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[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]

 
    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
                                     
                [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     

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

                               __________

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Washington, DC 20402-0001

                     COMMITTEE ON HOMELAND SECURITY

                   Peter T. King, New York, Chairman

Don Young, Alaska                    Bennie G. Thompson, Mississippi
Lamar S. Smith, Texas                Loretta Sanchez, California
Curt Weldon, Pennsylvania            Edward J. Markey, Massachusetts
Christopher Shays, Connecticut       Norman D. Dicks, Washington
John Linder, Georgia                 Jane Harman, California
Mark E. Souder, Indiana              Peter A. DeFazio, Oregon
Tom Davis, Virginia                  Nita M. Lowey, New York
Daniel E. Lungren, California        Eleanor Holmes Norton, District of 
Jim Gibbons, Nevada                  Columbia
Rob Simmons, Connecticut             Zoe Lofgren, California
Mike Rogers, Alabama                 Sheila Jackson-Lee, Texas
Stevan Pearce, New Mexico            Bill Pascrell, Jr., New Jersey
Katherine Harris, Florida            Donna M. Christensen, U.S. Virgin 
Bobby Jindal, Louisiana              Islands
Dave G. Reichert, Washington         Bob Etheridge, North Carolina
Michael T. McCaul, Texas             James R. Langevin, Rhode Island
Charlie Dent, Pennsylvania           Kendrick B. Meek, Florida
Ginny Brown-Waite, Florida

                                 ______

     SUBCOMMITTE ON EMERGENCY PREPAREDNESS, SCIENCE, AND TECHNOLOGY

                 Dave G. Reichert, Washington, Chairman

Lamar S. Smith, Texas                Bill Pascrell, Jr., New Jersey
Curt Weldon, Pennsylvania            Loretta Sanchez, California
Rob Simmons, Connecticut             Norman D. Dicks, Washington
Mike Rogers, Alabama                 Jane Harman, California
Stevan Pearce, New Mexico            Nita M. Lowey, New York
Katherine Harris, Florida            Eleanor Holmes Norton, District of 
Michael McCaul, Texas                Columbia
Charlie Dent, Pennsylvania           Donna M. Christensen, U.S. Virgin 
Ginny Brown-Waite, Florida           Islands
Peter T. King, New York (Ex          Bob Etheridge, North Carolina
Officio)                             Bennie G. Thompson, Mississippi 
                                     (Ex Officio)

                                  (II)

                            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

                    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.
    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.
    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 over-stretched 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.

    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 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 large-scale 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 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 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 
hospitals 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.
    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 available. The widespread practice of holding admitted 
patients in the ED ties up precious space, equipment, and staff that 
cannot be used to meet the needs of incoming patients.
    When crowding reaches dangerous levels, hospitals often divert 
ambulances to other facilities. In 2003, U.S. hospitals diverted more 
than 500,000 ambulances--an average of one per minute. Diversion may 
provide a brief respite for a beleaguered staff, but it prolongs 
ambulance transport times and disrupts established patterns of care. It 
also creates ripple effects that can compromise care throughout the 
community. Because crowding is rarely limited to a single hospital, 
decisions to divert ambulances can prompt others to do the same. When 
this happens, a community may experience the health care equivalent of 
a ``rolling blackout''. Everyone's access to care is affected--insured 
and uninsured alike.
    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 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.
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, 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.
    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 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 on-call specialists 
due to: fewer practicing emergency and trauma specialists; lack of 
compensation for providing theses services to high percentage of 
uninsured and underinsured patients; substantial demands on quality of 
life; increased risk of being sued and high insurance 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 on-call 
        specialist coverage, compared with two-thirds (67 percent) in 
        2004.
         Fifty-one percent reported deficiencies in coverage 
        occurred because specialists left their hospitals to practice 
        elsewhere.
         The top five specialty shortages cited in 2005 were 
        orthopedics; plastic surgery; neurosurgery; ear, nose and 
        throat; and hand surgery. Many who remain have negotiated with 
        their hospitals for fewer on-call coverage hours (42 percent in 
        2005 compared with 18 percent in 2004).
    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 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
    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).
    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.
         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 decision-making.
         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.
         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.

