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EMERGENCY CARE CRISIS: A NATION

UNPREPARED FOR PUBLIC DISASTERS

HEARING

BEFORE THE

SUBCOMMITTEE ON EMERGENCY 

PREPAREDNESS, SCIENCE, AND 

TECHNOLOGY

OF THE

COMMITTEE ON HOMELAND SECURITY 

HOUSE OF REPRESENTATIVES

ONE HUNDRED NINTH CONGRESS

SECOND SESSION

JULY 26, 2006

Serial No. 109–94

Printed for the use of the Committee on Homeland Security 

Available via the World Wide Web: http://www.gpoaccess.gov/congress/index.html
COMMITTEE ON HOMELAND SECURITY

PETER T. KING, New York, Chairman 

DON YOUNG, Alaska 

LAMAR S. SMITH, Texas 

CURT WELDON, Pennsylvania 

CHRISTOPHER SHAYS, Connecticut 

JOHN LINDER, Georgia 

MARK E. SOUDER, Indiana 

TOM DAVIS, Virginia 

DANIEL E. LUNGREN, California 

JIM GIBBONS, Nevada 

ROB SIMMONS, Connecticut 

MIKE ROGERS, Alabama 

STEVAN PEARCE, New Mexico 

KATHERINE HARRIS, Florida 

BOBBY JINDAL, Louisiana 

DAVE G. REICHERT, Washington 

MICHAEL T. MCCAUL, Texas 

CHARLIE DENT, Pennsylvania 

GINNY BROWN-WAITE, Florida 

BENNIE G. THOMPSON, Mississippi 

LORETTA SANCHEZ, California 

EDWARD J. MARKEY, Massachusetts 

NORMAN D. DICKS, Washington 

JANE HARMAN, California 

PETER A. DEFAZIO, Oregon 

NITA M. LOWEY, New York 

ELEANOR HOLMES NORTON, District of 

Columbia 

ZOE LOFGREN, California 

SHEILA JACKSON-LEE, Texas 

BILL PASCRELL, JR., New Jersey 

DONNA M. CHRISTENSEN, U.S. Virgin Islands 

BOB ETHERIDGE, North Carolina 

JAMES R. LANGEVIN, Rhode Island 

KENDRICK B. MEEK, Florida

SUBCOMMITTE ON EMERGENCY PREPAREDNESS, SCIENCE, AND 

TECHNOLOGY

DAVE G. REICHERT, Washington, Chairman 

LAMAR S. SMITH, Texas 

CURT WELDON, Pennsylvania 

ROB SIMMONS, Connecticut 

MIKE ROGERS, Alabama 

STEVAN PEARCE, New Mexico 

KATHERINE HARRIS, Florida 

MICHAEL MCCAUL, Texas 

CHARLIE DENT, Pennsylvania 

GINNY BROWN-WAITE, Florida 

PETER T. KING, New York (Ex Officio) 

BILL PASCRELL, JR., New Jersey 

LORETTA SANCHEZ, California 

NORMAN D. DICKS, Washington 

JANE HARMAN, California 

NITA M. LOWEY, New York 

ELEANOR HOLMES NORTON, District of 

Columbia 

DONNA M. CHRISTENSEN, U.S. Virgin Islands 

BOB ETHERIDGE, North Carolina 

BENNIE G. THOMPSON, Mississippi (Ex Officio)

(II) 
(III)

C O N T E N T S

Page 

STATEMENTS

The Honorable Dave G. Reichert, a Representative in Congress from the 

State of Washington, and Chairman, Subcommittee on Emergency 

Preparedness, Science, and Technology 

Prepared Statement ............................................................................................. 1

Oral Statement ..................................................................................................... 2

The Honorable Bill Pascrell, Jr., a Representative in Congress from the 

State of New Jersey, and Ranking Member, Subcommittee on Emergency 

Preparedness, Science, and Technology ............................................................. 4

The Honorable Bennie G. Thompson, a Representative in Congress from 

the State of Mississippi, and Ranking Member, Committee on Homeland 

Security ................................................................................................................. 6

The Honorable Donna M. Christensen, a Representative in Congress from 

the U.S. Virgin Islands ........................................................................................ 62

The Honorable Charlie Dent, a Representative in Congress from the State 

of Pennsylvania .................................................................................................... 57

The Honorable Norman D. Dicks, a Representative in Congress from the 

State of Washington ............................................................................................. 60

The Honorable Nita M. Lowey, a Representative in Congress from the State 

of New York .......................................................................................................... 64 

WITNESSES

Dr. Robert R. Bass, Member, Committee on the Future of Emergency Care, 

Institute of Medicine: 

Oral Statement ..................................................................................................... 7

Prepared Statement ............................................................................................. 9

Dr. Frederick Blum, President, American College of Emergency Physicians: 

Oral Statement ..................................................................................................... 12

Prepared Statement ............................................................................................. 14

Ms. Mary Jagim, Member, Emergency Nurses Association: 

Oral Statement ..................................................................................................... 37

Prepared Statement ............................................................................................. 39

Dr. Steven Krug, Chairman, Committee on Pediatric Emergency Medicine, 

American Academy of Pediatrics: 

Oral Statement ..................................................................................................... 43

Prepared Statement ............................................................................................. 46

(1)

EMERGENCY CARE CRISIS: A NATION 

UNPREPARED FOR PUBLIC HEALTH 

DISASTERS 

Wednesday, July 26, 2006

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON HOMELAND SECURITY, 

SUBCOMMITTEE ON EMERGENCY PREPAREDNESS, 

SCIENCE, AND TECHNOLOGY, 

Washington, DC. 

The subcommittee met, pursuant to call, at 2:03 p.m., in Room 

210, Cannon House Office Building, Hon. David Reichert [chairman 

of the subcommittee], presiding. 

Present: Representatives Reichert, Rogers, Dent, Pascrell, Dicks, 

Lowey, Christensen, and Thompson. 

Mr. REICHERT. The Committee on Homeland Security, Subcommittee on Emergency Preparedness, Science and Technology, 

will come to order. The subcommittee will hear testimony today 

from health and medical experts about the state of emergency and 

medical preparedness and response in the United States. 

We are in a different room today for us, so I think I see people 

in the back. This is like a—it is kind of in a tunnel here. 

Thank you all for being here. Yes, bowling alley, Bill says—it 

kind of reminds me of. But I have an opening statement I would 

like to give and we will move to other members to give their opening statement. 

And let me just first welcome our distinguished witnesses this 

morning, and thank you so much for taking time out of your busy 

schedule to be here with us. And we look forward to your testimony. 

I would like to congratulate the Members first, before we get 

started on the subcommittee, on the passage yesterday of H.R. 

5852, the 21st Century Emergency Communications Act of 2006, by 

a vote of 414 to 2. The members of the subcommittee didn’t just 

develop this bipartisan legislation overnight. It was a series of 

hearings and a product of hard work over the past spring to address the state of emergency communication in our country. And I 

would like to extend my thanks to Mr. Pascrell, Ranking Member 

of the subcommittee, for all of his hard work on this legislation and 

Mr. Thompson, the Ranking Member of the full committee for his 

hard work and leadership on this issue, and all the subcommittee 

members. 
2

Given the success of our series of hearings on emergency communications, it is my intent for the subcommittee to replicate this 

process in the future. 

That is, pick the problematic policy issue, hold hearings examining a variety of perspectives on that topic, and then move bipartisan legislation based on the record established by those hearings 

through the legislative process. 

I think a few issues more problematic or more important than 

the state of emergency of medical preparedness response in the 

United States—I can think of only a few issues more problematic. 

And that is why today’s hearing will be the first in a series of hearings examining our Nation’s emergency medical care crisis from 

prehospital treatment to mass decontamination and mortuary services. There is no question about the state of our Nation’s readiness 

to handle a surge of sick or injured persons during a public health 

energy emergency. We are neither prepared nor capable of responding. 

According to recent reports released by the Institute of Medicine 

and the American College of Emergency Physicians, emergency 

medicine in the United States is at its breaking point. Emergency 

rooms are dwindling and overcrowded. Ambulances are routinely 

diverted. Key specialists in neurosurgery and trauma care are often 

unavailable. And emergency rooms often lack the equipment and 

supplies needed to treat patients, especially children. 

I could go on and on. The problems are legion. As the tragic 

events in New Orleans and other communities along the gulf coast 

made clear, this is a real problem. 

The hospital and public health infrastructure currently in place 

in most areas of the country is barely adequate to get through a 

busy Saturday night in the emergency room and, believe me, as a 

law enforcement officer I have been in emergency rooms on a Saturday night. 

Indeed, the potential threat of a mass trauma event from a 

weapon of mass destruction or pandemic influenza outbreak would 

quickly overwhelm our already overstretched emergency medical 

system. Homeland security must include preparing our Nation for 

public health emergencies. But given the multiple problems facing 

our Nation’s emergency medical system, can we honestly say that 

America could cope with the immediate medical needs of thousands 

of people injured by an act of terrorism? Are we prepared to handle 

the needs of hundreds of thousands, if not millions, injured by a 

weapon of mass destruction? Quite frankly, the answer is no. 

It is for this reason that today’s hearing is so important. This 

hearing will help set the stage for the subcommittee’s activities in 

this area of medical preparedness and response, which, I am sad 

to say, has not received as much as attention as it deserves. 

The subcommittee’s intent therefore will focus its attention on a 

number of medical preparedness and response issues, including the 

extent of collaboration between the Departments of Homeland Security and Health and Human Services, where the national disaster medical system should be located, whether the metropolitan 

medical response system is as robust as it needs to be, and whether 

our Nation’s emergency medical services personnel have the support necessary to fulfill their responsibilities. 
3

I am eager to hear the testimony of our witnesses today. And I 

look forward to working with you to ensure that we as a Nation 

will be able to care for our citizens, regardless of the circumstances. 

Again, thank you for joining us. 

[The information follows:]

PREPARED STATEMENT OF CHAIRMAN DAVE REICHERT

Let me first welcome our distinguished witnesses. We greatly appreciate your appearance before us today and look forward to your testimony. 

Before we begin, I’d be remiss if I didn’t congratulate the Members of this Subcommittee on the passage yesterday of H.R. 5852, the ‘‘21st Century Emergency 

Communications Act of 2006,’’ by a vote of 414 to 2. The Members of the Subcommittee didn’t just develop this bi-partisan legislation overnight. Rather, H.R. 

5852 was the product of a series of hearings held this past Spring on the state of 

emergency communications. I’d like to extend my thanks to Bill Pascrell, the ranking Member of this Subcommittee, for his hard work on this legislation. 

Given the success of our series of hearings on emergency communications, it is 

my intent for the Subcommittee to replicate this process in the future—that is, pick 

a problematic policy issue, hold hearings examining a variety of perspectives on that 

topic, and then move bi-partisan legislation based on the record established by those 

hearings through the legislative process. 

I can think of few issues more problematic or important than the state of emergency medical preparedness and response in the United States. That is why today’s 

hearing will be the first in a series of hearings examining our Nation’s emergency 

medical care crisis. From pre-hospital treatment and mass prophylaxis to mass decontamination and mortuary services, there is no question about the state of our 

Nation’s readiness to handle a surge of sick or injured persons during a public 

health emergency—we are neither prepared nor capable of responding. 

According to recent reports released by the Institute of Medicine and the American College of Emergency Physicians, emergency medicine in the United States is 

at its breaking point. Emergency rooms are dwindling and overcrowded. Ambulances are routinely diverted. Key specialists in neurosurgery and trauma care are 

often unavailable. And the equipment and supplies needed to treat patients, especially children, are often unavailable. 

I could go on and on—the problems are legion. As the tragic events in New Orleans and other communities along the Gulf Coast made clear, this is not merely a 

theoretical problem. The hospital and public health infrastructure currently in place 

in most areas of the country is barely adequate to get through a busy Saturday 

night in the emergency room, let alone treat the thousands of sick and injured resulting from a catastrophic act of terrorism, a natural disaster, or other emergency. 

Indeed, the potential threat of a mass trauma event from a weapon of mass destruction or pandemic influenza outbreak would quickly overwhelm our already overstretched emergency medical system. 

Homeland security must include preparing our Nation for public health emergencies. But, given the myriad problems facing our Nation’s emergency medical system, can we honestly say that America could cope with the immediate medical needs 

of thousands of people injured by an act of terrorism? Are we prepared to handle 

the needs of hundreds of thousands, if not millions, injured by a weapon of mass 

destruction? Quite frankly, the answer is no. 

It is for this reason that today’s hearing is so important. This hearing will help 

set the stage for this Subcommittee’s activities in the area of medical preparedness 

and response, which, I’m sad to say, has not received as much attention as it deserves. 

The Subcommittee, therefore, will focus its attention on a number of medical preparedness and response issues, including: 

• The extent of collaboration between the Departments of Homeland Security 

and Health and Human Services; 

• Where the National Disaster Medical System should be located;* Whether the 

Metropolitan Medical Response System is as robust as it needs to be; and 

• Whether our Nation’s emergency medical services personnel have the support 

necessary to fulfill their responsibilities. 

I am eager to hear the testimony of our witnesses, and I look forward to working 

with you to ensure that we, as a Nation, will be able to care for our citizens regardless of the circumstances. Thank you again for joining us this afternoon.
4

Mr. REICHERT. And the Chair now recognizes Mr. Pascrell, the 

Ranking Member, for his statement. 

Mr. PASCRELL. I want to thank our good friend, Chairman 

Reichert, for charting the course for the subcommittee that has 

gone virtually unexplored in Congress. 

This hearing will be the first in a series of hearings examining 

the state of medical preparedness and response in the United 

States. I don’t think I am engaging in excessive hyperbole, Mr. 

Chairman, when I say this is about as important an issue as we 

can possibly address. 

The fact is this: The emergency medical care in the United States 

is on the verge of ruin. 

We have a declining number of emergency rooms, as the Chairman just pointed out, that are already dangerously overcrowded 

and too often unable to provide the expertise needed to manage seriously ill people in a safe and competent manner. 

I have seen hospitals in New Jersey that have an infrastructure 

in place that is barely adequate to get through an average Saturday evening, let alone effectively treat the thousands of sick and 

injured resulting from a devastating act of terrorism or natural disaster or any emergency. 

New Jersey is better equipped than most States. Nationwide we 

have a veritable epidemic of inadequate emergency care. It is a crisis that cannot be ignored. 

You don’t have to take my word for it. Just read the grim conclusions from a series of recently released reports by the Institute of 

Medicine on the Future of Emergency Care, as well as the National 

Report Card on the State of Emergency Medicine issued by the 

American College of Emergency Physicians. 

According to the Institute of Medicine, few hospitals have personnel trained in disaster preparedness. Most hospitals have inadequate medical equipment and supplies needed for an influx of entries, and most hospitals have ineffective isolation capacities needed to quarantine infectious patients. 

Another major concern is the lack of critical specialists in emergency medicine available to treat patients in our Nation’s emergency departments. This lack of on-call specialists can obviously 

lead to tragic, heartbreaking results. 

And things are getting worse. From 1993 to 2003, the United 

States population grew by 12 percent, but emergency room visits 

grew by 27 percent. From 90 million to 114 million people use the 

emergency rooms. 

In that same period, 425 emergency departments closed, along 

with about 700 hospitals and nearly 200,000 beds. I mean, I am not 

a mathematical wizard, but you can figure out the mathematics 

here. We are heading for disaster. 

I know Massachusetts put forth a health plan, universal health 

plan for the State, several months ago, bipartisan plan which is 

primarily directed at covering children who don’t have health insurance coverage. The primary purpose of that plan is to keep people out of emergency rooms. They figure they are going to save millions and millions of dollars in doing that. 

We should be doing that anyway—anyway—regardless of what 

the situation could possibly be. But we have in our hands here a 
5

real difficult situation which we are going to hopefully try to address. 

In 2003, over 500,000 ambulances were diverted from the hospital where they normally would have delivered a patient because 

the emergency room was full. 

2004, 70 percent of urban hospitals reported that their emergency departments had been on diversion at least once. 

About 14 percent of emergency room patients end up admitted to 

the hospital. A study by the Government Accountability Office in 

2003 found that 20 percent of emergency departments had to board 

patients in hallways or other temporary spaces for an average of 

8 hours before a bed opened. We are talking about the United 

States of America here. We are not talking about Calcutta. 

Lets get that straight. This can’t continue. 

With the threats of terror and natural disasters lurking, we have 

to be prepared for every worst-scene scenario. Many proposals we 

have for easing the solution—the situation ranging from new regional systems to improve the flow of patients to the most appropriate and least crowded emergency rooms, to an infusion of money 

to cover unpaid emergency care to bolster preparedness for largescale disasters. Fixing this problem will require money. 

It is my hope that through the leadership of the subcommittee, 

Congress can start tackling these critical problems, perhaps even 

be able to get the powers that be in this institution to stop focusing 

on gay marriage, flag burning, tax breaks for millionaires, and instead focus on real problems and real issues that truly affect the 

lives of our citizens. Oh, that is something different. 

