Component plan. Emergency medical services

COMPONENT PLAN EMERGENCY MEDICAL SERVICES
GEORGIA STATE HEALTH POLICY COUNCIL and the
GEORGIA STATE HEALTH PLANNING AGENCY 4 Executive Park Drive, N.E. Suite 2100 Atlanta, Georgia 30329 OCTOBER 1986
Publication of this document has been supported in part by
the Department of Health &Human Services, Public Health
Service, Grant and Policy Standards pertaining to Public Law 93-641 (Title XV, Section 1523), and amendments.

PREFACE This Component Plan is a product of the Georgia State Health Policy Council and the Georgia State Health Planning Agency which are funded through and operate within the authority of Georgia Law Act 552 and Federal Public Law 93-641 and amendments. The purpose of this Plan is to identify and address health issues, and recommend goals, objectives and system changes to achieve official State Health Policies. This Plan has been produced through an open, public participatory process developed and monitored by the 25-member Govenor-appointed State Health-Policy Council. The Plan, once approved by the Governor, supersedes all related section of both the 1981 and the 1983 editions of the State Health Plan, and is designed to be consistent with the overall State Health Policies espoused in the 1983 Plan edition. For purposes of the administration and implementation of the Georgia Certificate of Need (CON) Program and Capital Expenditure,Review under Section 1122 of the Social Security Act, criteria and standards for review (as stated in the Rules, Chapter 272-1, 272-2 and 272-3) are derived from this Component Plan. The Rules, which are published separately from the Plan, and which undergo a separate public review process, are an official interpretation of the appropriate parts of the Georgia State Health Plan, and any official Component Plans which the review function has the legal authority to implement. The Rules are reviewed by the State Health Policy Council (prior to their adoption) for their consistency with the Plan. The Rules, as a legal document, represent the final authority for all review decisions. Any questions or comments on this Component Plan should be directed to the Planning and Implementation Division of the State health Planning Agency, 4 Executive Park Drive, N.E., Suite 2100, Atlanta, Georgia 30329; telephone (404) 325-8939.

Joe Frank Harris
GOVERNOR

STATE OF GEORGIA
OFFICE OF THE GOVERNOR
ATLANTA 30334

December 19, 1986

W. Douglas Skelton, M.D. Chairman State Health Policy Council 4 Executive Park East, N.E. Atlanta, Georgia 30329
Dear Doug:
In accordance with your request and with the authority granted me in Section 1524 (c) (2) (c) of the National Health Planning and Resources Development Act, as amended, I have reviewed the Component Plan for Emergency Medical Services and do hereby approve it. I would like to commend the council and the State Health Planning Agency on the time and effort which have gone into the development of this plan.
I am particularly pleased with the open, public participatory process which has been initiated by the council. and the agency in the development of both the component plan and the certificate of need rules. If I can be of further assistance on this or any other matter of concern to you, please contact me.
With kindest regards, I remain
C5:Zt Joe Frank Harris
JFH:mbe

ANNETTE MAXEY, Director

State Health Planning Agency

4 EXECUTIVE PARKl DRIVE, N.E. / ATLANTA. GEORGIA 30329/ (404) 894-4899

Suite 2100

GIST 222-4899

November 18, 1986
The Honorable Joe Frank Harris Governor The State of Georgia The State Capitol Atlanta, Georgia 30334 Honorable Sir: It is with great plea:ure that the State Health Policy Council tTdnsmits to you for your approval this Component Plan:
EMERGENCY MEDICAL SERVICES The Plan is a product of the Council and the State Health Planning Agency, which operate within the authority of Georgia Law 552 and Federal Public Law 93-641 and amendments. The Federal Law provides for your Plan approval powers as follows:
'The State Health Plan or any revised State Health Plan approved by the (State Health Policy Council) shall be the State Health Plan for the State for the purposes of this title after it is approved by the Governor of the State. The State Health Plan for a State may be di sapproved by the Governor only if the Governor determines that the Plan does not effectively meet the statewide health needs of the State as determined by the State Agency for the State.'
- Public Law 93-641 as amended, Section 1524(c)(2)(C) This Component Plan identifies and addresses issues related to hospitalbased emergency medical services and recommends goals, objectives and system changes. Standards for Trauma Services and Emergency Departments to insure a statewide system of cost effective and efficient care are included. The Plan is designed to achieve official state health policies relating to quality care, as well as cost containment.

The Honorable Joe Frank Harris November 18, 1986 Page 2
This Plan has been produced through an open, public participatory process initiated and monitored by the Policy Council. The Policy Council and the State Agency commend this Plan to you, and urge your approval of it. It is believed that the Plan provides a rational basis for the continued development of needed emergency medical services for Georgians. Sincerely,
-
,JJ9U-C\S~
W. Douglas Skelton, M.D. Chairperson WDS/etg Enclosure

TABLE of CONTENTS PAGE
PREFACE

I. INTRODUCTION

1

II. HEALTH STATUS

1

A. Cardiac Diseases

3

B. Accidental Death and Injury

4

C. Perinatal Problems

6

D. Psychiatric and Behavorial Problems

6

E. Accidental Poisoning

7

F. Burns

8

G. Spinal Cord Injury

8

III. HEALTH SYSTEM

A. Introduction

10

B. Health System Definitions

10

C. Background and Historical Perspective

11

1. Regionalization

12

2. Categorization

15

3. Georgia's Involvment in EMS

17

4. Georgia-specific Standards for

EMS System Development

20

D. Costs for Emergency Medical Care

21

E. Reimbursement for Hospital-based EMS

25

F. Freestanding Emergency Centers

26

G. Supply and Distribution of EMS in Georgia

27

H. Critical Care Services and Reported

Categorization Levels of Georgia Hospitals

31

1. Trauma Services

32

2. Poison Control Services

33

3. Burn Services

34

4. Spinal Cord Injury Services

37

5. Perinatal Services

37

6. Cardiac Services

38

7. Behavorial Services

38

PAGE

I. Ut,lization of Emergency Medical Services

39

J. Manpower for Hospital-based Emergency Services

44

IV. GUIDELINES for AVAILABILITY and ACCESSIBILITY

A. Emergency Departments and Trauma Services

47

v. GOALS, OBJECTIVES and RECOMMENDED ACTIONS

A. Health Status

49

B. Health System.

49

VI. REFERENCES

54

VI!. APPENDIX

1. Standards for Trauma Centers

58

Hospital-based Emergency Centers

68

2. Summary of General Hospitals with 24-hour

Emergency Room Services, by EMS Region and HSA

78

3. Treatment Modules for Categorizing Burns

98

4. Maps

99

5. Membership of EMS Technical Advisory Task Force

103

6. Excerpts from The New England Journal of Medicine 105

NOTE: Numbers in parentheses in the text indicate references.

I. INTRODUCTION
In the first edition of the State Health Plan, a chapter on Emergency Medical Services (EMS) laid the groundwork for planning for the system.{l) Included in that chapter were definitions, an outline of the 15 required services which make up the EMS regional network, community planning, capacity for system development by region, transportation and categorization of hospital-based services.{l) It may be useful as a reference document for examination of the pre-hospital system and an overview of the total system, recognizing that the data are not current, but that the principles and concepts set forth in 1981 still obtain in 1986 and beyond. At some later date, pre-hospital services will be updated in a new Component Plan.
This Component Plan will update the original ~lan section. Its primary focus will be hospital-based emergency care. It will provide definitions and guidelines for the orderly development of those departments and services for which there is a clear need, to assure access to high quality hospital-based emergency care for all Georgians.
II. HEALTH STATUS Hospital-based emergency departments (EDs) are called upon to provide care for people of all ages who have conditions that range from simple colds to lifethreatening illnesses and injuries. For some of these patients, a visit to a physician1s office would be appropriate. It is estimated that over 80% of the visits to emergency departments are for conditions which, although they are of major concern to the person or family presenting for care, are not true emergencies in that they are not immediately life-threatening or disabling, or that with a delay of more than 12 hours could become disabling or life-threatening. It is not to this 80% that this Plan is addressed, but rather it speaks to care requirements for service for the 5% who are in need of immediate care to prevent death and/or to prevent or minimize disability; and to the 15% who are in need of urgent care where a significant delay might increase the chances for severe outcomes. How hospital emergency departments are utilized is born out by the table below; 41.3% of the reported visits were made to the ED because it was either the patient1s customary care resource, or because other care was unavailable.
1

......... Perc..., Ohtrt"'thM of 'htts to Itos,ttal E.......' !lepartMnt,
IIJ Perc.t".d S"'lI't t, of CoMt ltOIt.
RII.... fer SllecU... till ~.IftC, DlpartMnt, ... S.lected Charactertsttcs
lIItU... Stlt.. , JI_r, JIM 1_

Charactertsttc
..-Total \IMII' 17 yean l7 . . . 18n 45 18n .......
Sa
...1. F_I.

....... of "stts. lit "tllt....
31.'
,.,
1'.2 7.'
11.0 11.0

Perc.t.... SlwerU, of Colllltttolt. Perclltt Ohtrt...tt..

lilt, LIf..TIlI'eIt...t",
IIIIs.. fw S.lectt", EMre' !lepartMItt

Totll

L I f. . T h r l l t. . . t . . .

Total

Otller tar. not AYitlalll.

I ..t ".c for that ColIlItttOlt

US... for Most ,..tc.1 tare

100,0

U.S

a5.S

37 .0

27.6

. 3

Otller 11.6

100.0

10.0

100.0

10.3

100.0

23.1

88:1

.'.3

21

3.7

1.

a'.1

37.3

21.3

U

11.3

7'.1

21 .2

21.1

3.3

11.0

1".0

12.1

100.0

I'.'

SI.l

35.'

30.0

3.7

l7 .0

a'.1

31.1

25.2

..a

11.1

Rac.
lIlIU. lIad All otller

25.'

100.0

1.0

100.'

12.' 11.3

1

1".0

11.1

al.'

37.'

21

11.2

33.1

21

3.1 7.0

11.1 11.7

10.1

33.5

23.7

I.S

17.1

197' F.n, 1 _

LIIS &hi. SI0.000

t.1

100.0

17.3

"""..... SSZlOS..ODOOOO erS_Z'_.til

13.1 5.' 3.'

100.0 100.' 1".0

IZ.5 10.2 IZ.I

al.S SI.l

3lZ7..''

11.1

4'.3

a7.D

31.5

Ex,...'. . S-C'I IIIU. .1 CoItur fer ....It' StiUsttcs. utntzatt. . .f ttls,tul -...c, a" ..tpett..,

IIItt. .1 ....tc.1 Can utntza't. . . .

SWWey. Pnlt.tlllry R.,..c lilt. 2. llllIIS

S_tc """'_' D.C U.S. &lw...-t "'tItU", Offlc F. . . .ry 1913

ZI.'

I.'

15.3

21.0

2.'

11.3

27.D

J.I

17.1

25.3

4

II.'

r . .ts. lIIttt. Statll. JI_ry."'110 1_. lilt. (PItS) 13.2000. "'Illtc HIIltlt

Of the above number of visits perceived to be life-threatening, about 42% were admitted to the hospital, and 6% of the visits perceived as life-threatening were, in fact, more serious than the patient expected and also resulted in hospital admissions, and that about 14% of all visits resulted in hospital admission. More than one-fourth of emergency room visits were made by people with incomes under $25,000 a year, while fewer than one-half of that number (where income was known) had incomes over $25,000. Other ,data provided in the section on utilization of emergency departments provides further detail.

Among the patients who present with true emergencies are cardiac patients, high risk neonatal and maternity, and psychiatric patients, substance abusers, severely burned patients, and those who have ingested poison, persons with spinal cord and head injury and other victims who have multiple and severe traumatic injuries. The table below shows caHses of death in the U.S. and Georgia for 1982 from the above-listed medical incidents.

2

~\Ue of Deaeh
Is~hm1~ aeare D1se. .e (410-414)

Uni.ted States

Rate per

~

100,000

554,988

2"39.7

~orgia

Rate per

~

100.000

1,035

182.9

Car.brov. .~ular Disease

L59,638

68.9

4.269

75.:'

(430-438)

Mocor Vehicle Accidents

46,630

20.1

L.269

24.0

(E 810-E: 285)

.~l ~cher 1ccidencs (E 800-~07-d26-~49)

~6.050

21.2

L.:'68

25.9

Injury ~ poisoning
(E aoo-a 999)

~.A.

:I.A.

4,.361

77.0

~ental Disorders

:I.A.

~.A.

375

6.6

SOURCES: ~orlia Vteal Statistics Sook. 1982.
a.S. Mouthly Statistical Report. National Cencer for aealth
Stat1sti~s, Vol. 31, ;13, O~eober 1983.

It may be assumed that not all of the above deaths were preventable even with the most accessible and efficient emergency care. But it may also be assumed that many of the deaths above may have been prevented had appropriate and timely c~~e been available and accessible.

If only 3~ of the deaths reported for Georgians in the above table could have been avoided by prompt and appropriate care, there would have been 663 fewer lives lost in that one year. Using the percentages in the literature which range from 15 to 40~ for cardiac and trauma, the number of lives lost would have been even more significantly reduced. The key words in making these assumptions are 'timely and appropriate carel.

A. Cardiac Diseases The literature and research clearly state that early recognition and appropriate definitive care of acute myocardial infarction (AMI) may reduce deaths by as much as 30-50~.

In Georgia in 1982, there were a total of 571 deaths from AMI. If these deaths were reduced by even 15~, there would have been 86 fewer deaths due to AMI. In other sections of the State Health Plan, need for education for heart health, knowledge of signs and symptoms of heart attack, need for prompt response to the symptoms, training of first responders, advanced and cardiac EMT training, ~mbulances equipped for advanced life support, and definitive care are covered. They will not be repeated here, except to say that personal life

3

style choices, coupled with knowledge of symptoms and adequate response to the life-threatening event are all essential elements in lowering the death rate from heart attack.

B. Accidental Death and Injury

When analyzing health status and reviewing the 10 short causes of death and

specific mortality rates for them, one finds that the two leading causes of

death are heart disease and cancer. Accidents are third. However, included

in the leading cause of death are many older persons who may be close to the

end of their life expectancy. A more graphic approach, and one which shows a

different pattern, is to examine the years of projected life lost (YPlL) ..

Using YPlL, accidents rank first for all age groups (over one year and under

65 years) in Georgia as the table below illustrates.

L.ad1ng eaua of Years of Poc_ncit&! Lif. Lose. 1984 -

C&ua.. of d.ach

.L.:.1

AI. Groul'

10 - L9

20 - 49

50 - 64

Acc:idacs

9.120

18.001

40.851

C&Dc:.r

1.5l3

1.706

22.767

a.arc Dis....

L.004

988

20.679

lio1II1c:id. Slli.c:id.
tnf.e:Cious dis..... "'*

865
a
L.9Z7

2.0S3
L.780 647

L.645
L2.739 5.075

Cerebrovase:ular d15....

296

2S5

4.717

Alcotlol

a

a

2.553

Cor.. 0 "'**
Diab.ca.

188

L96

L.231

a

a

1.907

- ~or p.rsons ov.r on. rr of ag
"'* IDc.lwi pn.UIMnli.a. 1.Dfluau& aDel ~gicis. "'** Chrom.e: obaenc:civ. lUDI d15.....

2.872. L9.827 20.974
748
L.405 L.664 3.623
945 l, 789 1.147

SOUle!: Georaia Epidemiolosy R.vorc. Offic:a of E~idemiology.
Divu10n of fubllc: a!ctl. January L986.

When YPlL due to selected accidents are examined, a focus is provided for

preventive strategies which may yield a reduction over time in deaths, and

also the need for emergency services.

~.ars of poc.ncica! Life Lose due co selec:ceel accidencs Georgia. 1984

Caus.s of deach.

~

All Accid.ncs

70.844

~cor v.h.1cle accidencs

46.031

Drowning.

5.243

Fires

4.854

~oisonings

3.539

~alls

2.406

Suffocacions

1.411

- ~or p.rsons over one year of age.

or ~u1Db.r

death.s

2.102 L.282
L28 L43 121
LL2
SO

SOURCE: Georgia Epidemiolosy Revorc. Office of Epidemiology. Division of ~ublic Realtn. January L986.

Georgia data for motor vehicles and other accidents are found in the Georgia Office of Highway Safety Fy I 8S Plan. In 1983, accidents increased across the

4

state by 11,976(7.6%). Injury accidents, which increased by 2,565(6.3%) have been rising annually since 1970 with an increase over the 10-year period of 102.3% or 21,889 accidents. Fatal accidents increased by 5.5% over the previous year, but have declined over the 14-year period by 340 accidents or 29.4%.(25) Several factors, including improved highways and standards for cars, increased fuel prices and reduced mileage during fuel shortages, the motorcycle helmet law, lower speed limits and improved emergency medical services contributed to this result. The Office of Highway Safety cites excessive speed and drunk drivers as the pr8mary causes of highway accidents and has designed multi-media and community oriented programs to address prevention of these problems.(25)
After the event, it has been demonstrated in a number of research studies that trauma, one of the nation's and Georgia's leading causes of death, can have improved outcomes with timely, appropriate and high quality emergency interventions. Studies in several areas of California, Portland, Denver and other metropolitan areas compared motor vehicle deaths in regions with and without trauma centers. Improved outcomes were found when trauma center care was available. It was found that 50% of trauma deaths occur at the scene, and that 30% of trauma deaths occur within the first few hours of injury.(16) These are the patients that can be brought to trauma centers and can benefit from sl.lch services. (16)
As far back in history as Homer's Illiad, a regional trauma care system is described. During both world wars and in Korea and Vietnam, the rapid evacuation of personnel and the immediate availability of surgical care decreased mortality significantly and decreased the numbers and severity of disabilities.(17) From West Germany comes data to show that a 25% reduction in motor vehicle mortality was achieved by a regional system of trauma care.(16) Data from Orange County, California show that 73% of non-central nervous system deaths secondary to motor vehicle accidents were judged preventable.
After a regional trauma system of care was developed, this preventable category of deaths was reduced to 9% provided that the patients were treated ina trauma cente-r. If pati ents were tri aged to a non-trauma center, the
5

preventable death category remained at 67%. Permanent disability was not addressed in this study.(17)
In 1983, it was estimated that there would be 164,000 deaths nationwide due to trauma, and that for every death, there would be two permanent disabilities. (17) Since trauma affects primarily young people and accounts for more years of life lost than heart disease and cancer combined, it is apparent that there remains a major shortfall in trauma prevention, delivery of trauma care and trauma resources in the U.S. Georgia, through the Department of Human Resources' Emergency Health Services Section, is currently reappraising its trauma resources.
C. Perinatal Problems Data show that improved care of the high risk neonate has made a difference over time resulting in decreased mortality. In 1954 the infant mortality rate was 26.6/1000 live births in the U.S. and 31.5 in Georgia. By 1977, Georgia's rate had declined to 16.9/1000 live births, with a neonate rate of 11.1/1000 live births compared with the U.S. rate of 9.9 with a continuing decline projected through 1985. Deaths in the perinatal period for 1982 were reported at 10.7. While life style, age of the mother and prenatal care playa large role in the well-being of the baby at birth, providing appropriate care to high-risk infants is also a factor that cannot be overlooked. And Georgia has expended a large amount of energy as well as financial resources to improve neonatal care. The neonatal resources may be found in the 1983 Georgia State Health Plan and further along in this Plan.
D. Psychiatric/Behavorial Problems The State Health Component Plan for Inpatient Psychiatric and Substance Abuse Services discusses the admission rate for psychiatric patients and for substance abusers.(18)
In an attempt to isolate psychiatric emergency visits from all others, data from the Annual Survey of Hospitals done by the AHA. and compiled by GHA for 1981, 1982 and 1983 were examined. It is apparent that there was significant under-reporting ~y psychiatric hospitals both public and private. The total visits for 'occasions of outpatient psychiatric emergency' services in 1981
6

was 5,475; in 1982 only 445 visits were reported, and in 1983 there were no visits in: this category reported for all of the freestanding psychiatric hospitals in; Georgia. Using psychiatric admissions to general hospitals as a . proxy indicator for emergency psychiatric and substance abuse emergency visits from the Component Plan on Psychiatric and Substance Abuse Inpatient Services, it was found that there were 29 general hospitals that reported psychiatric/ substance abuse beds in 1982. There were 16,275 admissions to psychiatric services and 836 admissions for substance abuse to these hospitals.(18) One might assume that a large percentage of the patients admitted to psychiatric and substance abuse services in general hospitals were emergent patients. However, this is an assumption with no back-up information for Georgia, since visits to emergency departments are not reported by diagnosis or service.
E. Accidental Poisoning There are no data that are Georgia-specific to indicate the incidence of accidental poisonings, either by ingestion or expOSIJre. National data show that in 1983, there were nearly 600,000 discharges from acute care general hospi- . tals whose first diagnosis fell within rCDA Codes 960-980. A variety of toxic materials and exposures (except for radiation) are included in these codes. (24) The above discharges do not include all of the visits to emergency rooms of persons who were treated, but not admitted to inpatient services for a poison incident. Using national data above, the rate for discharges for poison incidents in the U.S. in 1982 was 265.4/100,000 population. Using this as a proxy indicator, it is estimated that over 14,000 Georgians may have been treated as inpatients and discharged with one of the above diagnoses in 1982.
In Georgia, the officially designated poison control center is Grady Hospital in Atlanta. This center had over 91,000 inquires through its 24-hour/7 day a week telephone hotline in 1984.(31) These calls were from Georgia, surrounding states and several foreign countries.
It is apparent that an increased effort should be made to prevent accidental poisoning in Georgia.
7

F. Burns The American Burn Association estimates that there are 2,000,000 persons burned in the U.S~ each year.(29) Many of these people seek care in emergency .rooms, and it is estimated that 10 are treated as outpatients for everyone admission. Because of the critical nature of burn injuries, the American Burn Association has compiled standards for the treatment of burn patients. The Association has categorized both the types of burn injuries and hosp~tal facilities.(29)

Care for victims who are burned begins at the site of injury, continues through transportation to a hospital where definitive care may be given, or where the patient may be stabilized and transferred to a specialized unit in another hospital.

In Georgia, three hospitals reported that'they had dedicated beds to serve pat.ients who had been burned. These three units admitted a total. of 636 patients in 1984.(30) It is not known how many patients were admitted to other hospitals in Georiga who may have been less severely burned, or what care was able to be provided in . a hospital with a critical care unit. Maps showing patient origin for the three burn centers are found in the Appendix.

G. Spinal Cord Injury Georgia1s Spinal Cord Registry provides data on all spinal cord injured patients admitted to Georgia's hospitals. In FY I 8S, 122 injured patients were added to the Registry.(51) While a number of Georgia's hospitals admit patients with spinal cord injury, the majority of seriously spinal cord injured patients are transferred to the Shepherd Spinal Center in Atlanta. An activity report is provided below, reprinted from The Spinal Column, the hospital's quarterly publication.

Huaael' yc Full 'rul' PaC1.u,.
"v.ca,. LIt"IC" 01 Stay Ave, AI.
Rae. of Occ~'''IU:y

l..I"~ .. r1p J.c. Paraplic.
"'al F.... l

712 574 1,016 270

fyp ~c lUJuc1

.\uCtJ

:"41

'aU

172

Tu8OC/01.