                                                                       Appendix E
                                    Recommendations and Responsible Entities from the Future of Emergency Care Series
                                                  HOSPITAL-BASED EMERGENCY CARE: AT THE BREAKING POINT
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                   EMS     Private   Professional
                                                            Congress   DHHS   DOT  DHS  DOD  States  Hospitals  Agencies  Industry  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       X          X      ....  ...
   million for the purpose, to be administered by the
   Centers for Medicare and Medicaid Services..
   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   .........  X      X     ...  ...  ......  .........  ........  ........  X              .....
       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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 3.2 The National Highway Traffic Safety Administration,   .........  .....  X     ...  ...  ......  .........  ........  ........  X              .....
   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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  3.3 The Department of Health and Human Services should   .........  X      ....  ...  ...  ......  .........  ........  ........  .............  .....
 convene a panel of individuals with emergency and trauma
   care expertise to develop evidence-based indicators of
                       emergency care system performance.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  3.4 The Department of Health and Human Services should   .........  X      ....  ...  ...  ......  .........  ........  ........  .............  .....
        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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  3.5 Congress should establish a demonstration program,   X          X      ....  ...  ...  ......  .........  ........  ........  .............  .....
        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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.6 Congress should establish a lead agency for emergency  X          X      ....  ...  ...  ......  .........  ........  ........  .............  .....
     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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Chapter 4: Improving the Efficiency of Hospital-Based Emergency Care
--------------------------------------------------------------------------------------------------------------------------------------------------------
      4.1 Hospital chief executive officers should adopt   .........  .....  ....  ...  ...  ......  X          ........  ........  .............  .....
        enterprise-wide operations management and related
      strategies to improve the quality and efficiency of
                                          emergency care.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4.2 The Centers for Medicare and Medicaid Services should  .........  X      ....  ...  ...  ......  .........  ........  ........  .............  .....
           remove the current restrictions on the medical
       conditions that are eligible for separate clinical
                             decision unit (CDU) payment.
--------------------------------------------------------------------------------------------------------------------------------------------------------
       4.3 Training in operations management and related   .........  .....  ....  ...  ...  ......  .........  ........  ........  X              X
            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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
        4.4 The joint Commission on the Accreditation of   .........  .....  ....  ...  ...  ......  .........  ........  ........  .............  X
 Healthcare Organizations (JCAHO) should reinstate strong
   standards that sharply reduce and ultimately eliminate
                    ED crowding, boarding, and diversion.
--------------------------------------------------------------------------------------------------------------------------------------------------------
      4.5 Hospitals should end the practices of boarding   .........  X      ....  ...  ...  ......  X          ........  ........  .............  .....
    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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                    Chapter 5: Technology and Communication
--------------------------------------------------------------------------------------------------------------------------------------------------------
       5.1 Hospitals should adopt robust information and   .........  .....  ....  ...  ...  ......  x          ........  ........  .............  .....
 communications systems to improve the safety and quality
       of emergency care and enhance hospital efficiency.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                    Chapter 6: The Emergency Care Workforce
--------------------------------------------------------------------------------------------------------------------------------------------------------
6.1 Hospitals, physician organizations, and public health  .........  .....  ....  ...  ...  ......  X          ........  ........  X              X
      agencies should collaborate to regionalize critical
                         specialty care on-call services.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 6.2 Congress should appoint a commission to examine the   X          .....  ....  ...  ...  ......  .........  ........  ........  .............  .....
    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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6.3 The American Board of Medical Specialties and its   .........  .....  ....  ...  ...  ......  .........  ........  ........  X              X
         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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
    6.4 The Department of Health and Human Services, the   .........  X      X     X    ...  ......  .........  ........  ........  .............  .....
      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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
     6.5 The Department of Health and Human Services, in   .........  X      ....  ...  ...  ......  .........  ........  ........  X              .....
      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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
    6.6 States should link rural hospitals with academic   .........  .....  ....  ...  ...  X       X          ........  ........  .............  .....
 health centers to enhance opportunities for professional
         consultation, telemedicine, patient referral and
        transport, and continuing professional education.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                           Chapter 7: Disaster Preparedness
--------------------------------------------------------------------------------------------------------------------------------------------------------
 7.1 The Department of Homeland Security, the Department   .........  X      X     ...  ...  ......  .........  ........  ........  .............  X
          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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
      7.2 All institutions responsible for the training,   .........  .....  ....  ...  ...  X       .........  ........  ........  X              X
              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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
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  .........  .....  ....  ...  ...  ......  X          ........  ........  .............  .....
      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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 8.2 The Secretary of the Department of Health and Human   X          X      X     X    X    ......  .........  ........  ........  .............  .....
  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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
8.3 Congress should modify Federalwide Assurance Program   X          .....  ....  ...  ...  ......  .........  ........  ........  .............  .....
   (FWA) regulations to allow the acquisition of limited,
 linked, patient outcome data without the existence of an
                                                     FWA.
--------------------------------------------------------------------------------------------------------------------------------------------------------