I look forward to hearing from our witnesses today, Mr. Chairman, and thank you for putting us together. 

Mr. REICHERT. Thank you Mr. Pascrell. 

Before we get started and move to Mr. Thompson, I would like 

to ask unanimous consent to enter into the record a report issued 

by the American College of Surgeons, entitled ‘‘A Growing Crisis in 

Patient Access to Emergency Surgical Care.’’ 

Without objection, so ordered. 

Mr. REICHERT. The Chair now recognizes the Ranking Member 

of the full committee, Mr. Thompson. 

Mr. THOMPSON. Thank you, Mr. Chairman. I appreciate the opportunity to give these comments during this hearing, as well as 

to support the comments of Ranking Member Pascrell who just presented earlier. 

Mr. Chairman, while firefighters and law enforcement are our 

first line of defense, our hospitals, EMS personnel and public 

health agencies also stand directly on the front lines. Unfortunately 

our Nation’s emergency medical system has received little focus 

from this Congress and this administration. As we all know, terrorists threaten to use biological, chemical, radiological and traditional 

explosive weapons against the United States. If successful, an attack has the potential to result in a large amount of casualties. 

In addition, naturally occurring catastrophes such as hurricanes 

and pandemic flu also have the potential to overwhelm many of our 

communities. How the United States responds to such an attack or 

natural disaster will depend upon the preparedness of local hospitals, outpatient facilities, emergency medical services and health 
6

care professionals. It would also depend on the preparedness of 

States and the Federal Government to augment local capabilities. 

While preparing for, preventing, and responding to any large incident is a local responsibility, the Federal Government has a significant role in assisting cities and States to ensure that they are 

ready. So where do we stand as a country right now? In June of 

this year, the Institute of Medicine released three reports culminating its extensive look at the state of the emergency care system 

in the United States. According to the report, most hospitals are 

not prepared for public health emergencies. 

Few hospitals have personnel trained in disaster preparedness, 

and most hospitals have inadequate equipment and beds needed 

for an incident resulting in a large surge of patient. In fact, Mr. 

Chairman, from 1993 to 2003, the U.S. population grew by 12 percent, but the emergency room visits grew by 27 percent, from 90 

million to 114 million. In that same period, 425 emergency room 

departments closed, along with about 700 hospitals and nearly 

200,000 beds. 

In addition, a report released in June by the Institute of National 

Security and Counterterrorism at Syracuse University entitled 

‘‘Are We Ready’’ examined the strategic national stockpile and 

whether America is truly ready to respond to a public health emergency. 

The report found overlaps in management, jurisdiction, confusion 

in decision-making situations, and a lack of full capacity in supply 

and distribution. 

Mr. Chairman, I would like unanimous consent to introduce a 

copy into the record. 

Mr. REICHERT. Without objection. 

Mr. THOMPSON. Thank you very much. I would also like to personally thank and acknowledge the work of Barbara Andersen, 

Adam Piner, Nicholas Rossmann, Kerri Weir, Dan Wilder, Jason 

Yaley and Matthew Zeller. These graduate students, under the direction of Professor William Banks, produced a thorough report 

with many excellent recommendations that I urge my colleagues to 

look at. 

I would like to thank the witnesses again for appearing before 

us today and I look forward to that testimony. 

I yield back. 

Mr. REICHERT. Thank you, Mr. Thompson. 

Other members of the subcommittee are reminded that opening 

statements must be submitted for the record. 

We are pleased to have with us our distinguished witnesses 

today. 

First we have Dr. Robert Bass, the Executive Director of the 

Maryland Institute for Emergency Medical Services System and a 

Member of the Institute of Medicine’s Committee on the Future of 

Emergency Care. 

Dr. Frederick Blum, the President of the American College of 

Emergency Physicians and an Associate Professor of Emergency 

Medicine, Pediatrics, and Internal Medicine at the West Virginia 

University School of Medicine. 

Ms. Mary Jagim, Internal Consultant for Emergency Preparedness and Pandemic Planning for MeritCare Health System in 
7

Fargo, North Dakota and Past President of Emergency Nurses Association. 

And, finally, Dr. Steven Krug, the head of Pediatric Emergency 

Medicine at Children’s Memorial Hospital in, Chicago, Illinois, and 

the Chairman of the Committee on Pediatric Emergency Medicine 

for the American Academy of Pediatrics. 

Let me remind the witnesses, please, that their entire written 

statement will appear in the record. We ask that witnesses strive 

to limit their testimony to no more than 5 minutes. 

Mr. REICHERT. The Chair now recognizes Dr. Bass. 

Dr. Bass. 

STATEMENT OF ROBERT R. BASS, M.D. 

Dr. BASS. Good morning Mr. Chairman, members of the subcommittee, my name is Robert Bass. I am the Executive Director 

of the Maryland Institute for EMS Systems, that is the State EMS 

agency in Maryland, 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. 

The Institute of Medicine’s Committee on the Future of Emergency Care in the United States was formed in September 03 and 

consisted of 40 national experts from fields including emergency 

care, trauma, pediatrics, health care administration, public health 

and health services research. 

I will briefly summarize the committee’s findings and recommendations, giving particular attention to those that relate to 

emergency preparedness. 

In 2003, nearly 114 million visits were made to hospital emergency departments. Emergency care has made important strides 

over the past 40 years. Yet just beneath the surface, a growing crisis in emergency care is brewing, one that could imperil everyone’s 

access to care. 

Many emergency departments—EDs as we call them today—are 

severely overcrowded with patients, many of whom are being held 

in ED because no inpatient bed is available. When crowding 

reaches dangerous levels, hospitals often divert ambulances to 

other facilities. This prolongs ambulance transport times and disrupts established patterns of care. And because crowding is rarely 

limited to a single hospital, commonly a community may experience 

a health care equivalent of a rolling blackout where overcrowding 

just rolls from hospital to hospital and everyone’s access to care is 

affected, insured and uninsured alike. 

Physician shortages are another problem. Gaps in specialist coverage, especially surgical, deprive patients of necessary care once 

they arrive in the ED. 

With many hospitals 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. Regardless of the cause 

of the disaster, our Nation’s emergency care system simply lacks 

the capacity to mount an effective response. 

Training for EMS personnel and hospital staff in disaster procedures is limited. 

Many hospitals lack critical infrastructure to manage the consequences of a large-scale population emergency. Protecting hos-
8

pitals and their staff from secondary contamination in the event of 

biological or chemical events poses extraordinary challenges. 

The outbreak of 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. 

An important tool of limiting the spread of air-borne pathogens is 

negative pressure rooms that are engineered to keep airborne 

germs from spreading. The number of such rooms in hospitals in 

the United States is very limited. 

Training in and access to personal protective equipment for hospitals as well as prehospital EMS personnel is inadequate. Disaster 

response capabilities are also hindered by poor communications 

and a lack of coordination. 

Health care and EMS professionals are frequently not included 

in local disaster planning. 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. 

As a result, large amounts of funding are directed towards some 

priorities but not others that may be a greater priority. There are 

presently 52 Centers for Public Health Preparedness funded by the 

CDC to address various aspects of bioterrorism, but not one federally funded center focused on civilian consequences of terrorist 

bombings; yet we know that explosives are the most common instrument of terrorism worldwide. 

Funding received by hospitals is inadequate to enable them to 

develop the needed surge capacities 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. 

I would just like to highlight a few committee recommendations. 

First and foremost, the best way to ensure an effective response in 

the event of a disaster is to create an energy care system that effectively functions on a day-to-day basis. 

The committee recommends that Congress, number one, establish a federally funded demonstration program to develop and test 

various approaches to regionalize delivery of prehospital and hospital care, and, number 2, designate a lead agency for emergency 

care in the Federal Government. 

The committee recommends that States actively promote regionalized emergency care services to ensure that the right hospital—

excuse me—that the right patient gets to the right hospital in the 

right time. 

The committee also recommends that Congress significantly increase preparedness funding in fiscal year 2007 for hospitals in the 

U.S. in a number of key areas, and that EMS be brought to a parity level 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 all emergency care professionals. 
9

To address the special needs of pediatric patients in preparing 

for disasters, the committee made a number of specific recommendations which are included in its reports. 

Finally, the committee concluded that there should be greater integration of the Veterans Affairs health care resources into civilian 

disaster planning. 

In closing, 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. 

Thank you for the opportunity for testifying. I would be happy 

to answer any questions that the subcommittee might have. 

Mr. REICHERT. Thank you, Dr. Bass. 

[The statement of Dr. Bass follows:]

PREPARED STATEMENT OF ROBERT R. BASS

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.

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, giving 

particular attention to those that relate to emergency preparedness.

GENERAL FINDINGS 

Emergency and trauma care are critically important to the health and well being 

of Americans. In 2003, nearly 114 million visits were made to hospital emergency 

departments—more than 1 for every 3 people in the United States. While many 

Americans need emergency care only rarely, everyone counts on it to be available 

when needed. 

Emergency care has made important strides over the past 40 years: emergency 

9–1–1 service now links virtually all ill and injured Americans to an emergency 

medical response; EMS systems arrive to transport patients to advanced, life-saving 

care; and scientific advances in resuscitation, diagnostic testing, trauma care and 

emergency medical care yield outcomes unheard of just two decades ago. Yet just 

beneath the surface, a growing crisis in emergency care is brewing; one that could 

imperil everyone’s access to care. 

Many emergency departments (EDs) today are severely overcrowded with patients, many of whom are being held in the ED because no inpatient bed is avail-
10

able. 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. 

Physician shortages are another problem. The rising cost of uncompensated care, 

fear of legal liability for performing risky procedures, and disruptions of daily practice and home lives has led more surgical specialists to opt out of taking ED call. 

Gaps in specialist coverage increase the frequency of ambulance diversion, because 

hospitals cannot accept certain types of patients if no specialist is available to treat 

them. 

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

With many hospitals 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. 

In addition to lack of capacity, many hospitals lack critical infrastructure, such 

as sufficient intensive care unit (ICU) beds, ventilators, and decontamination units 

to manage the consequences of a large scale population emergency. 

Protecting hospitals and their staff 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. 

If a patient with SARS walked into an American emergency department tonight, 

the effect would be like tossing a lighted match into a tinder-dry forest. 

An important tool in limiting the spread of airborne pathogens is negative pressure rooms that are engineered to keep airborne germs from spreading throughout 

the emergency department. Unfortunately, the number of such rooms is very limited, and is generally restricted to a handful of tertiary care hospitals in each major 

population center. Staff must also be protected through appropriate personal protective equipment and respirators. Currently, staff training and provision of equipment 

are inadequate. 

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.’’ 

Fragmentation of local efforts is mirrored by 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 towards some priorities, but not others. For example, federal spending on bioterrorism and emergency preparedness in the Department of Health and Human 
11

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 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 hospitals and staff, the Committee recommends that Congress significantly increase preparedness funding in FY 

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.
12

CLOSING 

The Committee believes that 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? The Committee believes that 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 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 the Subcommittee might have.

Mr. REICHERT. The Chair recognizes Dr. Blum. 

STATEMENT OF FREDERICK BLUM, M.D. 

Dr. BLUM. Thank you, Mr. Chairman. My name is Rick Blum. I 

am the President of the American College of Emergency Physicians. I am a practicing emergency physician in Morgantown, West 

Virginia. I can tell you the problems you have outlined today are 

present in small-town America as well as large cities. 

In the past few years, we have had the unfortunate experience 

in this country of experiencing some of the biggest disasters, both 

natural and man-made, that we have ever had. During those 

events, the American public has come to rely on the emergency department as a key player in the care of—in the medical needs of 

the patient that result from those disasters. 

We have become very good at doing more and more with less and 

less. But that has a limit, and we are here today to talk about that 

limit. 

This testimony today comes not only from my own experience, 

but the thousands of members of the American College of Emergency Physicians, and it also comes from data that has already 

been outlined here from the Institute of Medicine and from the national report card that the College put out earlier this year. 

For several years now, the College has worked to raise awareness of these issues. It is perhaps a symptom of how good we have 

become at doing more and more with less and less that so far we 

don’t feel like these messages have been heard. 

But right now as we sit here today, every minute of every day 

an ambulance is being diverted away from an emergency department. 

Right now, as we sit here today, there are hospitals, probably in 

this city—certainly in most cities in the country—where patients 

critically ill oftentimes are lying in the hallways and waiting hours 

to get into inpatient beds. 

This creates a gridlock situation in our emergency departments 

that prevents us from doing what we know how to do, which is 

take care of patients as they present to the emergency department. 

We simply have no place to see them. 

What are the contributing factors to this situation? Well, there 

are many. First of all, there is lack of access to basic health care 

for many Americans. It would be a misconception to think that our 

emergency departments are crowded with people that don’t need to 

be there. 

It is more appropriate to say that they are crowded with people 

who, if they had access to reasonable health care somewhere else, 
13

would have their health care conditions not get to the point where 

they need an emergency department. 

Most of our patients actually need to be in the emergency department, but many of them are there because they can’t get basic 

health care. 

We also have a significant lack of inpatient beds; that has already been outlined today, over 200,000 in the past few years decrease. 

We have tried to control cost in this country by controlling our 

building of hospital beds, which I think has been a flawed public 

policy. We also have a growing population and the baby boomers 

are still pretty healthy. They have not even hit the system in big 

numbers yet. And when they do, most of us are predicting a pretty 

disastrous situation. 

We have a shortage of nurses and other providers. You are going 

to hear more about that today, I am sure. It is a critical shortage. 

We cannot staff the beds we do have in this Nation in inpatient 

beds or in the emergency department because of the shortage. 

We have reduced reimbursement for Medicare, Medicaid, and 

other payers to the point where 50 percent of all emergency care 

in this country is not reimbursed. That is simply not a sustainable 

business model for most hospitals. They often make the decision to 

close their emergency department rather than to continue to lose 

money at that rate. That is simply not sustainable. And that is at 

a time when the number of ED visits have gone up and the number 

of EDs have dropped, as you’ve mentioned. 

To be prepared, we really must take steps now to shore up the 

critical infrastructure of the emergency care system in this country. 

And I am not talking about ventilators or negative pressure rooms. 

I am talking about human resources and I am talking about basic 

support. 

If an emergency department closes, if a trauma center closes, it 

closes for everybody, whether you have insurance or not. We have 

seen that in communities around the country; in Las Vegas, when 

they lost their trauma center and patients were being shipped to 

California. 

My written testimony outlines specifics. I won’t repeat them all 

here. I will summarize four. 

We simply have to increase surge capacity by ending the practice 

of boarding patients in the emergency department. We have proposed some specific measures, including H.R. 3875 and Senate bill 

2750. 

We must promote protocols and information systems that collect 

real-time data on diversion and on capacity and also provide the 

function of syndromic surveillance. 

We must make sure that Homeland Security agencies at both the 

Federal, State, and local levels recognize that emergency care in 

the emergency department is part of the first response. 

We know that 75 to 80 percent of patients in many disasters bypass many agencies and come directly to the emergency department. 

Emergency physicians and nurses simply must play a role in 

planning for these disasters. We must be included, as I said, as 

first responders. 
14

I can tell you—I will sum up by saying that when the next big 

disaster occurs, the Nation’s emergency physicians and nurses will 

be there. They will be doing their job, just as they did in Katrina 

where they cared for patients for days, without food or water or 

electricity or linen. We will be there. We will be doing our job as 

best we can, but please let us do that job effectively by giving us 

the resources that we need. Thanks. 

Mr. REICHERT. Thank you Dr. Blum. 

[The statement of Dr. Blum follows:]

PREPARED STATEMENT OF FREDERICK C. BLUM, M.D., F.A.C.E.P., F.A.A.P. 

Introduction 

At an alarming and increasing rate, America’s emergency departments are overcrowded and understaffed to meet the needs of patients. An ambulance is diverted 

away from a hospital every minute in our country. Patients admitted to the hospital 

every minute in our country. Patients admitted to the hospital lie in hallways for 

days waiting for transfer to inpatient beds. America’s ability to ‘‘surge’’ in a crisis 

is greatly diminished or eliminated altogether. This is affecting the nation’s ability 

to respond to acts of terrorism and save lives during disasters, such as Hurricane 

Katrina. 

Mr. Chairman and members of the subcommittee, my name is Dr. Rick Blum, and 

I would like to thank you for allowing me to testify on behalf of the American College of Emergency Physicians, the largest specialty organization in emergency medicine, with nearly 24 000 members committed to advancing emergency care. 

The testimony I give is not only from the experiences of emergency physicians, 

but from the findings of the Institute of Medicine reports, released in June, and of 

a National Report Card on the State of Emergency Medicine, released in January. 

ACEP has been working to raise awareness among lawmakers and the public of 

the critical conditions facing emergency patients today and how this is affecting the 

ability of emergency physicians and nurses to ‘‘surge’’ in a crisis. These the findings 

of a 2003 GAG report on crowding; conducting a stakeholder summit last year; and 

commencing a rally on the west lawn of the U.S. Capitol attended by nearly 4,000 

emergency physicians to promote H.R. 3875/S. 2750, the ‘‘Access to Emergency Medical Services Act’’. 