154

01vln~

134

Cun.hoC Wauna

129

1 . ~o,occYf,;

n

:icnu:k

78

~'uc; ..

25

.unl., 1~1 Rille, , IlJiU.l

18

.0\1 1 uthe,

II

l t~16 90 Day.
35 over 90%
lS%
~5%
79% 21%
lSI 13% 12% 10% 10%
7% 0% 2%
.'.t
8

'actc A,
0-10 IL-20 21-10 11-40 41-50 Sl-60 61-70 71-90

La

L%

260

20%

~59

36%

254

20%

145

11%

n

6%

~9

4%

26

2l

Pac lent tn.utac..",,, C~v.,al!.

PrlVaClII: Carr leI' 51>9

~4%

~'cUcai<l

253

20%

81ulI ere :i

177

14%

~ock.r. t.:o_lp.

151>

12%

~.dlcac.

98

/%

:illtj, f-ptAV

!5

~%

1/0 e.;.. Renao

~

1%

Two data items are particularly striking. One, the average age of these patients is 35 years, with 76% of them between the ages of 11 years and 40 years. Children and the young adult are the largest age cohorts who suffer this injury most often, with sequallae calling for life-long adjustments and medical follow-up. Thirty-five percent of the injuries were the result of automobile accidents. To effect a decrease in these numbers, and to assist the population cohorts most at risk to become aware of the risks and their prevention will require an age-appropriate educational campaign for each group. Taachers, health care providers, the media and car manufacturers, dealers and volunteers such as Mothers Against Drunk Driving, all working together toward increased auto safety and accident prevention could make a difference over time.
9

I I I. HEAL TH SYSTEM
A. Introduction The response system to emergency illness and injury is made up of a complex set of components which, when properly linked and administered, is capable of saving the lives of many of those who call upon it for service. To assure a common understanding of terms, a set of definitions is provided. The historical background leading to the development of regionalized emergency medical service systems and some of the problems related to system development are discussed. How the service capabilities of participating hospitals can be differentiated is also addressed, as is Georgia's supply and utilization of its emergency services.
Guidelines and standards are included and their universal adoption is recommended. While there is full recognition of the importance of the pre-hospital care of the emergent patient, this Plan will deal primarily with facility based/hospital emergency medical services.
B. Health System Definitions 1. Emergency Medical Services System: fA system which provides for the arrangement of personnel, facilities and equipment for the effective and coordinated delivery, in an appropriate geographic area, of health care services under emergency conditions (occurring either as a result of the patient's condition, or natural disaster, or similar situation) which is administered by a public or non-profit entity which has the authority and resources to provide effective administration of the system. 1(5)
Six Basic System Components - Discovery and Notification: someone must find the victim and send for help. - DispatCh of Help: the agency receiving the call for help must dispatch appropriate vehicles and personnel to help the victim. - On-site Care: the individual who discovers the victim may begin care for the victim and turn the care over to better trained persons when help arrives. Care must continue until the victim reaches the emergency facility.
10

- Transportation: the victim must be moved from the point of discovery to a facili-tywhich is able to render definitive care.
- Initiate Care in the Emergency Facility: life-threatening conditions must be corrected, the victim stabilized and a diagnosis made so that definitive care may be provided.
- Definitive Care: care that will cure (or restore the patient to optimal condition) and return the patient to society.
2. Hospital Emergency Facilities: include an adequ~te number of easily accessible institutional sites which are collectively capable of providing 24-hour a day, seven day a week care, and which meet certain standards related to location, personnel and equipment under hospital administration and coordination.
3. Hospital-based Emergency Medical Services Program: is one of the organized departments (in a licensed acute care general hospital or a specialized hospital) which provides 24-hour coverage to receive any ill or injured person who presents him/herself to the hospital, and who requires immediate care. The program is organized, managed, staffed and equipped to fit into one of the four accepted categorization levels set forth by the Joint Commission pn Accreditation of Hospitals (JCAH). Hospital-based emergency medical services may include one or more of the following services: emergency departments, critical care services, ambulances and communications.
4. Critical Care Services/Facilities include trauma, burn, poison control and spinal cord centers; coronary care and intensive care; detoxification, high risk infant and psychiatric units. This aggregation of necessary specialty services may be provided in one hospital, or distributed among several hospitals in one or more emergency medical service regions. Access to these services therefore, may require transportation within one region or between regions as is feasible in terms of time, distance and patient requirements for care. Critical Care Services are categorized vertically.
c. Background and Historical Perspectives
Prior to 1966, little attention was given to emergency medical services. In 1966, the National AcademY of Sciences published a paper which called for im-
11

provements in the" care of 'trauma victims by a coordinated system of care. This action st~~ulated the Congress to pass the National Highway Safety Act (P.L.89-564). The intent of the Act was to reduce the reported annual mortality (65,000 persons) due to motor vehicle accidents, and the non-fatal injuries (111,000) also associated with motor vehicle accidents.
In 1973, Congress enacted P.L.93-154, the Emergency Medical Systems Act, which was extended in 1976 by P.L.94-573. Through these bills, funds were allocated to public entities to develop regional emergency medical systems. These funds gave impetus to the development of emergency medical services in over 200 areas across the nation, and in Georgia's 10 health districts.(33)
1. Regionalization Regionalization of emergency medical service systems was mandated by Federal statute in the mid 70s. Its precursors were several experiments in behalf of isolated physicians and hospitals in rural areas which did not have the resources to provide all needed specialty services. As early as 1931 in Rumford, Maine, a pilot project was established which created a voluntary affil~ iation of eight to ten community hos~itals, with basic core support from the Pratt Clinic and the New England Hospital in Boston and in conjunction with Tufts Medical School. Through cooperation and coordination, including consultation, resident rotatioi~ and new patterns of referral as well as sharing of other assets, improved services to the participating communities resulted. In 1946, the Rochester New York Regional Hospital Council identified a service area and established a formal structure among the participating institutions including inter-hospital agreements. These sharing models may have value for Georgia as it continues the development of regionalized systems for delivering emergency care.
Regionalization of obstetric services has been given impetus through early experiments in the 60s, and by the publication of service standards by the American College of Obstetricians. Experience showed that there is a minimum number of deliveries that are needed to assure a consistently high standard of care and to justify the cost of equipment and personnel. Georgia has been working toward a three-tiered regional perinatal care system since 1978, and has three neonatal Level III centers for the state.
12

Approximately 20 years of study and demonstrations in many communities indicated that unnecessary death and disability stemmed from haphazardly organized emergency medical services. With support from the Robert Wood Johnson Foundation and later from the Federal government, specialized emergency medical services centers were developed on a regional basis. However, to state that a regionalized system should be developed, and to implement the concept or superimpose it on a highly pluralistic extant system provides one of the most difficult of challenges.
Perhaps the most easily identifiable component of hospital-based emergency services is the trauma center. The critically injured victim of trauma is easily identified and has clinical needs manifestly beyond the fiscal and medical capacity of the average local hospita1.(7)
A nationally recognized and replicable model of regiona1ization of trauma centers was developed in Illinois. Trauma centers are placed into ~hree categories: local trauma centers usually with a nurse in the emergency room and an . emergency physician at all times within the hospital. The emphasis in these centers is upon resuscitation and stabilization prior to evacuation. Local trauma centers usually cover an area of 50 miles. Area-wide trauma centers have 24-hour staffing in the emergency department and associated critical care specialists who perform resuscitation and provide definitive care for injured patients. Such centers maintain operating rooms, intensive care units, laboratory services, blood banks, resuscitation equipment and x-ray (including arteriography). A trauma director is present at each center, usually a practicing general surgeon experienced and skilled in triage. Specialty consultants are available (or on call) at all times. Area-wide trauma centers are based in general community hospitals in communities with about 50,000 population. Regional trauma centers in Illinois are based in university-affiliated medical complexes. They provide highly specialized care, educational support and coordination for the statwide system. There are 10 regional centers including three specialized regional centers, a Spinal Cord Center, Children's Trauma Center and a Central Nervous System Trauma Study Center.
It is worthy of note that patients are retained at the local cente,' unless the patient1s primary physician at the local center determines a need for and
13

authorizes and initiates a transfer to an area-wide or regional center. While communications-linkages among the centers seem to reinforce de-regionalization by making consultation available, the transportation system reinforces regiona1ization through the medium of trauma coordination and the regionalized hospital system, as well as the coordinators work with the medical/political actors to make for acceptance of the regional concept. This model of regionalized trauma service may serve as a model for Georgia.

A major ingredient of the regional transfer system is air evacuation. Helicopters provide over 200 transfers a year to regional centers, each of whicrr has a heliport. Fixed wing transfers for distances over 200 miles is provided by cooperative arrangements with the Illinois national guard and federal military installations. Illinois data show a 289~ decrease in the death injury ratio over the last two years of the program. The Gramm-Rudman cuts may interfere with the use of the a~ resources in the centers in Georgia. Hospitals in Atlanta, Augusta and Savannah have helicopters available for emergency transportation. A charter service in Atlanta also has helicopters and fixed wing planes of various sizes for charter.

The Board of Regents of the American College of Surgeons in an approved

report, 'Hospital and Pre-hospital Resources for Optimal Care of the Trauma

Patients 1, published in the Bulletin in June 1983, issued the following

statement:

'On the basis of available evidence, a s~stem designed specifically

for trauma care will effect a reduction ln morbidity and mortality

due to trauma. The system must necessarily address the pre-hospital

care rendered to the patient, as well as the personnel and resources

with commitment to trauma care. 1(8) *

NOTE: * emphasis added.

In the above-cited report, the point is made that designation of trauma facilities by the proper authority is a political process.(8) To mesh communications and transportation among designated hospitals requires the community to focus on the entire system.(8) Further, the committee stipulates that the most significant ingredient for optimal care of the trauma patient is commitment - of both personnel and the institution.(8) The necessity to have experienced and expert personnel, costly and sophisticated quipment including sophisticated 1a-borar. ory and radiological equipment, implies dedication and commitment of the medical personnel, as well as the hospitals' board.(8)

14

The report provides guidelines for the care of trauma patients at three levels: severe (immediately life-threatening); urgent (not as medically lifethreatening, but may become so, or result in significant disability); and nonurgent (not immediately life-threatening nor presenting risk of permanent disability). These categories account for 5% of injuries and 50% of deaths for severe trauma; 10-15% of injuries fall into the urgent category, with 80% being classifi~d as non-urgent.
Data from various areas of the U.S. indicate that there are 1,000 severe injuries annually per 1,000,000 population. For Georgia, this may mean more than 6,000 persons each year. Since in certain specialties the outcome of surgical procedures is correlated with the number of procedures the surgeon does on an annual basis, one may assume a similar outcome for trauma care. Therefore a network of appropriately staffed and equipped hospitals, with inter-hospital transfer agreements and adequate transportation capability is essential.
Since the higher level of category a hospital strives to provide, the higher the costs of the service, it behooves the regional planning bodies to assure that sufficient capacity exists in the region, and that in deference to controlling costs, excess capacity is not developed.
2. Categorization - a Function of System Development In 1971, the American Medical Association Commission on Emergency Medical Services published guidelines for the categorization of hospital emergency capabilites. Subsequently the JCAH developed categorization standards for purposes of evaluating the overall capacity of each hospital and accrediting hospital emergency services to parallel AMA and AHA efforts.(10) There were four basic levels of care capability called 'Comprehensive', 'Major', 'General' and 'Basic', and these categories translated into capability that ranged from advanced emergency care of all patients at one extreme, to basic resuscitation and stabilization at the other. While these categorizations continue to be supported by the Commission, it is recognized that horizontal categorization did not provide sufficient information about the institution's ability to handl~ specific emergent conditions, nor were t~r needs and problems of rural and semi-rural areas or some urban institutions recognized, that
15

is, where a broad range of emergency capability in ever~ hospital was not needed, or was not feasible or cost effective.

In 1975, a relatively new approach - vertical categorization - appeared to be

a valuable supplement to the earlier horizontal categorization schema because

each hospital's capability to effectively manage specific critically ill pa-

tient groups becomes immediately known. A hospital is thereby provided the

flexibility to choose the service(s) it will provide, and to maintain or up-

grade its service lever without committing its resources to other of the

services which it may choose not to provide. The following are the areas

recommended to be included in vertical categorization:

Trauma

Poison Control

Burns

Neonatal

Cardiac

Behavorial

Spinal Cord Services

IT MUST BE EMPHASIZED HERE THAT THE CATEGORIZATION OF HOSPITAL EMERGENCY SERVICES IS NOT A MEASURE OF QUALITY OF CARE, BUT RATHER AN ASSESSMENT OF THE AGGREGATION OF PERSONNEL AND EQUIPMENT AVAILABLE TO PROVIDE EMERGENCY MEDICAL SERVICES AS AN ORGANIZED HOSPITAL DEPARTMENT FUNCTION, TOGETHER WITH THOSE CRITICAL CARE SERVICES WHICH MAY BE REQUIRED FOR THE EMERGENCY AND DEFINITIVE CARE OF PATIENTS.

Not all hospitals can or should have all of thE! personnel and equipment to treat every illness or injury. Nor does every sick or injured patient need a wide range of specialists and equipment to receive high quality care appropriate to his/her medical care needs.

Several factors determine whether a hospital will choose to provide any given service, and the level at which the service will be offered: availability of physician and other specialty manpower; the number of patients needed to assure cost efficient use of equipment, space and services, and the maintenance of staff skills; and the costs of both manpower and equipment in relation to the hospital's capital availability. So it may be seen that high quality care on those services a hospital decides to offer may be expected whether or not the hospital provides an organixed emergency medical care department, or all or few of the seven critical care services.

16

One ~f the problems associated with categorization is the belief by some physicians and hospital administrators that the public does not need to know about categorization. Some hospitals and physicians fear that public misunderstanding of categorixation may lead people to question the quality of care the hospital provides if the level is less than comprehensive. Therefore disclosure of categorization has not been made. There is an expressed concern that hospitals will lose patients if they agree to participate in a network, are not high level centers and must transfer critical care patients to other levels of care. Further since patients flowing through the emergency department are a source of hospital admissions, there is little incentive to eliminate the utilization of this service by any patients. This is inappropriate, costly and may lead to the establishment of more emergency departments than are really needed in a region.
3. Georgia's Involvement in EMS Early in 1970, in order to capture Federal funds, the Department of Public Health and the Comprehensive Health Planning Agency in a joint planning effort, devised a schema to address Georgia's EMS needs. Firt 10 EMS regions were designated. Hospitals then categorized their emergency services with some assistance from the Department. After the State's hospitals were categorized, central counties (those with Level I or II services) were identified. Counties within a radius of 20 miles of the central county wer'e identified as outlying counties, and those beyond 20 miles were said to be remote counties. This original attempt at establishing regional networks recommended EMS regional councils to develop internal regional plans, and a statewide coordinating council to advise the Department of Human Resources in the development of a state plan. One imperative was agreed upon - that there be at least one category I (comprehensive) or a category II (major) emergency service in each region. The role of category III and IV hospital emergency medical services was envisioned as primarily one of 'early access, stablize and refer ' .(9) The category IV emergency room would have limited staff and the equipment needed to resuscitate patients. The category III hospital might have one of the critical care services, and could stabilize and admit patients to that specialty service . It was generally accepted that certain of the Level I critical care services such as trauma, burns, spinal cord injJry and neonatal intensive care would not be found in a hospital with a Level III or IV emergency department.
17

With the prospect of capturing funds appropriated under the Highway Safety Act, the Depar~ent of Human Resources/Emergency Health Section with financial and planning assistance from the Office of Highway Safety and the Department of Administrative Services began to plan for and implement emergency medical technician training, ambulance inspection and improvements, establishment of EMS Councils at the regional level, communication systems and equipment purchases.
A statewide EMS Advisory Council pressed for legislation to set standards for ambulance services, EMT training and communications, and succeeded in obtaining passage of EMS legislation. Chapter 11, Title 31 of the Georgia Code provides for the Department of Human Resources Ito adopt and promulgate rules and regulations for the protection of public health:
a. prescribing reasonable health, sanitation and safety standards for transporting patients in ambulances; b. prescribing reasonable conditions under which ambulance attendants are required; c. establishing criteria for the training of ambulance attendants '
The Code further provides for the certification and recertification of EMTs at three levels of expertise, the required records to be kept by ambulance services on all trips; the licensing and inspection of ambulances; the requirement for each ambulance service to have a medical advisor who is a physician, and the designation of DHR as responsible for the administration of the development of an area emergency medical systems communication program lacting upon the recommendation of the local entity which coordinates the program l .(14)
Under P.L.93-154, each of the EMS regions which applied for planning grants was required to develop an EMS coordinating council. Funding in 1978-79 was awarded to areas VI (Augusta), VII (Athens), VIII (Albany), IX (Savannah) and X (Columbus). Macon was not funded that year and other regions did not apply. Albany and Athens were in their third year of funding in 1979, Augusta and Columbus in their second year and Savannah in its first year. Atlanta had already captured all of the funds that were available to it prior to this date.
It is not unexpected that those regions which were able to capture federal funds were able to move ahead in planning and implementation of their EMS
18

regional activities at a faster pace than those areas which received no funds or entered the 'program at a later date. In 1979 Federal support to Georgi a for EMS planning and implementation was $1,320,000. In addition, vehicle purchase funds (ambulances) and training funds in the amount of $331,085 were made available through the Office of Highway Safety, state and local matching monies.
At the expiration of Federal EMS funding legislation, and with the advent of block grants, the EHS became the oversight agency for grants review and funding for the 10 EMS regions.
In FY I 86 (July 1985-June 1986), each of the EMS regions received $90,000 in grant funds from the preventive health block grant monies, and for all but two regions, state funds were made available in amounts ranging from $34,807 to $42,140, for a total of $311,503 in state funds. The prima~ focus of most of the regions is on EMT training and advance~ EMT training and recArtification, transportation and development of transfer agreements and procedures.
If categorization is addressed, it is given a relatively low priority, nor is it stated in these applications how many hospital-based emergency departments or critical care services are needed or at what levels care should be provided.
In February 1985, it was reported that between 1980 and 1983, eight hospitals in five regions were selected by the regional EMS councils to operate trauma centers. Of these, six have submitted RFPs to the EHS and two have been confirmed at the proposed level by the state. The above report also showed that there were 14 facilities functioning as trauma centers without designation as of February 1985; three of these have a trauma director, five use the chief of surgery in lieu of a director, one has an organized dedicated trauma service and is estimated to operate at Level I. One has a trauma committee and call roster, but has no estimated level of service; one has a trauma call roster and is estimated to operate at Level III; eight have no specific organization for trauma care. None of these facilities has submitted an RFP to the state so that their status can be confirmed by reVieW and on-site survey.(34)
19

There is no statute that mandates requirements for hospital-based emergency services. Ther~_,are no mandated statewide standards that assure comparable care from region to region, nor is there a mechanism for enforcing them. Nor has there, heretofore, beeen a statewide plan which provided such standards.
In fact, there is little to suggest that the expanding EMS components have been planned and organized to approximate a statewide system. Rather, there ;s an amalgamation of competing public and private resources in urban and rural settings with planning, organization and statutory authority scattered among state, federal, regional, city and county agencies. It 'is not known how many statutes relate to the various components of EMS, nor the number of boards, commissions or departments with some involvement in EMS at the state, regional and local levels; nor is the problem unique to Georgia.
4. Georgia-specific Standards for EMS System Development Realizing that some regions were well organized, some were modifying national standards to accomodate to the available resources to carry out categorizations, and that there was a real need to recognize the differences among the 10 regions, the State Health Planning Agency and the State Health Policy Council determined to find a mechanism to address the problem. What was needed was a way to incorporate the best and most necessary standards of the national organizations, but with certain modifications that address Georgia's regional differences.
The classification system guidelines originally recommended by the American Medical Association Commission on Emergency Medical Services, the JCAH, the American College of Surgeons, and the American College of Emergency Physicians were incorporated into two sets of standards for use by individual institutions, regional councils and official agencies in Georgia. They are appended to this Plan. They are the work of a group of dedicated health care providers and volunteers who have been involved with emergency medical services in Georgia either as career choices or as community service volunteers. The group was called into being in August 1985 by the Georgia State Health Planning Agency and the Georgia State Health Policy Council as the EMS T~chnical Advisory Task Force. Some of its members were recommended by provider organizations such as the Medical Association of Georgia,
20

the Georgia Hospital Association and the American College of Emergency Physicians. Other representatives were recruited to represent the EMS regional coordinators, the Department of Human Resources/Emergency Health Section, the statewide ES Advisory Council, Medical College of Georgia, Emory University School of Medicine and the Emergency Medical Technicians organization. A list of the membership may be found in Appendix 4.
The work of this body resulted in the adoption of standards for emergency departments and trauma services. In addition, the group addressed the need for and supported new legislation to strengthen emergency medical services statewide. Accessibility and availability standards were also recommended by the Task Force. These recommendations have been incorporated into this Plan either as guidelines or as standards for the use of all concerned with quality EMS care. They are found in the Appendix.
D. Costs for Emergency Medical Care To examine costs for emergency medical services, several approaches may be taken. First there are the human costs: lives saved!! lives lost, and decreases in the number and severity of the sequallae of presenting illnesses or injuries. These costs may be tallied in terms of quality of life and dollars saved in support of victims, families and society. Some of these costs have been explored in other Plans and components, and will not be elaborated here.
There are also the costs involved in planning, developing and supporting this high cost system and its several high cost components: transportation, communications, manpower training and education, and facilities. Capital costs for facilities and their equipment are not known for the state; there is little hard data to reflect costs for hospital-based emergency departments in Georgia. But even a small emergency department with minimal staffing (physician contract, nursing and equipment) can be a considerable expenditure. Costs vary by size of the service, staffing, equipment and utilization. There is little hard data to reflect costs for hospital-based emergency departments in Georgia.
Utilization of emergency services anc costs vary from hospital to hospital, and with the makeup of the local populations.(23) Patients using central urban hospitals in one study were 'poorer', had 'less education', were likely
21

to be 'members of a minority group' and 'more likely to be inadequately covered bi health insurance' .(23) They generally arrived at the hospital in public transportation or walked, seeking relief from 'minor episodes' such as 'colds, upper GI upset or minor muscular aches and pains'. Many of their complaints were 'not of recent origin'.
Patients coming to the peripheral urban hospitals were 'for the most part well educated and well covered by health insurance'. Their complaints were Imostly related to traumatic injuries of recent origin ' .(23)
Laboratory and x-ray referrals for additional care also varied with the hospital's locus and clientele. Fewer of the above services were provided to inner city residents whose complaints were more primary. care oriented than to the suburban patients whose complaints were trauma related.(23) It must be noted that these are generalizations from a study of several hospitals of specific locus. There is no national (or state) stereotype/profile of emergency service. Each hospital in each community is quite unique.
In reviewing the 1983 Joint Hospital Questionnaire for costs/charges for emergency room visits in Georgia, there was a range of average charges from a low of $17.50 in one hospital ED to a high of $125 in another. This wide divergence may be explained by determining what was included in the reported aVE!rage charges.(39) A spot check of the highest charges revealed that physician fees were included. These fees ranged between $30 and $50. Size of hospital and sophistication of the hospital capabilities apparently were not specifically related to the reported charges, since some of Georgia's largest hospitals offering the most complex services fall into the middle of the charge range. It was noted that publicly supported hospitals fell (for the most part) into the lowest range of average charges, as did the smallest hospitals with the most basic (stabilize and transfer) capabilities.
An examination of 1984 preliminary data for selected services delivered in 25 hospitals across Georgia, all of which had an evaluated capacity of over 300 beds, showed average charges for emergency department services ranged from a low of $20 per visit to a high of $130. It was learned that the latter charge included"the physician fee. The median of the charges reported for this group
22

of hospitals was $?2.45. Mutual of Omaha Insurance Company, in a letter to prospective cu~tomers, quotes $170 as an average ED cost for their insured clients who were seen in hospital emergency rooms across the country in 1984. (39)
A review of total unit costs of service in one EMS region in California shows a range of from $15.32 to $104.55, while revenues per unit of service for these two extremes were $27.22 and $43.03 respectively. The lowest costs were achieved with services to more than five times the number of visits when comparisons between the two units were made. By and large, direct unit costs, highest number of visits, and an inverse correlation between. units costs, revenue and visits was also found. Until such time as cost and revenue data for Georgia are acquired, it is uncertain that the fin9ings above occur in this state. Perhaps more important than basic charges for emergency room care although in most instances they exceed charges for physician office or primary care center charges - are t~e additional charges accruing from ancillary services such as laboratory, x-ray, pharmacy and other hospital departments.
In a study in California, it was determined that 100 out of 1,560 possible charge items were responsible for 90.9% of the total charges to emergency department patients. (24) In the interest of cost control, a study was made analyzing all individual charges to emergency patients which included physician fees, hospital room and nursing care charges, laboratory, x-ray (inclUding professional fees as well as supplies such as splints, bandages, monitor leads).(24) The computerized study was for an eight-month period with the first two months used as the base months.
During that period, 32,116 ED charges totaling $514,~50 were entered into the computer. The charge data for 6,482 patients treated during the base period (prior to cost containment efforts) were compared with the same number of consecutively treated patients after cost containment efforts were instituted. The results were as follows: of the 1,560 different cost items, 100 accounted for 90.9% of the total charges for laboratory, x-ray and pharmacy. Charges for the base period accounted for $299,980 or 44% of the total for the period. (32)
23

