The Hope of RAES

     Since the development of modern-day EMS, Americans have witnessed stunning reductions in sudden cardiac death, trauma and burns. This prevention allows many more Americans to lead productive lives, but also predictably results in a population that develops diseases of older age. These diseases have exacerbations that inevitably lead to the need for emergency care, and our economic system has not been adequately prepared to account for the cost of providing care to an aging population with more chronic illnesses.

     We were certain to arrive at a time where the consequences of our prevention success met the realities of resource shortages. Recognizing the stresses in the emergency system, authorities at the Institute of Medicine prepared a report, Emergency Medical Services at the Crossroads, which they delivered to Congress in 2006. In it they said:

     The Committee believes the challenges that exist in the system today can best be addressed by building a nationwide network of regionalized, coordinated and accountable emergency care systems. They should be coordinated in the sense that, from the patient's point of view, delivery of emergency services should be seamless. To achieve this, the various components of the system—9-1-1 and dispatch, ambulances and EMS workers, hospital EDs and trauma centers, and the specialists supporting them—must be able to communicate continuously and coordinate their activities…The system should be regionalized in the sense that neighboring hospitals, EMS and other agencies work together as a unit to provide emergency care to everyone in that region. A patient should be taken to the optimal facility within the region based on his or her condition and the distances involved.

     The report promotes the development of regionalized emergency care systems. To this end, I propose the creation of regional accountable emergency systems, or RAES for short. These would involve networks of prehospital and emergency department leaders working with key members of their communities to provide and facilitate the fast and efficient provision of unscheduled healthcare. Developing RAES would reverse the 20-year trend toward fragmenting and decentralizing emergency medical services, and better enable ED and field personnel to work optimally together.

     EMS is our frontline medical resource and a vital extension of our hospital emergency departments. Twenty percent of patients arriving in EDs come via EMS. EMS also provides the important transportation link for interhospital transfers, discharged patients and the growing nursing home population. It represents a significant pathway for patients admitted to hospitals and an important access service for patients who are typically the sickest or worst injured. Like hospitals and their emergency departments, it is severely constrained by finances and under tremendous tort pressure to minimize bad outcomes.

     The IOM's vision for the future includes proactive development of systems that utilize and coordinate a region's resources—prehospital, hospital and specialty—appropriately and efficiently. This type of system can distribute patients to open emergency departments suited to care for them, helping prevent diversions and rerouting. It can get the right care to the right patients faster.

     I had the opportunity to participate in the development of this kind of regional system. In the 1990s, fire and EMS leaders in Dayton, OH, led the creation of CareNow, a program that brought together EMS providers, ED leaders, 9-1-1 directors, physicians, payers and other stakeholders to collectively determine how to most effectively provide unscheduled medical care. Key among their concerns was reducing unnecessary stresses on their emergency system.

     Through CareNow, patients were provided phone and computer access to a system that gave them care advice on non-trauma issues and linked them to regional medical resources suitable for addressing their needs. If you were worried about a persistent headache, you could call and be routed to your primary care physician for advice. This significantly reduced unnecessary ED visits and freed up EMS resources, and it increased cooperation among professionals from different sectors of the healthcare system.

     Too far ahead of its time to have stable funding, CareNow is now defunct. But its model of collaboration between field and hospital emergency providers gave us a glimpse of the future of emergency care. We face dramatic opportunities to improve our systems in ways that will benefit all those needing care in the future. With our heritage of success in prevention and delivery, RAES can help us realize them.

Jim Augustine, MD, FACEP, is the medical director for a number of fire services in the Atlanta area, including Atlanta Fire Rescue, which includes operations at Hartsfield-Jackson Atlanta International Airport. He has served since 1981 as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.