And we know from our experience with Hurricane Katrina that more people 

would have lived had surrounding hospitals had more surge capacity. 

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 Institute of Medicine (10M) report ‘‘Hospital-Based Emergency Care: At the Breaking Point,’’ which was just released on June 14. I 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 emergency departments could be alleviated; commencing 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/S. 2750, the 

‘‘Access to Emergency Medical Services Act;’’ 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. 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 
15

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 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 

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.

Emergencv Department Overcrowding and Lack of Surge Capacity 

As the frontline of emergency care in this country, emergency physicians are particularly aware of how the lack of surge capacity in our nation’s emergency departments is affecting patients. Here are two true patient stories that with ACEP that 

illustrate this point: 

I know of a little girl with abdominal pain who came to a crowded emergency department in Texas. The waiting room was crowded with people, and there was literally no room for her to lie down. So she went home, and her appendix burst. The 

ambulance raced her back to the hospital where she was treated right away. She 

nearly died, and it took three months for her to recover. Three months of needless 

fear, pain, suffering and costs that would have been avoided—and could have been 

avoided. 

I know of a 50-year-old Ohio man with chest pain who came to an overcrowded 

emergency department. The initial EKG showed no signs of heart attack, so he had 

to wait in the waiting room due, because no beds were available. His pain worsened 

and he arrested in the waiting room and died while waiting for a bed. 

The root of this problem exists due to lack of capacity in our nation’s 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. 

Every day in emergency departments across America, critically ill patients line 

the halls waiting hours—sometimes days—to be transferred to inpatient 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 a lack of hospital inpatient beds; a 

growing elderly population and nationwide shortages of nurses, physicians and hospital support staff. As indicated by the 10M report, another factor that directly impacts emergency department patient care and overcrowding is the shortage of oncall 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 and relaxed Emergency Medical Treatment and 

Labor Act (EMTALA) requirements for on-call panels. 

ACEP and Johns Hopkins University conducted two national surveys, one in the 

spring of 2004 and another in the, 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 one year. quarters 

(73 percent) of emergency department medical directors reported inadequate oncall 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). 

Two anonymous stories dramatize the complex challenges of the on-call problem: 

I know of a 23 year-old male who arrived unconscious at a small hospital in 

Texas. It turned out he had a neurosurgical services. Ten minutes away was 

a hospital with plenty of neurosurgeons, but the 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 FINALLY was accepted 
16

by a hospital many miles away, with a 90-minute Life flight helicopter transfer. 

The patient died immediately after surgery. 

I know of a 65 year-old male in emergency department complaining of abdominal 

pain. showed a six-centimeter abdominal aortic aneurysm and he was unstable for 

CT scanning. The hospital had no vascular surgeon available within 150 miles; a 

general surgeon was available, but he refused to take the patient out-of-state. The 

emergency team reversed the Coumadin transferred the patient three hours away 

to the nearest Level I trauma center, but he died on the operating table. I understand he probably would have lived had there not been a three-hour delay. 

In addition, 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 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 non-clinical 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 two hours and nearly 20 percent of hospitals reported an average boarding 

time of eight 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 cancelled 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 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 hour 

(Weiss et al., 2004; Bradley, 2005). 

As previously mentioned in my statement, 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. 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 
17

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 one in 10 hospitals reported being on diversion 20 percent of the time 

(more than four 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 arrived by ambulance, and that 70 percent of those patients had urgent 

conditions that required care within an hour. A companion study found 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. 

emergency departments have filled all of their beds, there is no reasonable way to 

expect that these stressed systems will be able to suddenly create the surge capacity 

necessary to effectively manage a pandemic, natural disaster, terrorist attack or 

other mass-casualty event.

ACEP Recommendations 

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. 

As my colleague, ACEP Board member David Seaberg, M.D, C.P.E., F.A.C.E.P., 

noted in his testimony before a joint hearing conducted by this subcommittee and 

the Prevention of Nuclear and Biological Attack Subcommittee on February 8, 

ACEP has developed a 10-point plan to achieve these goals and we continue to urge 

Congress to enact these measures in order to effectively manage a pandemic, natural disaster, terrorist attack or other mass-casualty event. We have noted where 

ACEP’s recommendations are complimented by several key I0M report proposals, 

which I have included as an addendum to my testimony. 

1. We must increase the surge capacity of our nation’s emergency departments by 

ending the practice of ‘‘boarding’’ admitted patients in emergency departments because no inpatient beds are available. As mentioned previously in my this will require changing the way hospitals are funded to allow for inpatient and intensive 

care unit surge capacity to manage this burden. This proposal is specifically addressed in the I0M report recommendations (# 4.4 and # 4.5). 

2. We must time data for syndromic surveillance, hospital inpatient and emergency department capacities and ambulance diversion status. Collection of this data 

is vital to developing appropriate protocols. 

3. Homeland, State, and Local levels need to understand that hospitals and Emergency Departments are part of the community Critical Infrastructure. We can not 

have response and recovery in a disaster without fully functioning, protected, and 

connected health resources. This proposal is specifically addressed in the IOM 

report recommendation (# 6.1). 

4. We must require hospitals and communities that are severely affected by a natural or man-made disaster, or even a severe influenza outbreak, to postpone elective 

admissions until the crisis has abated. We must develop a way to compensate those 

facilities for their loss of revenue. 

5. Command and control of disaster medical response must be more coordinated 

across federal, state and local agencies and departments. 

6. We must establish a committee of stakeholders and disaster medicine experts 

from the public—and private-sectors and academic institutions to develop and/or refine national medical preparedness priorities and standards. We must change the 

national preparedness culture to one which is consensus-driven and evidence-based. 

7. We must provide federal and state funding to compensate hospitals and emergency departments for the unreimbursed cost of meeting their critical public health 

and safety-net roles to ensure these emergency departments remain open and available to provide care in their communities. This proposal is specifically addressed in the IOM report recommendation (# 2.1). 
18

8. We must establish a sustainable funding mechanism for disaster preparedness 

for hospitals, emergency departments and emergency management that is tied to 

national benchmarks and deliverab1es. 

9. To ensure and are considered in any national allocation of resources and protective measures Congress should continue to include them in any definitions regarding first responders to disasters, acts of terrorism and epidemics. 

10. Congress should pass H.R. 3875/S. 2750, the ‘‘Access to Emergency Medical 

Services Act’’ which provides incentives to hospitals to reduce overcrowding and provides reimbursement and liability protection for EMTALA-related care.

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. 

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-tenn solution to a surge of patients, ultimately we need long-tenn 

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 ten 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 of the American public. 

Let me close by assuring you that in any local, regional or national disaster or 

epidemic the nation’s emergency physicians and emergency nurses will be there to 

do their jobs, as was evident during the Hurricanes Katrina and Rita, as well as 

the terrorist attacks on September 11. ACEP urges this committee and the U. S. 

Congress to consider the 10-point plan that I have presented here today and specifically advocate the enactment of H.R. 3875/S. 2750, the ‘‘Access to Emergency Medical Services Act.’’ 

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.

Attachments

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 Health care 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., 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 

in 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. an environment where emergency department’s 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. 
19

• 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. 

• 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 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. 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. 
20

• Ensure emergency medical care is available to all regardless of ability to 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.
21

Appendix E 

Recommendations and Responsible Entities from the Future of Emergency Care Series 

HOSPITAL-BASED EMERGENCY CARE: AT THE BREAKING POINT 

Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 

Chapter 2: The Evolving Role of Hospital-Based Emergency Care

2.1 Congress should establish dedicated funding, separate from DSH payments, to reimburse hospitals that provide significant amounts of uncompensated emergency and trauma care for the financial losses incurred by providing those services. 

• Congress should initially appropriate $50 million for the purpose, to be administered by the Centers for Medicare and Medicaid Services. 

X X 

• CMS should establish a working group to determine the allocation of these funds, which should be targeted to providers and localities at greatest risk; the working group should then determine funding needs for subsequent years 

Chapter 3: Building a 21st-Century Emergency Care System

3.1 The Department of Health and Human Services and National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop an evidence-based categorization system for EMS, EDs, and trauma centers based on adult and pediatric service capabilities. 

X X X 

3.2 The National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidence-based model prehospital care protocols for the treatment, triage, and transport of patients. 

X X 
22

Appendix E—Continued

Recommendations and Responsible Entities from the Future of Emergency Care Series 

HOSPITAL-BASED EMERGENCY CARE: AT THE BREAKING POINT 

Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 

3.3 The Department of Health and Human Services should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency care system performance. 

X 

3.4 The Department of Health and Human Services should adopt regulatory changes to the Emergency Medical Treatment and Active Labor Act (EMTALA) and the Health Insurance Portability and Accountability Act (HIPAA) so that the original goals of the laws are preserved but integrated systems may further develop. 

X 

3.5 Congress should establish a demonstration program, administered by the Health Resources and Services Administration, to promote regionalized, coordinated, and accountable emergency care systems throughout the country, and appropriate $88 million over 5 years to this program. 

X X 
23

3.6 Congress should establish a lead agency for emergency and trauma care within 2 years of the publication of this report. The lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of EMS, emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital EMS (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care. 

X X 

Chapter 4: Improving the Efficiency of Hospital-Based Emergency Care

4.1 Hospital chief executive officers should adopt enterprisewide operations management and related strategies to improve the quality and efficiency of emergency care. X 4.2 The Centers for Medicare and Medicaid Services should remove the current restrictions on the medical conditions that are eligible for separate clinical decision unit (CDU) payment. 

X 

4.3 Training in operations management and related approaches should be promoted by professional associations; accrediting organizations, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA); and educational institutions that provide training in clinical, health care management, and public health disciplines. 

X X

4.4 The joint Commission on the Accreditation of Healthcare Organizations (JCAHO) should reinstate strong standards that sharply reduce and ultimately eliminate ED crowding, boarding, and diversion. 

X
24

Appendix E—Continued

Recommendations and Responsible Entities from the Future of Emergency Care Series 

HOSPITAL-BASED EMERGENCY CARE: AT THE BREAKING POINT 

Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 

4.5 Hospitals should end the practices of boarding patients in the ED and ambulance diversion, except in the most extreme cases, such as a community mass casualty event. The Centers for Medicare and Medicaid Services should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing and other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures, and incentives for implementation, monitoring, and enforcement of these standards. 

X X 

Chapter 5: Technology and Communication

5.1 Hospitals should adopt robust information and communications systems to improve the safety and quality of emergency care and enhance hospital efficiency. x 

Chapter 6: The Emergency Care Workforce

6.1 Hospitals, physician organizations, and public health agencies should collaborate to regionalize critical specialty care on-call services. 

X X X

6.2 Congress should appoint a commission to examine the factors responsible for the declining availability of providers in high-risk emergency and trauma care specialties, including the role played by medical malpractice liability in specific, and to recommend targeted state and federal actions to mitigate the adverse impact of the responsible factors and ensure quality of care. 

X 
25

6.3 The American Board of Medical Specialties and its constituent Boards should extend eligibility for certification in critical care medicine to all acute care and primary care physicians who complete an accredited care fellowship program. 

X X

6.4 The Department of Health and Human Services, the Department of Transportation, and the Department of Homeland Security should jointly undertake a detailed assessment of emergency and trauma workforce capacity, trends, and future needs, and develop strategies to meet these needs in the future. 

X X X 

6.5 The Department of Health and Human Services, in partnership with professional organizations, should develop national standards for core competencies applicable to physicians, nurses, and other key emergency and trauma professionals, using a national, evidence-based, multidisciplinary process. 

X X 

6.6 States should link rural hospitals with academic health centers to enhance opportunities for professional consultation, telemedicine, patient referral and transport, and continuing professional education. 

X X 

Chapter 7: Disaster Preparedness

7.1 The Department of Homeland Security, the Department of Health and Human Services, the Department of Transportation, and the states should collaborate with the Veterans Health Administration to integrate the VHA into civilian disaster planning and management. 

X X X

7.2 All institutions responsible for the training, continuing education, and credentialing and certification of professionals involved in emergency care (including medicine, nursing, EMS, allied health, public health, and hospital administration) incorporate disaster preparedness training into their curricula and competency criteria. 

X X X
26

Appendix E—Continued

Recommendations and Responsible Entities from the Future of Emergency Care Series 

HOSPITAL-BASED EMERGENCY CARE: AT THE BREAKING POINT 

Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 

7.3 Congress should significantly increase total disaster preparedness funding in FY 2007 for hospital emergency preparedness in the following areas: 

• strengthening and sustaining trauma care systems; • enhancing ED, trauma center, and inpatient surge capacity; • improving EMS response to explosives X • designing evidence-based training programs; • enhancing the availability of decontamination showers, standby ICU capacity; negative pressure rooms, and appropriate personal protective equipment; • conducting international collaborative research on the civilian consequences of conventional weapons (CW) terrorism.

Chapter 8: Enhancing the Emergency and Trauma Care Research Base

8.1 Academic medical centers should support emergency and trauma care research by providing research time and adequate facilities for promising emergency care and trauma investigators, and by strongly considering the establishment of autonomous departments of emergency medicine. 

X 
27

8.2 The Secretary of the Department of Health and Human Services should conduct a study to examine the gaps and opportunities in emergency and trauma care research, and recommend a strategy for the optimal organization and funding of the research effort. This study should include consideration of; training of new investigators; development of multi-center research networks; funding of General Clinical Research Centers (GCRCs) that specifically include an emergency and trauma care component; involvement of emergency and trauma care researchers in the grant review and research advisory processes; and improved research coordination through a dedicated center or institute. Congress and federal agencies involved in emergency care research (including DOT, DHHS, DHS, and DoD) should implement the study’s recommendationS. 

X X X X X 

8.3 Congress should modify Federalwide Assurance Program (FWA) regulations to allow the acquisition of limited, linked, patient outcome data without the existence of an FWA. 

X 

Appendix E 

Recommendations and Responsible Entities from the Future of Emergency Care Series 

EMERGENCY MECICAL SERVICES AT THE CROSSROADS 

Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 

Chapter 3: Building a 21-Century Emergency Care System

3.1 The Department of Health and Human Services and National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop an evidence-based categorization system for EMS, EDs, and trauma centers based on adult and pediatric service capabilities. 

X X X 
28

Appendix E—Continued

Recommendations and Responsible Entities from the Future of Emergency Care Series 

EMERGENCY MECICAL SERVICES AT THE CROSSROADS 

Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 

3.2 The National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidence-based, model prehospital care protocols for the treatment, triage, and transport of patients. 

X X 

3.3 The Department of Health and Human Services should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency care system performance. 

X 

3.4 Congress should establish a demonstration program, administered by Health Resources and Services Administration, to promote regionalized, coordinated, and accountable emergency care systems throughout the country, and appropriate $88 million over 5 years to this program. 

X X 
29

3.5 Congress should establish a lead agency for emergency and trauma care within 2 years of the publication of this report. This lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of EMS, emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital EMS (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care. 

X X 

3.6 The Department of Health and Human Services should adopt rule changes to the Emergency medical Treatment and Active Labor Act (EMTALA) and the Health Insurance Portability and Accountability Act (HIPAA) so that the original goals of the laws are preserved but integrated systems may further develop. 

X 

3.7 CMS should convene an ad hoc work group with expertise in emergency care, trauma, and EMS systems to evaluate the reimbursement of EMS and make recommendations regarding inclusion of readiness costs and permitting payment without transport. 

X 

Chapter 4: Supporting a High quality EMS Workforce

4.1 State governments should adopt a common scope of practice for EMS personnel, with state licensing reciprocity. 

X 

4.2 States should require national accreditation of paramedic education programs. 

X 
30

Appendix E—Continued

Recommendations and Responsible Entities from the Future of Emergency Care Series 

EMERGENCY MECICAL SERVICES AT THE CROSSROADS 

Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 

4.3 States should accept national certification as a prerequisite for state licensure and local credentialing of EMS providers. 

X 

4.4 The American Board of Emergency Medicine should create a subspecialty certification in EMS. 

X 

Chapter 5: Advancing System Infrastructure

5.1 States should assume regulatory oversight of the medical aspects of air medical services, including communications dispatch, and transport protocols. 

X 

5.2 Hospitals, trauma centers, EMS agencies, public safety departments, emergency management offices, and public health agencies should develop integrated and interoperable communications and data systems. 

X X X

5.3 The Department of Health and Human Services should fully involve prehospital EMS leadership in discussions about the design, deployment, and financing of the National Health Information Infrastructure (NHh). 

X 

Chapter 6: Preparing for Disasters

6.1 The Department of Health and Human Services, the Department of Transportation, the Department of Homeland Security, and the states should elevate emergency and trauma care to a position of parity with other public safety entities in disaster planning and operations. 

X X X X 
31

6.2 Congress should substantially increase funding for EMSrelated disaster preparedness through dedicated funding streams. 

