care training vary widely across localities, regions, and States.¹⁸⁷ IOM identified specific challenges to pre-hospital pediatric care including: the lack of essential pediatric equipment on ambulances; gaps in Food and Drug Administration (FDA) approved medical countermeasures for children; a lack of pediatric inter-facility transfer agreements among hospitals; and a lack of pediatric training requirements for pre-hospital emergency medical technicians.¹⁸⁸ A 2009 IOM workshop convened to examine progress in improving emergency care since the previous report found that, despite some new Federal programs and initiatives, many of these gaps still exist.¹⁸⁹

The Interim Report included a recommendation to increase funding for the EMSC program¹⁹⁰ within HHS.¹⁹¹ The Commission concurs with the IOM recommendation that the EMSC be funded at $37.5 million per year for five years.¹⁹² Additional funds will help States meet the EMSC's pediatric-specific performance measures, including: pediatric equipment on ambulances; interfacility transfer guidelines and agreements to expedite pediatric transfer; pediatric education requirements for pre-hospital providers; and online, offline, or written pediatric medical direction¹⁹³ for pre-hospital providers.^194,195 These funds can support: the establishment and maintenance of a full-time EMSC administrator in every State and territory; research to build an evidence base for the development of standardized prehospital pediatric disaster care practices and protocols; and the evaluation of each State's performance in providing EMS services to children, which provides incentives for progress and public transparency in the use of the funds.

There are other existing mechanisms of Federal support for EMS providers that can be directed to support EMS disaster preparedness. For example, the Centers for Medicare & Medicaid Services (CMS) provides reimbursement for medical services to EMS providers.¹⁹⁶ The Commission recommends that CMS, as a condition for reimbursement, require first responder and emergency medical response vehicles to acquire and maintain pediatric equipment and supplies, in accordance with the national guidelines for equipment for basic life support (BLS) and advanced life support (ALS) vehicles.¹⁹⁷ In 2007, only 16 percent of BLS units and 18 percent of ALS units reported meeting EMSC performance measures for essential pediatric equipment and supplies as outlined in the national guidelines.¹⁹⁸ States and territories, which are responsible for the licensing and regulation of patient transport vehicles, also should require BLS and ALS units to meet the national guidelines.

In addition, the Commission recommends that Federal emergency preparedness grant programs establish stronger pediatric EMS performance measures. The Hospital Preparedness Program within the HHS Office of the Assistant Secretary for Preparedness and Response should hold hospital grantees accountable for acquiring recommended pediatric equipment and supplies and establishing interfacility transport guidelines and agreements for children, in alignment with the EMSC's performance measures. According to a 2003 survey, only 6 percent of hospital emergency departments carry essential pediatric equipment¹⁹⁹ and only 14 percent of hospitals have interfacility transport guidelines containing all the subcomponents recommended by EMSC.²⁰⁰ Interfacility agreements and guidelines are necessary to ensure hospitals are prepared to quickly and effectively move patients to appropriate definitive care, which is essential for hospitals that lack the capability to care for pediatric trauma patients.²⁰¹

Also, the Department of Homeland Security (DHS) should establish stronger pediatric EMS accountability measures within the DHS Homeland Security Grant Program (HSGP) in alignment with the EMSC's performance measures. State grantees should adequately support EMS providers and the regionalization of EMS assets to enhance both pediatric and adult medical surge capacity during disasters. As cited in the HSGP FY 2010 guidance, DHS requires State and local grantees to include EMS in all State and urban area homeland security plans.²⁰² The HSGP guidance also suggests that these plans include the needs of infants and children as well as individuals with disabilities.²⁰³ However, the HSGP grants enable States to establish their own priorities and accountability measures for meeting these requirements, and DHS does not promote or monitor the provision of funding to EMS providers.²⁰⁴ State and local emergency management agencies must have stronger requirements and incentives to work closely with State EMSC program coordinators to improve EMS and meet disaster preparedness goals.