After educational sessions with staff, and posting of a list of highest cost items, with th~_,recommendation that careful consideration be given to ordering these itmes, a follow-up was done on charges for the second group of patients. During the cost containment period, there was a 10% savings overall and a 3.3% reduction in charges to patients. High cost, low clinical yield tests, or those that had useful substitutes at lower costs were responsible for most of the savings.
This study concentrated on an area of high cost to emergent patients - diagnostic, laboratory and x-ray charges - an area over which physicians can have a direct impact on medical care costs.(24)
A sample of items specifically flagged as high cost were: arterial blood gases, saving $6,772; electrocardiographs, saving $1,059 and cultures, saving $2,102. With just these three items, savings totaled $9,933. The author states that quality of care was not addressed directly in this study 'because emphasis was on providing the same level of care without compromise l .(24) Rather the emphasis to physicians was on careful consideration of the necessity for tests to arrive at a clinical decision.
Considering that this study was for a limited number of patients in only one hospital, it may not seem to provide a strong rationale for cost containment efforts. However, the author makes the point that judicious ordering of 1abatory and x-ray tests might result in a potential savings of almost one billion dollars based on a projected patient visit total of 300 million visits. For Georgia, this might mean a share of that saving which might run as high as $7.3 million/year, if pre- and post- control cost physician practices in this state were similar to the practices of the study population. Replication of such a study might have value for Georgia.
A California study of 35 hospitals showed that 18 hospitals lost money on their emergency services. The balance showed a positive cost-to-revenue ratio for their emergency services.(33) There was no overall pattern to explain why some hospitals lost money on their emergency service since loses were spread over hospitals wi.th low utilization and those with high utilization. Nor were total service costs able to be pinpointed, since some hospitals with close to
24

the same utilization and with lower total service costs were in the losing column. Most ~spita1s suffering losses showed the lowest amount of revenue per visit.
Nothing has been mentioned heretofore about 'patient dumping', a practice which has been cited in the New England Journal of Medicine, Newsweek, U.S. News and World Report and other periodicals. The focus on costs and profits ;n the medical care industry has created this phenomenon, which has been described as 'diagnosis by insurance coverage', since that ;s the first question asked prior to admission to the emergency service.(40) Articles from the New England Journal of Medicine are cited in the references (52, 53) and in Appendix 5.
A legislative goal to outlaw this practice (based on the action of the Texas legislature) has been developed.
E. Reimbursement for Hospital Emergency Medical Services Since even those facilities which do not have organized emergency departments are eligible to participate in Medicare reimbursement, there is a disincentive to educate the public to appropriate use of hospitals which are, by habit and custom, the providers of care to a given community. In Georgia in 1984, there were over 7,000 visits to hospitals with no organized emergency departments. Medicaid also reimburses hospitals for the care they provide in emergency rooms to eligible patients. A cap has been placed on the reimbursement for services rendered to Medicaid-eligible non-emergent patients. Since 80% of visits are estimated to be non-emergent, the hospitals serving large numbers of indigent patients who use the emergency department in lieu of a family physician suffer large losses. Actually the cap on services is not a disincentive to the patients who use the ED inappropriately. But to the hospital which suffers the loss due to the cap, it is a disincentive to continue in the emergency service provider ranks.
How to assist the public to select an appropriate care provider (where such a provider exists) and to call on emergency departments for true emergencies is a task for health- educators, physicians, nurses, clinics and the public information resources of the state.
25

How to assure that emergency departments which care for a large caseload of persons who ara,medically indigent receive sufficient funding to continue to provide this service to the needy population is a task for providers, EMS councils, the legislature, official agencies and local governments to address in a united effort.
A goal related to reimbursement and strategies for support of hospital emer'gency departments is stated elsewhere in this Plan.
F. Freestanding Emergency Centers There are more than 35 freestanding centers which have as their primary function the provision of primary care and intervention for minor emergencies which do not require the aggregation of personnel and equipment found in a hospital emergency room. While these centers provide an alternative to the inappropriate use of hospital emergency departments and are somewhat less costly charges for their services, to call them 'emergency centers' is somewhat confusing to the public. To eliminate such misconceptions, several states. have enacted statutes prohibiting the use of the title 'emergency' ex~ cept for those facilities equipped and staffed to receive critically injured and ill persons and patients in need of urgent care - the 20% of the most severe cases. Georgia, to date, has not enacted such legislation nor promulgated such regulations.
A paper published in 1984 details the development of freestanding urgent care centers as a function of physician groups, medical care corporations and several hospitals. These so-called 'docs-in-a box' usually locate in shopping centers, in areas of suburban affluence and in towns in rural areas.(64) It is highly likely that these centers will have a noticeable impact on emergency department utilization in those communities where they spring up. These centersare also one of the factors considered in the projected decline of EMS visits that was stated as one of the GMENAC manpower need method assumptions.
26

G. Supply and Distribution of Hospital-based Emergency Medical Services in Georgia In order to, update the inventory of facilities providing emergency medical services (as an organized department operating 24 hours a day, 7 days a week) and to estimate the utilization of these services, a mini special survey of hospitals was mailed to 211 hospitals in Georgia in the fall of 1985. One hundred seventy-one (171) acute care general hospitals responded. Of these; 150 reported providing 24 hour/day, 7 day/week emergency room services in 1984. The inventory of the 171 hospitals is appended to this Plan.
Also, in Appendix 1 are summaries of these services by EMS region and by Health Service Area. The data show the number of hospitals, hospital size and utilization. If used in conjunction with the map in Appendix 2, it may be seen that the distribution of EMS hospital-based facilities has kept pace with the general pattern of growth of medical care facilities in the state, with some excess ;n areas of high population concentration.
While there are several counties in central Georgia which lack a hospitalbased facility, there are sufficient services"in adjacent counties to assure that needed care is available, provided the pre-hospital system (ambulances and well-trained EMTs with. medical control) is in place and functioning optimally. In fact, on close examination of the number of treatment stations currently in place, it might be concluded that there may be excess capacity in every region and in all but a very few hospitals.
The breakdown by level of service (and it must be noted here that many of the levels are self-reported, unconfirmed by the regional EMS Councilor other source) show that only 29 of the 150 hospitals provide Level IV care, the most basic services (that is, stabilize and transfer). Given Georgia's large number (87) of small hospitals under 100 beds, these levels may need to be reassessed. There were six hospitals which reported their emergency departments as providing Level I or comprehensive emergency care, with the availability of all six critical care specialty services in-house (cardiac, poison, obstetric, spinal cord, burn, psychiatric and trauma).
27

The table below shows how the hospitals reported categorization levels by EMS region and hospttal size for 1984.

L984 Re90r~ea SU99ly ana Dis~ribucion of gmergency D.9~~~ts by Lavel and S1ze of Hos9ical in LO EMS Regions

EMS Region

~ of Councies

Bed

~ of

& Populacion I Capaciey I Hospieals

Reporeed Levels
L I2 i 3 i 4

2
3 4
5
-
6 7
8
9 LO

countie. L6

> 50

!,.

~Ol) 360,235

50-~9 ~OO-~49
:50+

3,
-,

-------- L3-

I - -'050-99

.l
6

\l09. - 256,244

LOO-249

L

250+

L

councies - 8

50-99

3

LOO-249

LO

P09.- l.961.673 230+

2

counCie. - l~

> )U
50-99

'L"

pop. - 379.288

LOO-249

6

2.50+

L

councie. - 23

> SO

4

50-99

6

pop. - 519.638

100-249

3

2.50+-

2

couneie. - LJ

> SO

2

50-99

4

\l09. - 358.4l2

LOO-249

2

250+

3

I counCi.e. L7

I > 50 50-99

4 2

\lOp. 119. l66

I LOO-249
250+

L 3

counties 24

> 50

9

50-99

7

pOp 525 .308

LOO-249

4

250+

2

counci.e. 24

> SO

5

50-99

7

pOp. - 368.867

LOO-249

2

250+

5

councie. - LO

I
I

> 50
50-99

2 3

I \lOp 229,296

100-249 250+

2 L

- ! ----

3
--,

2

- , i

---

-~

i "-

L
-- L

I

-

-L 128 2

-
-----.

LO L L

----

--
-3

-
1 2 1

-'" -L

--- L L 2 11

1Z
- - -3 2 1

--
-

--
L

2L

I 3
-L

--L

L3

- - - -- I - 1 -

2

- IL

- - - I 3 I

- I_

6

3

: I;

- I2
- -L --- L
L

. ----

--
2,

- 5 2
- - L

;I
~!
-

3
--,L

2-- --L

I STATE i counties - L59 I POll -S. 227 , 360

22,310
> 50
50-99

I I

L50 37 4.7

I

I LOO-249

33

250+

11

SOURCE: Special Survey of Rospieals. L985 Stace aealth ~lanning Agency, Georgia

6 156 59 29 OiL L6 20
L i 9 30 i

0 1 24. 7

2

" 5 22

0

28

Since there have been no universal statewide mandatory standards for categorizing these serY~ces in Georgia, these self-designations in some instances, may be subject to question. This may also be true for trauma services since only two hospitals in Georgia have been designated by the Department of Human Resources/Emergency Health Section as trauma centers prior to March 1986.
Further, when asked whether the hospital had an organized trauma service, 15 hospitals responded affirmatively. Only eight of these hospitals reported the number of trauma cases, a total of 2,501. Grady Memorial Hospital in Atlanta, with national recognition as a trauma center, which reported 255,690 patient visits to its emergency department, did not break out its trauma patients separately, nor did any of the hospitals which reported that 'we do a lot of trauma cases, but don't have an organized service'. One of the requirements for recognition as a trauma center is willingness to participate in the trauma registry. This integral part of an organized trauma service enables hospitals and ~roviders to monitor the results of trauma care, and to make necessary adjustments in services as outcomes dictate.
Several assumptions were made about system linkage, that is, pre-hospital and definitive care, that undergirded the request for ambulance information. Only 67 hospitals were able to report the number of patients brought to the ED by ambulance. Most of these hospitals ran the ambulance service. Fewer (61) were able to report the number of patients transferred out by ambulance. Since destination of these transfers was not known, and since fewer than onehalf of the hospitals reported, these data are of little use. A more productive question might have been transfers to another hospital for definitive care and in future, this information will be sought.
To look at excess capacity, it is necessary to adopt a reasonable utilization standard. The literature available has stipulated that it can be projected that a treatment station may serve 3,000 patients/year in a fully operational emergency department.(33, 55) Based on the reported visits to the 150 acute care general hospital emergency departments and the treatment stations available, it may be seen that some hospitals are optimally utilized and might need additiLna1 stations, but that most hospitals were not optimally utilizing the
29

allocated resources. The table below shows the utilization of treatment stations by HSA and EMS region.

HSA 2
"
6 STATE

Visits 25.71& 254.59& 972.7&3 228.242 246.151 23&.276 229.507 2.193.251

~ Treatment
Stations
15 L20 405 l4& LOS L11 99 lOOl

Rate 1714 2122 2402 L5&3 2344 2129 2318 2191

SOURCE: State Health ?lann1ng Agency Special Survey of Hospitals. L985

Region 1 2 3 4 5
6 7
8 9 10

EMS Resion

Visits 219.656 90.034 800. &64 L29.636 l85.038 L40.295
85.571 211.818 229.507 101.032

Treatment Stations
102 53 30& 74 7& 107 38 L02 99 44

Rate 2153 L&99 2617 l752 2435 l311 . 2252 2077 2318 2191

If the purpose of regional planning is to assure access and availability to needed medical care with prudent use of resources to contain costs, then the data above may be helpful to regional planning efforts, showing as it does an apparent marked oversupply of treatment stations in EMS regions 2, 4 and 6, . and that in no region has capacity (3,000 patients/treatment station) been reached. If more liberal guidelines were applied and an estimate of between 2,000 and 3,000 patients/treatment station were used, the three EMS regions (2,4,6) would still be markedly under-utilized, while in the balance of the regions, there would seem to be sufficient and fairly well utilized capacity. In reviewing capacity by HSA, excess capacity is noted in HSAs 1 and 4 regardless of the standard applied.

As regional plans are updated, it may be useful to examine each hospital's utilization, the excess capacity and the costs. to see whether some modifications in service sites and resource application should be made. As a case in point, in EMS region 2, only two of the 12 hospitals had over 2,000 visits/ station, while two others had fewer than 1,000/station. This is mountainous country and travel on mountain roads may necessitate the deployment of wider spread resources than in the flat lands of south Georgia. Knowing these special factors of terrain are the strength of regional planning. However

30

with 159 counties in the state, and some of these with low population density and small land ~ass, it must be noted that not every county, nor every hospital should be in the business of providing emergency services, especially if the pre-hospital care system is functioning optimally.
H. Critical Care Services and Reported Categorization Levels of Georgia Hospitals As has been noted, there are seven critical care services which are though of as integral and necessary to assure appropriate treatment for emergencies. They are: trauma, spinal cord, burn, cardiac, neonatal, poison and behavioral services. Few hospitals can provide these services at the most comprehensive level. Many hospitals provide several of these services and at a sufficient capacity to serve the patients they admit; that is, they may be able to care for a minor or moderately severe burn injured patient, but would have to transfer a severely burned patient. The purpose of a regional system is to determine which institution has which services, and at what level of investment the service can perform, and then to assure that a reasonable distribu-_ tion of the services needed in the region is maintained, that inter-hospital transfers and protocols are set up and that inter-regional transfers for needed services are also planned for. To do this, it is essential that all parties work together in behalf of the system.
To date none of the councils has published a plan which includes a need methodology by which to determine the locations, numbers and levels of services needed in their region, and how they plan to assure that needed services are developed and duplicative services, if they exist, are either eliminated or assisted to develop services that are unavailable at needed predetermined levels. Several of the councils have made a start at this with trauma service. To assure the universal adoption of such a system, there may be the necessity to mandate requirements legislatively. The alternative to mandatory requirements would be a consensual effort by the political, professional and civic-minded local actors to develop a cooperative system. This has been achieved in some areas and should be the goal of all regional councils.
31

Fina11y, the problem of financial constraints and incentives to eachinstitution providing.MS must be taken into account. Medicare, Medicaid and private insurers reimburse for services (physician and hospital) provided to emergent patients. As previously noted, reimbursement ceilings or caps for certain procedures decrease revenues and the incentive for providing emergency medical services to indigent patients.
If the system is to work, 'there must be a method of financially supporting the institutions which provide these necessary and costly services, and this too is a function of the EMS council and the organizations involved to address and to solve through cooperative arrangements among themselves and with local and state governments.
The following pages show how regional councils through the EMS regional coordinators reported the categorization status of hospital services in their regions. Of the 10 regions, three did not respond in the original request for data; one responded in a cOllll1ent letter. One regional coordinator reported that only trauma services were categorized. It is possible that these data do not reflect the operational levels of the emergency departments across the state due to omissions in reporting. However, since data from 1979-81 may also not reflect current status, these reports may require validation and updatinq.
1. Trauma Services In Georgia, trauma is the only one of the critical care services for which the Emergency Health Section (EHS) has set up protocols. As of February 1986 only two hospitals in Georgia have received designation from EHS as trauma centers. To accomplish this, these hospitals requested recommendation from the local coordinating entity, sent in an RFP to EHS requesting consideration, were inspected by a traama team and found to meet all the requirements of the State Trauma Committee. A number of other hospitals have begun the process. Since trauma services are complex, requiring a high degree of commitment and resources, only a few such centers are required to serve the population. 'Standards for trauma services have been recommended.by the EMS Technical Advisory Task Force and are appended to this Component Plan. They will be used by EHS to determine the readiness of a hospital to be designated by the Board
32

of Human Resources at the appropriate level of trauma care. The Board of Human Resources wil] receive recommendations from the regional EMS councils and the EHS, and its decisions will be based on the standards and need for these services in the region and the state.

In January 1985, regional coordinators submitted the information on trauma services set forth below.

:>.egJ.on

~

n ~eve.i.

~a'le.i. :II :. :v

t

J

(1

1

:ll

~.e. (ll

tV

:l.e.

V

~.e. ~.c.
j

~.e. ~I.C.
~o

Vt(2)

2

2

9

vtI

l

J

5

'lUI

2

II

:<1

:<

2

I

. (l) ~.c ~oe ~ae.,or1&.4 or aoe r.l....4 for puOLLcaeion.

(2) C&e.,ortz.4 lm 1979. Oft. ~.Yel L ~1ID&ee4 by ~. 1985.

SOlllCZ: G.ars1& Rep.oaal DIS .Coor41Daeors. JaDuary 1985.

These data differ somewhat from the reported services in the State Health

P'anning Agency1s Special Survey of hospitals in the fall of 1985 and from the EHS report of February 1985. It is apparent that a great deal of effort has

been expended to begin to develop the much needed trauma system for Georgia,

but that additional effort is needed. Beginning with a regional plan and the

consensus of all participating institutions and agencies, there is little

reason to doubt that a sound regional/statewide trauma system could be avail

able to Georgians in the near future.

2. Poison Control Services

Po1&Oft Camerol Servtc.. C&e.,oct&.e~Oft

R.sioft h!!!!.l

~avel t1

Leval [II ~ tV

t tI
[UD) tV
'~(2)
Vt(4)

a a
l*
!I.e.
~.c.
l

~.c. ~.c.

J 9 /l.C. :/.C.

'It!

2

7

veIL

!6

tX

:<

l

l

6

(l) /l.C /loe ~.e.,oct&.4 or ~oe :.le.sa4 tor publi~ac1on. (2) So. . of enes. ~.e.~ort&.c1on. ~.ce Era. 1978-80 and are

are ~urrenely be,inn1n, co be re-.v.luaced.

(J) Geor,ia coneraccs wicn Gradv ~o.p1cal tn Re,J.on tIL co

prOvide ene SCac. wicn poison concrol ~encer servi~es.

(4) Poison ~nd asyentaeric services caCe,ori&acion ~one t~

1979 ace reporced under ene above 1ual headin~. enere-

Eore how ~aen wa. cace~or~&.d ts unavailable. Under

en1s jolne caeelory, enere were ~ Level t ~ervi~es and

8 Leve! tV servic... Univers1cy ~ospiea! - AUlusea has

been reeo~nJ.&e4 ~ Levei t ooison ~encer ~v :he ~S

CounCil en 1986.

SOURCE: Gaor':l.a Rel:l.Onai EMS I:oordinacors. ;anuarv ,985.

33

As can be seen, this table provides incomplete documentation of the poison control resourcasin the state. Nor are the linkages with Georgia's designated comprehensive poison control center shown.
Grady Hospital is Georgia1s officially designated poison control center.* A $280,000 contract between the State of Georgia, through DHR/EHS makes it possible to provide consultation, training, public information and a 24 hour a day, 7 day a week hotline which provides information and assistance to callers across Georgia, the neighboring states and several foreign countries. Approximately 91,000 calls were handled by the center during 1984.(28) It is probable that using the national standards, Grady Hospital may be the only Level I poison control center in Georgia.
3. Burn Services The system for providing care for burned patients must begin at the site of the injury ard continue through emergency care and transportation to initial hospital care, and thence to a specialized burn care cent/unit.(36) In 1984, the American Burn Association published revised guidelines for the care of patients with burn injury. In this update, Iburn unit l and Iburn center l are used interchangeably to denote a service which has the capacity to care for the most severely burned patients (major burns) and will also care for moderately and mildly burned patients to assure sufficient numbers of patients to maintain staff skill levels. The term 'burn program l may be used to denote a facility which has exhibited interest in treating burned patients, and in which burn care is organized into a single service and provided according to standard protocols.(37)
* The American Association of Poison Control Programs provides guidelines for this service.
34

The level of burn care required can be measured by the extent of the burn injury. The diagram below clearly illustrates the mode of assessment and initial care requirements of the patient with burn injury using the Rule of Nines.

TT,N*,ni__
AQe

> 15'1\, > 2%
<5ar >aD

> 20% > 10%
<5ar >60

SOURCE: Joinc Comais8ion of the American Burn Associacion and the Co-.itc.. on Trauma of the American College of Surgeons
Burn care is a high cost service. It has been estimated that caring for a typical patient with burn injuries may run in excess of $50,000. Such a patient may be hospitalized for more than 100 days and require 30-50 hours of care each day. The nursing care and equipment needed to care for one of these sever1y injured patients may often equal that needed for six to ten medical/ surgical patients. (35) Few community hospitals can bear this strain on their resources, and since there are few such patients each year to be cared for, dedicated burn units, like trauma units, should be developed with consideration of both need and cost.
In developing standards for burn units/centers, the American Burn Association has cited the JCAH standards as those required to be met in its revised paper of 1984.
35

The three treatment modules (identified as major burn injury, moderate uncomplicated burn injury and minor burn injury) are detailed in Appendix 3.