X 

6.3 Professional training, continuing education, and credentialing and certification programs of all the relevant EMS professional categories, should incorporate disaster preparedness training into their curricula, and require the maintenance of competency in these skills. 

X X X X

Chapter 7: Optimizing Prehospital Care through Research

7.1 Federal agencies that fund emergency and trauma care research should target additional funding at prehospital EMS research, with an emphasis on systems and outcomes research. 

X X X X X

7.2 Congress should modify Federalwide Assurance Program (FWA) regulations to allow the acquistions of limited, linked, patient outcome data without the existence of an FWA. 

X 

7.3 The Secretary of Department of Health and Human Services should conduct a study to examine the gaps and opportunities in emergency and trauma care research, and recommend a strategy for the optimal organization and funding of the research effort. This study should include consideration of: training of new investigators; development of multi-center research networks, involvement of emergency medical services researchers in the grant review and research advisory processes; and improved research coordination through a dedicated center or institute. Congress and federal agencies involved in emergency care research (including Department of Transportation, Department of Health and Human Services, Department of Homeland Security, and Department of Defense) should implement the study’s recommendations. 

X X X X X 
32

Appendix E 

Recommendations and Responsible Entities from the Future of Emergency Care Series 

EMERGENCY CARE FOR CHILDREN: GROWING PAINS 

Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 

Chapter 3: Building a 21st-Century Emergency Care System

3.1 The Department of Health and Human Services and National Highway traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop an evidence-based categorization system for EMS, EDs, and trauma centers based on adult and pediatric service capabilities. 

X X X 

3.2 The National Highway Traffic Safety Administration, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidence-based model prehospital care protocols for the treatment, triage, and transport of patients, including children 

X X 

3.3 The Department of Health and Human Services should convene a panel of individuals with emergency and trauma care expertise to develop evidence-based indicators of emergency care system performance, including performance of pediatric emergency care. 

X 

3.4 Congress should establish a demonstration program, administered by the Health Resources and Services Administration, to promote regionalized, coordinated, and accountable emergency care systems throughout the country, and appropriate $88 million over 5 years to this program. 

X X 
33

3.5 The Department of Health and Human Services should adopt rule changes to the Emergency Medical Treatment and Active Labor Act and the Health Insurance Portability and Accountability Act so that the original goals of the laws are preserved but integrated systems may further develop. 

X 

3.6 Congress should establish a lead agency for emergency and trauma care within 2 years of the publication of this report. The lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of EMS, emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital EMS (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency and trauma care. 

X X 

3.7 Congress should appropriate $37.5 million each year for the next five years to the EMS–Program. 

X 

Chapter 4: Arming the Emergency Care Workforce with Knowledge and Skills

4.1 Every pediatric and emergency care-related health professional credentialing and certification body should define pediatric emergency care competencies and require practitioners to receive the appropriate level of initial and continuing education necessary to achieve and maintain those competencies. 

X 

4.2 The Department of Health and Human Services should collaborate with professional organizations to convene a panel of individuals with multidisciplinary expertise to develop, evaluate, and update pediatric emergency care clinical practice guidelines and standards of care. 

X X 
34

Appendix E—Continued

Recommendations and Responsible Entities from the Future of Emergency Care Series 

EMERGENCY CARE FOR CHILDREN: GROWING PAINS 

Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 

4.3 EMS agencies should appoint a pediatric emergency coordinator and hospitals should appoint two pediatric emergency coordinators—one a physician—to provide pediatric leadership for the organization. 

X X 

Chapter 5: Improving the Quality of Pediatric Emergency Care

5.1 The Department of Health and Human Services should fund studies on the efficacy, safety, and health outcomes of medications used for infants, children, and adolescents in emergency care settings in order to improve patient safety. 

X 

5.2 The Department of Health and Humane Services and the National Highway Traffic Safety Administration should fund the development of medication dosage guidelines, formulations, labeling, and administration techniques for the emergency care setting to maximize effectiveness and safety for infants, children and adolescents, EMS agencies and hospitals should implement these guidelines, formulations, and techniques into practice. 

X X X X 

5.3 Hospitals and EMS systems should implement evidencebased approaches to reduce errors in emergency and trauma care for children. 

X X 

5.4 Federal agencies and private industry should fund research on pediatric-specific technologies and equipment used by emergency and trauma care personnel. 

X X X X 

5.5 EMS agencies and hospitals should integrate family-centered care into emergency care practice. X X 
35

Chapter 6: Improving Emergency Preparedness and Response for Children Involved in Disasters

6.1 Federal agencies (the Department of Health and Human Services, the National Highway Traffic Safety Administration, and the Department of Homeland Security) in partnership with state and regional planning bodies and emergency care provider organizations should convene a panel with multidisciplinary expertise to develop strategies for addressing pediatric needs in the event of a disaster. This effort should 

encompass the following: X X X X 1) Development of strategies to minimize parent-child separation and improved methods for reuniting separated children with their families. 2) Development of strategies to improve the level of pediatric expertise on disaster Medical Assistance Teams and other organized disaster response teams. 3) Development of disaster plans that address pediatric surge capacity for both injured and non-injured children. 4) Development of and improved access to specific medical and mental health therapies, as well as social service, for children in the event of a disaster. 5) Development of policies that ensure that disaster drills include a pediatric mass casualty incident at least once every 2 years. 

Chapter 7: Building the Evidence Base for Pediatric Emergency Care
36

Appendix E—Continued

Recommendations and Responsible Entities from the Future of Emergency Care Series 

EMERGENCY CARE FOR CHILDREN: GROWING PAINS 

Congress DHHS DOT DHS DOD States Hospitals EMS Agencies Private Industry Professional Organizations Other 

7.1 The Secretary of DHSS should conduct a study to examine the gaps and opportunities in emergency care research, including pediatric emergency care, and recommend a strategy for the optimal organization and funding of the research effort. This study should include consideration of training of new investigators, development of multicenter research networks, involvement of emergency and trauma care researchers in the grant review and research advisory processes, and improved research coordination through a dedicated center or institute. Congress and federal agencies involved in emergency and trauma care research (including the Department of Transportation, Department of Health and Human Services, Department of Homeland Security, and Department of Defense) should implement the study’s recommendations. 

X X X X 

7.2 Administrators of statewide and national trauma registries should include standard pediatric-specific data elements and provide the data to the NTDB. Additionally, the American College of Surgeons should establish a multidisciplinary pediatric specialty committee to continuously evaluate pediatric-specific data elements for the NTDB and identify areas for pediatric research. 

X
37

Mr. REICHERT. The Chair recognizes Ms. Jagim. 

STATEMENT OF MARY JAGIM 

Ms. JAGIM. Good, Mr. Chairman and members of the subcommittee. Thank you so much for convening this hearing today 

and allowing us to speak with you. 

I am Mary Jagim, the Internal Consultant for Emergency Preparedness and Pandemic Planning for MeritCare Health System in 

Fargo, North Dakota, and I was a member of the committee that 

oversaw the development of IOM reports. 

I am here today, though, representing the Emergency Nurses Association where I have served on the board of directors and was the 

2001 president. ENA, with over 30,000 members, is the only professional nursing organization directed toward defining the future of 

emergency nursing and emergency care. And on behalf of ENA I 

appreciate the opportunity to discuss our concerns regarding hospital surge and mass trauma care capacity. 

Over the past 5 years, millions of dollars have gone to strengthen 

our country’s disaster preparedness. However, one area, as you 

have heard, still has not received the level of support it needs to 

prepare for mass casualty episodes. It is emergency care providers 

and hospitals, the ones who provide the emergency medical care for 

patients and family members during a disaster. Hospitals and 

EMSs have been underfunded, undersupported, and, in many 

cases, just plain left out. And it is the emergency care system of 

our country that right now is the most fragile, most oversaturated, 

and most fragmented of all of our health care needs. 

So despite national expectations that our emergency care system 

on a day-to-day basis is there for people, instead, it is extremely 

overloaded and vulnerable, lacking the ability to respond appropriately when needed. How then is it to respond when the extraordinary occurs? 

I want to focus most of my comments, though, on a vital role 

within our emergency preparedness response system, and that is 

the role of the emergency nurse. 

There is an expansive skill set and knowledge base required to 

be an emergency nurse, as we must be prepared to care for every 

type of illness and injury of every age group, all of whom are in 

a state of crisis when they come to our doors. 

Nurses entering the field of emergency nursing need a minimum 

of 2 years following their educational preparation simply to acquire 

the core knowledge needed to work in an emergency department. 

And years beyond those first two are necessary to fully master 

their significant role as a coordinator of patient care. For it is that 

coordinator-of-care role, along with their critical thinking skills, 

that really enables an emergency nurse to swiftly assess the situation at hand and respond appropriately and bring to the patient 

the resources they need at that moment in time. 

Let’s take, for example, the occurrence of a mass casualty event 

in one of your communities. When that occurs, it is the emergency 

nurse that receives the call from EMS that an event has occurred 

and that multiple victims will be brought to the hospital. It is that 

emergency nurse that activates the hospital’s response plan and 

calls in additional nurses and physicians as well as others to assist. 
38

It is the emergency nurse who then goes on to make arrangements 

to get all the current emergency department patients either admitted, discharged, or moved to other locations. 

It is the ED nurse that organizes triage to receive the arriving 

victims and who direct the EMS crews and coordinates the disaster 

decontamination teams. It is emergency nurses then who also stay 

at the patient’s bedside providing care and comfort in their time of 

need, and it is the nurses who notify family members and console 

those who have lost loved ones. 

And most likely, it was an emergency nurse who helped to write 

the plan that activated the response, including the procurement of 

appropriate supplies and equipment, and who developed the educational training program and trained the staff—that is, if those 

plans and training have occurred in the first place. 

The emergency nurse has a vital role, more precious right now 

because of the nursing shortage. During the 10-year span between 

2002 and 2012 health care facilities will need to fill more than 1.1 

million R.N. job openings. 

The nursing community has been urgently asking Congress to increase funding for nursing workforce development programs, and 

especially to increase funding for nursing faculty preparation. 

Do you know that the Federal investment in nursing education 

is less than 600-thousandths of the total Federal budget, whereas 

in 1974 during our last serious nursing shortage, Congress appropriated 153 million for nurse educational programs. In today’s dollars that would be equivalent to $592 million, which is about four 

times what the Federal Government is currently putting towards 

nursing education. 

Applications to nursing programs have been increasing during 

this past time, but in the last school year, 147,000 qualified applicants had to be turned away because there were not enough faculty 

in the schools to teach them. 

The results of the disparities in workforce supply and demand 

are played out in staff shortages in the majority of emergency departments and hospitals across this country. And it results in staff 

who are struggling to provide care, to ED crowding, to ambulance 

diversions, and to the patients who are ultimately the ones who 

suffer. And the situation is only going to get worse as our population ages. 

The emergency nurses of this country have been underrecognized 

and undervalued and truly undersupported in their roles. Yet they 

so strongly desire to provide skills and compassionate emergency 

care to their patients. 

We ask you, please, to support the recommendations that ENA 

has outlined in our written testimony and to work with us to create 

a coordinated, regionalized, and accountable emergency care system that is staffed, that is trained, and that is prepared, so that 

when our communities need us we can be there. 

We cannot achieve this alone. Thank you. 

Mr. REICHERT. Thank you Ms. Jagim. 

[The statement of Ms. Jagim follows:]
39

PREPARED STATEMENT OF MARY M. JAGIM, RN, BSN, CEN, FAEN 

Good morning, Mr. Chairman and members of the Subcommittee. Thank you for 

convening this hearing to examine the current condition of emergency care and its 

implications for maintaining security 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 Mary Jagim, the Internal Consultant for Emergency Preparedness and Pandemic Planning for MeritCare Health System in Fargo, North Dakota, and a member of the Institute of Medicine’s (IOM) committee that oversaw the development 

of the report, Future of Emergency Care in the United States Health Sys-tem.

I am here today representing the Emergency Nurses Association (ENA) where I 

have served on the Board of Directors and as the 2001 President. 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 more than 30,000 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 discuss with the Subcommittee our particular concerns regarding hospital surge and mass trauma care capacity.

MASS TRAUMA AND EMERGENCY NURSING CARE 

Emergency nurses are no strangers to mass casualty challenges. We engage continually in every aspect of patient care throughout the emergency care system. 

Emergency nurses conduct triage, the first application of medical care in the ED, 

assessing patient conditions and swiftly prioritizing needs within a rapidly changing 

scenario. We coordinate treatment and autonomously intervene at a moment’s notice. In addition, it is our role to invest quality time with patients and their families 

as we teach them how to manage their conditions and prevent injuries. Emergency 

nurses are a critical member of daily emergency care and, owing to our requisite 

knowledge and skills, we occupy a unique role on the team of professionals delivering mass casualty care. 

All hospitals and medical facilities across our country are vulnerable to mass casualty incidents. A mass casualty incident occurs as a result of an event where sudden and high patient volume exceeds an ED’s resources. Such events may include 

the more commonly realized multi-car pile-ups, train crashes, hazardous material 

exposures in a building or across a community, high occupancy structural fires, or 

the extraordinary events such as pandemics, weather-related disasters, and intentional catastrophic acts of violence. In all cases and degrees of calamity, the emergency department is the entry point into the hospital system and is the initial facility-based, patient-care area for victims of a mass casualty incident.

FRAGMENTATION/REGIONALIZATION 

ENA supports the IOM’s assertion that the U.S. emergency care system 

needs to be coordi-nated and regionalized. The IOM report acknowledges that 

the nation’s emergency care system is poorly prepared to care for ill and wounded 

patients following a mass casualty incident. It describes today’s emergency care system as saturated, highly fragmented, and variable. 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 statewide trauma 

care systems. Although only eight states have fully developed trauma systems, these 

statewide healthcare 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 FY 2006, provided critical national leadership, and leveraged additional scarce 

state dollars, to optimize trauma care through system integration that offered seri-
40

ously 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 this result 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.

DISASTER PREPAREDNESS 

ENA supports development of basic and advanced continuing-education 

courses and training to prepare emergency nurses in the care and treatment of victims, across all age groups and diverse populations, of mass casualty incidents. Disaster preparedness is an essential function of frontline emergency nurses and the emergency care continuum. Emergency preparedness for mass 

casualty incidents should be a major part of an emergency nurse’s training and 

should be reflected in the work she or he does every day. Our organization, through 

its conferences and publications, including the quarterly Disaster Management 

and Response journal, provides its members with information and resources on 

disaster preparedness. But as the IOM report points out, in general, a lack of planning, training, and supplies, along with limited federal funding, complicates the 

mass casualty readiness situation at the hospital ED level across the country. 

ENA joins the IOM in urging an increase in federal funding allocated to 

assist hospitals in plan-ning, in training, and in equipment and supply procurement for all-hazards disaster prepared-ness. Although EDs play a significant role in the medical response to major disaster events, a current imbalance exists in funding allocations. Funding either has not reached all hospitals, or—for 

those that received funding—the average amount was between $5,000 and $10,000 

in 2002 and 2003. Owing to the capacity needs and infrastructure that must be advanced to meet the national goal of an emergency care system ready to appropriately respond to all-hazards disasters, the allocation of federal emergency preparedness funds is grossly insufficient. 

For example, a considerable amount of the federal funding has been allocated to 

fire. Much of this funding has been used for equipment procurement and training 

involving chemical and biological contamination. Past experience has shown that in 

disasters of mass contamination, only a portion—as little as 20 percent—of the victims remain on scene for decontamination and medical care. The remaining 80 percent present at the hospital ED, where the appropriate equipment and training have 

been under funded, if funded at all. The fire and EMS personnel and equipment at 

the disaster scene are not available to respond and assist with the decontamination 

needs of the majority of the victims who are presenting to the ED. The allocation 

of emergency preparedness monies to hospitals has been disproportionate to the 

share of the medical response to major disaster events delivered by EDs. Without 

specific funding provided to hospitals for the purposes of planning, training, and 

procurement, these activities will not occur, leaving hospitals under—or unprepared, 

and our national goal of disaster preparedness unmet. 

The ENA unites with COMCARE, a nonprofit national advocacy organization dedicated to ad-vancing emergency communications, in advocating 

that emergency communications systems and ‘‘interoperability’ are defined 

to include interorganizational data communications and data communications generally. Coordinated and comprehensive communication is another critical 

aspect of disaster preparedness for mass casualty events. Appropriate protection of 

the public requires continuous, redundant, and reliable systems of all forms of communications and information technology. As a member of COMCARE, ENA recognizes the vital nature of data and information technology, whether supporting emergency alerts to agencies and the public, shared systems for incident management 

and situational awareness, patient tracking applications, resource management, or 

scores of other uses. Fully interoperable parameters necessitate the use of integrated, multimode emergency communications systems designed to communicate 

with one another on demand in real time, and—as necessary—support voice and 
41

data interchange between the emergency and emergency support organizations, in 

addition to radio communications with mobile staff. 