                                                                       Appendix E
                                    Recommendations and Responsible Entities from the Future of Emergency Care Series
                                                      EMERGENCY MECICAL SERVICES AT THE CROSSROADS
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                   EMS     Private   Professional
                                                            Congress   DHHS   DOT  DHS  DOD  States  Hospitals  Agencies  Industry  Organizations  Other
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Chapter 3: Building a 21-Century Emergency Care System
--------------------------------------------------------------------------------------------------------------------------------------------------------
     3.1 The Department of Health and Human Services and   .........  X      X     ...  ...  ......  .........  ........  ........  X              .....
       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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 3.2 The National Highway Traffic Safety Administration,   .........  .....  X     ...  ...  ......  .........  ........  ........  X              .....
   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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  3.3 The Department of Health and Human Services should   .........  X      ....  ...  ...  ......  .........  ........  ........  .............  .....
 convene a panel of individuals with emergency and trauma
   care expertise to develop evidence-based indicators of
                       emergency care system performance.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  3.4 Congress should establish a demonstration program,   X          X      ....  ...  ...  ......  .........  ........  ........  .............  .....
            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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.5 Congress should establish a lead agency for emergency  X          X      ....  ...  ...  ......  .........  ........  ........  .............  .....
     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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  3.6 The Department of Health and Human Services should   .........  X      ....  ...  ...  ......  .........  ........  ........  .............  .....
    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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
        3.7 CMS should convene an ad hoc work group with   .........  X      ....  ...  ...  ......  .........  ........  ........  .............  .....
  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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Chapter 4: Supporting a High quality EMS Workforce
--------------------------------------------------------------------------------------------------------------------------------------------------------
    4.1 State governments should adopt a common scope of   .........  .....  ....  ...  ...  X       .........  ........  ........  .............  .....
         practice for EMS personnel, with state licensing
                                             reciprocity.
--------------------------------------------------------------------------------------------------------------------------------------------------------
     4.2 States should require national accreditation of   .........  .....  ....  ...  ...  X       .........  ........  ........  .............  .....
                            paramedic education programs.
--------------------------------------------------------------------------------------------------------------------------------------------------------
    4.3 States should accept national certification as a   .........  .....  ....  ...  ...  X       .........  ........  ........  .............  .....
 prerequisite for state licensure and local credentialing
                                        of EMS providers.
--------------------------------------------------------------------------------------------------------------------------------------------------------
     4.4 The American Board of Emergency Medicine should   .........  .....  ....  ...  ...  ......  .........  ........  ........  X              .....
              create a subspecialty certification in EMS.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                 Chapter 5: Advancing System Infrastructure
--------------------------------------------------------------------------------------------------------------------------------------------------------
    5.1 States should assume regulatory oversight of the   .........  .....  ....  ...  ...  X       .........  ........  ........  .............  .....
       medical aspects of air medical services, including
        communications dispatch, and transport protocols.
--------------------------------------------------------------------------------------------------------------------------------------------------------
     5.2 Hospitals, trauma centers, EMS agencies, public   .........  .....  ....  ...  ...  ......  X          X         ........  .............  X
    safety departments, emergency management offices, and
     public health agencies should develop integrated and
           interoperable communications and data systems.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  5.3 The Department of Health and Human Services should   .........  X      ....  ...  ...  ......  .........  ........  ........  .............  .....
  fully involve prehospital EMS leadership in discussions
       about the design, deployment, and financing of the
        National Health Information Infrastructure (NHh).
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                         Chapter 6: Preparing for Disasters
--------------------------------------------------------------------------------------------------------------------------------------------------------
    6.1 The Department of Health and Human Services, the   .........  X      X     X    ...  X       .........  ........  ........  .............  .....
 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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  6.2 Congress should substantially increase funding for   X          .....  ....  ...  ...  ......  .........  ........  ........  .............  .....
      EMS-related disaster preparedness through dedicated
                                         funding streams.
--------------------------------------------------------------------------------------------------------------------------------------------------------
    6.3 Professional training, continuing education, and   .........  .....  X     ...  ...  X       .........  ........  ........  X              X
      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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Chapter 7: Optimizing Prehospital Care through Research
--------------------------------------------------------------------------------------------------------------------------------------------------------
7.1 Federal agencies that fund emergency and trauma care   .........  X      X     X    X    ......  .........  ........  ........  .............  X
 research should target additional funding at prehospital
   EMS research, with an emphasis on systems and outcomes
                                                research.
--------------------------------------------------------------------------------------------------------------------------------------------------------
7.2 Congress should modify Federalwide Assurance Program   X          .....  ....  ...  ...  ......  .........  ........  ........  .............  .....
   (FWA) regulations to allow the acquistions of limited,
 linked, patient outcome data without the existence of an
                                                     FWA.
--------------------------------------------------------------------------------------------------------------------------------------------------------
     7.3 The Secretary of Department of Health and Human   X          X      X     X    X    ......  .........  ........  ........  .............  .....
  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.
--------------------------------------------------------------------------------------------------------------------------------------------------------