A review of the 1984 Joint Hospital Questionnaire provides the following information about Georgia's dedicated burn units/center:
o Grady Hospital in Atlanta has 29 dedicated beds in its burn center. They report admitting 339 patients to the service.(30)
o Humana Hospital in Augusta reported that it had a 25-bed burn unit with 195 admissions. (30)
o Medical College of Georgia Hospital (formerly Talmadge) also in Augusta reported six dedicated acute care beds in a burn unit, a total of 10 beds for burn patients, with 60 admissions to that service. (30)

A number of hospitals in Georgia admit patients with burn injuries. The table

below shows the level at which hospitals in some areas of the state have been

categorized in the past as reported by the regional EMS coordinators in Jan-

uary 1985. As may be seen, this service has not been evaluated in six of the

10 regions.

Ver~1cal Caeelorizae1on of Bura C~re Service.

Resion

~

~eYel (I

~eYel (II & (V

{

(,

L

tI

Z

~

ttl

If.C.(l)

If.C.

/f.C.

lV

Il.C.

Il.C.

Il.C.

V(Z) Il.C.

/f.C.

1'l.C.

VI

Z

L

La

Vtl(3)

L

7

Vlll
(X(4)
:<

N.C.

N.C.
l

26 N.C.
7

(l) N.C Noe caeelor1zed. Grady Kospieal - Aelanea - ~..

a ourn ceneer of 29 oed., (Z) this npon baa cacelO~1z" ouy tra_ care.

(3) ~eelor1zae1on .... doae ill 1978. (4) ~ rel10a ~. . Zl ~os,1e&la wieh ...r,ency service.

24 ~our./day. 7 days/veek.

SOURCE; Georl1a lelioaal EKS Coordinators. January 1985.

In 1984, the North Central Georgia Health Systems Agency published a burn policy paper which identified a number of hospitals which admitted patients with burn injuries.(40) Most of these hospitals were in HSA III, although one hospital in HSA IV was also noted. All of these hospitals do admit patients with minor or moderately severe burn injuries. However, the patients in need of long-term and isolation care are customarily transferred when stabilized to one of the ~nree burn centers/units in Atlanta or Augusta.

36

4. Spinal Cord Injury Services The Shepherd Spinal Center in Atlanta was designated to serve as a regional center. It originally opened with 40 beds (another 40 beds were approved in 1983), all but eight of which were set up and staffed by May 1, 1985. Because of the highly specialized services required by patients with spinal cord injury, few of GeorgiaJs general hospitals are staffed or equipped to provide comprehensive services to these patients.

According to the reports received from the regional EMS coordinators, few hospitals requested categorization for this service. The cate~Qrizations reported by the coordinators are found below:

Spina! Cor~ tajurT Service.

Reion

~

~eve! tI

~eve! (II ~ tV

t

4

4

tI

Z.

9

tIl

/I.C. (1)

!I.C.

II.C.

tV

/I.C. (Z)

!I.C.

/I.C.

'I

!I.C.

!I.C.

/I.C.

'11(3)

J

4

9

'III

l

7

'1III

4

43

(X

II.C.

II.C.

II.C.

~

4

(,

(1) II.C !lac cacesorizea. the Shepller~ SpiD&! Ceacer

i.s locac.et in cilia re,ioa.

(Z) the Roo...e!c (a.cicuca for Rallaoilicacioa. ~.r

Spriftaa La in Ra,ioa tV. wlcll lO rehabilicacioft ~eeta.

(3) tha '1ecerana Ada1n1scracioft Ko.piCa! is in Re,ioa '11

wiCII a oo-oeet ca-prelleaaiva ~aic. '1A will ~ccepc

...r,aacy paciaacs aaet craaafer wileD scabil1%eet.

SOUaCE: Gaorlia Ra,ioaa! EMS Coord1n&cor January 1985.

s. Perinatal Services
Perinatal resources are fully discussed in the Perinatal Component Plan and will not be further elaborated here.

Categorization of neonatal critical care services as reported in January 1985 by the regional coordinators is found in the table below.

~eoaaca! Service. Cace,orizacioD

Rasion

~

~evel (I

~evel III & (V

t

!

8

tl

4

9

(IICZ) II.C.(l)

/I.C.

II.C.

lV(Z) II.C.

/I.e.

II.C.

'1(Zl /I.C.

/I.e.

II.C.

'I t

2

l

II

'It!

l

4

'1tII

l

l2

tx

II.C.

/I.C.

/I.C.

x:

l

7

(ll II.C /lac cace,ortzed or noc released for publicacion.

(2) Re~ion tIl haa ac leaac cvr ~evel t neonaca! cencers.

Grady and Kenr1ecca E~!escon KoaD~ca! for Chi!dren.

Au~usca and ~acon also have a ~.vel l 3erv1ce.

SOURCE: Geor~~a Re~1onal ~S Coordinators. Januarv [985.

37

6. Cardiac Services From discovery to definitive care, the rate of mortality from cardiac diseases can be markedly influenced by appropriate and timely treatment procedures. First responders, EMTs, ambulances and finally facilities working together save Georgians' lives daily.

Not all regions have attempted vertical categorization. Categorizing this service should be resumed at an early date in all regions.

Cat.lor1:at1on at C~raiac s.rv~~

R.!10n

~

~av.i (I

~.v.i (II ~ rv

(
(I
(lI(l) tV (l)
v

~.c. (2)
!I.e.
II.C.

" Z
II.C.
~.c.
N.C.

L2 9
~.c.
:-I.e.
II.C.

Vt(l)

"

2

8

VII VIII
tx

l N.C.

) 2
II.C.

" II !I.C.

; II

2

-

6

(l) II.C !Ioc ~ac.lor1Z.e or noc r.l....e for publicacion.

SOURCE: Gaora1a Ralional !KS Coordinacors. January 198'.

7. Behavioral Services The Psychiatric/Substance Abuse Component Plan details the resources available in Georgia for the definitive care of behavioral problems. As one of the critical care services provided in general hospitals, the categorization of behavioral services is as important as any of the others, though less discussed. The following table shows the categorization of this service as reported by regional EMS coordinators. This s\!rvice, too, should be reappraised in all regions at an early date.

Sehavor1&l Service. Caeegorizaeion

Recion

Level 1

Level 11

Level tIl & tv

1

4

!I

2

9

1II

M.C.(t)

M.C.

M.C.

1V

~.C.

M. C.

~. C.

'I

~.C.

~.C.

~.C.

n(2)

'III

2

1

7

'lUI 1X

-
~.c.

1
~.c.

12
s.c.

X

L

L

6

(1) ~.C Moe caeegorized or ~oe released Ear publicaeion.

(2) poison and psyehiaeric serv1ees caeegorizacion done in

1979 are repor~ed under che above dual heading. chere-

Eore how each ~ categorized is unavailable. Under

chis joine caeegory, chers ~ere 6 Level 1 services and

8 Level 1V service.. University aospital - Augusta-

has been recognized as a Level 1 poison cencer by che

EMS Council in 1986.

SOURCE: Georgia Regional EMS Coordinators, January L985.

38

1. Utilization of Emergency Medical Services Between 1960 an~,1980, there was a 113% growth in the use of emergency departments in the U.S., from approximately 38 million to over 80 million patient visits. Emergency rooms had taken the place of the family physician for many highly mobile families, and for families without the financial or transportation resources to secure private physician care. After hours and weekend primary care needs were also being met in emergency rooms as doctors changed their practice patterns.(SO}
Between 1979 and 1982, the number of emergency visits declined approximately 11%. This decrease was accompanied by (and perhaps in response to) the proliferation of alternative care services including new urgent care centers and primary care centers, as well as hospitals beginning to offer services in outpatient departments and clinics.(50}
In Georgia, in addition to the decline in report psychiatric emergency visits in a three-year period, there was a 10% decline in the number of emergency department visits reported between 1981 and 1983. The decline in psychiatric emergency visits as reported may be attributed to the fact that a large number of general hospitals in Georgia now offer psychiatric and drug abuse services, and that most patients experiencing a psychiatric emergency are admitted and reported in an undi fferenti ated count of emergency toom vi si ts. Georg i ans made 2,264,641 visits to emergency rooms in 1981, 2,052,774 visits in 1983, and 2,202,006 visits in 1984.
From the point of view of emergency medical specialists, a decline in nonemergent visits may be desirable since it frees up highly trained and expensive staff and equipment to serve severely ill or injured patients. From the hospita1's point of view, the visit decline may be a mixed blessing in that although the staff and equipment may be used more appropriately, losing patients to other sources of care outside the hospital may mean a decline in revenue that helped to support the emergency team. Cost aspects of emergency departments are explored elsewhere in this Plan.
There have been a number of studies devoted to how emergency departments have changed over time, and how patients use these services. The table on page 2
39

illustrates how patients perceived their illnesses or injuries and how, in
fact, they were rated as to seve~;ty when seen by a medical care provider. In

that study, 43~ ~f reported visi~s were made to the emergency services be-

cause it was either the patient~s customary care provider or because other

care was unavailable.

I

/

What is of most interest in thk table is the percentage of the total visits
considered to be life-threate~ing in this national sample, and the comparison with the projections for 'Geq~ia using the customary national estimate that

20~

of

all

patients

I
seen' need

immediate

or urgent

care.

With 13.5% of visits

I

deemed to be for life-threatening conditions, and Georgia1s hospital admission

through the emergency department at 13.4~, Georgians seem to behave close to

the national norm reported in this study.

The reported utilization of Georgials emergency services is taken from the Special Survey of Hospitals for the year 1984, and completed in the fall/winter 1985. Of the 171 general acute care hospitals responding, a total of 153 reported visits to their emergency departments. Three of the hospitals . did not provide 24 hour a day/7 day a week services. Together'the three did report a total of 7,755 visits, and two of the three hospitals reported admitting a total of 769 patients. This was 10~ and 15% of the patients seen in the two hospitals.

A total of 2,201,006 patient visits were reported in 1984. Of this number, 297',144 were admitted to the hospital for definitive care. Statewide the percent of admissions through emergency departments was reported to be 13.5%. There was a large variation of percent of patients admitted from hospital to hospital, with a high of 60~ to a low of 1.0~. The table below shows the admission rates grouped according to frequency:

AdDLission Rates

t AdIIIi. t ted

/1 of Rospita.1.s

5

l5

5- 9

l4

l5 - 19

J5

20 - 24

l5

25 - 29

6

JO 51 over

6

40

Fifty-three percent of all hospitals admitted fewer than 15% of the patients seen in the eme~ency department. Four percent admitted over 30%; of these, three hospitals had fewer than 50 beds. It is expected that hospitals under 50 beds would stabilize and transfer the larger percentage of their emergency patients. These three hospitals seem to be exceptions. The larger number of under 50 bed hospitals reported from 1% to 7% admissions. In comparing admission rates among the HSAs, it was found that HSA VII had the lowest rate of all HSAs (1,125/1000 visits). HSA I had the highest admission rate (347.8/1000 visits).* A chart showing these rates is included in Appendix 3. What is of interest in these data is that when percent of admissions by EMS reg10n is examined, no region had more than 16.4%. The table below compares actually reported Georgia admissions with projections based on 20% true emergencies. Georgia's admission rates are in line with NCHS data above.
* One of the two HSA hospitals had an admission rate of 35%.
41

COMPARISON of GEORGIA's 1984 ADMISSIONS wieh NATIONAL EXPECTATION LIFE-THREATENING and ~ERGENCY INCIDENTS

EMS UGIuN

/I of VISUS

EXPECTED 5 % LIFE TlUlEATENING

EXPECTED 15 % URGENT

1

219.656

10.982

32.948

2

90.034

4.501

13.505

3

800.664

40,033

120.099

4

129.636

6,482

19,445

5

185,038

0,481

19.445

6

l40.295

7.014

21,0442

d5.5il

4.~78

l2.335

13

.:l1.818

lO,590

31.772

9

220.507

11,475

34.426

10

101,032

5,051

15.154

STATE

2,193,251

109,662

328.987

SOURCE: Special Survey of Hospitals. 1985 State Health Planning Agency, Georgia

TOTAL , EXPECTED VISITS
43.930 18,006 160,132 25,927 25.926 28,058 17.113 42.362 45,901 20.205
438,649

TOTAL ADMISSIONS
35,985 13,076 95.695 16,464 l6.435 25.937 l2.821 31, 186 25.840 15,955
294,647

%
ADMITTED
16.4 14.5 12.0 12.7 14.0 L5.5 l5.0 l4.7 l1. 3 15.8
13.4

If percent of visits admitted are used as a proxy indicator of severity, the projected number of visits using the 20~ estimate of true emergencies was not met in any of Georgia1s EMS regions.

It is important to note that the visit count may not be an unduplicated count

since there is no way of knowing whether some of these visits were recorded

for the same patient seen in two emergency departments for the same episode.

If there is a significant number of duplicate visits counted, then the esti-

mate of severity, using admissions as a proxy indicator, may provide a lower

incidence of severity than is found in the Georgia population. The table

below illustrates the variances in admission/lOOO population for HSAs and EMS

regions.

Ca.~arLaOQ ~c ~LaL'S '0 1i04pLcals ~L'n 24 ~our/7d.y/~e.K ~D.

eMS tte"Lon
l 2

* ano Rac. or Aa.~aSLon/lUOO by liSA .no ~S lte~LOn

It 'Ju .. 's

A d a i . . . .i L o n s

~ .~daLS.L~nll

:l.a,./LUOO ~i.SHS

ll'l.oJO

35,~d5

t&.4

l&).8

'ld.UJ/o

l),u16

l4.:'

145.2

10u.06/o

95.695

l2.u

lL9.3

4

l29.oJ6

Lb.4J5

l!l5,'J)!i

25.937

L2.7 (4.0

L26.7 140.L

~
7 d <j
LU
~lAn.

l40.295
d) .511
Zll.dld 22~ , Su 1 lOl.Un
1 . I'll . 25 I

2L.717 l2.d21 11.186 ,5 . 8/00 l5.955 1'I/o , 5/0 7

lS.3 ,Lu
l4.7
ll. ) lS.~
LJ . ..

l5/o.7 149.a
l47.2
LIZ. 5 l57.<j
LJ/o. )

liSA l
:. OJ
~
7 :'Uli:.;

25.716
25/0,396
972.763 .!2tS. Z4Z ~40. d l
lJ6.~7"
~2.'i , 5u 7
~hL;'; p~cc:"!nt.H~tl! '354) .UH1 ClHU'i!

d.9/oS
36.7'l.l l17 ,667
);.330

)/0. a'
L4.4
l2. l .S.5

)47. :I' 14/0 .l L20.9 LS 5.0

)/0 ,Ud7 )5. d5-
:5.340

,J . .i
.3. " ~ 1 ~

')ll. '.5l.7 ~ t 2. . '5

:.~ '''t!W~U :JV CU~ ; I.ze .Jl ')ne IO~CLC..ll') JQla L.,.'i Lon

Jeln~ ')ULy -:.wo r",,:jDLcaLs ~n -:nL.:i ,.]a'lOLl:!.

42

To explain the wide variances in admission rates between these EMS regions, additional information about the regions is needed. Both region 1 and 2 and HSA I and II are mountain areas with narrow, winding roads, but there is a wide margin of difference in their admission rates. Region 3 and HSA III cover the Atlanta metropolitan area with a high density population for the most part, a large inner city population and congested highways with a large number of tourists unfamiliar with the traffic pattern. Still, the admission rate ;s among the three lowest for all regions and the lowest for the HSAs. Region 10 is a college town, and one might argue that they cuuld - based on the age of their population in residence at school - have a high vehicular accident rate. But lacking additional data on vehicular accidents and ages of admissions, this is purely conjecture. At some point, additional data from the tra~ma and burn registries and EMT/ambulance trip tickets may shed more light on these variances.
A comparison of availability and utilization by HSA and EMS region yields some slight differences in availability ~ utilization. In comparing HSA availa- _ bility and use, it was found that HSA I with the lowest rate of facilities (2/1000 population, with 14.0 treatment stations/1000 population) also had the lowest ratio of visits (240.2/1000 population). HSA VI, with the highest rate of treatment facilities to population, had the highest rate of visits/1000 population.
For EMS regions, the highest use rate (440.6 visits/1000 population) in region 10, showed no correlation with rate of facilities to population. The lowest use rate (268.1/1000 population) was in region 7 which did not have the lowest facility to population rate; rather that honor went to EMS region 3 with 1.3 facilities/1000 population and a use rate that was second highest, 407.3 visits/1000 population.
The EMS region with the lowest utilization of treatment stations was EMS region 6 with a visit to treatment station ratio of 1,311; second lowest was region 2 with 1,699. The highest ratio of visits to treatment stations occurred in region 3 with 2,617 visits/treatment station, close to the ideal 3,000 . It also must be noted here that when individual hospital repor;s are reviewed, a number of hospitals exceeded the 3,000 visits/treatment station utilization ideal.
43

It is most probable that several factors not addressed herein, such as population density, highways and miles driven/population, population age, availability and access1bility of physicians and income playa more significant role in emergency room utilization than facility availability.

Other comparisons of interest may lie in the visit to population ratio which for HSAs ranged from 240.2/1000 population to 641.6/1000 in HSAs I and VI respectively. For EMS regions, the range was 268.1/1000 population to 382.9. The marked variances above cannot be explained by the data collected in the survey. Additional information not currently available is needed to explain these variances.

J. Manpower for Hospital-based Emergency Services The emergen~ physician is a relative newcomer to the field of medicine. There was a time when it was felt that any doctor, and most especially interns and residents could cover the emergency room of the hosnital well enough, and little attention was paid to the staffing of these services. With the realization that specially trained personnel could make a difference in the years of possible life lost, and that severe trauma patients could be salvaged with appropriate and timely care, the need for special training and adequate staffing was recognized. In 1984, according to the hospitals participating in the survey, 48 used emergency physician specialists as directors of their service, and 78 of the hospitals contracted for these services. Forty-six hospitals reported that a general surgeon was the ED director, while 11 reported a family practice physician directed the service. Seventeen reported either nuring personnel, EMT or other discipline as director and 28 reported having no director per see Sixty-two hospitals reported that they had full-time coverage of their service, while the balance used on-call physicians and/or PRN nursing or other personnel.

A tabulation of the physician specialists most often associated with medical manpower needed by emergency patients shows the following number of physicians who claimed the five listed specialties as their areas of practice.

e:_rgency Medicine
l71

General 3urgery
522

(nternal
~ed~c~ne
999

Card~ologlscs
l27

Cardiovaltcular
,4 3urgery

44

The Georgia Center for Health Statistics published this tabulation of medical manpower from the November 1983 records of the Composite State Board of Medical Examiners. A total of 8,307 physicians were licensed to practice medicine in Georgia. There were 46 counties in which none of the above specialists was available. However because of the growth in numbers of contract emergency physician groups, it is possible that hospitals in some of these 46 counties had one or more emergency physicians contracted to work at least part of the time. With increased emphasis on trauma services, it is estimated that Georgia will need a larger pool of emergency physicians in the future.

Using the Delphi technique, the Graduate Medical Education National Advisory Commrittee (GMENAC) projected the need for an increased number of emergency medical physicians by 1990. This was one of the few specialists that was under-represented in the physician manpower pool.(38)

The table below shows the proportion of visits estimated by ACEPand the GMENAC Delphi panel fbr 1990.

~re8 of argellcy
EmarzellC I1r l81lC
!ioll-~rg.Il'
'1ia4ca.1 LOa ,aou
E'0plIJ,&cioll
Emergellc arlellC ClOD-w:'g8IlC
'tOTAL

ACEP ~ '1isi.cs
L2.6 54.4 33.0
4,131 L6,930 LO.828 Jl,a89

L2.2 55.8
n.a
4,000
L8,JOO l2d.Q2 J2, dOO

Given the minimal differences between the ACEP projections and output of the GMENAC modeling panel, the projections that will be used to calculate the projected Georgia need for emergency physicians by 1990 is the GMENAC projection although a range between the two projections would probably be acceptable. What should be noted here is that the modeling panel made some assumptions about declining utilization based on cost, the percent of delegation of nonurgent and urgent visits to other team members and the supply of community physicians and their practice patterns in 1990.

Applying these projections to the Georgia civilian non-institutional population projection for 1990 of 6,319,496, the following estimates are given for vi sits in 1990:
45

Sav.rie:y Emergene: '_, Urgene: /lon-urgene:
roTA!.

GM!NAC ~roJece:ions Visie:s/LUO,UOO
4,000
l8.3UO lO.SOO ~

Gaorg4a Ese:imae:e4 Visie:3 !oe:a1
252:779 l, 156 .46u
633.546
Z.072.78S

As may be seen, this aggregate of visits is slightly less than the number of visits reported in 1984, reflecting the GMENAC panel's projected reduction. Thirty point one percent of all visits were estimated to be able to be delegated to other team members including resid~nts.

Although Georgia has few residency programs, the volume of visits in the Atlanta setting in which residents are present represents approximately 12.8% of all visits; therefore 265,316 would be in such settings. If 5.1% of these visits were delegated to residents, and 25% to other non-emergency physician team members, then a total of 572,121 of all visits could be delegated to other team members. If it is further assumed that the emergency physician will see 4,6000 patients/year or 100 visits/week for a 46 week work year, then Georgia will require 326 patient care emergency physicians by the year 1990, or nearly twice as many as are presently available.

While it may be appropriate for general surgeons to fill in the current gaps in service, it is possible that with the projected growth in the number of physicians and the projected oversupply of general surgeons, some of these already well prepared practitioners will seek specialty certification in emergency medicine. Inasmuch as the GMENAC panel also projects a need for approximately 8% of the emergency manpower pool to be available for non-patient care activities such as teaching and administration, the total number of emergency physicians estimated to be needed in Georgia by 1990 is 428. This assumes that Georgia physicians will have the same productivity as the GMENAC panel estimates, and that the faculty and administrative requirements are in line with Georgia1s requirements.

An EMS specialty physician goal has been developed to emphasize the need for board certified or board eligible emergency medical physicians in Georgia so that projected needs reflected in the standards can be met.