ED nurses, along with all other medical and emergency responders, need to be 

able to receive, send, and access all kinds of patient data on a daily basis. An example is the frequent occurrences of patients arriving at the ED on their own, by ambulance, or as a result of an evacuation from another hospital without any information regarding their medical history. Healthcare workers should have access to all 

of the appropriate information: Who is the primary physician? What medicines is 

the patient taking? What are the vitals? What treatments have already been given? 

Our members need to communicate and share information with other professions 

and jurisdictions so that we can provide the best care possible to our patients during 

and after everyday emergencies and mass casualty disasters. 

ENA supports COMCARE in recommending that the local, regional, and 

state emergency com-munications planning and implementation required 

by current federal guidelines be conducted as an integrated whole, including all organizations involved with emergency response, and all forms of 

communications. We are concerned that the current planning processes are focused too narrowly and are compromising our nation’s ability to rapidly improve our 

response capabilities. All organizations involved in emergency preparation and responses need to participate in planning and deployment. Furthermore, not only 

must funding guidelines allow expenditures on software and emergency services information technology in addition to equipment procurement, but the guidelines also 

must provide for planning and training.

THE FOUNDATION OF THE EMERGENCY CARE SYSTEM 

Preparing for hospital surge and mass trauma care capacity will not happen without remediation of the general emergency care system infrastructure.

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 interchangeable resources. The expertise of a seasoned ED nurse is critical to achieve 

quality patient outcomes in a dynamic healthcare system that demands competencies for a multitude of situations, including all-hazards mass casualty events. 

Hospital staffing systems must acknowledge the need for, and incorporate, training 

and education time and funding for emergency nurses. 

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. Today’s nursing shortage is very real and very different from 

any experienced in the past. The existing shortage is evidenced by an aging workforce and too few individuals entering the profession. A critical factor exacerbating 

the national nurse-workforce deficiency is the declining number of qualified nurses 

available to teach future generations of registered nurses. 

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.

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 
42

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 U.S., 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.

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 
43

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 with readiness for mass casualty events 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 United States 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. The Emergency Nurses Association pledges our efforts and our expertise to work with you and your colleagues to 

assure the population’s protection and well-being as homeland security compels.

Mr. REICHERT. The Chair now recognizes Dr. Krug. 

STATEMENT OF STEVEN KRUG, M.D. 

Dr. KRUG. Thank you, Mr. Chairman, and I appreciate the opportunity to testify today. 

My name is Steven Krug. I am a pediatric emergency physician, 

and I am the head of the Division of Emergency Medicine at Children’s Memorial Hospital in Chicago. Today I am proud to represent the American Academy of Pediatrics where I have the privilege of chairing the Academy’s Committee on Pediatric Emergency 

Medicine. 

Emergency medical services are the foundation our Nation’s defense of public health disasters. 

In addition to the many concerns raised by my colleagues and 

within the IOM report regarding the overall health of our Nation’s 

emergency medical services, these systems also bear some specific 

limitations in their ability to meet the medical needs of children. 

It has been said that children are not little adults, and this is especially true in an 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. 

For example, children are particularly vulnerable to aerosolized biological or chemical agents, because they normally breathe faster 

than adults do and because these agents, being heavier than air, 

tend to circulate down near the ground in the breathing zone of 

children. There are dozens of other such crucial differences that 

make children more vulnerable. 

Once children are critically ill or injured, their bodies respond 

very differently than adults in similar medical crises. In addition 

to their physiological vulnerabilities, children need different dosages in formulations of medications and smaller-sized equipment 

specific to their needs. 

This is an adult-sized endotracheal breathing tube. You could not 

use this on a child. A small infant would require a tube of this size. 
44

In pediatric emergency medicine, one size does not fit all. In fact, 

there are 12 different sizes between these two tubes. You have got 

to have the right size for the right patient or the patient is not 

going to survive. 

In addition to having the appropriate medications and resuscitation equipment, it is critical that all health care workers be able 

to recognize the unique signs and symptoms of children that indicate a life-threatening situation, and that they then possess the 

skills to intervene accordingly. 

The Institute of Medicine characterized the status of pediatric 

emergency readiness in 2006 using the word ‘‘uneven,’’ noting that 

not all children have access to the same quality of care. The report 

documents several examples of the problem. I will just list a few. 

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 of those hospitals have written 

transfer agreements with hospitals that actually have that capability. 

Finally, pediatric emergency treatment patterns and protocols 

vary widely across emergency care providers and across geographic 

regions. 

Each of these shortcomings has major implications for just dayto-day emergency care and disaster preparedness. I can’t emphasize this next point enough. Systems that are unable to meet everyday care needs for children, by definition, are unlikely to be able 

to deliver the care that we need during a time of disaster. 

The IOM also observed that disaster plans have often overlooked 

the needs of children, even though their needs differ greatly from 

those of adults. One Federal program provides a clear example of 

the general neglect of children’s issues in disaster planning. 

HRSA’s National Bioterrorism Hospital preparedness program 

provides funds to States in 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 not really clear 

whether they are required to be represented in proportion to the 

number in the State’s population. A State could arguably plan for 

499 adults and 1 child and actually satisfy the guidance. 

Outside of that single pediatric mention in benchmark for surge 

capacity, children’s issues are otherwise absent from the guidance. 

Surge capacity issues are fundamental but many other issues require similar attention. We must plan for the availability of drugs 

and antidotes in the appropriate formulations and dosages for children. In many cases, medication dosing for children is determined 

by their weight. A simple device known as a Braslow tape—I have 

one right here—is a rather unique device which actually helps 

emergency care providers to calculate the weight-based dosing of 

vital resuscitation medications by measuring the length of the patient. This allows those health care providers to dose medications 
45

quickly and accurately. Unfortunately, only about half of our disaster management assistance teams have devices like this. 

Perhaps the most important and successful Federal program in 

improving emergency health care for children has been HRSA’s 

Emergency Medical Services for Children program, or EMSC. With 

a modest budget allocation, EMSC has driven significant improvements in pediatric emergency care, including disaster preparedness. 

As just one example, in the 21 years since the program was established, child injury rates have dropped by 50—rather, by 40 percent, excuse me. The American Academy of Pediatrics fully endorses the Institute of Medicine’s comments regarding the value of 

the EMSC program. The program should be reauthorized and funded at or above the level recommended by the IOM. 

The American Academy of Pediatrics has some specific recommendations for policymakers regarding children in emergency 

and disaster preparedness. 

First, we must invest in creating effective local, State and Federal disaster response systems built upon a healthy, adequately 

funded, well coordinated, and functional emergency medical services system. 

Secondly, pediatricians should be included in emergency planning at all levels of government and in all types of planning. Standards for pediatric emergency readiness for prehospital and hospitalbased emergency services and the regionalization of pediatric trauma and critical care should be developed and implemented within 

every State and region. 

Federal, State, and local disaster plans should include specific 

protocols for the management of pediatric casualties, including 

strategies to improve the level of pediatric equipment and medication readiness and clinical expertise in disaster response teams; improve access to pediatric medical and surgical subspecialty care 

and pediatric mental health care professionals; integrate schools 

and day care facilities in local and regional disaster plans; minimize parent and child separation and develop systems for the timely and reliable reunification of families; address the care requirements of children with special health care needs; and ensure the 

inclusion of pediatric mass casualty incident drills at both the Federal and State planning levels. 

In addition, more research must be funded into all aspects of pediatric emergency planning response and treatment. 

And, lastly, the EMSC program should be authorized and funded 

at or above the level recommended by IOM. 

In conclusion, the American Academy of Pediatrics greatly appreciates this opportunity to present our concerns and recommendations related to pediatric emergency and disaster preparedness at 

this afternoon’s hearing. Our children must not be an afterthought 

in emergency and disaster planning. They are our most valuable 

resource. 

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. Thank 

you. 

Mr. REICHERT. Thank you, Doctor. 
46

[The statement of Dr. Krug follows:]

PREPARED STATEMENT OF DR. STEVEN KRUG

I appreciate this opportunity to testify today before the Homeland Security Subcommittee on Emergency Preparedness, Science and Technology at this hearing, 

‘‘Emergency Care Crisis: A Nation Unprepared for Public Health Disasters.’’ My 

name is Dr. Steven Krug, and I am the Head of the Division of Pediatric Emergency 

Medicine at Children’s Memorial Hospital in Chicago, Illinois and a Professor of Pediatrics at the Northwestern University Feinberg School of Medicine. Today I am 

proud to represent the American Academy of Pediatrics, a non-profit 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. I have the privilege of chairing the 

Academy’s Committee on Pediatric Emergency Medicine.

BACKGROUND 

Emergency medical services are the foundation of our nation’s defense for public 

health disasters. I expect today’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.i 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. As 

a representative of the Academy, and as an advocate for children, my testimony will 

focus on issues concerning pediatric emergency preparedness so you 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.ii

• 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 cooper-
47

ate with decontamination.iii 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.iv

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.v

• Children may be developmentally unable to communicate their needs with 

health care 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 health care 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.vi 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% surviving the event, and with 75% 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% of all emergency department 

visits in the U.S., and 5 to 10% 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% of children receive their 

emergency care in a non-children’s hospital or non-trauma 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. 
48

I have alluded to the growing number of children with chronic medical conditions. 

Children with special health care needs vii are the fastest growing subset of children, 

representing 15 to 20% of the pediatric population.viii 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.ix, x

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 health care 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.xi

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% of emergency departments across the nation have all of the supplies 

necessary for managing pediatric emergencies. 

• Only half of hospitals have at least 85% 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.xii

• 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. Lastly, 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 
49

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.xiii

A unique consideration in pediatric emergency care and disaster planning is the 

role of schools and day care facilities. Children spend up to 80% of their waking 

hours in school or out-of-home care. Schools and day care 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.xiv Families should also be 

encouraged to engage in advance planning for emergencies and disasters.xv

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.xvi

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 

health care providers to calculate dosages quickly and accurately. However, one 

study showed that 46% of Disaster Medical Assistance Teams were lacking these 

tapes, in addition to other critical pediatric equipment.xvii

Training is vital to pediatric preparedness. Many health care 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 health care 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 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.xviii
50

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.xix 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.xx 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.xxi 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.xxii Just last month, the IOM 

issued its report on the pediatric aspects of the emergency care system.xxiii 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 health care 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%. 

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 state-wide 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 
51

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 policy makers, researchers, providers and professional 

organizations across the spectrum of emergency care, is well positioned to assume 

this leadership role.’’ xxiv

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 hospitalbased 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 health care 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 health care facilities to address pediatric preparedness, including maintaining surge capacity and creating specialized treatment areas for children, such as isolation and decontamination rooms. 

• Schools and day care 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 health care professionals; 

• Address the care requirements of children with special health care needs; 

and 
52

• 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.xxv

School and day care issues: Children spend up to 80% of their waking hours in 

school or out-of-home care. Schools and day care facilities must be integrated into 

disaster planning, with special attention paid to evacuation, transportation, and reunification with parents.xxvi

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 health care.xxvii

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 health care 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. i 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. ii 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.) iii 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 iv 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 v 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. 
53

viMarkenson 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. viiMacPherson M et.al. A New Definition of Children with Special Health Care Needs. Pediatrics, Vol. 102, No. 1, July 1998. 

viii 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. ixSeidel JS, et al: Emergency medical services and the pediatric patient: Are the needs being 

met? Pediatrics,Vol. 73, June 1984. xSeidel 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. xiDurch JS, Lohr KN (eds): Emergency Medical Services for Children. Report of the Institutes 

of Medicine Committee on Pediatric Emergency Medical Services. Washington, D.C., The National Academies Press, 1993. Available at: http://books.nap.edu/catalog/2137.html. xii Institute of Medicine. Future of Emergency Care Series, ‘‘Emergency Care for Children: 

Growing Pains.’’ National Academies Press, June 2006. xiii 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. xivSchools 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. xvFamily Readiness Kit. http://www.aap.org/family/frk/frkit.htm. xvi National Bioterrorism Hospital Preparedness Program FY 2005 Continuation Guidance, 

HRSA Announcement Number 5–U3R–05–001, http://www.hrsa.gov/bioterrorism/

hrsa05001.htm. xviiMace 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. xviii Committee on Hospital Care. Family-Centered Care and the Pediatrician’s Role. Pediatrics, Vol. 112, No. 3, September 2003. 

xix National Advisory Committee on Children and Terrorism. Recommendations to the Secretary. Washington, DC: DHHS, 2003. xx Committee on Pediatric Emergency Medicine. The Pediatrician’s Role in Disaster Prepared- ness. Pediatrics, Vol. 99 No. 1, January 1997. xxi AAP Task Force on Terrorism. All related documentation at www.aap.org/terrorism. xxiiPediatric Preparedness for Disasters and Terrorism: A National Consensus Conference. 

2003. http://www.ncdp.mailman.columbia.edu/files/pediatric—preparedness.pdf. xxiii Institute of Medicine. Future of Emergency Care Series, ‘‘Emergency Care for Children: 

Growing Pains.’’ National Academies Press, June 2006. xxiv Institute of Medicine. Future of Emergency Care Series, ‘‘Emergency Care for Children: 

Growing Pains.’’ National Academies Press, June 2006. xxv Committee on Environmental Health. Radiation Disasters and Children. Pediatrics, Vol. 

111, No. 6, June 2003. xxviSchools 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 xxvii 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.

Mr. REICHERT. I have a few questions and then we will move to 

other members of the committee. 

Part of the challenge of this committee—and as a new Member 

of Congress, this is my freshman year—is trying to identify how 

the Federal Government can really help rather than hinder. So 

part of the reason for your presence here today and your testimony 

is to help us understand the problem a lot more clearly, hopefully, 

and then also have you help us identify solutions to the problems 

that you so readily see every day that you come to work. 

So I have just jotted down lots of notes and the other members 

have also. And some of the things I have noted from the witnesses 

that they are also—not only are you presenting problems, but you 

are presenting some solutions. 

And we just want to know, really—I guess the first question I 

have is for Dr. Bass. You mentioned in one of your points that 

there should be some Federal funding in an effort to put together 

a pilot program, a regional pilot program. Would you describe that 

more for me, please? 
54

Dr. BASS. Yes, sir, I will. The committee believes that emergency 

care can best be delivered in the form of regionalized care, where 

the bottom line is trying to get the right patient to the right hospital in the right time. Meaning, for instance, the trauma patient 

that has severe trauma gets to a trauma center; the patient with 

an acute heart attack gets to a center that can provide the right 

care; the pediatric patient with critical care needs gets to a hospital 

that has the ability to provide pediatric intensive care. 

That system should be—there should be data collected as to how 

that system performs, such as issues such as bypass, response 

times, diversion issues, et cetera. So it should be accountable. And 

it should be coordinated, meaning that different elements of the 

system should be working together. Hospitals should be working 

with the prehospital care, should be working with disaster management, to make sure that the care is integrated. The care that is 

provided in the prehospital care environment should be completely 

seamless, if you would, from the care that is provided in the emergency department, and then the hospital as a continuum of care, 

and we should be able to build on that. It can’t be fragmented. It 

needs to be coordinated. So coordinated, accountable, regionalized 

care is one of the central themes of the IOM report. 

Mr. REICHERT. This would include EMS personnel, ambulance 

personnel? 

Dr. BASS. EMS emergency departments, specialty care trauma 

centers, all of those would be included in that. 

Mr. REICHERT. And would include communication systems, I suppose, in the health IT protocol? 

Dr. BASS. Interoperable systems with respect to both data and 

voice. 

Mr. REICHERT. Do you know if there is a community in the Nation here that currently has a plan underway that—I am sure most 

of these things start at the local level and then 

Dr. BASS. I was in a difficult position while the committee met. 

I really am very proud of the State of Maryland, and we were cited 

as an example in the IOM report. And I am not saying we have 

achieved all of the goals and recommendations in the report, but 

we have a statewide system. It started with trauma care in 1970. 

We have a statewide Medevac program. We know that 87 percent 

of our patients with serious injuries make it primarily to a trauma 

center. 

We are working on cardiac and stroke now. We have a statewide 

communications system where hospitals can talk to EMS, and we 

are adding public health to that now, and it is all through a coordinated center that operates out of Baltimore. 

Mr. REICHERT. What has been your contact with the Department 

of Homeland Security in putting this sort of a plan together? 

Dr. BASS. Well, we work fairly closely with DHS on a variety of 

different projects. I met with Dr. Rungy, for instance, who is the 

chief medical officer, on a number of occasions. 

Mr. REICHERT. Federal grants awarded as a part of putting this 

program in? 

Dr. BASS. We get the State grants primarily, and then the State 

grants we distribute through—we have a process that we use to 

distribute through Homeland Security and our emergency manage-
55

ment agency. And I will say in my State, very proud to say that 

the health and medical folks are there at the table. 

Mr. REICHERT. What sort of Federal grants then come to the 

State, or are they part of the UASI? 