Finally, the Commission recommends that HHS provide funds to address the research gaps identified in the EMSC National Resource Center's (NRC) Gap Analysis of EMS Related Research.²⁰⁵ The NRC analysis concludes further research in EMS disaster preparedness for both adults and children is needed in the areas of education and training of disaster and EMS personnel; systems efficacy for surge capacity, staffing, and strategies to minimize parent-child separation; and outcomes of patients being treated and released by EMS personnel. The analysis also indicates a need to develop a unique structure of research that is specific for disasters or mass casualty events.²⁰⁶ The Commission agrees with the importance of this finding and recommends a specific emphasis be placed on pediatric needs.

Furthermore, the Commission concurs with the 2006 IOM recommendation that the HHS Secretary examine the gaps and opportunities in emergency and trauma care research to outline the organizational structure, priorities, and funding for future research efforts.²⁰⁷ The Commission recommends that the HHS Secretary provide funds to support an initiative that identifies new strategies for creating research networks, assimilating emergency care researchers into grant review processes, and developing a pediatric clinical research center or institute.²⁰⁸

Recommendation 4.3: HHS should develop a national strategy to improve Federal pediatric emergency transport and patient care capabilities for disasters. Conduct a national review of existing capabilities among relevant government agencies 209 and the private sector for emergency medical transport of children.

When State and local emergency medical response capabilities are overwhelmed, the National Disaster Medical System (NDMS)²¹⁰ and other Federal assets may be deployed to provide medical support upon request. As discussed in Chapter 3, one component of NDMS is patient transport. Specifically, NDMS partners with the Department of Defense's (DoD) U.S. Transportation Command (USTRANSCOM) to coordinate and execute patient evacuation and transport from a disaster site to receiving points for definitive care within the U.S.²¹¹

Although USTRANSCOM is called on to evacuate and transport patients of all ages from disaster sites, DoD reported to the Commission that it has limited ability to provide medical care and transport for children. DoD's deployable teams are primarily trained and equipped to support military forces.²¹²

In addition, DoD's capacity for patient transport in general is limited by the availability of medical aircraft and trained aeromedical personnel.²¹³ NDMS and DoD are not the only entities activated to provide support for medical care and patient transport during disasters. The Coast Guard and State National Guard units may also be activated during emergencies for medical response.^214,215 Also, FEMA manages a National Ambulance Contract to provide ground ambulances, air ambulances, and paratransit vehicles to any location in the country within 24 hours of activation.²¹⁶ In addition, many health care organizations and hospitals have their own private patient transport assets or vendor agreements.²¹⁷

The Commission recommends that HHS, as the coordinator and primary agency in charge of Emergency Support Function (ESF) #8,²¹⁸ develop a national strategy to ensure a baseline capability to provide appropriate emergency care and transport of children during disasters. A national strategy is necessary to improve coordination during large-scale medical evacuation and transportation of children to appropriate definitive care during disaster response.²¹⁹

To inform a national strategy, the Commission recommends that HHS conduct an assessment to determine Federal and non-Federal pediatric medical transport capacities. The assessment would examine local, regional and national pediatric patient transport capabilities, including necessary equipment and training to provide emergency care to children. The assessment should provide a gap analysis that compares the supply of available pediatric-capable assets with demand under all hazards scenarios in different regions of the country. In addition, the review should outline: the organizational structures of medical transport units; the State or regional differences in EMS requirements; the estimated number of EMS units; the resource capacities of EMS teams; and the skill capabilities of medical transport personnel. The assessment should also include private air ambulance assets, as many injured children evacuated from Haiti to Florida after the 2010 Haiti earthquake were transported via private air ambulances outside the NDMS system.^220,221

The Commission's recommendation builds on a 2008 report issued by the National Biodefense Science Board, which recommended that NDMS develop "a standard patient movement concept of operations"that explicitly addresses the needs and management of at-risk individuals, including children and pregnant women, as well as an "accounting/tracking system that can properly register the true capacity of non-overlapping NDMS medical personnel who can be deployed for an event."²²²

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