46

IV. G~IDELINES for AVAILABILITY and ACCESSIBILITY of CERTAIN EMS S~RVICES
1. Availability: which services should and do exist to serve the needs of the Georgia population.
2. Geographic Accessibility: the maximum travel distances that are consistent with the physical/emotional condition of the person seeking services.
3. Financial Accessibility: in a life-threatening event, consideration of ability to pay is not consistent with rendering emergency services.
4. Population Base: the number of people needed to assure that the cOS'~s of the service can be met.
5. Inter-hospital Transfer Agreements/Protocols: the way in which hospitals develop formal and informal agreements on how patients will be referred and accepted from one institution to anothe.r.
6. Transportation: the availability of vehicles with required life support equipment and trained personnel to care for adults, children and youth who are criticall ill or injured as they are transported between care sites.
A. Emergency Departments and Trauma Centers There should be one Level I emergency department (which would include a comprehensive Level I trauma service) within 150 miles of 95% of Georgia residents. There should be not more than one Level I emergency department which includes a comprehensive (Level I) trauma center for every 500,000 residents in Georgia metropolitan areas of over one million population. There should be at least one Level II emergency department that includes a Level II trauma center in each EMS region. There should be a Level lIar IV emergency department within 20 minutes travel time for 95% of Georgians. Where two or more Level II emergency departments are located in the same region, a Level III trauma center should exist in one of these in areas where no other such resources exist. There should be no Level III trauma centers in metropolitan areas where Level I and Level II trauma centers are located.
47

Ability to pay for the service, or payment source, should not be a consideratipn in the admission and treatment of emergency patients; therefore: all emergency patients should be triaged and stabilized without regard to avi1ity to pay for the service, and prior to transfer to another hospital, notice to and acceptance by the receiving institution must be given.
Discussion: As has previously been stated, it is infeasible both from the standpoi nts of manpower and cost for small rural hospi ta1s, and even some urban hospitals, to attempt to provide. all of the critical care services that a Level I comprehensive emergency service should have; in fact, few hospitals can manage such extens1ve treatment capability. Also, while most hospitals have the cpacity to respond to life-threatening emergencies in their in-house patients, and can provide the equipment and manpower to resuscitate and stabi 1ize most patients, many do not have an organized emergency service. In addition, highly trained ambulance personnel under medical control with appropriate communications linkages can begin to resuscitate and stabilize victims in the field. Therefore transportation to the nearest hospital may not be in the best interest of the patient. In fact, it has been stated that such a practice is no longer acceptable. (8)
What the ultimate capability of the referral system should be is an appropriately distributed network of services that provides the capacity system-wide to serve each patient at the level needed at the least cost.
48

V. GOALS, OBJECTIVES and RECOMMENDED ACTIONS
A. Health Status Goal #1: Decrease the rate of motor vehicle deaths in Georgia (E8I0-E235) from 22.4/100,000 to 20.4/100,000 population. Objective 1: By 1990, the number of deaths from motor vehicle accidents in Georgia decreased from 22.4/100,000 population to 20.4/100,000 population.
Discussion: Although alternative actions for health status goals will be reflected in the health system goals and objectives, it is the intention of this Plan to emphasize system changes which could lead to the above. decrease by calling attention to the need for increased use of seat belts and sa!ety devices in cars and the retention of low speed limits, both of which preventive measures have been demonstrated to reduce motor vehicle accident sequallae. In addition, a health education initiative addressed to specific age cohorts (as described in the DHR/Public Health Division Plan) should be implemented and supported with needed funding.
Goal #2: Reduce deaths from all other accidents (E800-807-828-949) from 25.9/100,000 population to 23.9/100,000 population.
Objective 1: Reduce deaths from all other accidents (E800-807-828-949) from 25.9/1000 population to 23.9/100,000 population by 1990.
Goal #3: Reduce deaths from accidental poisoning in Georgia from 77/100,000 population to 75/100,000 population.
Objective 1: By 1990, reduce deaths from accidental poisoning from 77/100,000 population to 75/100,000 population.
Health System Goal #1: A fully implemented comprehensive, high quality regionalized system of emergency medical services available and accessible to all persons in Georgia who require emergency care. Objective 1: By 1988, all EMS regions in Georgia with implementable plans descriQing the pre-hospital services, medical control schema, facil-
49

ity distribution and level of service for each emergency department and crjtical care service in the region, the standards used for designation of each service, and a means for funding services that need to be developed and modified.
Recommended Acti on: Because of pri or federal fundi ng, certai n of the regi ons have been able to achieve more system coordination and resource development than others. It might be useful to bring several regions together to explore each other1s successes, and t~ review the ways in which some of the problems arising out of the planning process were resolved. In this process of exchange, coordinators, community leaders and providers from those areas which have achieved more highly organized systems might be called upon to provide insight into how roles and responsibilities of the various actors were negotiated. Partnering and intergroup sharing has been successful in other programs where progress among boards or council s was uneven, and/or where impetus to further progres~ was desirable.
For the purpose of inter-regional coordination, funds might be held in escrow to underwrite inter-regional travel, mailings, etc.
A continuation of orientation and training on an ongoing basis should also be supported by the above-i dentifi ed funds, so that as members hi p and staff changes occur, the community development process, group process and system building functions of the local bodies and their staff are not diluted.
Objective 2: By 1989, legislation enacted, money appropriated, and regulations promulgated to delineate the role and function of the actors in EMS at state and local levels, and to mandate standards for pre-hospital services including ground and air transportation, training of ani:lulance personnel and their certification, medical control and standards for categorization of facilities and critical care service.
Recommended Action: The Department of Human Resources, in consul tati on wi th the Medical AssQ.ciation of Geo""gia, ACEP and the State Trauma Committee, the Georgia Hospital Association and other interested parties should press for
50

passage of Senate Bill 400 as amended, and draft such new legislation as will insure the en~~ced capacity of the 10 EMS regions to develop high quality coordinated EMS systems usi ng the same standards for each servi ce across the state. The appropriations required for coordination should also include additional funds for inter-regional consultation, training and travel.
Goal #2: Increase the number of board-certified and/or board-prepared emergency medical physicians who provide patient care, faculty and administration activities from the 1983 total of 171 to a total of 398.
Objective 1: By 1995, the number of emergency physicians who are boardcertified and providing patient care services in Georgia increased to 325.
Recommended Action: Currently, Grady Hospital with 255,692 patient visits to their five emergency departments in 1984, has only four residents per year on its emergency medical physician speciality service. The hospital has the capacity to provide three times that number of residencies. The problem that impedes expansion, according to one administrator, is lack of funds. Further, Grady Hospital is the only site in Georgia accredited for the three-year emergency medical physician residency program.
One of the criteria for opening a three-year residency priogram in emergency medicine is a minimum of 24,000 patient visits per year. According to the visit reports in the special survey on emergency departments by the State Health Planning Agency, there were 24 hospitals across Georga which could meet that criterion. There must be a board-certified emergency physician director of the service and at least five of the 24 hospitals meet that criterion. Other criteria would also have to be met and the accreditation process might take several years.
In addition to accreditation, funds would have to be made available. Residents customarily are salaried at between $19,860 and $21,660 per year. With the addition of two residents a year at Grady Hospital, a total of $125,560 additional dollars would be required for the first year, and an equal sum for each succeeding year would need to be added, so that an annual total of
51

$373,680 would be required t~ fund the program during the third year and each year thereafter-if the current level of stipend were paid to each resident. Points in the program1s favor are: residents being funded by the state would be required to remain in the state to payoff their obligations. Increasing this manpower pool could increase the quality of the EMS program statewide and save lives, and there are more available physicians who want to enter this speciality than there are training slots. Therefore recruitment and retention present no problem.
It is therefore recommended that the State Legislature set up an ACEP program similar to that funded to the Joint Board of Family Physicians, and allocate funds to the Medical College of Georgia to develop a residency program at a cost of $119,160 for six residents the first year, plus administration and faculty costs, and increase the appropriation as needed to support six residents. The Grady program shou1d be funded for six addi ti ona1 res i dents, an d since the administrative costs are already covered, only residency salaries would be needed.
It is further recommended that one additional program be set up in one other hospital in the southern section of the state, thereby providing for a total expansion of 18 residency slots. these programs to be undertaken until sufficient physicians are available in Georgia to staff all hospitals which require board-certified emergency physicians.
Goal #3: Trained personnel prepared to triage trauma patients in every emergency department in the state.
Objective 1: By 1987, a plan for training all personnel who are customarily assigned or called to work in emergency departments in hospitals which do not have an amergency physician or general surgeon available.
Recommended Acti on: During the preparati on of thi s Component Pl an, a broadly representative EMS Technical Advisory Task Force was convened to work on standards for emergency medical services. Because of their ongoing interest in EMS and their commitment to excellence, it is recommended that the State
52

Health Policy Council and the State Health Planning Agency reconvene this body to develop a plan and review extant curricula, and recommend such background and clinical training as should be included in a training module for non-physi ci an personnel who work in emergency departments. Thi s Task Force shoul d a1so recommend an impl ementati on strategy, detennine the costs for such an effort and identify one or more funding sources to underwrite the program.
Goal #4: A mechanism for reimbursement for uninsured patients served in Georgia's hospital emergency departments and critical services be developed.
Objective 1: By 1991, a mechanism in place to support care to non-insured Georgians requiring emergency services and definitive care.
Recommended Action: To solve the problem of access for uninsured ~eorgians who require medical care, the State of Georgia should request a planning grant from the Robert Wood Johnson Foundation or other source, to plan for and experiment with several potentially viable models of payment for this needy patient pool. A coordinated/collaborative effort among several entities including the DHR/Family Health Services section, the Georgia State University and other parties of interest, and in consultation with the Legislative Study Comnrittee, a single Georgia program should be developed.
53

REFERENCES

REFERENCES

1. Georgia State Health Plan, Vol.II, Georgia Statewide Health Coordinating Council, Atlanta, January 1981.

2. AMH/85, Accreditation Manual for Hos~itals, Joint Commission on Accreditation of Hospitals, Chicago, 198

3. Recommendations of the Conference on the Guidelines for the Cate~orization of Hospital Emergency Capabilities, American Medical Association, Chlcago, 1971.

4. Rules and Regulations for Hospitals, Chapter 290-5.6, Department of Human Resources/Division of Physical Health, Atlanta, February 1971 (revised).

5. Public Health Service Act 1976, Title XII, p.503.

6. Paper delivered by John J. Hanlon, M.D., Special Assistant to the Administrator for Publich Health/DHEW, First Regional Emergency Medical Services Conference, 1972.

7. Gibson, Geoffrey, 'Emergency Medical Services: Regionalizating Intents and Realiz;~ Effects', Regionalization and Health pOlich' Eli Ginsberg, Editor, U.S. Department of HEW Public Health services, Healt Resources Administration, Washington, 1977.

8. IHospital and Pre-hospital Resources for Optimal Care of the Trauma Patient', Committee on Trauma of the American College of Surgeons, American College of Surgeons' Bulletin, Vol.68, #10, October 1983.

9. Proposed Georgia Emergency Medical Services Plan, 1974.

10. Provisional Guidelines for Optimal cateeorization of Hospital Emer~ency Capabilities, American Medical Association ommission on Emergency Medlcal Servi ces, 1981.

11. Telephone conversation with Charles Hill, Governor's Office of Highway Safety, February 18, 1985.

12. the

1983 American Hosiital Association Annual Georgia Hospital ssociation, Department

Survey of of Research

H&osbaittaa,ls1, 9c8o5m. piled

by

13. Accidental Death and Disabilit~: The Nelected Disease of Modern Society, National Acade~ of sciences, Washlngton, 1 66.

14. Official Code of Georgia - Annotated, Vol.23, Title 31, Chapter 11, The Mitchie Company, Charloattesville, vA, 1984.

15. 'Report of the Inter-Society Commission for Heart Disease Resources', Cardiovascular Disease Guiaelines for Prevention and Care Resources, DHEW Publication #(HSM) 73-7022, U.S. Government Printing Office, Washington, 1972.

54

16. Trunkey, Donald, M.D., 'Do Trauma Centers Make a Difference?', Infections and Surgery, p.~?4, December 1981. 17. Trunkey, Donald, M.D., 'The Value of Trauma Centers', The Bulletin, October 1982. 18. Component Plan: Psychiatric and Substance Abuse Inpatient Services, Georgia State Health Policy Council and State Health Planning Agency, 1985. 19. American Hospital Association Survey of Hospitals, 1981-82, compiled by the Georgia Hospital Association, 1985. 20. Cales, Richard M., M.D., 'Trauma Mortality in Orange County: The Effect of Implementation of a Regional Trauma System', Annals of Emergency Medicine, January 1984. 21. Spencer, James H., M.D., The Hospital Emergency Department, Charles H. Thomas Press, Springfield, Illinois, 1972. 22. Cross, R. E., Jr. and L. M. Riggs, M.D., The Hospital Role in EMS, American Hospital Association Publishing Co., Inc., Chicago, 1984. 23. Torrens, Paul R., M.D., M.P.H. and Donna G. Yedvab, M.B.A., 'Outpatient Care', Hospital Topics, December 1966. 24. Karas, Stephen, Jr., M.D., ICost Containment in Emergency Medicine l , Journal of the American Medical Association, Vol.234, #13, April 4, 1980. 25. State of Georgia Highway Safety Plan, FY'85, Governor's Office of Highway Safety, Atlanta, 1984. 26. Standards for Poison Control Programs, American Association of Poison Control Centers, Chicago, 1981. 27. Developing Regional Poison Systems, DHEW/Health Resources Administration. 28. Telephone conversation with Dallas Jankowski, Director, DHR/EHS, May 10, 1985. 29. ITotal Care for the Burn Patient', Bulletin of the American College of Surgeons, American Burn Association, Chicago, October 1977. 30. Joint Hospital Questionnaire 1983, Georgia State Health Planning Agency. 31. Detailed Diagnosis and Surgical Procedures for Patients Dischar~ed from
Short-stay Hos~itals, U.S. 1983, U.S. Department of Health &Human ervices,
Public Healthervice, National Center for Health Statistics, Series 13, #82, March 1985. 32. Edlich, Richard F., M.D., et.al., 'Systems Conceptualization of Burn Care on a Regional Basis', Topics in Emergency Medicine, October 1981.
55

33. Interim Report: Directions in Eme~ency Medical Services, Orange County Health Planning Council, Are~ 13 Healt Systems Agency, Orange County California, March 1985. ;

34. 'Report of Trauma Services, February 1984', DHR/EHS, February 1985.

35. Senate Bill 400 - passed both Senate and House, March 1986. Held up in conference committee.

36. Specific Optimal Criteria for Hoseital Resources for the Care of Patients with Burn Injury, American Burn Assoc1ation, 1976.

37. 'Guidelines for Service Standards and Several Classifications in the Treatment of Burn Injury', The Bulletin of the American College of Surgeons, American Burn Association, October 1984.

3E8d.ucMaatinopnow, eur .sR.eqDuHirHeSm, ePntusblfiocr

Eme~ency Medicine, Office of Graduate Medical Health service, Health Resources Administration,

Washington, 1981.

39. Thomas, John E., Mutual of Omaha Claims Research 1984, Mutual of Omaha, Nebras ka, 1986.

40. Burn Care Policy Paper, North Central Georgia Health Systems Agency, Inc. Atlanta, January 1984.

41. AHC/85 Ambulatory Health Care Standards, Joint Commission of Accreditation on Hospitals, Chicago.

42. Feller, Irving and Keith Crane, 'Planning and Designing a Burn Care Facility', Institute for Burn Medicine, Ann Arbor, Michigan, 1983.

43. Grahm, Robert, 'The GME Quandary: Who Will Pay the Piper?', Public Health Reports, Vol.99, #1, January/February 1984.

44. Davis, Harvey, et.al., 'The 1990 Objectives for the Nation for Injury Prevention: A Progress Review', Public Health Reports, Vol.99, #1, January/ February 1984.

45. 'The World's Premiere Burn Care Center', Profiles, W. K. Kellog Foundation, Battle Creek, Michigan, Spring 1986.

46. Telephone conversation with Jane Woofter, Planner, Medical Center, Columbus, GA., March 25, 1986.

47. Joint Hospital Questionnaires 1985: Kennestone, Pidemont, St. Joseph's, DeKalb General, Medical Center (Columbus), Grady Memorial, Doctors (Augusta) and Medical College of Georgia Hospitals.

48. Special Survey of Hospitals 1985, Georgia State Health Planning Agency.

4q. Special Patient Origin Reports: Grady Memorial, Doctors and Medical College of Georg1a Hospitals, Burn Unit Report, 1985.

56

50. Telephone conversation with Jim Carrell, Director, Spinal Cord Registry Program, Warm Springs, April 9, 1986. 51. Proceedings of Workshop on Emergency Health Services in Vermont, Sugarbush Inn, Warren, Vermont, January 26-27, 1973. 52. Wreurt, Keith, 'No Insurance, No Admission', The New England Journal of Medicine, Vol.312, #5, February 7, 1985. 53. Curran, William J., 'Economic and Legal Considerations in Emergency Carel, The New England Journal of Medicine, Vol.312, #6, February 7, 1985. 54. 'Emergency Care Guidelines. 55. Rich, Whittaker, 1984 Resource Projections, Orange County Health Planning Council, Tactin, California, June 21, 1984. 56. Baseline for the Future, 1985 Oklahoma Tri-centennial State Health Plan Oklahoma Planning Commission, Oklahoma city, Oklahoma, July 1985.
58. Northwest Georgia EMS P1Jnning Project Region I, Floyd County Board of Health, Rome, GA, January 1980. 59. Shires, Thomas G., M.D., Emergency Medical Services: Measures to Improve Care, Macy Foundation, New York, 1980. 60. A Decade of Progress in Burn Medicine, National Institute of Burn Medicine, Ann Arbor, Michigan, 1980. 61. The W. K. Kellog Foundation Great Lakes Regional Burn Care Dmonstration Project 1972-77, University of Michigan Burn Center and the National Institut~ of Burn Medicine, Ann Arbor, Michigan, 1978. 62. Emergency Medical Services surve~ and Plan Development Report, Stanford Research Institute, Menlo Park, Cali ornia, 1970. 63. Webb, M. R., 'Emergency Medical Care System in a Metropolitan Area', Department of Medical Care and Hospitals, Johns Hopkins University, 1970. 64. Dann, Si, 'Doc in a Box', Eastern Review, August 1985.
57

APPENDIX 1 Standards for Trauma Centers
Hospital-based Emergency Services

Institution

PROPOSED
UQUDDIJITS

Trauma Center "Level"

_

Population Bas. S.rved (for trauma care)

*The following table shows lev.ls of caeegorization and th.ir essential (E) or d.sirable (D) characteristics.

A. GDDAL ASncrs

1. COMMITMENT STATEMENTS
a. Agre.ment to obligation to fulfill and maintain all r.quir.ments

I II

III

..;B;;.-.~--=B;....~-=B;....-

b. Agr....nt to acc.pt all trauma patients for initial

---------+---;-...;.-- stabilization r.gardl.s. of ability to pay.

B

B

c. Agr....nt to pra.ptly transf.r to high.r l.v.l car.

------+---+--- when.v.r medically indicat.d by r.gional protocol.

B

B

B

d. Agr....nt to provide r.qu.sted data (pati.nt car.,

syst.. function, and adainistrative) to designating

authority for syst.a management, m.dical audit and
res.arch.--------------------------+E---+E ----

e. Agr....nt to permit periodic announc.d or unannounc.d sit. visits by d.signating entity or d ign (appropriate f will b. s.t by d.signating authOrity).

I
1 E_~i--B-~-B---

f. Agreement to assure specialty medical and surgical care capability whenever need.d.

I
E_ _~ - - E - - ~ - - E - - - -

------------;.----+--- g. Agreement to acc.pt pati.nts only wh.n care capabilities (personnel and faciliti ) available. h. Agreement to maintain and support the quality assurance

EI E I

prograa which includesl

( 1)
(2)

Hospital Hospital

trauma trauma

c01llllli IIIObrl..

dt tietye~/-m-o-~rt-a-1-l-..-ty-~-c-o-n-f -e-r-e-n-E c=eE~~..,EE =__..,...--:EE=__-

(3) Trauma registry

E

E

E

(4) Educational progr...



B

E

E

(5) Yearly r.port

E

E

E

(6) Regional trauma c01lllllittee participation

B

E

E

I

2. SYSTEM PARTICIPATION

a. Agreement that the trauma center wi 11 operate Within and actively support t he Regional EMS system.

;

E

B

E

b. Agreement to actively adhere to and support the insti-

tution and/or maintenance of an organized medical control

prograa in the region to prOVide supervision of pre-

hospital trauma care and triage.

E

E

E

58

c. Agreement to use standardized triage criteria for trauma patiettt selection as devised by state and regional co-ordinating entities:

(1) Trauma Scoring (2) Injury mechanism (3) Anatomic severity

d~ Agreemant to actively participate in regional trauma council (if present in region).

e. Trauma center designated as p.rt of official aegional

EMS Trauma program effort (include documentation letter

from EMS Council).



f. If Trauma center not designated as part of official aegional EMS Trauma program.

LEVE1.S

I

II

III

I E I E E

E: I ; I

I

II I

E, I I I

-:I::...._..I:.-J. -D=-_
_

(1) Regional Trauma Program has been im~lemanted

(2) O(inthc.lrudhion.g~idta.sliginnaytioounrs)regbyionEMScuIrnrteitnyt.ly-a~l-s-o-------~----------

prOViding tr.uma care at l.v.l you indicated

at b.gianing of this document (include letter from

EMS authority which is co-si~.d by State EMS

Trauma Con.ultant indicating your in.titution

is functioning a~~ro~riatly a. a Trauma Center

within your regional EMS/Trauma program.)

__

S. BOSPrrAL OIGdIZA'fIOW

1. TRAUMA SEaVICE

a. Se~arate organiz.d defin.d Trauma Service with separate surgical staff.

b. Director of Trauma S.rvic.:

(1)
(2)

aNoamared-C~.-r-t-i~f~i~c-a-t~i-o-n----------

(3) ATLS Cours. pd (4) Onderstand. and is res~nsibl. for Q/A program (5) Sp.cific involvement in pre-hos~ital system
(at least trauma care Q/A) .

c. ~ surgeon. on trauma service call:

(1) "Soard certified/eligible

( 2) ATLS Course passed

(3) Agreement to fully arcicipate in Q/A program

(4) Maintain trauma ca load:

Orban-50 trauma admissions/year each

Rural-24 trauma admissions/year each

(5) 16 hours/year in a roved trauma CME (6) Total number of tr Da surgeons taking call

.

I

I

D

E i I I' I

E! I 1 I

.

i

EI E I E

E iIi E

I

EI I

E

EI I

EI

I

EEE

P:

I

E

59

d. Active hospital trauma committee (monthly meetinls)
e. All 'major trauma patients (determined by standard triale criteria) evaluated in Emergency Room by trauma surleon orolllot 1V'.
f. All major trauma patients (determined by standard triale criteria) acimitted to trauma service
g. Total number of trauma admissions last year
h. Total number of maior trauma admissions (de1\ermined by standard triaIe criteria) last year
i.' Trauma Co-ordinator:
(1) Full time (2) Part time
2. SURGE&Y DUAllTMINtS/DIVISIONS/SE&VICES/SECTIONS
a. Each staffed by qualified specialists
(1) Cardiothoracic Surlery (2) General Surlery (3) Neurololic Surlery (4) Obstetrics-Gynecololic Surlery (5) Ophthalaie Surlery (6) Oral Surlery-Dental (7) Orthopaedie Surlery (8) Otorhinolaryulololic Surlery (9) Pediatric Surlery (10) Plastic and Maxillofacial Surlery (11) Urololic Surlery
3 !M!R.GENCY DEPAllTMINT/DIVISION/SER.VICE/SECTION
a. Staffed by qua lified specialists
4. StJaGICAL SPECIALITIES AVAILABILITY
a. In-house 24 hours a day:
(1) General Surlery (2) Neurololic Surlery
b. Immediately available on ER arrival of patient:
(1) General Surlery (2) Neurololic Surlery
c. Available fo llowinl ER physician consult:
(1)- General Surgery (2) Neurologie Surgery
60

LEVELs

I

II III

E

E

E

E

E

E

E

E

E

i

X

I

X

E

X

D

E

E

X

X

E

D

D

E

D

D

D

E

X

X

D

X

D

XI D

.E ! D

X

X

E

~
:1
"
E ~" 041
I
\
I I
iE o4!
I I I
I
E
D

~ ....~

d. On-call and promptly available from inside or outside hospital:

I

II

III

( 1) '-,C~rdiac S (2) General S
(3) Neurologi (4) Microsurg (5) Gynecolog (6) Rand Surg (7) Ophthalmi (8) Oral Surg (9) Orthopaed (10) Otorhinol (11) Pediatric (12) Plastic a' (13) Thoracic (14) Urologic

gery
gery Surgery ., Capabilities
.,Surgery
Surgery .,-aental Surgery '/tlgologic Surgery urgery
MaXillofaCial Surgery rge1'1 rge1'1

E

D

E

D

E

D

E

D

E

D

E

E

D

E

D

E

E

D

X

X

D

X

D

X

E

D

X

X

D

X

X

D

5. NON-SURGICAL SPECIALtIES AVAILABILITY

a. In-hospital 24 ours a day:

(1) !Mrgency ad1cine (2) Ane.the.1 ogy

xS ES E

, Xv

I'

1

b. au-call and pr ptly available from inside or outside hospital:

(1) !Mrgency oom physician coverage

(2) Ane.thesi ogy

..