Dr. BASS. We get UASI, we get State Homeland Security grants, 

we get the HRSA bioterrorism grants. That comes through the 

health department. And we have an agreement with the hospitals, 

their support, and the health department; 10 percent of that goes 

to prehospital care. 

Mr. REICHERT. And one last quick question. The Department of 

Health and Human Services have been just as helpful, I would 

imagine. 

Dr. BASS. We have worked very closely with them as well, and 

sometimes we wish they would work as closely with each other as 

they do with us. 

Mr. REICHERT. That was my next question. I will complete my 

questioning and move on to Mr. Pascrell. 

Mr. PASCRELL. Thank you very much, Mr. Chairman. 

I am curious. We have four distinguished folks in front of us on 

the panel, and I want to throw a specific problem at you and I 

would like to know what your response and reaction is. 

I have read about what is going on in New Orleans and in the 

aftermath of people who lost their lives in a hospital. Decisions had 

to be made in that hospital during a time of crisis. That is easy 

for me to make value judgments, sitting miles away. I don’t know 

of what was going on in the doctors’ or the nurses’ minds, the three 

of them, when they made the decision. Or did they make that decision? 

Do you think that the hospitals—you know, we talk about being 

prepared; do we have an exit strategy? Do we have a strategy that 

would assist in vacating hospitals, or any facility for that matter, 

if there was a crisis? 

I want your quick opinion, which is not fair to you, but that is 

okay. I want your quick opinion about what you—how you assess 

what has happened there, in that one particular hospital with the 

doctor and two nurses, in view of the patients dying. What does 

that reflect in the system, or is it just unique to New Orleans or 

that hospital? 

Dr. Krug. 

Dr. KRUG. I am not going to offer an ethical opinion to their actions. But I guess I would comment that at the very least, there 

was an extraordinary situation there, and in fact what happened 

is also not just there but at other institutions as well. We had patients and care providers stranded with no help, with little security 

support, without basic infrastructure, and with no clear understanding when they would receive relief. 

In the pediatric universe, in fact, the sickest of the children at 

the children’s hospitals were not evacuated by a Federal or State 

response. They were evacuated through a shared-aid system 

through other children’s hospitals that sent teams down to help 

them out. And in fact, because of coordination issues, there was 

some hazard there. 
56

So I am not surprised that there was a sense of desperation. 

And, again, I can’t comment on their actions. I am not sure what 

the right thing is to do. 

Mr. PASCRELL. Ms. Jagim. 

Ms. JAGIM. I think that when it comes to evacuating hospitals, 

that is a very complex issue and it certainly articulates, I think, 

the need for community-wide planning and regionalization also. 

You need to have a plan, because when we sit down as a community back in Fargo and talk about evacuation, it is evacuating hospitals, nursing homes, group homes, all kinds of places; and everybody thinks they can rely upon the the same resources to accomplish that, and that is not realistic. And so it is very complex. 

And I think it is a great example of what is not in place and 

what isn’t going to work should another crisis occur. 

Mr. PASCRELL. Thank you. Dr. Blum. 

Dr. BLUM. I too can’t comment about the specifics of that case, 

I simply don’t know enough about them to be able to comment 

about that. I don’t know enough about the specifics of that case to 

comment specifically about the ethics or the decision making that 

went into that. 

I could make a few general comments, though, and that is all 

emergency care, especially in the mass casualty, mass illness situation, uses the principle of triage, which is basically the principle of 

where can you do the most good for the most people, you know, 

over a short period of time. 

And during those times, sometimes very, very difficult decisions 

have to be made about who gets care first— 

Mr. PASCRELL. Right. 

Dr. BLUM. Et cetera. So that is a general principle of emergency 

care. As far as hospital evacuation is concerned, understand that 

hospitals are very unique places. I could tell you my hospital in 

Morgantown, West Virginia, if we had to evacuate, the closest 

equivalent facility is over 100 miles away. And to evacuate the type 

and complexity of patients we have in that tertiary care hospital 

would require a massive effort, probably a massive airlift effort. It 

is a nearly 500-bed— 

Mr. PASCRELL. Are people talking about that? 

Dr. BLUM. There simply aren’t the resources immediately locally 

available to do that very easily, and so while we talk about it, the 

solutions are not very obvious. It simply—and we saw that in New 

Orleans. These were some very big hospitals with lots and lots of 

patients, many of whom were very sick, that needed to be evacuated, often under fire. And all I can tell you is that at least from 

the emergency medicine perspective, the docs stayed and took care 

of patients, often bagging them by hand for long periods of time because there was no power to the ventilators. 

Dr. BASS. I would emphasize the importance of prior planning, 

and, as was mentioned by one of my colleagues, I believe a lot of 

folks believe they can call 911 and 911 will help them with their 

evacuation. The problem is if you have 100 or 200 or 500, or as one 

of our counties might have, 7—or 800 facilities to evacuate, 911 

can’t handle all that. 

So you have to know where the patients are, where the people 

are that need to be evacuated, and that is not just hospitals, it is 
57

nursing homes; now we have assisted living facilities, we have a 

number of people. And we need to, one, know where they are; two, 

have a plan, work with transportation to, A, get appropriate vehicles, B, have routes planned, et cetera. You have to do that kind 

of planning or you end up with a situation where people are desperate. 

Mr. PASCRELL. Mr. Chairman, it would—it strikes me in the testimony, I glanced through all of the panelists, and the comments 

today, it strikes me that perhaps—just perhaps—you cannot discuss emergency services without discussing the other services of 

the hospital. And many of those hospitals are hanging by a thread, 

and you can’t expect the emergency room to be in any better shape. 

So we may, you know, we are not going to generalize to the point 

of looking at the entire health system in its delivery forces, although we may be forced to do that in order to prepare for the 

worst. 

Thank you, Mr. Chairman. 

Mr. REICHERT. Thank you, Mr. Pascrell. 

And the Chair recognizes that are other committees and subcommittees that certainly have jurisdiction over the issue that we 

are discussing today. We are today focusing on Homeland Security, 

and certainly the system is so interconnected that we can’t ignore 

one part of the problem to solve another part of the problem. It is 

going to be solved together. So hopefully we can work—as you have 

worked with Homeland Security, Dr. Bass, and the Department of 

Health—we hope to work with the other committees and subcommittees in helping the Nation be a lot more ready for—a lot 

more prepared for any emergency that might come into our trauma 

centers and emergency rooms. 

The Chair now recognizes Mr. Dent. 

Mr. DENT. Thanks, Mr. Chairman. Good afternoon. 

In your opinion—and I know this is a question for all the panelists—but what do you see is the level or extent to which there is 

cooperation and coordination between Department of Homeland Security and HHS for these types of public health disasters or medical emergency situations? 

Maybe, Dr. Bass, do you have any thoughts or insights on this? 

Dr. BASS. I would be candid. I have good friends and colleagues 

in both agencies, but at the same time, I sometimes get incredibly 

frustrated. I think during Katrina and Rita was a good example of 

where, in trying to work with the two agencies, we saw sometimes 

very sort of different approaches to how they were going to address 

the needs of the folks who were down in the gulf area, and, you 

know, one talking about evacuation, the other talking about moving Federal treatment facilities down into the area. 

And that is—it is well and good to have different plans, but at 

some point these plans need to come together and they need to be 

integrated. And that is the one thing I think that I can say on behalf of all of my State director colleagues, is that we would really 

very much like to see DHS and DHHS work more closely and in 

a more integrated way when things such as Katrina and Rita 

occur. 

Mr. DENT. Dr. Blum. 
58

Dr. BLUM. I think it is an evolving and improving relationship. 

But from the perspective of my colleagues I would say that both—

both entities tend to take for granted the emergency departments 

in the part of the equation. If you think about it, most of the planning that goes on for disaster preparedness has as its end point the 

delivery of a patient to an emergency department. 

In it is argued that very often no one has looked to see whether 

that emergency department is able or capable of taking care of the 

number and types of and complexities of patients it might get from 

all those planning efforts that are aimed at delivering the patient 

to the emergency department. 

I guess my message today is that is a critical part of the puzzle 

as well, that is a critical part of the planning; and if we ignore that 

part, we have created an incredible system to deliver a patient to 

a dysfunctional system and that doesn’t make any sense. 

Ms. JAGIM. I would just like to add I think that the emergency 

department, as Dr. Blum had indicated, we have one foot in the 

public response entity and we have one foot in a private hospital 

business, and I think that that is a part of why we have been left 

out of a lot of the disaster preparedness conversations or planning 

because we are not seen as part of that solely public emergency response, and I would like to see more—at least on the frontlines—

feel more integration and more focused coordinated leadership related to emergency response. 

Mr. DENT. Dr. Krug? 

Dr. KRUG. I don’t want to take up time here, but I soundly agree 

with the comments made by my three colleagues. I think there is 

good intention on both sides, but there really can only be one plan 

and the plan has to reflect the reality of the foundation or the response, which is the crisis we are here talking with you guys about 

this morning or this afternoon. 

Mr. DENT. And my final question and you don’t have to give long 

answers, but as you may be aware, there is a training facility for 

these medical preparedness situations down at the Noble Facility 

in Alabama. Have any of you taken advantage of that training? 

Just anybody want to say anything, would you like to comment on 

that? 

Ms. JAGIM. I think it is a great resource. I was there a couple 

of years ago. I think it provides a lot of different types of courses. 

The access—I am not sure that everybody has all the information 

about it or has had an opportunity to experience it, but I think it 

has provided a lot of education. 

Mr. DENT. Thank you. Dr. Blum, do you want to say something? 

Dr. BLUM. I have not taken advantage of the training at that 

specific facility, but I have had some training in this area. Again 

though, I want to emphasize that most natural and even manmade disasters, the medical conditions that need to be treated are 

medical conditions that we see and treat every day. There are 

unique situations that we have to deal with depending on the entity that is involved, but in the vast majority of situations, you know, 

it is basic trauma care, it is basic emergency care, and that is what 

we do every day. 

Mr. DENT. And either Dr. Krug or Dr. Bass, you have had any 

experience? 
59

Dr. BASS. I am familiar with Noble and I think it is a great resource but I think it is underutilized and a lot of people don’t know 

about it. 

Mr. DENT. Thank you. Okay, yield back. 

Mr. REICHERT. Chair recognizes the ranking member of the full 

committee, Mr. Thompson. 

Mr. THOMPSON. Thank you very much and I appreciate the testimony of our witnesses. One of the things we grapple with is whether or not from a lessons learned standpoint if another Katrina/Ritatype situation happened, are we in any better situation today than 

we were 11 months ago? Have you seen in your professional duties 

on a day to day, any leadership on the part of DHS or HHS to better prepare your profession or the communities you work in for 

these situations? And I will go down the line. 

Ms. JAGIM. You know, the only difference I have seen in 11 

months is we were finally able to get some funding at my hospital 

within the last year to help with supplies and equipment related 

to mass casualty or any type of patient surge issues, but up until 

that point in time we had not received any support. 

Dr. KRUG. I mean, there has certainly been ongoing planning in 

various communities that were already engaged in the process. 

However, I share your concern. I think there are a lot of lessons 

to be learned from Katrina and I am not yet sure we have taken 

the time to learn and react to what we have saw. So I would be 

greatly concerned about what would happen if Katrina came again 

this hurricane season, and then this also then gets back to the 

point that we are here talking with you about, just the overall system, the emergency delivery care system. This year is no better 

than it was last year. In fact, it could be one year more worn than 

it was a year ago because, if nothing else, I am sure ED visits continue to rise. 

Dr. BASS. I would offer that I know that the Gulf States and surrounding States have been meeting together and working very hard 

to help plan with some Federal support to do that. I also know that 

HHS and DHS have been working together as well to—and after 

beating up on them, I think it is fair to say to we have seen some 

efforts for them to work together to make sure that the Federal 

Government can come in and provide backup to the States in an 

efficient and quick way. 

So obviously the proof is going to be in the pudding. If we have 

to face something like Katrina or Rita again, we will know, but I 

think it is fair to say that we have seen some evidence that there 

is an effort on the part of both defendants. 

Mr. THOMPSON. Well, Dr. Blum, let me give you another question 

and you can take both of them. Our national response plan says 

that certain things kick in once the incident of national significance 

has been declared. Are you comfortable that if that incident of national significance is declared that the emergency response systems 

in this country can manage another Katrina-type catastrophe at 

this point? 

Dr. BLUM. No. I am sorry. No. To answer the first question, I believe the Federal performance and the State performance as a follow-on to the immediate disaster I think will be improved with the 

next event. I think the lessons learned from Katrina in those areas 
60

will improve the imperformance at both the Federal and State levels. But again I seem to be a broken record on this, the initial response will be from—by the local emergencies, by the local emergency departments, and their infrastructure is stretched to the 

breaking point today, and so the question of whether the local response will be adequate I think is very much up in the air, and I 

can tell you without qualification that the emergency care system 

in general in this country, especially with regard to the emergency 

department, is worse today than it was this same time last year 

and if we don’t change things it will be worse next year than it is 

today. 

Dr. KRUG. I guess the one positive to this is we have been doing 

our planning in Chicago both in hospitals and throughout the city. 

What we learned from Katrina is that that basic tenet of the Federal response is something that we can’t rely upon, and so we will 

be better prepared to function on our own for a longer period of 

time because of that. And again, the proof will be in the pudding. 

Let’s hope it never happens again, but we are going to have to wait 

and see what happens again the next time this does happen. 

Mr. THOMPSON. Thank you, Mr. Chairman. 

Mr. REICHERT. Thank you, Mr. Thompson. The Chair recognizes 

Mr. Dicks. 

Mr. DICKS. Thank you, Mr. Chairman. I want to thank you for 

holding this hearing. I think this is a very appropriate hearing, and 

one that I think—I am glad that we are getting down to these 

kinds of issues. And I know this is a problem in Washington State 

where I am from. Let me ask you, Dr. Blum, you were pretty 

strong in saying the emergency room—emergency department situation has declined. Is the reason for that because the hospitals are 

closing down these emergency departments because they don’t 

want to have to pay the cost of treating these people, many of 

which don’t have insurance? I think—what did you say, I think it 

was 50 percent do not have insurance? Is this the reason this is 

happening at a time when we should be strengthening the emergency medical system, faced with these possibilities of terrorist attacks in the future, what we are seeing is a national decline in 

these services that people consider to be crucially essential? 

Dr. BLUM. Yes, sir, that is a huge part of it. It is not the only 

cause. 

Mr. DICKS. What else is it? Give me all the causes you can think 

of. 

Dr. BLUM. I will try to summarize them. There are many. There 

is increasing demand, first of all. 

Mr. DICKS. That is because people don’t have insurance, right? 

Dr. BLUM. Well, there is multiple reasons for it. People do not 

have insurance, 47 million Americans do not have insurance at all. 

There is another probably 40 million Americans who are underinsured and that is a big part of it. But even people with insurance, 

there is an increasing demand. Managed care, one of the side effects of managed care has been that primary care practitioners are 

very, very tightly scheduled. So that if there is any event that occurs in their patients’ lives that kind of falls outside that very, very 

tight schedule for the practitioner, the emergency department is 

often the only option to receive care, and so actually we have seen 
61

an increased volume of patients in the number of patients that 

have insurance as well as that don’t have insurance. We have seen 

declining reimbursement from insurance companies as they try to 

figure out ways not to pay for emergency care. 

Mr. DICKS. Including the Federal Government with the reduced 

cost—reimbursements for Medicare and Medicaid? 

Dr. BLUM. That is correct. I went to a meeting earlier this year 

in Washington where a senior official for Medicaid said in the very 

same sentence that we are going to add a million new people to the 

Medicaid rolls, and we are going to decrease the budget by $10 billion. Well, you don’t have to be a rocket scientist to figure out that 

that doesn’t make sense, and it especially doesn’t make sense for 

the emergency care aspect of Medicaid. And that is using just one 

example. 

Mr. DICKS. Let me ask one thing. In Washington State, for example, we have—I think there is a Level 1 trauma care, isn’t that 

right, where the most severe injuries go, that is Harbor View. We 

have created a little program in Pierce County with the Madigan 

Army Hospital and some of the local hospitals in Tacoma to have 

a Level 2, but that is it in the whole State of Washington. And people have to be flown in by helicopter. If they have a severe injury, 

they have to go to one of those two places and many times it is the 

Harbor View and they are underfunded now. They are having their 

funding cut off by the State of Washington for some reason. I 

mean, is this happening around the country? Is this not—I assume 

this is the same kind of problem we are facing in other parts of the 

country. 

Dr. BLUM. Yes, sir. In many of those specialized care entities, 

such as trauma centers, exist within the large public hospital entities within the given State or city, and those often bear disproportionate proportion of the under and uninsured patient population. 

So their finances are more vulnerable to any up or downswings 

that compare to, you know, private hospitals, and that should be 

a concern to everybody because when—West Virginia only has one 

Level 1 trauma center in Morgantown. Only one for the whole 

State. If that closed, it would close for everybody, whether you had 

insurance or not, and I can tell you that it is a challenge to keep 

that trauma center running whenever we—we also are the State’s 

primary provider of care for the uninsured and underinsured. 