                                                                       Appendix E
                                    Recommendations and Responsible Entities from the Future of Emergency Care Series
                                                       EMERGENCY CARE FOR CHILDREN: GROWING PAINS
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                   EMS     Private   Professional
                                                            Congress   DHHS   DOT  DHS  DOD  States  Hospitals  Agencies  Industry  Organizations  Other
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Chapter 3: Building a 21st-Century Emergency Care System
--------------------------------------------------------------------------------------------------------------------------------------------------------
     3.1 The Department of Health and Human Services and   .........  X      X     ...  ...  ......  .........  ........  ........  X              .....
       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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 3.2 The National Highway Traffic Safety Administration,   .........  .....  X     ...  ...  ......  .........  ........  ........  X              .....
   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
--------------------------------------------------------------------------------------------------------------------------------------------------------
  3.3 The Department of Health and Human Services should   .........  X      ....  ...  ...  ......  .........  ........  ........  .............  .....
 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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  3.4 Congress should establish a demonstration program,   X          X      ....  ...  ...  ......  .........  ........  ........  .............  .....
        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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  3.5 The Department of Health and Human Services should   .........  X      ....  ...  ...  ......  .........  ........  ........  .............  .....
    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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3.6 Congress should establish a lead agency for emergency  X          X      ....  ...  ...  ......  .........  ........  ........  .............  .....
     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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 3.7 Congress should appropriate $37.5 million each year   X          .....  ....  ...  ...  ......  .........  ........  ........  .............  .....
              for the next five years to the EMS-Program.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Chapter 4: Arming the Emergency Care Workforce with Knowledge and Skills
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4.1 Every pediatric and emergency care-related health   .........  .....  ....  ...  ...  ......  .........  ........  ........  X              .....
 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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
  4.2 The Department of Health and Human Services should   .........  X      ....  ...  ...  ......  .........  ........  ........  X              .....
 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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4.3 EMS agencies should appoint a pediatric emergency   .........  .....  ....  ...  ...  ......  X          X         ........  .............  .....
   coordinator and hospitals should appoint two pediatric
      emergency coordinators--one a physician--to provide
               pediatric leadership for the organization.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Chapter 5: Improving the Quality of Pediatric Emergency Care
--------------------------------------------------------------------------------------------------------------------------------------------------------
  5.1 The Department of Health and Human Services should   .........  X      ....  ...  ...  ......  .........  ........  ........  .............  .....
         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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.2 The Department of Health and Humane Services and the   .........  X      X     ...  ...  ......  X          X         ........  .............  .....
    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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5.3 Hospitals and EMS systems should implement evidence-   .........  .....  ....  ...  ...  ......  X          X         ........  .............  .....
       based approaches to reduce errors in emergency and
                                trauma care for children.
--------------------------------------------------------------------------------------------------------------------------------------------------------
   5.4 Federal agencies and private industry should fund   .........  X      X     X    ...  ......  .........  ........  X         .............  .....
          research on pediatric-specific technologies and
   equipment used by emergency and trauma care personnel.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 5.5 EMS agencies and hospitals should integrate family-   .........  .....  ....  ...  ...  ......  X          X         ........  .............  .....
              centered care into emergency care practice.
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           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
--------------------------------------------------------------------------------------------------------------------------------------------------------
     7.1 The Secretary of DHSS should conduct a study to   .........  X      X     X    X    ......  .........  ........  ........  .............  .....
     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.
--------------------------------------------------------------------------------------------------------------------------------------------------------
     7.2 Administrators of statewide and national trauma   .........  .....  ....  ...  ...  ......  .........  ........  ........  .............  X
    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.
--------------------------------------------------------------------------------------------------------------------------------------------------------