(3) Card10101Y.

(4) Che.t MAId cine

(5) Gastroent rology

(6) ae. .tology,

(7) Infectiou Disease..
(8) Internal edicine

( 9 ) Nephro logy,

( 10) Neuroradi,ology

(11) Pathology

( 12) Pediatric'S

( 13) Psychiatry'1, ( 14) Radio logy,

C. SPECIAL PACD.rrms/usonczsICAPABD.ITDS

R

R

n

n

R

n

1P.



n

I:

n





11'

1r

R

n

n

~lR

1P.

1P.

1P.

1P.

R

n



1P.

lr.

1. EMnGENCY DEPAR,nt!NT



a. Personnel:

(1) De.1gnate hysician Director

I

I

I

(2) Physician th special coapetence in care of the

criticall njured who is a designated member of the

trauma te and physically present in the ED 24

hours a d

E

E

E

( 3) _Emergency ~oom physician coverage promptly a~ailable

24 hours day

(4) RN's. LPN , and nurses' aides in adequate numbers

I

E

E

61

-.

I

II

III

b. Equipment for resuscitation and to provide life support

for the critically or seriously injured shall include but

noc.belimited to:

(1) Airway control and ventilation equipment including

laryngoscopes and endotracheal tubes of all sizes,

bag-mask resuscitator, sources of oxygen, and

mechanical ventilatot' (2) Suction devices (J) Electrocardiogt'aph-oscill08cope-defibt'illatot'

E

E

!

E

I

K

(a) internal (b) external (4) Apparatus to establish centt'al venous pt'es8ure

E

I

I

E

E

I

lDOnitoring (5) All standard int~avenous fluids and administration

E

E

I

deVices, i ncluding intt'avenous cathetet's

E

I

K

(6) Sterile sut'gical sets fot' procedures standard for ED,

such as thot'acosto~, cut-down etc.

E

K

K

(7) Gastric lavage equipment

E

E

E

( 8) Drugs and supplies necessat>y fot' emergency care

E

E

E

(9) X-ray capability, 24 hour coverage by in-house

technicians

E

E

E

(10) Two-way t'adio linked with vehicles of e. .t'gency tt'anspot't system

EIK

K.

(11) Pneumatic An&i-Shock Garmenc (needed alao aa supply

t'eplacement item for EMS ct'ews)

E

1

K

(12) Cervical spine stabilizing equipment

K

K

R

2. INTENSIVE CAllE TJtfITS (ICU) rOll TRAUMA PATIXNTS (ICU may b. sepat'ate specialty units)

a. D.signated Madical Directot'

K

K

!:

b E1bys ic ian on ducy in lCU 24 hours a day ot' immediately available ft'OIa in-hospital

K

K

D

c. Nurse-pacient miniDIWD ratio of 1:2 on each shift
d. Immediate accesS to clinical labot'atory services

K

K

K

R

R

R

e. Equipment:

(1) Airway conct'ol and ventilation devices ( 2) Oxygen source with concentration controls (3) Cardiac e. .rgency cart (4) Tempot'at>y tt'ansvenous pacemaker (5) Electt'ocat'diograph-oscilloscope-defibrillator (6) Cardiac outpuc lDOnitoring (7) Electt'onic pressure lDOnitoring (8) Mechanical ventilator-respirators (9) Patient we ighing devices <10} PullDOnat>y function measuring devices (11) Tempet'atut'e control devices (12) Dt'ugs, intravenous fluids, and supplies (13)" Intracran1". al pt'essure lDOnitoring deVices
62

E

E

E

E

E

R

E

E

I

E

I

I

E

I.

I

E

E

D

It

I

D

I

X

E

X

I

D

I

I

E

I

I

E

I

I

E

I

It

D

I
3. POSTANESTRETIC RECOVERY R.ooM (PAR) (Surgical Qtensive care unit is acceptable)

a. R.egiS red nurses and other essential personnel 24 hours

a day.

E

b. Appro riate monitoring and resuscitation equipment

E

4. ACon: HEMODIALYSIS CAPABILITY

E

5 ORGANIZED BURN CAR!

a. Physi ian-dir.cted Burn Center/Unit staffed by nursing

perso n.l trained in burn car. and equipp.d properly for

car. f the ext.nsively burn.d pati.nt t or transf.r agree ant with nearby burn center or hospital with a

burn nit

II:

6. ACon: SPI AL COI.D INJURY MANAGEMENT CAPABILITY

a. T.ans .r agr....nt should b. in effect and there should b.

proto ols for early transf.r to spinal cord injUry rehab-

Uita :ion c.nt.rs .

K

7. RADIOLOGI AL SPECIAL CAPABILITIES

a. Angio raphy of all types

~

b. Sonog aphy

E

c. Nucl. r scan~ing

E

d. In-ho s. computeriz.d tomography with technician

E

8. UHABILIT ~ION MEDICINE in-house capability or transfer

a g r. . . .n t

II:

D. OPDAnBG SUI'l'B leur. UQUDWiDIS (equipment-in rumentation)

1. OPEBATING DOH ADEQUATELY STAFFED IN-HOUSE AND IMMEDIATELY

AVAILABLE 4 HOUIS A DAY

K

2 CAllD IOPULMONAllY BYPASS CAPABILITY

1!:

3. OPERATING ICROSCOn

...

4. t'HERMAL C TROL EQUIPMENT

a. For ient

~

b. For od

~

5. X-RAY CAP ILITY

~

6. ENDOSCOPE ALL VAIUETIES

~

63

LEVELS

II

III

E-

E

E

ED

! ~

II:

...

1!:

~

n

n

n

~

I:

n

n

n

~

~

~

~

~

1l'

~

11'

I

7 CRANIOTOME

I:

8 MONITOllING . EQUIPMENT

I:

E. CLIBICAL LAJOL\'lOUIS SDVICIS (ilDlllediately available 24 hours a day in-house)

1. STANDARD ANALYSES OF BLOOD, UB.INE, AND OTHER BODY FLUIDS

I:

2. BLOOD TYPING AND CROSS-MATCHING

!

3. COAGULATION STUDIES

!

4. COMPUlmNS lYE BLOOD BANK 01. ACCESS TO A COMMUNITY CENTRAL

BLOOD BANK AND ADEQUATE aOSPITAL STOB.AGE FACILITIES

I

5 BLOOD GASES AND pH DETDHINATIONS

E

6. SERUM AND UB.INE OSMOLALITY

I

7. MICIDBIOLOGY

E

8.. DI.UG AND ALCOROL SCUDING

E

I n ASSUUBCB

1. MEDICAL CAD EVALUATION INCLUDING:

a. I.es ponsibility of trauma service director

I:

b. 1I0sllttal trau.a ca..ittee with monthly ..etings

I:

(1) A11 surgical subslJecialities represented

I:

(2) Nursing represented

I:

(3) Anesthe.ia represented

I

c. Morbidi tyI morta11ty conference with trauma death audit

I:

2. OUTllEACB PROGRAK

a. Telephone and on-site consultations with physicians

of the community and outlying areas

I

3. PUBLIC!DUCATION

a. Injury preven~ion. in -the homa and industry, and on the

highways and athletic fields; standard first-aid; proble~

confronting public, medical profession, and hospitals re-

garding optimal care for the injured

!

. 4. COMPLETE TRAUMA UGISTllY USING STANDARD STATE COT FORMAT

!

II

III

!

D

I:

!

I:

!

!

!

I:

!

I:

D

E

I

B

D

B

D

B

D

I

I

--

B

I:

I:

I

I

E

!

!

I:

I:

!

!

D

!

E

64

G. TlAmtA a:sSEAllCB PBOG' Ii. TIAIlIIlIG PIOGIAH
1. FORMAL PROG
a. Staff C"" '; - - - - - -
b. Nurses c. Allied health personnel d. Community physicians

J.iAVI:o~

.L. I

II

III

-

!

!

!

D*

!

!

D*

!

!

D*

*Specific trauma continuing education (provided by Level I or II Trauma Centers)

65

NOTES
1. The emergency department staffing should ensure immediate and appropriate care for the trauma patient. The emergency department physician should function as a designated member of the trauma team, and the relationship between emergency department physicians and other participants of the trauma team must be established on a local level, consistent with resources but adhering to established standards and ensuring optimal care.
2. Requirements may be fulfilled by senior residents capable of assessing emergent situations in their respective specialties. They must be capable of providing surgical treatment immediately and to provide the control and surgical leadership for the care of the trauma patient. When residents are used to fulfill availability requirements, staff specialists must be on-call and promptly available.
3. The established trauma system should ideally ensure that the trauma surgeon will be present in the emergency department at the time of the patient's arrival. When sufficient prior notification has not been possible, a designated member of the trauma team will immediately initiate the evaluation and resuscitation. Definitive surgical care must be instituted by the trauma surgeon in a timely manner that is consistent with established standards.
4. An attending neurosurgeon must be promptly available and dedicated to that hospital's trauma service. The in-house requirement may be fulfilled by an in-house neurosurgeon or surgeon (or physician in Level II facilities) who has special competence, as judged by the Chief of Neurosurgery, in the care of patients with neural trauma, and who is capable of initiating measures directed toward stablilizing the patient and initiating diagnostic procedures.
5. In Level I and Level II institutions, requirements may be fulfilled by senior level emergency medicine residents capable of assessing emergency situations in trauma patients and providing any indicated treatment. When residents are used to fulfill availability requir~ments, the staff specialist on call will be advised and be promptly available.
6. Requirements may be fulfilled by residents capable of assessing emergent situa~ions in trauma patients and of providing any indicated treatment. When residents are used to fulfill availability requirements, the staff anesthesiologist on call will be advised and be available promptly.
7. May be fulfilled when local conditions assure that the staff anesthesiologist will be in the hospital at the time or shortly after the patient's arrival: in the hospital. During the interim period, prior to the arrival of the staff anesthesiologist, a certified anesthetist (eRNA or PA) capable of assessing emergent situations in trauma patients and of initiating and providing any indicated treatment will be available.
8. Requirements may be fulfilled by certified registered nurse anesthetists (CRNAs/PAs) capable of assessing emergent situations in trauma patients and of prOViding any inQicated treatment. When CRNAs/PAs are used to fulfill availability requirements, the staff anesthesiologist on cal~ will be advised immediately and will attend promptly.
9. Regular and periodic multidisciplinary trauma conferences that include all members of the trauma team should pe held. This conference will be for the purpose of quality assurance through critiques of individual cases.
66

STANDARDS FOR HOSPITAL-BASED EMERGENCY SERVICES

The following table shows levels of categorization and their essential (E) or desirable (D) characteristics:

LEVELS

A. BASIC ASPECTS

I

II III

IV

1. Commitment s tatements:

a. Agreement to fulfill and maintain all requirements.

EE

b. Agreement to accept and assess all patients without

regard t o ability to pay (policies, protocols and

procedures should reflect appropriate disposition of

all patients.

E

E

c. Agreement to accept all patients in need of

stabilization and life support without regard

to abUity to pay.

E

E

d. Agreement to transfer any patient in need of a

higher 1evel of care whenever indicated by

regional protocols.

EE

e. Agreement to provide requested data (patient

care, system function and administrative) to

EMS authority for medica~ audit and research.

EE

f. Agreement to permit periodic announced or

unannounced visits by EMS authority or entity(s).

E

E

g. Agreement to assure specialty medical care as

needed.

E

E

h. Agreement to retain patients only when care

capabilities ( personne1, equipment, facilities)

are available.

E

E

i. Agreement to maintain quality assurance program

. which ineludes:
(1) E.D Committee

E

E

(2) Education and training programs (staff)

E

E

(3) Participation in regional EMS council

E

E

2. System Participation:

a. Agreement to support and participate in the

regional EMS system.

E

E

b. Agreement to adhere to, support, and participate/

maintain the organized medical control program in

the EMS region that provides supervision of pre-hospital

emergency care as detailed in the regional EMS plan.

E

E

c. Agreement to use standard triage criteria for

trauma and burn patient selection as promulgated

by the s tate:

(1) Trauma Scoring

E

E

(a) injury mechanism

E

E

(b) anatomic severity (2) Burn severity

E

E

.

E

E

*See addendum attached-to end of document.

d. Agreemen t to provide commu"lity with the hospital's

capabihties.

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

68

3. Care Rendered: a. Total in-house capabilities for all medical conditions. b. Total in-h~~s. capabilities for all emotional conditions. c. In-house cap bilities for most medical conditions (with transf r as appropriate). d. In-house cap bility for most emotional conditions (with transf r as appropriate). e. Some in-hous capability for medical and emotional conditions w th needed specialty consultation available by patient cransfer. f. Ca?ability t determine if emergency exists. g. Life-saving irst aid.
4. Communications b tween emergency facility and pre-hospital sys em
B. ORGANIZATION AND STArFING
1. Separate departm nt in-hospital organization. 2. 24 hour on-duty mergency medicine physician. 3. Physician on cal to E.R. (promptly) . 4. Physician specia ty availability (board certified/
eligib le staff 0 senior resident in that specialty): a. Medicine:
(1) in-hous (24 hours a day). (2) prompt 1 available. b. General Surg ry: ( 1) in-hous (24 hours a day). (2) prompt 1 available. c. Orthopedics: (1) in-hous (24 hours a day). (2) prompt 1 available. d. Obstetrics/G necology: (1) in-hous (24 hours a day) (2) prompt 1 available e. Pediatrics: (1) in-hous (24 hours a day) (2) prompt 1 available ~. Always promp ly available to Emergency Department: (1) neurolo ic surgery (2) cardiac surgery (3) ophthal lic surgery (4) oral su gery (5) otobino .arygologic surgery (6) pediatr c surgery (7) plastic surgery (8) thoraci surgery (9) urologi surgery (10) cardiol gy (11) chest m, dicine (12) gastroe terology ( 13) hemato' gy (14) infect1- us diseases ( 15) interna medicine (16) nephrol gy (17) neuro 10 Y
69

I

II

III

IV

E E
E E
EE

E E E

E

E

E

E

E

E

D

D.

E

E

.

X

E

E

E XI E

E

X

D

X

E

Xl

X

E

El

E

E

D

EX

D

EE

D

E

E

.D

EX

D

E

E

D

E

E

D

E

E

D

E

E

D

E

E

D

XE

D

E

E

])

EE

D

E

E

D

EE

0

E

E

0

E

E

0

I

~- <l .

S'l'AHDAlDS lOR aoSPITAL- BASED EKBllGUCY SDVICZS

!he following table shows levels of categorization and their es.ential (E) or d.sirable (D) characteristics:

LEVELS

A. BASIC ASPECTS

I

II

III !V

1. Commitment s tatements:

a. Agr.emant to fulfill and maintain all requirements.

I

I

b. Agr....nt to accept and asses. all patients without

r.gard t o ability to pay (policies, protocol. and

proc.dures should reflect appropriate disposition of

all patient

I

I

c. Agreemant to accept all pati.nt. in need of

stabilization and life support without regard

to ability to pay.

I

I

d. Agr._"t to transfer any patient in need of a

higher 1evel of care whenever indicated by

regional protocols.

I

I

e. Agr...." t to prOVide reque.ted data (patient

care, syst.. fancti01l and admini.trative) to

EMS authority f~r medical audit and res.arch.

!

I

f. Agree. .nt to permit periodic announced or

unannoWlced visits by EMS authority or entity(s).

!

B

g. Agree. .nt to assure specialty medical care as

needed.

I

!

h. Agre..." t to retain patient. only when care

capabilities (personnel, equi~nt, facilities)

are available.

K

K

i. Agree. .nt to maintain quality assuranc. prog~am

which includ.s:

(1) E.D CoIIIaittee

EE

(2) Education and training progra.. (staff)

I

I

(3) Participati01l in regional EMS council

BI

2. Syst.. Participation:

a. Agr.e. .nt to support and participate in the

r.gional EMS sy.te

I

I

b. Alre_nt to adhere to, support, and participat.1

maintain the organized _dical control program in

the EMS region that prOVide. supervision of pre-hospital

emergency car. a. detail.d in the regional EMS plan.

K

I

c. Agre_nt to us. standard triage criteria for

traulII4 and burn patient selection as promulgated

by the s tate:

(1) TraWIIa Scoring

I

!

(a) injury mechanism

I

E

(b) anatomic s.verity

I

E

(2) Burn s.verity

EE

*S.e addendua attatched to the end of document.

d. Agreement to provide cau.unity with the hospital's

capabilities.

I

E

I

E

I

I

I

I

I

!

I

I

!

!

K

I

B

I

I

!

I

E

I

E

I

I

I

!

!

E

E

E

E

E

I

E

E

E

70

3. Care Rendered: a. Total in-house capabilities for all medical eonditio,~s. b. Total in-house capabilities for all emotional conditions. c. In-house cap . ilities for most medical conditions (with transf as appropriate). d. In-house cap i11ty for most emotional conditions (with transf as appropriate). e. Some in-hous capability for medical and emotional conditions w b needed specialty consultation available by at1ent tran..cer. f. Capab-Uity t determine if emergency exists. g. Life-saving rst aid.
4. Communications b ~een emergency facility and
pre-hospital sys
B. ORGANIZATION AND STAl?INC
1. Separate departm.nt in-hospital organization. 2. 24 hour on-duty mergency medicine physician. 3. Physician on cal to !.l. (proaptly). 4. Physician specia ty availability (board certifiedl
eligible staff 0 senior resident in that specialty): a. Medicine:
(1) in-hous (24 hours a day). (2,) prolDptl available. b. General Surg ry: (1) in-bous (24 bours a day). (2,) proaptl available. c. Orthopedics: (1) in-hous (24 hours a day). (2) proaptl available. d. Obstetrics/G necology: ( 1) in-hous, (24 hours a day) (2) proaptl available e. Pediatrics: (1) in-nous (2,4 hours a day) (2) proapt available f. Always proup ly available to Emergency Department: (1) neurolo :ic surgery (2) cardiac surgery () ophtha tic surgery (4) oral su 'gery (5) otorbin ,larygologic surgery (6) pediatr ,c surgery (7) plasti surgery (8) thorac : surgery (9) urolog : surgery (l0) cardio IIY (ll) chest idicine (12) gastro lterology (13) hemato Igy (14) infect us disease. (15) intern medicine (16) nepnro IY (17) neural ;y
71

LE'v'ELS
I II III !V I
I !
! !

!

!

! I I

!

!

!

!

!

!

D

D

I

I

!

1

I

I

I

I

I

I

D

I I

- ! i

!

B

!L

I: I:

BB

1I

I: I

,I B

I

I

I

I:

I

1

I

I:

I

E

I

I

I

E

I: E

I: I

I: E

I: E

EE

D D D D D. 'D .
D D D D D
!)
D D D D D

LEVELS

I

I!

II!

(18) radia logy

!

!

D

(19) psych~atry

EE

0

(20) pathology

E

E

D

(21) psychology (non-physicia~ specialists) 5 Emergency services direction:

!

I

D

a. Specialized emergency medicine physician director

with 3 yeAI'S traiDinl/ezperi~ce. (1) Name

!

!

0

(2) Board certification (3) ACLS course passed (4) ATLS course passed

I

12

02

E"

lr3

(5) Is l'esponsible for Q~A program

E

E

R

(6) Is i nvolved with the/pre-hospital system including

planning. developmeat, and implementation of the

..dical control prolram. (i.e. base station course

participation) b. Physician deputy director with 3 years training

E

1r

w4

or eXl'8rience. c. Director or deputy director alway. available.

E

~

~

d. Director (non-specialized) or multi-diciplinary

medical staff caa.ittee to supervise. 6. Permanant R.N positions assigned.
7 All surgeons on call are:

~

11:



a. Agree to participate full in Q/A prolraa

11:'

b. Maintai::..;. appropriate case load if specialty center

care is provided

for trauma

11:

1'.

n'

for burn

'R

R

n

c. 16 hours/year approved trauma/burn CME

E

1r.

n

d. Total number of surgeons takinl call

8 . Emergency Med icine physician prOViding coverage:

a. Board certified/prepared

!

D

'D

b. Agree to participate in Q/A program.

II:

1r.

1r.

c. CME 50 hours/year d. ACLS cour.e passed

'R

R

tr3

"1'.3

e. ATLS course passed 9. Non-Emergency Medicine physicians providing coverage:
a. Agreement to participate in Q/A program b. ACLS course passed c. ATLS course passed d. CME 50 hour./year

..3

..3

.. ..

....
1P



1'.

C. ADDITIONAL SERVICES/RESOUllCES

1. Clinical laboratorie. services (illllD8diately available 24 hour. a day in-aouse): a. Standard analy.e. of blood, urine, and other body flul". ds b. Blood tYl'inl and cross-matchinl c. Coagulation studies d. COlRl'rehensive blood bank or acce.s to a comaunity central blood bank and adequate hospital storage
facilitie
e. Blood ga-. ~s and pH determinations f. SerUIII and urine osmolality g. Microbiology h. O-rug and alcohOL screening
72

I

II:

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0

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0

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.
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1P 1"1l' 1"-
R
n

LEVJ::L.::l

I

II

III _ IV

2. Radiological special capabilities:

a. Standard diagnostic radiology services b. Angiography of all types

- E !
EE

!

c. Sonography d. Nuclear scanning e. In-house computerized tomography

! ! !

!
-I -!