Mr. DICKS. Ms. Jagim, you mention—and I will ask everybody 

else to respond. You mention the cutback in funding for nurses. Is 

that now—where—that is in the Health and Human Services budget I take it? In the Federal Government’s— 

Ms. JAGIM. I believe so, yes. 

Mr. DICKS. Or is that under Medicare? 

Ms. JAGIM. No. I think it is in Health and Human Services. 

Mr. DICKS. And how many years has this been cut now? 

Ms. JAGIM. Well we—I think the amount of funding has been 

fairly low but stable, but we need to increase it in order to— 

Mr. DICKS. So we don’t have enough nurses? 

Ms. JAGIM. Right. There is a shortage, and we need help to fix 

it. 

Mr. DICKS. And I would assume we are short emergency nurses 

as well as nurses in general. 
62

Ms. JAGIM. Absolutely. Absolutely. And as I indicated, you know, 

they are not an interchangeable resource. It requires a lot to get 

them at the level that you need them to perform in that emergency 

nursing role. And so it is not to be taken lightly, and that is why 

we need to shore up the resources. 

Mr. DICKS. Dr. ug, do you have a comment? 

Dr. KRUG. Just a couple of comments. It is true that the underinsured and the uninsured are overrepresented in emergency departments in comparison to their proportion in the Nation. That 

said, it would be a mistake to simply look at that population of patients and summarize that that is where the problem exists. That 

is part of the problem, but in fact as people have studied this, insurance has nothing to do with it. It is access to a primary care 

provider. I have got great insurance. I am a pretty savvy utilizer 

of health care. I can’t see my doctor when I get sick. So if I am 

really sick I have one place to go. It is the emergency department. 

It has been argued that the largest increase in emergency department utilization over the past 5 years has not been by the uninsured but by people with insurance. The other key points about 

emergency department overcrowding is that emergency departments are not only crowded with patients trying to get in, but with 

patients trying to get out. And so in my emergency department 

right now if I was to call there— 

Mr. DICKS. Trying to get into the hospital. 

Dr. KRUG. Exactly. If I would call there right now, I am just 

guessing, in our 16-bed emergency department where we jam 

55,000 patients a year through every year, I would bet you five of 

those beds are filled with patients waiting for beds upstairs. And 

that is a phenomenon in every emergency department or most 

emergency departments and particularly in the ERs and places like 

trauma centers and tertiary care centers, the places where you are 

sending the sickest patients to begin with. 

So there is a huge problem. And then it could be argued that if 

we could actually build a bigger emergency department, my next 

dilemma would be finding the people to work there. So there is a 

shortage of emergency physicians, subspecialists, and particularly 

of nursing. We are running into a brick wall as it relates to nursing, at least based upon what I have seen. 

Mr. DICKS. Thank you, Mr. Chairman. 

Mr. REICHERT. Thank you, Mr. Dicks. The Chair recognizes Mrs. 

Christensen. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. And I am going 

to say it anyway, although I don’t have to tell you how pleased I 

am that we have finally gotten to this type of a hearing, and I 

thank you and the ranking member for holding it. I also am going 

to say in advance that this is where the rubber meets the road for 

me, and I know a lot of times we are asked to abide by bipartisan 

agreements. But if we don’t address this in legislation, and if relevant legislation does not significantlyCdress this, I am voting no. 

I am not going to be a part of those agreements. We clearly are unprepared for what is most likely to be—well, what is one of the 

most likely terrorist events, and that is bioterrorism and especially 

in our poor and our rural and our communities of color. 
63

I have a lot of questions. I am sure I am going to end up submitting some for you to send to our panelists. We received this book 

last week, and I guess this would probably be speaking of 2005, 

and it said, there are still no official agreed upon measurable performance standards of accountability for State bioterrorism and 

emergency public health preparedness programs and activities. 

Is that still the case, that we don’t have any standards that are 

at least the basic minimum standards that have been communicated to emergency departments and hospitals that must be met 

to reach a certain level of preparedness; is there any standard that 

has been promulgated? 

Dr. BASS. There are standards that are in the process now. 

Mrs. CHRISTENSEN. Within the Department of Homeland Security? 

Dr. BASS. Correct. Targeted capability lists, TCLs, that have actually been underway. I think it is part of HSPD–8. There are multidisciplinary processes. Again, I think to talk about the fragmentation issue, DHS is doing that, but the ET program is principally 

at HRSA. I will say now that we are seeing some evidence that 

they are beginning to work together and HRSA is willing to recognize, and they are beginning to recognize each other’s standards. 

So I believe that situation is improving. 

Mrs. CHRISTENSEN. I am going to follow up with another question. We have a chief medical officer who comes to the Department 

of Homeland Security with good experience. Do you think that office is necessary? What is the role—what should the role of that officer be? Do you think it is a necessary office? And what would you 

like—what would you like to see it do? Anyone can answer. 

Dr. BLUM. I think it is critical. I don’t think it is necessary. I 

think it is critical. And I think you have a very, very talented and 

an appropriate person in that position, and I guess my view would 

be that that is a very undermanned position, given the scope of 

problems that you all have to plan for. It is inconceivable to me 

that any significant threat from a homeland security standpoint 

wouldn’t have huge medical consequences, and the coordination of 

those activities via the department I think are absolutely critical 

if we are really going to effectively respond to the kinds of things 

that you are talking about. And so I would say not only do you 

have—not only is it appropriate that you have a very, very talented 

and good person in that position, but I would say that they need 

a lot more support in the future. 

Ms. JAGIM. I think I would echo that we would want to see them 

have a much greater role than they have. 

Mrs. CHRISTENSEN. And the HBHPP, I put that down there, abbreviation, but the National Bioterrorism Health Preparedness Program I guess is supposed to support hospital readiness to meet terrorists and other public health programs. What grade would you 

give it in doing this? 

Dr. BASS. Are you referring to the HRSA BT program again? 

Mrs. CHRISTENSEN. The bioterrorism hospital program, the funding that goes to hospitals and— 

Dr. BASS. I don’t think—without doing a comprehensive assessment, it would be difficult for me to put a grade on it. I can say 

that they have been funding hospitals. I know it comes through our 
64

Department of Health in Maryland, and it is really the only source 

of dedicated funding that I am aware of now. 

Mrs. CHRISTENSEN. Do you think that the funding is anywhere 

near where it needs to be? I went to Highland Hospital. It is a 

major trauma center in a big city, covering a big area of the country, about 200,000. 

Dr. BASS. If there is a limitation of the HRSA BT program, it is the amount of funding. I believe it is somewhere around $500 million, maybe slightly short of that now. If you divide that among 50 

States, that ends up being actually what, $10 million say, for instance, that my State would get that comes down, and that money 

has to be divided up between what health department is doing, and 

we take 10 percent for pre-hospital care because we also want to 

make sure they are prepared, trained, equipped to handle BT 

events. And then you have got the amount coming to the hospitals, 

you divide that among 47 hospitals. It ends up being enough money 

to do a little bit of training, to buy a little bit of equipment, but 

not really to do the job. 

Mrs. CHRISTENSEN. Dr. Krug? 

Dr. KRUG. I don’t have enough information to give it a grade. I 

would comment that I agree with the math of Dr. Bass, but arguably the money needs to be targeted towards the foundation. Again, 

we are planning for acts of terrorism and it is important that we 

do that, but we have arguably little disasters that occur in our 

emergency department every day of the week, flu season, trauma 

season, and I would comment that there is variation in terms of 

what is happening on a state-by-state level and in the arena of pediatrics, I am not sure we would give them a terribly high score 

at this point. 

Mrs. CHRISTENSEN. If Dr. Blum could answer? 

Dr. BLUM. I have no problem giving a grade and it would be incomplete for the reasons Steve mentioned. You know the whole 

base of the pyramid of the response, which we believe to be, you 

know, as I said, the emergency—emergency department is the first 

response for 75 to 80 percent of the patients in most scenarios that 

you could generate, and I can tell you very little of that money has 

trickled down through all those entities to the emergency department, even when the hospital gets some, very—it seems that very 

little has actually gotten to the place where the rubber actually 

does meet the road, which is in the emergency department. So I 

would say emphatically it is an incomplete grade. 

Mrs. CHRISTENSEN. Mr. Chairman, I don’t want to ever—I agree 

completely with what Dr. Krug said. Whatever funding we have, if 

it doesn’t prepare our hospitals, our emergency room and the whole 

health system to meet the daily needs of the communities around 

them, it is not going to be able to help us in a terrorism or natural 

disaster event. 

Mr. REICHERT. Thank you, Mrs. Christensen. The Chair would 

absolutely agree with that. And Mrs. Lowey is recognized. 

Mrs. LOWEY. Thank you very much. And I personally want to 

thank the Chair and the ranking member for holding these issues. 

I also sit on the Labor-HHS Appropriations Committee, as you 

know, and these issues have been upper most on my mind for 

many a year. And in fact, I can’t resist asking you, have you ever 
65

heard—do you interact with the HHS command center? Have you 

heard of it? 

Dr. BASS. I have. Yes, I have on occasion. I am a regional person, 

and we have met with them during regional events. 

Mrs. LOWEY. Let me not play 20 questions here. But several 

years ago—I won’t ask the Chair and the ranking member if they 

have heard of it. But several years ago our Appropriations subcommittee was asked to visit the command center by Secretary 

Thompson. It was an extraordinary room, Mr. Chairman, probably 

four times the size of this. Screens everywhere, every hospital was 

identified, every health facility was identified, and we were all very 

optimistic that this was going to be a great, great resource. Now, 

not criticizing any of the staff in this room, but I was trying to remember the name of it, and I must have asked at least a half 

dozen members of this staff, including my own, who are all very 

efficient, and I won’t ask you, Mr. Chairman and Mr. Ranking 

Member, because I can see the look on your face, but megamillions 

of our taxpayer dollars were invested in this center and the whole 

idea was to evaluate and coordinate surge capacity. If an avian flu 

epidemic broke out, God forbid, in New York City or the suburbs 

where I am the Congresswoman, they would know exactly how 

many beds are here, how many beds are there, who has sufficient 

supplies of everything that is necessary. Well, needless to say, I 

have been talking to my hospitals. They haven’t heard of it either, 

and there hasn’t been any interaction. 

So my first question was, Dr. Bass responded, have you—and you 

have important responsibilities. Has there been any contact with 

the HHS command center? Do you feed into it? Do you have confidence that the Federal—I see you shaking your head—that the 

Federal Government really knows what is happening in every part 

of this country? Now, I have no idea, Mr. Chairman, whether this 

is still functioning, whether the millions of dollars that have been 

invested are just sitting there in the equipment, and maybe some 

of us should visit again or find out whether it has functioned. I see 

one head shaking. What about Dr. Blum, are you aware of this? 

Dr. BLUM. In my role in my regular job, it wouldn’t be my role 

to regularly interact with an entity like that. So I would have to 

say no, that I have not interacted with it, but I would speculate 

that they would have difficulty currently in the environment as it 

exists meeting their mission because of the data problems that we 

have in the interoperatability of the data systems that we have. 

That is one—if you will remember, that is one of the recommendations we have as a college is to develop a uniform way of collecting 

data on capacity and diversion, et cetera, and that doesn’t exist 

right now, and until it does exist there is no way for any entity to 

really collect the data and do the function that you described. 

Dr. BASS. I was going to say, in Maryland we have our communication center we call SYSCOM/EMRC, which is in Baltimore, and 

one of its principal tasks is to stay in touch with all the hospitals. 

We have links with all the hospitals. We have a tool that is a webbased tool we call FRED, Facility Resource Emergency Database. 

And in an emergency, we can use FRED to inform the hospitals of 

what is happening but also FRED can bring information back from 

a hospital, like how many beds they have, how many doses of anti-
66

biotics, ventilators, things like that, and we do that statewide in 

Maryland. 

Mrs. LOWEY. Do you report to the Federal Government? 

Dr. BASS. Other States—not many other States do it on a statewide basis. Many communities do but I will reiterate what Dr. 

Blum said, the problem here is it comes back to the data 

interoperatability issue, in that the way we collect it and other people is not the same. We count things differently. And I will tell you 

just last week I saw a proposal from HHS to pull that together. 

Their goal is to be able to pull in the data from Maryland and other 

communities and hopefully all States would be doing what we are 

doing in Maryland and put that in their database. 

Mrs. LOWEY. Well, I will save the rest of my questions because 

the red light is on, but I hate to say it is business as usual, Mr. 

Chairman. We went to visit this center at least 3 or 4 years ago. 

It was before my current staff was working on the issue. And I am 

glad to know that someone there is interested in pulling all this information together several years later. So I would certainly suggest 

that we get an update and find out what this center is doing, and 

I am glad to see that the current administration of—I don’t know 

which agency, at HHS is beginning to think about using a facility 

such as this and bringing the information together. 

So I thank you and I thank you for your testimony, and I think 

we all know that there is a lot more work to do, certainly in my 

area, in the metropolitan region of New York, and we appreciate 

your service to your community and your country. Thank you. 

Mr. REICHERT. Thank you, Mrs. Lowey. We will direct the staff 

to get us an update of the current status of the HHS special operations centers so we have more detailed information on that for all 

the members of this committee, and if the witnesses could just bear 

with us a few more minutes, we want to have a second round of 

questions. And it looks like there might be three or four of us here 

to ask those additional questions. 

I want to go back and focus on the—I love to solve problems. We 

have heard a lot about, you know, what the issues are and what 

the problems are that we are facing and all the way from Medicare 

to access to primary care and there is lots of reasons that we don’t 

have access, or some do have access, and shortages of nurses and 

physicians and shortages of facilities and instructors and professors 

with no training and on and on. One of the things that we did in 

the bill that I mentioned when we started this hearing, the 

interoperatability bill, we listened to the people who were the ones 

doing their job, and they helped us come up with some legislation. 

We don’t want to write legislation just for the sake of producing paperwork and laws. So Federal standards are one thing. I heard 

some discussion on that. And there was a mention of a need for 

written transfer protocols. Is that something where the Federal—

the Department of Homeland Security or the Congress could get involved in and helping to set some sort of standards on, just for an 

example, one of the problems on written protocols on transfers? 

Dr. BASS. That really I believe is a State and regional issue, and 

also the Joint Commission for the Accreditation of Health Care Organizations also has requirements that hospitals have transfer 

agreements. In my State we do that because we have a regional-
67

ized system of care. We put out a booklet that says, for instance, 

these are our trauma centers, these are our burn centers, these are 

the hand centers, and those are recognized regional centers. So 

there is no agreement required. The hospital can know that within 

our system they can transfer patients to those patients in our EMS 

providers and to know to take those patients there primarily. 

Mr. REICHERT. So we know that the care to date—yes, sir, doctor. 

Dr. KRUG. I agree it is not a Federal mandate, but the simple 

observation is in spite of the joint commission process and in spite 

of State rules and regulations, there are a significant number of institutions that don’t have that. So the question then becomes—and 

this gets back to the fragmentation of the process. 

Mr. REICHERT. Yes. 

Dr. KRUG. At some point if we want this all to work, somebody 

is going to have to define a process that is fairly consistent from 

one State to the next because it needs to be consistent from one 

State to the next. 

Mr. REICHERT. We talked a little bit about identifying a lead 

agency. Who would you suggest that might be? Anybody on the 

panel. 

Dr. BASS. A lead agency for emergency care? I think— 

Mr. DICKS. At the Federal level, Mr. Chairman? 

Mr. REICHERT. Yes, Federal level. 

Dr. BASS. At the Federal level, I mean, the Institute of Medicine 

report recommends that that be at the HHS simply because—not 

simply, but because of the fact that it looked at this overarching 

system that would include trauma care, emergency medicine, prehospital care, EMS for children, that is really, I mean, that is all 

fundamentally related health care and ideally that would be at 

HHS. 

Mr. REICHERT. Anyone else have an opinion? 

Dr. BLUM. Agree. 

Mr. REICHERT. Everyone would agree with that? And the key 

then is to get DHS and HHS to communicate more clearly. 

Dr. BASS. The other issue is that just because you have a lead 

agency at HHS doesn’t mean that other agencies aren’t significantly involved with that system and so not only does there need 

to be a lead but there still needs to be coordination, 

interoperatability, and so on, or we are just—even with the lead 

agency we are going to be fragmented. 

Mr. REICHERT. Yes. 

Ms. JAGIM. If I could I just want to echo what Dr. Krug said. Not 

all systems are as well coordinated as Dr. Bass’. Certainly in my 

part of the world, we do not have the strength of the Maryland system by any means. And I also want to point out that many States 

yet have not even established a basic trauma system. And you 

know that is kind of the blueprint that we are using when we talk 

about regionalization, and that is a stepping point. You know, we 

need to get—part of that basic infrastructure that needs to be developed across the country, that is the need for that central leadership to make sure that every State gets onboard, every region is 

coordinated because that is not so now. 