    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. 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:]

        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 seriously injured individuals, 
wherever they lived, prompt emergency transport to the nearest 
appropriate trauma center within the ``golden hour.'' The IOM report 
bolsters support for such regionalized models of care by drawing on 
substantial evidence that ``demonstrates that doing so [i.e., creating 
a coordinated, regionalized system] improves outcomes and reduces costs 
across a range of high-risk conditions and procedures.''
    ENA supports the IOM's call for a series of research demonstration 
projects that will put these ideas into practice by testing these 
strategies under various emergency care conditions. Achieving 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 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 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 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.
    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 
day-to-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 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 hospital-based 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.
    [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 cooperate 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.
    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
    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
    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 
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 hospital-based emergency services, and 
        regionalization of pediatric trauma and critical care, should 
        be developed and implemented in every state.
         Evidence-based clinical practice guidelines for the 
        triage, treatment and transport of acutely ill and injured 
        children at all levels of care should be developed.
         Pediatric emergency care competencies should be 
        defined by every emergency care discipline and professional 
        credentialing bodies should require practitioners to achieve 
        the level of initial and continuing education necessary to 
        maintain those competencies.
         Primary care pediatricians and pediatric medical and 
        surgical subspecialists should be included in emergency and 
        disaster planning at every organizational level--at all levels 
        of government, and in all types of planning.
         Emergency preparedness efforts should use an ``all-
        hazards'' model that allows for holistic planning and 
        multipurpose initiatives, and should support family-centered 
        care at all levels of treatment.
         Pediatric 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
                 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.
    vi Markenson D, Reynolds S, Committee on Pediatric 
Emergency and Medicine and Task Force on Terrorism. The Pediatrician 
and Disaster Preparedness. Pediatrics, Vol. 117 No. 2 February 2006.
    vii MacPherson 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.
    ix Seidel JS, et al: Emergency medical services and the 
pediatric patient: Are the needs being met? Pediatrics,Vol. 73, June 
1984.
    x Seidel JS, et al.: Emergency medical services and the 
pediatric patient: Are the needs being met II. Training and equipping 
emergency medical services providers for pediatric emergencies. 
Pediatrics, Vol. 78, December 1986.
    xi Durch 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.
    xiv Schools and Terrorism: A Supplement to the National 
Advisory Committee on Children and Terrorism Recommendations to the 
Secretary. August 12, 2003. http://www.bt.cdc.gov/children/PDF/working/
school.pdf.
    xv Family 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.
    xvii Mace SE and Bern AI. Needs Assessment of Current 
Pediatric Guidelines for Use by Disaster Medical Assistance Team 
Members in Response to Disaster and Shelter Care. Annals of Emergency 
Medicine, 44(4): S35.
    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 Preparedness. Pediatrics, Vol. 99 No. 
1, January 1997.
    xxi AAP Task Force on Terrorism. All related 
documentation at www.aap.org/terrorism.
    xxii Pediatric 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.
    xxvi Schools and Terrorism: A Supplement to the National 
Advisory Committee on Children and Terrorism Recommendations to the 
Secretary. August 12, 2003. http://www.bt.cdc.gov/children/PDF/working/
school.pdf
    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?
    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 thenSec. 
    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 
management 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.
    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 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.
    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 man-made 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?
    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/Rita-type 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 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 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.
    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.Sec. 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 
significantly-dress 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.
    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 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 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 web-based 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 antibiotics, 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 regionalized 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, pre-hospital 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 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 follow-on, 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 
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 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.
    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 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 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 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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