3. Operating suite:

a. Operating room adequately staffed in-house and

immediately available 24 hours a day b. Operating room pr01lllttly available

r: ! I! I !

c. Cardiopulmonary bypass capability

!

d. Operating microscope

I

e. Thermal control equipment:

(1) for patient (2) for blood f. X-ray capability g. Endoscopes, all varieties h. Craniotome i. Monitoring equipment/defibrillator j. Pacemaker insertion equipment

I I

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r.:

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4. Intensive care Units: a. nesignated medical director

! I ~ I ~S

b. Physician on duty in tCU 24 hours a day, or

imm-diately available from in-hospital --~~~--------~~--~~---&r c. Nurse-patient minima. ratio of 1:2 on each shift

d. LDaediate access to clinical laboratory services

e. Equipment:

(1) airway control and ventilation devices

(2) oxygen source with concentration controls

(3) cardiac emergency cart -----------------+O-IiI--+---M.:1I""

(4) temporary transvenous pacemaker ~-:-~~~--_--.....+_-~+_-Mpo

(5) electrocardiograph-oscilloscope-defibrillator

. .+-

+-~~+- __

(6) mechanical ventilator-respirators

(7) patient weighing devices

(8) pulmanary function measuring devices

(9) temperature control devices

(10) drugs, intravenous fluids, and supplies

(11) intracranial pressure monitoring devices

5. Post-anesthetic recovery room (PAl) - surgical

intensive care unit is acceptable:

a. Registered nurses and other essential personnel

24 hours a day

II

I

b. Appropriate monitoring and resuscitation equipment

I!

!

6. Acute hesmdialysis capability or transfer agreement

II

II

7. Organized burn care:

a:~ Physician directed burn center/unit staffed by

nursing personnel trained in burn care and equipped

properly for care of extensively burned patients or

transfer agreement with nearby burn center or

hospital with a burn unit

EI

E

!

8. Acute spinal cord injury management capability:

a. Transfer agreement should be in effect and there should be

protocols for early transfer to spinal cord injury

rehabilitation centers.

_! !

E

E

D. 1'RAINtNG PROGRAM

1. Formal training program for nursing personnel and

other non-physicians providing patient care which

includes:

73

LEVELS

a. aecogni tion, interpretation, and recording of

I

. II III

patients' signs and symptom., particularly those

that oreq~ir.. notification of a physician

EE

!

!

b. Initiation of cardiopulmonary resuscitation and other

related life-support proc.dures

!

B

!

!

c. Parenteral administration of el.ctrolytes, fluids,

blood, and blood compon.nts

!

B

!

E

d. Wound care and manag.ment of s.psis e. Initial burn care f. Initial manag.ment of injuri.s to the extr.mities

'R

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I!:

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I!:

Jl.:

and central nervous system

R

E

g. Effective and safe use of electrical and electronic

life-support and other equipment used in the emergency

!:

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department/s.rvic.
h. Pr.vent ion of contamination and cross infection i. aecognition of, and attention to, the psychological

!:

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R

E

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Jl.:

E

E

and soc ial needs of patient. and their families

R

K

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E

E. POLICIES AN]) PROC!DUUS FOa !MERGZNCY DEPAB.TMDT

1. I.eveiv of po licie. and procedure. with annual approval

by hospital _dical staff. 2. Location, storage, and use of drugs, supplies and
.quipMnt.
3. Car. to~unaccoapanied mnor.

R

K

."1!

"11

4.. Care to unaccoapanied unconscioua patient. S. Specific notification of personal physician.

"
R

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6. Maint.nance of confidentiality.

11

R

7. Information release to police or others.

R

R

8. 'transfer and discharge of pati.nts. 9 Medica1 records and consent fora. 10. Inf.ction control _aaures.
11. Procedures if equi~nt failure occurs. 12. Pertinent safety practices.

1f

1f

11
"1f



11

tr

13. 'traffic cantrol, including visitors. 14.. Medication dispensing (by JCAB standards). 15. Handling of patients' valuables. 16r Th. E.D. and the hospital preparedness plan. 17. Scop. of treatment allowed. 18. Special procedur. policies. 19. Us. of standing ord.rs. 20. Property.xchange procedures during pati.nt transfers. 21. Circumatanc.s r.quiring patient r.turn visits. 22. Management of potential radiation exposure victims. 23. Handling of suspect.d sexual crime victims. 24.. Handling of suspect.d child abu.e ca

1f

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25. Management of pediatric emergencie

E

E

26. Patients dead on arrival, patients involving evidence

gathering, and ca requiring reporting to some

authority.

E

E

27. Patients under drug influence or emotional instability.

E

E

28. Initial management of burns, hand injuries, head

injuri.s, f ractures, multiple injuries, poisoning,

animal bite., gun.hot wound., stab wounds, other acute pro~ B B

28. Accid~nt prev.ntion in uncon.ciou. or irrational patients. B 1l

29. 'tetanus and rabies prevention/prophylaxis.

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74

LEVELS

F. LOGISTICS

!

!T ,,, III

I

1. The locatio&=of

ease and safety -- -------
a. Location si as indicating Emergency Service

appropriate '/ posted. b. The Emergen '/ Department shall be located for

II

ease of ing ess and exit. c. The entranc shall be identified externally and

IB

accessibile to emergency vehicles and pedestrians. d. There shall be waiting space, telephone and

II

lavatory av ilable to patients and persons

accoapanyin th... e. Visual and mditory privacy shall be a

I

B

considerati ~ in the design of the E.D. area. f. There are guidelines for the tyPe of patient,

BB

length of s ay and constant surveillance of

patients vb ~e ob.ervation beds are utilized.

IB

g b pid C01llllNllication with other departments in

the hospita is assured.

I: I:

h. Intra-depar Dint communications/alara syste. is

available t sum.on additional personnel in an

emergency.

EB

i. When anes th .ia is used in the 1.0., require. .nts

of the Nati ~l Fire Protection Association

standards, specially (NFPA 56A) Standard for the

use of Inha ation Anesthetics (Flam-able and Non-

fla--.b 1e) , 1978, and the Anesthesia Chapter of the

JCAB _nua1 are _to

BI

2. Iquip-.nt and s pplies to be readily available for use:

a. OXygen and ~e _ans of a~nistration

IB

b Mechanica1 Intilatory assistance equi~nt,

including a ~ay., sanual breathing bag and ventilator I: E

c. Cardiac def brillator with synchronization capability I I

d. aespiratory and cardiac IIlOnitoring equipment

I

I:

e. Thoracentes s and closed thoracosto., sets

B I:

f. Tracheosto., set

BB

g. Tourniquets

BB

h. Vascular cu down sets

BE

i. Laryngoscopes and endotracheal tube.

XI

j. Tracheobron hial and gastric suction equipment

I

B

k. Urinary cat eters with closed volu. . urinary syste. .

BB

1. Pleural and pericardial drainage set

I

B

Ill. Minor surgi al instruments

BK

Q. Splinting d vice.

KK

o. lmergency 0 stetrical pack

I

I

p. Suction dev ces

BE

q. Central ven, us pressure IIlOnitoring devices

I

I

r. Standard IV fluids and catheters

I

E

s. Gastric lav ,ge equipment

EE

t. Two way rad o linked with vehicle. of e..rgency

transport s 'ste.

EE

u. MAST garmet

EE

v. Cervical. sp ,ne stabilization device.

E

E

w. Medications

(1) standa 'd emergency drugs

IE

(2) antive ,in

E

E

(3) c01lllDQn poison antidote.

EE

75

I

I

I

E

B

B

I

I

E

I

B

I

I:

I:

I:

I:

B

I

I:

I

B

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E

E

I

E

I

I

B

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E

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I

E

E

E

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E

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E

E

~ . QUALITY ASSU'RANC% PROGUH
1. Whetl auchoriz.d, a co~y of the recorcl of emarlency service. reDdered shall be avai.lable ~o ehe privaee praceiCioller Q'r_dical facility res~!bl. for fo llow-ult care
Z. X-ray
.... ttm.ly reVie.. of x-ray. is cOllduceaci ~. Official inc.~etacioll of x-ray. shall be
availabl co the physi.ci.an proviciinl ...rs-ncy care, aD.d co eha privaca praceici.onar c. !here i. a _chanis. for recallinl p.ciellcs who t'equire aciciicioual raciiacioll scuciie., ar for ~ftoa a ala"... ~efiDicive racii.ololic inc.~recacioll ~. beell _cie j. LaOoracory rel'Ore.: a. ttm.ly laboracory rel'Orcs are available co ehe !.]). playai.ci.an
b. r.ao re~s are UI&Cie avai.l_le to the privac.
pllya i.e 1&11 c. then f.s a mec:haDi.aa for recall:i.D1 pacieDcs vtlo
re~. a441cioaal laDoracory scudi ~. !leccrocuocli.o~althic scudie
a. tw.ly ~. . of elecerocarclio~althic scuclie.
i. coaduc:cad
b. !leccrOCU"cliopoalthic scuciiea are ucie availAble co c!le ! .D. physi.c1.m
c. !leceroc:arcliopoaltbic scuci1e. are _cie avai.lable co' che pr1vac. pllyai.c1an
~. there ia a aec:haD1aa for recallinl paCiazacs. who reqa:i.n acidic10aal eleceroc:ard1o~althic scuci1e.
5. Pae1eac Crau fers shall be carrieci ouc conaisc.llc wieh wice.D prococols, anci acceltcance by ehe receivul iDac1cuciOQ shall be gaaranceed
6. Pac1.Dc. rae.ivins blooci erazasfusions are inclucieci ill ehe aacii.cal scaff revt. . of blooci ucilizac101l
7. !.D. pac1.llcs who receive aDC1bioc1cs shall be inclueted in ehe aacii.cal scaff rev1.. of clinical u.e of mcibi.oc1cs
8. Recorcl. of ehe prevtoua 24- hOQrs shall ba revieweci ui.ly by ehe I.D. ~ireccor
9. Mecii.caL care evaluaciOQ' a. Daily r.vi.. of ~c 24 hours acci.vi cy anci recorcls b. Morbicii.Cy/.orca1ic1 review c. totecii.cal tlursinl auciiC ~. tot.cii.cal recorda revie.. by !.D. comai.tcee
a. OtlTDAC1l PllOGUH
1. t.le,holle anci oll-sice consultaci.oll' witn physicialls in ehe co.-uni.ty anci ocher ar
2 Pub lic eciucacion accid.llcal injury preveneioll in eh. home; inciu.cry, hilbways, aChleeic fi.l~s; scanciard fir.c aid; problems cOIlfroncinl ~h. public, . .dical professiou anci hoa~ical regardi.ng o~cimal care for ena ill anci injured
76

! II !II tv

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&&

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II

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!

II

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!

!

E

!

!

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D

I

E

E

I DI
,

FOOTNOTES 1. If this service- is available in the hospital. 2. Board prepared acceptable until 1990. 3. If doctor does not meet Emergency Medicine board certified/prepared
status. 4. As detailed in the Regional EMS plan. 5. If Ieu Ls available in the hospital. 6. The special needs of infants and children shall be ~et as follows if
children are served: a) equipment appropriately sized to infants and children of all ages; b) policies/protocols for the management of pediatric emergencies; c) heat shield for infants; d) specific quality assurance plans for pediatric emergencies; e) agreement with a ter~iary pediatric medical center for consultation
and/or transfer.
77

APPENDIX 2 Summary of General Hospitals with 24-hour Emergency Room Services, by EMS Region and HSA

J/' :~/a6

SUMMARY OF GENERAL UOSPI1Al..S WInl 24tunm
EMERGENCY ROOM SEkVIC~S, BY EHS REGIUN
t 985 SPECIAl ~URVEY Of ttOsprrALS IN GEnRe; IA

D1S REe;ION

CAP.

lOTAl.

IADH

tTRTHT RATIO

ic: AlUi

NO.

BED.f PATIENTS

UOSP.

STA'S PATIST UO!\'P.

61

16 1,139

219,4'6

35,91)5

102

~~, 15:5

I 1 4

02

"I

t ,634

90,GJ4

13,674

5J

' , 6 9 C}

1L ~)

c....o....

OJ

24 6,14'

Q90.f ~6"

95,695 :J06

2,/11"1

12.0

04

12 I,J5t

'~9,436' 16,435

14

. , , -/52

I :! ./

O~i

15 1,764

la5,8J8

25,937

7~

2,435.

'4.0

06

tl 2,541

148,295

21,711 IGl

, ,JI ,

15.5

0'

'G 1,413

85.51'

'2,02'

JO

2,252

15 .. 0

ou

22 2,348

211,818

31,'06 102

2,011

14. '/

09

19 2,662

229,511

25,040

99

2,JHl

11.3

10

o

917

IOI,6J2

15,955

44

2,296

15.0

SlAlE

150 22,510 2,'93,2'1 294,641 ',GG'

2,'91

13.4

150 RECORDS TOTALED
SOl.meE : ';[Uf~G I A SlATE IIEAL.ltl f'LANNJUG AGENl;Y, FEltRUARY, '906.

4/07/B6

EHERGENCY ROOH SE~VICES IN ALL GENERAL UOSPITALS, &EORGIA t985 SPECIAL SURVEY Of HOSPITAL EHERGENCY ROOH SERVICES EHS REGION 01

f'AGE

COu,nY BARTOW

fACILITY NAHE HUHANA UOSP ITAL-CARTERSV ILLE

CAP. BEDS
62

24HR .tCAn E.R. LEVEL

YES

2

TOTAL PATIENTS
tB,OOO

tADH UOSP.
tBO

. ITRT"T RATIO STA'S PATISf

X ADH nOSf'

5

3,600

1.0

CATOOSA CnAlTOOGA

JOHN L. HUTCHESON HEHORIAL CUATTOOGA COUNTY HOSPITAL

237 YES

2

JI NO

25,550

B,943

tJ

1,965 35.0

.0

CUEROKEE

CnEROKEE ATOHEDIC HOSPITAl

21 NO

.0

CHEROKEE

R.T. JONES HEHORIAL

64 YES

2

12,815

t ,260

10

1,2B2

9.8

DADE

WILDWOOD SANITARIUH & HOSP.

39 YES

4

166

2

2

83

1.2

.......

f"ANtUN

fANNIN REGIONAL HOSPITAL

5. YES

2

4,3B8

921

3

1,463 21.0

1.0

FLOYD

fLOYD HEDICAL CENTER

314 YES

2

44,129

4,557

tJ

3,441 '0.2

FlOYD

REDHOND PARK HOSPITAL

201 YES

2

12,360

3,461

8

, ,545 28.0

laLHER

WATKINS "EHORIAL HOSPITAL

51 YES

3

2,"283

855

2

1,142

37~5

GORDON

GORDON HOSPITAL

65 YES

3

14,7,96

1,62B

7

2, "4 11.0

UARALSON

HIGGINS GENERAL HOSPITAL

85 YES

3

1,e83

992

J

2,361 14.0

HURRAY PAULDING

HURRAY CO. "E"ORIAL HOSPITAL PAULDING HE"ORIAL HOSPITAL

42 YES

J

8J YES

3

7,00e 7,972

74' 1,276

5

, ,400 10.7

6

1,329 '6.0

PICKENS

PICKENS GENERAL HOSPITAL

4e YES

4

2,184

lOB

2

1,092

4.9

POLK

POLK GENERAL HOSPITAL

6e YES

3

IJ,e7e

261

3

4,357

2.0

POLK

ROCK HART-ARAGON nOSPITAL

4B YES

J

5,685

39B

I

5,695

7.0

WHITfIELD HAHILTON "EHORIAL HOSPITAL EHS REGION TOTALS

297 YES

2

41,575 10,394

'9

2, 'B8 25.0

1,79'

219,656 35,9B5 '02

2,153 '6.4

4/07/86

EHERGENCY ROOH SERVICES IN ALL GENERAL HOSPITAU, GEORGIA '985 SPEf:IAI. SURVEY OF ttOSPITAl EHERGENCY ROOH SERVICES

F'AGE

2

EHS REGION 82

COUNTY

FACILITY NAHE

CAP. 24HR JCAIf . TOTAL 8EDS' E.R. lEVEL PATIENTS

IADH ttOSP.

,
ITRTHT RATIO .: X ADH STA'S PATIST . HOSP.

fORSYTH
FRAt~KLIN
HABERSHAH HALL

FORSYTH COUNTY HOSPITAL COBB HEHORIAL HOSPITAL HABERSHAH CO. HEDICAl CTR lANIER PARK HOSPITAL

36 YES

3

95 YES

2

59 YES

2

t24 YES

2

8,591
5,347 6,5'8 7,888

859 , .et6
911 ,758

4

2, '48 '0.0

5

, ,069 '9.0

4

, ,628 '5.0

5

, ,488 25.0

HALl.

NORntEAST GA. HEDICAL CTR

U8 YES

2

36,899

5, '66

'5

2,460 '4.0

a00

HART

HART COUNTY HOSPITAL

98 YES

3

2.460

'23

2

',238

5.0

lUHPKIN RABUN RABUN STEPHENS TOWNS UNION

LUHPKIN COUNTY HOSPITAL RABUN CO. HEHORIAl HOSPITAL RIDGECREST HOSPITAL STEPtiENS COUNTY HOSPITAL TOWNS COUNTY .'OSPITAl UNION GENERAL UOSPITAl

52 YES

3

34 YES

3

54 YES

3

99 YES

3

42 NO

45 YES

4

4,789 , ,838 , ,878 9,8S3 2,58e
4,919

565
,2'
384
t ,625
258
498

5

942 '2.0

,2

"9 , ,878

6.6 20.4

6

, .641 16.4

te.O

4

, .238 '0.0

EHS REGION TOTALS

,876

92,534 13.326

53

'.746 '4.4

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--:.
;,,;

- - - ..- - -- - - - - - -i- -- .=..

- - - !
- .-. - - -= - - = :: :: :: :: ::
- - - - - :.-

- :: ::

81

-\/0,/ /B6

EMER(;f,NCY RIIIltI SFRV I [ES HI IiI! (;ftU:r<AL 1I0!" I HILS. (;Ofi(; J(\
1985 SPECIAL SURVEY OF IIf1S.... n'.1. EMH~~ENCY RUUl1 S[f~VICFS
EMS REI; ION OJ

f'{IGE

4

COUt/TY

FACUIlY NAME

CAP. 241m .Jl:AII

TOTAL

(tEDS EaR. LEVEL PATIENTS

MDM IInsf'.

tmlHI RATIO, X ADH SlA'S PAT lSI .', ltOSf'.

FUL HilI

PIEDMONT 1I0Sf'Il'AI.

449 YES

2

26.000

4. -\20

I :S

2,000

1"1.0

FULTON

SAINT JOSEF'II'S - AH.ANTA

309 YES

2

9,929

2. I B4

15

662

22.0

FliLTON FULTON

SCOTT ISII RilE HOSPITAL SOUlH fULTON ttOSPITAL

88 YES

I

391 YES

2

14,426 36,890

600 3.6BO

.,9

1,603 2.453

4.2 HLO

FliLTON

SOUTtlWESI COMMUNIlY llOSPITAL

128 YE:S

2

17,438

1.321

5

3,488

7.6

fllUON

WEST PACES FERRY llOSP!TflL $

294 YES

2

10,385

1.765

6

1.731

17 .0

(Xl

N

(;WIN'~En

[tUFOf<D GENERAL IIOSPITAL

59 NO

6,291

466 11 3,145 7.4

GWINNETT

[tUTTON GWINNETT HOSPITAL

79

12,339 1,158 11 1,214 9.3

GWINNElT r;WINNETT NEWlON

IIUMANA llOSF'HAL GWINNETT JOAN GLANCY MEMORIAL NEWTON GENERAL ltOSPITAI.

122 YES

2

194 NO

87 YES

2

14,533
. 11 ,484
ICf,090

1,453
1,357
4,500

B

1.817

10.0

4 2,371 11.8

8

1,250

45.0

ROCKDALE

ROCKDALE COUNTY'HOSPITAL

190 YES

2

I I ,8U

1,895

9

1,316

16.0

EMS REGION rorALS

8,253

80e,664

95.695

306

2,611

12.0

4/07/86

E"ERGENCY ROO" SERVICES IN ALL GENERAL ..OSPHALS, GEORGIA 1985 SPECIAL SURVEY OF ..OSPITAL E"ERGENCY ROO" SERVICES EHS REGION e4

PAGE

5

COUNTY BUTTS CARROll.

FACILITY NAHE SYLVAN GROVE ..OSPITAL BOWDON AREA HOSPITAL

CAP. BEDS
28
"I

2....R JCA" E.R. LEVEL
YES .. YES ..

TOTAL PATIENTS
5,316 2,200

tAD" "OSP.
538 532

tTRT"T RATIO X AD" SlA'S PATIn .tOSP.

2

2,688 .', 10.0

3

133 24.2

CARROLL

TANNER HEHORIAL ..OSPITAL

192 YES

3

19,eeo

J80

9

2, I I I

2.0

CARROLL

VILLA RICA CITY HOSPITAL

5 .. YES

3

4,398

J95

2

2,199

9.0

COWETA

HUHANA HOSPITAL NEWNAN

I .... YES

2

tt,6&3

1,216

t6

125 11.0

COWETA

NEWNAN HOSPITAL

lee YES

2

7,881

1,340

3

2,621 11.0

(X)

HEARD

HEARD COHHUNITY HOSPITAL

w

29 YES

.

1,20e

192

2

600 16.0

HENRY

HENRY GENERAL HOSPITAL

le4 YES

2

t7 ,551

2,282

14

1,254 13.0

. HERIWEHtER SPALDING TROUP UPSON

HERIWETHER HEHORIAL HOSPITAL GRIFFIN-SPALDING CO. HOSP. WEST GEORGIA HEDICAL CENTER UPSON COUNTY HOSPITAL

38 YES

4

222 YES

.

288 YES

J

1t9 YES

J

2,1ee

810

1

2,100 30.0

22,819

2,454

4

5,720 10.7

. 19, ..e8

4,874

8

2,425 21.0

15,442

2,162

'0

',544 14.0

EHS REGION TOTALS

1,351

129,636 16,435

1..

1,152 12.7

4/0"1/86

I:~HERGEr~CY ROOH SERVICES W AU. r~ENERAL IfOSPIT(ILS, GEORGIA 1985 Sf;:ECIAL. SURVEY OF IfOSF'UAl fHERG[NCY ROOH SERVICES EHS RUlION 05

PAGE

COUNTY

fACILITY NAHE

r;AF' 2~IfR JCAH

lOTAL.

BEDS E,. R. LEVEL PATlErHS

tADH HRTHT RATIO HOSF'. STA'S PATIST

jj; ADH JlOSP.

EtALI>WIN (tUB

BALDWIN COUNTY HOSPITAl. COLISEUH PARK HOSPITAL

160 YES

2

250 NO

22,225

2.553

1.1

~., .104

11.5

.0

81&B

HEDICAL CENTER OF CENTRAL GA

562 YES

I

58.eoe

6.960

18

3.222 12.e

BIBB

HIDDLE GEORGIA HOSPITAL

I" NO

.0

BIEtB

RIVERSiDE CLINIC HOSPITAL

52

.0

BLECKLEY

BLECK LEY COUNTY HOSPITAL

64 YES

4

3,624

125

5

125 20.0

DODGE

DODGE COUNTY HOSPITAL

.. 3 YES

4

7,4ee

1,332

4

1.850 18.0

ttOUSTON

"EDICAL CTR OF HOUSTON CO.