Mr. REICHERT. If you have thought—had the time to think about 

this at all, what one piece of sort of legislation might you think we 
68

could start to promote, work on to help—well, the greatest need 

was the everyday service which goes beyond and prepares us for 

the emergency that we might face some time in the future. I guess 

you know how can the Federal Government—how can Congress 

help you? 

Ms. JAGIM. Well, I will take a dive in. I think number one is that 

strong central leadership point within the Federal Government because I don’t think—I don’t see any way that we can establish the 

coordinated regionalized care system that we need that has interoperable communications without that central Federal leadership. 

It is just not going to happen. And secondly, I would say the need 

for the study on workforce issues and how we can shore up that 

workforce or it is not going to be there. 

Mr. REICHERT. Anyone else? Yes. 

Dr. BLUM. Well, I am going to be more specific. I think a lead 

agency is a good start. But we could free up a huge amount of capacity in this country in the Nation’s emergency departments if 

we—and I would also judge this to be relatively low-hanging fruit 

as far as something that is doable. We could free up a huge amount 

of capacity in the Nation’s EDs if we simply stop the practice of 

boarding admitted patients in the emergency department. There is 

really nothing special about the hallway in the emergency department as compared to a hallway up on an inpatient unit. We could 

simply decide that this is not an acceptable way to do business 

anymore and stop it. That would free up a huge—as I said, a huge 

capacity and allows us to at least have the space to do our job. If 

we don’t have enough nurses and don’t have enough resources, we 

would at least have the ability to have the space to do our job. 

Mr. REICHERT. Thank you. 

Mr. Pascrell. 

Mr. PASCRELL. Dr. Blum, the National Disaster Medical System, 

NDMS, supports State and local agencies, as you know, during disasters. At the core of this system, there are the disaster medical 

assistant teams, assistance teams. There are regional teams of doctors and nurses and other health professionals. Do you think that 

the NDMS is properly equipped and organized to assist communities during large-scale disasters? And then I am going to ask you, 

who are your contacts in DHS and HHS? And what guidance are 

they providing to you in terms of planning? Got the questions? 

Dr. BLUM. Yep. I think so. I think I will do better with the first 

than the second. I think the disaster medical assistance teams 

work very, very well at their defined role, which is kind of a followon, you know, direct at the site of the disaster sort of role. Unfortunately they don’t go far enough. There probably needs to be another type of response that supports the disaster medical—the 

DMAT teams, and that is—and the phenomenon here is one that 

we saw in Katrina very clearly. We saw the destruction of the infrastructure, the medical infrastructure in the directly affected 

areas. So what happened then was the medical response pulled 

back to what we would call in medicine the penumbra or the surrounding area so that those hospitals became very rapidly overwhelmed with patients from the disaster area. They were still functioning, but their nurses, their doctors were overtaxed pretty quickly. And we need some way—especially in a disaster like Katrina 
69

that has week and month-long implications for medical care, we 

need to figure out some way to support those surrounding hospitals 

in a much more direct way than we do now. 

I could tell you my own personal response. I am an emergency 

physician. I am trained in the care of patients like existed in 

Katrina. I tried to volunteer for a period of 2 weeks to go do exactly 

what I am talking about, which is backfill in a functioning emergency department, and I discovered there was no way for me to do 

that within the Federal system. I had to sign up, you know, to be—

to either do a month stretch or more, and many, many of my colleagues found that they were simply unable to help, which was 

their natural instinct was, you know, I had some time off as it occurred, which is rare, and I wanted to go help for a while, but it—

the politics and the bureaucracy of it was simply more than could 

be done. I didn’t want to go put a tube in my teeth and go dig 

through wreckage. I just wanted to go to the surrounding emergency department and go do my job to help the people who were 

there, and it was not possible. 

Mr. PASCRELL. Are you getting guidance? You don’t want to answer that question. 

Dr. BLUM. Well, I am probably not the best person to ask that 

question because I am not even the disaster guru at my own hospital. That is just simply not my role. When it comes to disaster 

management on a personal level, I am one of the Indians, I am not 

one of the chiefs. So I am probably not the best person to ask that 

question to. 

I could tell you that our State has been very active in planning, 

but again, I would reiterate the same thing that I said before, that 

very rarely trickles down to the actual emergency department. 

Mr. PASCRELL. Thank you. 

Dr. Krug? 

Dr. KRUG. I would reiterate that point. The guidance that we receive is probably indirect through actually again our fragmented 

State. We work with both the Chicago Department of Health and 

also the Illinois Department of Health and Human Services because there is joint jurisdiction there. And so how that guidance is 

interpreted is actually then I think interpreted in part by the direct 

recipient of the grants, which is the State or the city, and again 

from our perspective as a children’s hospital, there is nothing in 

that guidance that helps us. So we actually do something well beyond what the guidance would suggest for readiness. 

I would reiterate Rick’s point about the disaster response. There 

were a lot of folks that wanted to help that couldn’t because there 

was no process to do that. In a variety of ways and other than sort 

of the traditional way. 

Secondly, I think that everything that we learned from Katrina 

is that these responses need to be prepared to provide support for 

a lengthy period of time. These response teams were set up to go 

in and do good for a certain period of time and then go back and 

maybe then send a second volley. Well, we need to consider a second volley, a third, a fourth, a fifth, a sixth, and today there is still 

a disaster there. There are still underserved patients, both adults 

and children, whose needs aren’t being met because the hurricane 
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came through and ripped out the infrastructure and what is left is 

inadequate. 

Mr. PASCRELL. Thank you, Mr. Chairman. 

Mr. REICHERT. Mr. Dicks. 

Mr. DICKS. Just a couple quick questions here. Let me just ask 

you, do you agree with these numbers? The Institute of Medicine 

report found that from 1993 to 2003 the U.S. population grew by 

12 percent but emergency room visits grew by 27 percent, from 90 

million to 114 million. That is accurate, right? In the same period, 

however, 425 emergency departments closed along with 700 hospitals and nearly 200,000 beds, and I would assume that is mainly 

for financial reasons. I know I have a number of hospitals in rural 

Washington State where I represent that are just barely hanging 

on, and you know, 50 or 60 percent of their patients are either 

Medicare or Medicaid, and they don’t—they just can’t make it financially. So again, I think this is a part of the problem that we 

are faced with and that we have to—we as a Federal Government 

have to look at. 

Now, the other thing I was—that we have here is that—as it 

says, as you know, the National Bioterrorism Hospital Preparedness Program administered by HRSA now—are you aware of this 

program? Prepares hospitals and supporting health care systems to 

deliver coordinated and effective care to victims of terrorism and 

other public health emergencies. The program received $474 million in fiscal year 06. I know Congresswoman Lowey knows about 

this because she is on that subcommittee. Is that sufficient funding 

for that program? Should dollars be distributed based on risk instead of population as it is now? What do you think of that? 

Ms. JAGIM. You know, it is a little bit of both. The other thing 

I just wanted to point out, too, you kind of touched on it as far as 

rural hospitals in Washington. I think the thing to keep in mind 

when it comes to rural facilities, we interface with them. Of course 

I wouldn’t be from North Dakota if I didn’t talk about rural hospitals. The problem that they have is they have low population 

bases that they are working with. Most of them in my State are 

critical access hospitals. 

Mr. DICKS. Exactly. They have all switched because they get a 

better reimbursement under Medicare. 

Ms. JAGIM. Fee for service payments instead of DRG-based, 

which has been helpful for them. It saved them from closing. 

Mr. DICKS. That is exactly the same for us. 

Ms. JAGIM. When it comes to emergency preparedness, they have 

no depth of their bench, so to speak, to pull from as far as resources for planning and training. You look at them and you talk 

to them about it and they have this lost, glazed look on their face. 

They are struggling out there, and they don’t have the depth of resources to help them accomplish what they need to do to prepare. 

And that is where when you look at—they are not a population 

base, but yet they are there, and they serve in a very, very key 

role. 

Mr. DICKS. Rural communities? 

Ms. JAGIM. Right. Right. 

Mr. DICKS. Without the hospital they would be in deep trouble? 

Ms. JAGIM. Exactly. 
71

Mr. DICKS. Some of the communities actually bond themselves to 

help subsidize the hospital, Mason County being one. 

Ms. JAGIM. If you don’t have a regionalized system of some sort, 

whether it is based on a trauma system or you have been able to 

advance it beyond that, there is no linkages that are occurring then 

between the rural hospitals and the larger regional centers. And 

that needs to happen. 

When we look at pandemic planning, where I am from in Fargo, 

we don’t have capacity in my hospital but we know that there is 

some capacity, maybe in rural, maybe not. But we know that if we 

are going to survive a catastrophic event, we are going to have to 

do it together and not separate individual entities, and that is 

where this concept of regionalization is so vitally important. 

Mr. DICKS. So—and I would assume that if we have an avian influenza outbreak, that would be—we are all focused kind of on hurricanes right now, but that is still hanging over our head, right? 

Ms. JAGIM. Correct. And again, they have a short bench, you 

know. So if you see an epidemic occurring, they may have some 

limited space in their hospital. They don’t have the resources. If 

they lose 40 percent of their workforce, it goes from like four people 

to one. You know what I mean? They just don’t have any depth. 

And I think that is really a concern, and you look to our whole system. Most of the hospitals in the country are community hospitals 

such as mine. There is many, many hundreds of rural hospitals in 

the country. Your EMS system in rural States such as mine is 98 

percent volunteer. It is not paid. It is volunteer, and you know, I 

think that we have got a lot of weaknesses in the system. 

Mr. DICKS. Dr. Krug. 

Dr. KRUG. Just to reiterate an important point that you made. 

This is akin to Katrina. As we disaster plan, we think of how we 

are going to provide services with existing resources to a large 

number of victims. But what happens if some of those victims are 

health care providers? The avian flu is a great example of that. 

That scares us a lot at a fairly well resourced institution. We have 

a big bench. So if we lost half of our physicians, we could still run 

our emergency department. Your average small community hospital loses its physician, what do they do? 

So the plans really need to consider that as well. We have talked 

about a buddy system where the bigger, better resourced institutions may need to be in a position to help others and not just simply say send us your patients. We are going to need to send them 

providers. 

Mr. DICKS. Yes, Dr. Blum. 

Dr. BLUM. Well, I would like to put a little bit different twist on 

this. I think you would have to build the entire system up because 

you can’t really predict how an epidemic or a pandemic is going to 

evolve. It may be that rural America is the answer and not the 

problem to a pandemic flu. If you look at how human-to-human 

transmission occurs in a pandemic flu, it is easy to conceive that 

urban areas may be increasingly impacted—have increased impact 

early in an epidemic and the capacity may actually exist for care 

in the rural parts of the country. So I don’t think you could look 

at it from where—let’s try to guess what is going to happen and 

where it is going to happen. I think you have to build the entire 
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system up because you can’t really predict how something like a 

pandemic is going to evolve over time. 

Mr. DICKS. And that hasn’t been done, right? 

Dr. BLUM. That hasn’t been done clearly. A critical access hospital where most of the inpatient beds have been converted to nursing home beds would be no help in a situation like that, and they 

might be a great help in, you know, in a pandemic flu, you know, 

if we needed additional hospital beds and capability. 

Mr. REICHERT. The gentleman’s time has expired. 

Mr. DICKS. Mr. Chairman, again, I compliment you for having 

the hearing. 

Mr. REICHERT. Mrs. Lowey. 

Mrs. LOWEY. Thank you again and thank you to the panel. This 

issue is so important I want to follow up on my colleagues’ comments and questions because I know in my district, which is the 

suburbs of New York City, they can barely accommodate increases 

in daily emergency room visits, let alone effectively treat thousands 

of sick and injured individuals resulting from an act of terrorism 

or public health emergency. And that is in the New York Metropolitan Area. 

We know that the Institute of Medicine study, the American College of Emergency Physicians report both found that hospitals 

across the country are not prepared to handle a public health emergency with specific gaps in surge capacity. Now, we know this. The 

Federal Government knows this. We have been hearing about this 

since 9/11 over and over again. 

So I guess my question is, what can, what should the Federal 

Government do to assist hospitals in increasing their surge capacity? For example, are there any Federal or State guidelines for creating surge capacity? Should all U.S. hospitals be required to increase hospital beds and staff by 20 percent—I am just throwing 

that out—within 8 hours of a public health emergency? 

I am really following up with your comment that it should be 

dealt with in both the rural areas and our obvious areas like New 

York City. Should there be specific guidance and performance 

measures? Are you recommending them for surge capacity? Has the 

Department of Health and Human Services even estimated the cost 

of creating a minimal level of surge capacity? And who is in—I am 

asking all of these together so perhaps you can comment. Who is 

in charge actually of ensuring that States and localities create the 

surge capacity for treating people who became ill during a public 

emergency or terrorist event? 

Maybe I should stop at that point and have you respond. Who 

is in charge? What should they be doing? Should the Federal Government assume a greater responsibility? And maybe we will all 

find out what that command center is doing these days with all the 

money that has been invested in it. Whoever wants to comment, 

that is fine. 

Dr. BASS. I would argue that would really, in my estimation, be 

the role of—the health department at the State level should lead 

the process for looking at surge planning and we do that in Maryland. We have had a process underway for several years. We work 

very closely with the hospitals. And I know that there are grants. 

I believe it is CDC grant. I don’t want to hold myself to that, but 
73

that is—that they are able to use to help to fund that process, and 

I believe the Federal Government should provide some guidelines, 

and they do, but that it really boils down to the States and the regions taking those guidelines and converting into operational plans, 

and that is where the rubber hits the road. 

Mrs. LOWEY. Well, if the rubber hits the road and we have an 

emergency and the State doesn’t do what you think they should do 

or that Maryland is doing, what is the Federal Government’s responsibility? 

Dr. Blum? 

Dr. BLUM. Well, you probably won’t like this answer, but you 

know the infrastructure problems that I outlined with regard to the 

emergency department quite frankly are not going to be fixed by 

grants from, you know, Homeland Security. They are not. They are 

simply too big and too pervasive. In order to truly— 

Mrs. LOWEY. How about HHS? How about HHS? 

Dr. BLUM. Well, perhaps at that level. One of the problems with 

emergency care in this country is that all the problems of the 

health care delivery system seem to be focused and concentrated in 

the emergency department. When any part of the system doesn’t 

work properly, the emergency department bears the brunt of it. I 

think probably the simplest thing we could do—and this isn’t the 

purview of this committee, but figure out how to share that burden 

across the entire health care, you know, enterprise in this country, 

which we don’t do right now. 

The answer to who is in charge is everybody and nobody. It depends on where you are. The State health department might be the 

right place if they are used to and regularly talk to the emergency 

departments. I could tell you in some States they do not. Those 

conversations don’t exist. And so the public health sector makes the 

same assumption that the public does, which is that the emergency 

departments are going to be there and functioning and have the capacity and their planning all reflects that. 

Mrs. LOWEY. If I could ask you—because I see my yellow light 

is on. But this I think has to do with the funding. The National 

Bioterrorism Hospital Preparedness Program, where you get a lot 

of money from, is administered by the Health Resources and Services Administration, and it does prepare hospitals and supporting 

health care systems, and so on. 

The program received $460 million in fiscal year 2006, which is 

a $10 million decrease from fiscal year 2005. Given all the needs 

that are out there, would you have recommended that they cut the 

program or do you think we need to invest more money in the program? 

I don’t want to put you on the spot, but I will. 

Ms. JAGIM. That is an easy question. No, it shouldn’t have been 

cut. And I would just like to tack on to the other comments that 

have been made. I think the ability of the State health department 

to assist with that surge capacity planning is somewhat based upon 

the day-to-day strength of that health department, and my personal perspective is I don’t know that I have a great deal of confidence in the strength of that in my own home State, and I think, 

however, they have put some tools into place, such as a bioterrorism wide area network that could connect all the hospitals in 
74

times of crisis so that we can communicate even when everything 

else goes down. 

So they have helped us to develop some basic guidelines, but I 

think the strength is variable across the country. 

Dr. KRUG. I have a local anecdote. A neighbor recently put on an 

addition to their house. Apparently there wasn’t enough attention 

paid to the foundation of that addition. Can you imagine what happened to the addition? It literally almost fell off the house. Everybody thought that was pretty amusing in the neighborhood. 

We have a similar problem. We can actually give hospitals lots 

of money to increase their surge capacity, but if you don’t deal with 

the foundation, if you don’t deal with the personnel issues, if you 

don’t deal with the access and the system issues, it is not going to 

work. It is really that simple. 

Mr. REICHERT. Gentlelady’s time has expired. 

I thank the witnesses for your time and your testimony. This was 

a very enlightening hearing, and as you can tell, the members are 

eager to help find some solutions to the problems that you described to us today, and the members of the subcommittee may 

have some additional questions for the witnesses, and if they do, 

we will ask that you respond to those questions in writing, please. 

The hearing record will be held open for 10 days. And without objection, this hearing is closed. 

Thank you. 

[Whereupon, at 4:01 p.m., the subcommittee was adjourned.]

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