250 YES

2

29.998

3.239

7

4.285 10.8

ex>

+::0

HOUSTON

PERRY-HOUSTON CO. HOSPITAL

45 YES

3

1,818

945

3

2,626 12.e

,JASPER

JASPER "EHORIAL HOSPITAL

.. 28 YES

1.632

271

2

816 11.0

LAURENS "ONROE PEACH PULASKI PUTNAH TELFAIR

FAIRVIEW PARK HOSPITAL "ONROE COUNTY HOSPITAL
:
PEACH COUNTY HOSPITAL R.J. TAYl-OR "EHORIAL PUTNA" GENERAL ttOSPITAL THREE RIVERS HOSP & HED CTR

198 YES

2

15.261

48 YES

.

le,115

16 YES

2

8.885

56 YES

3

5,591

5& YES

:I

52 YES

.

4,461 2,813

3,195
712
1,213
....,996
281

9

1.696 20.9

2

5.088

1.0

4

2,021

15.&

I

5,591

17.8

3

1,481 25.&

5

575 10.0

WASHINGTON "E"ORIAL-WASHINGTON CO.

56 YES'

3

5,186

199

6

864

15.4

WHEEl-ER

WttEELER COUNT' HOSPITAL

22 YES

2

2,649

1,589

I

2.649 60.&

E"S REGION TOTALS

2,232

185,038 25,931

16

2,435

14.&

4/(H/B6

E"ERGENCY ROO" SERVICES IN ALL GENERAL UOSplTALS, GEORGIA 1985 SPECIAL 'SURVEY OF HOSPITAL E"ERGENCY ROO" SERVICES E"S REGION &6

PAGE

1

COUNTY

FACILITY NA"E

CAP. 24HR JCAU

TOTAL

BEDS E.R. LEVEL PATIENTS

lAD" ITR1"1 RATIO ,: % AD" HOSp. STA'S pATlSf UOSF'.

BURKE

BURKE COUNTY HOSPITAL

57 YES

3

3,388

4&1

2

1,694 12.&

["AtmEL. JEFFERSON

E"ANUEL COUNTY HOSPITAL JEFFERSON HOSPITAL

13 YES

3

18. YES 3

6,&&G 4,131

I ,2&G 312

3

2,G&G 20.G

5

821

9.G

JENIe INS

JENKINS COUNTY HOSPITAL

4e YES

3

3,348

8G4

2

1,614 24.0

HCDUFFIE

HCDUFFIE COUNTY HOSPITAL

41 YES

3

1,728

85&

5

1,546 tl.G

OJ

RICUHOND

HU"ANA HOSP ITAL OF AU&US'TA

314 YES

2

le,959

2,521

12

913 23.8

01

RICHHOND

HEDICAL COLLEGE OF GEORGIA

177 YES

t

t I, 9te

3,573

12

993 3f).f)

RICtlHOND

SAINT JOSEPH'S - AU&USTA

248 YES

2

14,617 .2,.631

8

1,821 IB.&

RICUHOND

UNIVERSITY HOSPITAL

6ge YES

I

78,681

9,178

54

1,381 tJ .f)

SCREVEN

SCREVEN COUNTY HOSPITAL

76 YES

4

2,989

B7

2

1,455

3.~

WILKES

WILLS "EHORIAL HOSPITAL

66 YES

3

4,698

94

2

2,349

2.f)

EHS REGION TOTALS

2,54t

.48,295 21,711 187

1,31 I 15.5

<1/07186

EMERGENCY ROOM SERVICES IN ALL GENERAL UOSPITALS, GEORGIA t905 SPECIAL SURVEY OF tlOSF'ITAL EMERGENCY ROO" SERVICES
EMS REGION 80

F'AI;E:

9

COUNTY

FACILITY NAHE

CAP. 24HR JeAH

TOTAL

BEDS E.R. LEVEL PATIENTS

tADM URTMT RATIO ttOSP. STA'S PATIST

X ADM HOSP.

(lEN lULL

DORMINY HEHORIAL HOSPITAL

75 YES

J

6,058

t5t

6

t ,000

2.5

BERRIEN BROOKS

BERRIEN COUNTY HOSPITAL BROOKS COUNTY HOSPITAL

7' YES

J

45 YES

3

2,56t 4, '94

407

3

054 t9.O

"

4t9

2

2,897, 18.0

CALttOUN

CALHOUN HEHORIAL HOSPITAL

48 YES

3

,978

256

2

905 13.0

COLQUIT

COLQUITT COUNTY HEHORIAL

.55 YES

2

16,JJ8

4,099

6

2,722 3O.t>

COOK

MEHORIAL tlOSPITAL OF ADEL

48 YES

3

7,665

1,353

5

t ,533 n.7

DECATUR

HEHORIAL HOSP-DECATUR CO.

02 YES

3

9,888

1,245

3

3,e8e t3.8

DOUGHERTY PALHYRA PARK HOSPITAl

223 YES

3

'4,888

2,6J2

0

',758 to.O

.(.X....l

DOUGHERTY PHOEBE PUTNEY HEHORIAL

458 YES

2

44,722

4,473

to

2,405 te.e

EARLY

EARLY HEHORIAL HOSPITAL

49 YES

3

2,998

097

6

490 3fLO

GRADY

GRADY GENERAL HOSPITAL

68 YES

J

6,670

08'

2

J,339 t2.0

IRWIN

IRWIN COUNTY HOSPITAL

34 YES

4

1,7JO

31J

I

1,738 to.8

LANIER

LOUIS SHITH HEHORIAL

48 YES

3

1,411

J53

I

1, 4t I 25.8

LOWNDES

SHITH HOSPITAL

11 NO

1; 198

.8

l.OWNDES
. HILLER

SOUltl GEORG IA HEDICAL CENTER HILLER COUNTY HOSPITAL

208 YES

2

38 YES

4

24,538 1, 161

3,643 365

8

3,866 t4.9

t

1, t6t Jt.4

HITCttEU.

HITCHELL COUNTY HOSPITAL

54 YES

3

4,126

523

J

1,575 t t. t

SEHINOLE

DONALSONVILLE HOSPITAL

66 YES

4

3,888

720

2

I ,548 23.6

TERREll

TERRELL COUNTY HOSPITAL

J4 YES

3

2,895

313

2

1,848 14.9

HtDHAS

JOHN D. ARCHBOLD HEHORIAL

246 YES

2

25,8ee

J,S88

7

3,571 H.8

TIFT

TIFT GENERAL ttOSPITAL

t68 YES

2

25,984

J, t t2

9

2,878 12.8

TURNER

TURNER COUNTY tlOSPITAL

48 YES

4

1,899

35

2

558

:L2

WURTtt

WORTtt COMMUNITY tlOSPITAl

58 YES

4

4,9t 4

688

5

90J t4 .8

EMS REGION TOTALS

2,419

21J,616 Jt , 186 102

2,894 14.6

41'07186

EMERGENCY HilOH SERVICES HI AU GENERAL ..OSPHALS, GEORt IA 1985 SPECIAL SURVEY OF ttuSPITAL EH[R'Et~C'i Rum, SERVICES
EtlS REG ION (:)9

PAGE

10

COUNTY APPLING

FACILITY NAME APPLING GENERAL ttOSPITAL

CAP. IIEDS
41

2'1HR .JCAtt E.R. LEVEL

YES

4

TOTAL PATIENTS
, ,900

tADM "OSF'.
635

URTMT RATIO

STA'S PAT/ST

.,

I

1.900

% ADM ttOsP .
33.4

MCON

BACON COUNTY HOSPITAL

47 YES

3

3.824

153

5

765

4.0

IIUl.LOCH CAMDEN

DUl.LOCH MEMORIAL HOSPITAL GILMAN HOSPITAL

"4 YES

3

39 YES

J

15,382 3,692

154

12

1.282

I.e

554

3

1,231 15.0

CANDLER

CANDLER COUNTY HOSPITAL

68 YES

3

5,f)88

688

3

1.667 12.e

CHARLTON

CHARLTON MEMORIAL HOSPITAL

58 YES

2

4,580

315

2

2,250

7.0

00

CHAnlAM

CANDLER GENERAL HOSPITAL

335 YES

2

27,615

3,286

9

3.068 lL9

00

CHATHAM

MEMORIAL "EDICAL CENTER

465 YES

I

48,934

3,425

5

9.787

7.0

CHATHAM

SAINT JOSEPH'S - SAVANNAH

3e8 YES

2

13,644

2,456

10

1,364 18.0

CLINCH COFFEE

CLINCH MEMORIAL HOSPITAL COFFEE REGIONA~ ~OSPITAL

49 YES

4

"
157 NO

2,520

277

3

840 lLO .0

EfFINGIIA" EFFINGHAM COUNTY HOSPITAL

45 NO

3,457

519

I

3,457 15.0

EVANS

EVANS "E"ORIAL HOSPITAL

7J YES

3

8,&54

1,289

2

4,&27 16.0

Gl. ..NN

GLYNN-BRUNSWICK "E"ORIAl

348 YES

2

27,594

4,139

14

1,971 15.e

.JEfF DAVIS JEfF DAVIS IIOSPITAL

68 YES

3

7,212

865

I

7.212 12.&

LIBERTY PIERCE

LIBERTY "E"ORIAL HOS~iTAL PIERCE COUNTY HOSPITAL

58 YES

3

62 YES ...

5,872 2,927

58&

I

5,872

9.9

351

2

1.464 12.0

TATTNALL

TATTNALL ME"ORIAl HOSPITAL

48 YES

4

3,6&&

36&

1

3,60& ,e.o

TOO"EtS

JOliN ". MEADOWS "EMORIAl

92 YES

3

11,869

38e

9

1,238

3.4

WARE

"EMORIAL HOSPITAL-WARE CO.

257 YES

2

24,131

3,854

12

2,811 16.0

WAYNE

WAYNE MEHORIAL HOSPITAL

138' YES

2

12,&31

2,167

4

3,009 18.e

EHS REGION HITAl.S

2.864

232,964 26.359 100

2.330 lL3

-1/(,)7/86
,

EHERGENCY ROOH SERVICES IN ALL GENERAL HOSPITALS, GEORGIA t995 SPECI~l SURVEY OF .IOSPITAL EHERGENCY ROOH SERVICES ~HS REGION 1e

PA(;E

"

COUNTY

FAqllTY NAHE

CAP. 24HR JCAH

TOTAL

flEOS E.R. LEVEL PATIENTS

tAOH ITR1HT RATIO HOSP. STA'S PAT/Sf

H" OASDf'H.

BARROW CLARKE

BARROW HEOICAl CENTER ATttENS GENERAL HOSPITAL

44 YES

4

.328 YES

2

1,321 35,eeo

1J3 1,oeo

"

1,932

10.0

tt

3,182 20.0

CLARKE

SAINT HARY'S HOSPITAL-ATHENS

19& YES

2

24,4&5

2,441

tt

2,224 le.o

ELBERT

ELBERTON-ELBERT CO. HOSPITAL

&4 YES

J

5,eeo

I,eee

7

714 20.9

CO

GREENE

HINNIE G. BOSWELL HEHORIAl

&8 YES

4

3,588

428

1

J,5GO 12.8

~

JACKSON HORGAN

BANKS-JACKSON-COHHERCE HOSP. HORGAN HEHORIAl HOSPITAL

ge YES

3

.. 26 YES

9,555 3, teo

t ,&24 589

3

J, t95 t1.8

2

1,558 19.0

WALTON

WALTON COUNTY HOSPITAL

let YES

2

13,e135

2,142

5

2,&17 1&.4

EHS REGION TOTALS

911

181,'832 15,955

44

2,29& 15.8

FINAL TOTALS

24,891

2,281,88& 295,41& 1,802

2,191 13.4

111 RECORDS TOTALED . SOURCE: GEORGIA STATE t~ALTH PLANNING AGENCY, FEBRUARY, 198&.

4/07186

EHERGENCY ROOH SERVICES 1M ALL GENERAL HOSPITALS, GEORGIA
'985 SPECIAL SURVEY OF HOSPITAL EHERCENCY ROOH SERVICES HSA , - GEORGIA-TENNESSEE

PAGE

COUNTY
CAIOOSA DADE USA TOTALS

FACILITY NAHE JOliN L. HUTCHESON HEHORIAL WILDWOOD SANITARIUH , HOSP.

CAP. BEDS
231 39
216

24HR JCAn E.R. LEVEL

YES

2

YES

~

TOTAL PATIENTS
25,558 '66
25,1"

IADH HOSP.
8,943 2
8,945

URIHT RATIO SlA'S PAT/Sf

'3

, ,965

2

83

'5

',1'4

X ADH tlOSf'
35.8 t.2
34.8

o~

"l&1/96

E"ERGENCY ROO" SERVICES IN ALL GENERAL tlOSPITAI.S, GEORGIA t995 SPECIAL SURVEY Of ttoSPITAL E"ERGENCY ROO" SERVU:ES tlSA 2 - APPALACHIAN GA

PAGE

2

,

COUNTY

FACILITY NA"E

CAP. 2..HR JCAti

TOTAL

BEDS E.R. LEVEl. PATIENTS

IAI)" I1Rl"T RATIO tlOSP, STA'S PAll Sf

X AD" tlOSP.

DARTOW

tlU"ANA HOSPITAL-CARTERSVILLE

62 YES

2

'9.000

'00

:5

3.600

1.0

CtiATTOOGA CUATTOOGA COUNTY HOSPITAL

Jt NO

.0

FANNIN

FAIUIiN REGIONAL ttoSPITAL

5. YES

2

.. ,J89

92'

3

'."63 21.0

FLOYD

FLOYD "EDICAl CENTER

Jt4 YES

2

44.129

.. ,551

'3

3 ......

to.2

FLOYD

RED"OND PARK HOSPITAL

2e. YES

2

t2,J60

3.46'

9

',5"5 29.0

FRANKLIN COllEt "E"ORIAL tlOSPITAL

95 YES

2

5,3"1

1,616

5

, ,669

'9.0

\...0...

GIL"ER

WATKINS HEHORIAL tlOSPITAL

GORDON

. GORDON UOSPITAL

IIAlIERSUA" HAltERStiAH CO. HEDICAL CTR

5. YES

3

65 YES

3

~9 YES

2

2,283 '4,196
6,"0

955
'.62B 917

2

" t ..2

31.5

7..

2, "4 , .628

'1.0 ".0

tlALl ItAI.l

lANIER PARK HOSPITAL NORHlEASl GA. "EDICAL CTR

'2" YES'

2

3J8 YEl

2

l,ooe

'.75&

5

t,406 25.0

16,999

5, .61.

15

2.460 H.O

t1ARALSON

HIGGINS GENERAL HOSPITAL

05 YES

3

l,e03

992

3

2,36t

'4.&

tlART

tlART COUNTY HOSPITAL

9B YES

3

2,468

, 23

2

.,2JO

5.&

UJ"f'KIN

L.UHf'K! N COUNTY HOSP ITAl

52 YES

3

4,109

565

5

942 '2.&

HURRAY PICKENS POLK
f)Ol.l<
RABUN RAltUN

HURRAY CO. HE"ORIAl HOSPITAL PICKENS GENERAL tlOSPITAl POLK GENERAL HOSPITAL ROCK"ART-ARAGON HOSPITAL RA[tUN CO. HE"ORIAl HOSPITAL RIDGECREST tlOSPITAl

42 YES

3

48 YES

4

6e YES

3

40 YES

3

34 YES

3

54 YES

3

1.008
2, 'B4 t3,010
5,685 t ,030 t ,818

149
,eo
26' 390
'2'
30"

5

',46& '0.1

,2
3
,2

, .092
4,351 5,6B5
919 , .910

4.9 2.6 1.6 6.6 20.4

SlEf'HENS

STEPItENS COUNTY HOSPITAL

99 YES

3

9,803

, .625

6

t,641 16.4

TOWNS UNION
WHITFIEL.D USA TOTALS

TOWNS COUNTY HOSPITAL UNION GENERAL HOSPITAL tlAH II. lON "E"OR JAL HOSP IT AL

42 NO 45 YES 297 YES
2,301

..
2

2,500 4,919

250 .. 9 0

..

4',515

'0.19"

19

2:11,096

36.91'

126

2,500 '0.0

,..... , ,230
2, tBO 2, '42

1&.0 25.6

""'07/86

EHERGENCY ROOH SERVICES IN ALl GEtJERAL 1I0SPIlALS, LEORf.IA t 905 Sf'EC I AL SURVEY OF 1I0ST IT At HER'EtlC Y ROllH SERV U:ES
HSA J -, NORTtI CENTRAL 'A

f'ft(;E

]

COUNTY

FACILITY NAHE

CAP. DEDS

24HI< J(;AU E.R. LEVEL

TOTAL PATIENTS

IADH HUSf'.

tlKIHI RATIO nA'S PATlSf

X AI)H uosr-

liliT IS

SLVAN 'ROVE UOSPITAL

28 VES

4

5,370

538

2

2,088

HLE)

CAf,ROU
CA,mou

EtO&JDllI' AREA UOSPITAL TANtlER HEHORIAL uospnAL

41 YES

4

t92 ES

3

2,200 19,000

532

3

"1J3

24.2

JUO

9

2, It I

~.O

CitRROLlCIIEr.:OKfE

VilLA RICA CITV tlOSPITAL CUEROkEE A'IOMEIHC t10Sf'ITAL

54 YES

J

21 NO

4,398

395

2

2,199

,r 9 t O

.0

ClIEkllKfE

R.T. JONES MEMORIAL

64 YES

2

12,8t5

1,260

1O

1,202

9.B

CLAYTON

CLAnON GENERAL tlOSf'ITAL

J61 YES

2

44,2BO

4,162

15

2,952

9.4

COIl(t

CO(tEt GENERAL uospnAL

342 VES

2

JI,8n

4,342

15

2,868

14.0

COli(I

KENNESTONE UOSf'lTAL

539 YES

2

10,319

1,735

20

3,516

I .. e

C(UI(t CUDLi COWETA eoUETA

SHYRNA UOSPITAL WHlD tULL UOSf'ITAL
tiUHANA UOSf'ITAL NEW"AN NEWNAN tlOSP ITAL,

tOO YES

2

U5 YES

2

144 yES

2

100 VES

2

21,800

2,100

to

2,100

10.0

17 ,080

1,880

0

2,125

I" t

11,003

1,276

t6

125

1.. 0

l,ao,

1,340

3

2,627

17.0

IlEKAL B

DECATUR ItOSPITAL

120 NO

.0

IIEKALIl IIEKAUt

DEKALEt GENERAL t10Sf'ITAL DOCTORS t10Sf'ITAL-TUCKER

555 YES

2

233 YES

2

52,162 9,498

5,804 1,424

t7

3,184

11.0

1

1,350

15.0

~

IlEKAUI

EtiOR UNIVERSIlY UOSPITAL

593 NO

.0

N

IlEl<AL (t

UENRIETTA EGLESTON UOSf'ITAL

165 NO

.0

Ilf.KALlJ 1)0111;1 AS

SUALLOWfOkD COMMUtUn DOUl;LAS GENERAl- UOSP I TAL

178 YES

3

98 YES

2

10,495 IJ,406

1,565 I, 60~

7

2, :556

9.5

4

3,307

t t .C7

1l0Ur.tAS

PARKWAY f.:EGIONAL ttOSf'ITAl-

3S8 YES

J

13,768

2,60~

9

t ,530

i5.0

fORSYlU

FORSYTlt COUNrY HOSf'lTAL

36 YES

J

8,591

859

4

2,148

10.0

f'1I110N

AllANlA ttnSf'lTAl

12 NO

.0

fUUON

CRA&JFORD W. LONG 11EHORIAl-

410 ES

2

25,808

5,000

tI

3, t25,

:~O.O

FlIl-10N

DOCTORS HEHllkIAL-ATLAtHA

181 NO

.0

FUtTON

GEORr.IA ~AF'TIST MEDICAL CTf<

523 YES

I

25,128

154

IS

t,675

J.O

HIlION

GRADY MEMORIAl- UOSf'ITAl

1046 ES

I

255,092

28,126

~l

4,024

tLO

Hil-HIN

ttllGttES Sf'AUHNG COHMUNITV

124 YES

2

1,696

116

6

102

10.1

fllUClN

.JESSE PARKER \JlLlIAMS

50 NO

.0

Hll- TON

HETROf'OU IAN ttOSPITAl

64 NO

.0

FlltHIN

HIDTOUH HOSPITAL

19 NO

.0

nltToH

NOf<nl fill. TOI~ HEDICAl- CENIEf<

\15 VES

2

t2,800

2,080

7

t ,7'"

24.0

HIl.ION

NORlttSlDE tlOSPITAL

363 YES

2

27,500

3,300

13

2,1 t j

t2.6

.IIITOU Hll-IUN

PIIYSlCIAHS t SlIf.:tEONS P HDHONT tlUSf'llAl-

t84 YES

3

449 YES

2

13,311

952

'I

3,J20

7.2

20,800

4,420

Il

2,000

H.O

fill. TOU FIll-lllN FItl-lON
I Ill. HlN fllL lllN I;WItmrll (;t.IINNEH
WINHUI l~lJ I UNE II IIUIJW IIENJ\)'
UE t< 1~IE IllER
IlfW WII ...1'\111 I)) !-If,

SAItH JUSEF-tl'S - AH-ANTA SCIHUSII RilE IIUn'flAlSOIHlI FlIUON ttOSPITAI. SOIHtlWESl CUttHUNIlY ttoSf'HAl tolE SI PACt: S FlORRY ttOSnT Al (IUfORl) f.ENU.:Al. IIUSPITAL (litH ON tWINUEH 1I0Sf'ITAL. tlUI1AUA tillS I' n AI (; WI NNE n .IOAU f.IAUCY HEHURIAL ..EARl) CUI1HIJN IlY tlllSf'l1 AL IIEtU\Y t;D-llHAI IlIlSf'IlAI tlUnWHllI1( HEllutdAI. IIUSF'IlAI IlnlHIII l.fIlH:AI tlUSHIAI "1\1111)) m; IIUIU" I AI tlOSP 11,,)1

JOO YES

2

08 YES

I

39t VES

2

128 YES

2

294 YES

2

59 NO

--19
1 ~I~I

YES

2

104 110

29 YU'

4

10" YES

2

3U YES 117 )'ES

2"

UJ )'ES

,5

9,929 14,426 Jo,800 17,4J8 to,305
14 .533
I ,~~oa
t7,sn
2, NO 10.000
1. '//:'J.

2, HI4 600
:5,660 1,321 t,765
t ,4:> J
('n
2, :~u:! 010
4. ~)()il I.nt.

15

662

22.0

9

t,603

4 ~I

15

2,453

to.O

5

3,408

7.6

6

t. nt

tl.0

,,0

.0

U

t ,1117

10.0

.0

"

.!lOO

16.0

H,

t ,254 ::~, '/00

1:LO ]0,0

U

t ,2~;0

45. ()

,~t

I , :5:,~'1

I.!I.O

Ve1l86
COUNTY ROCKDAl.E SPAl.DING TROUP UPSON WALTON HSA TOTALS

EHERGENCY ROOH SERVICES IN ALL GENERAL .,OSPITALS, GEORGIA t985 SPECIAL SURVEY OF JIOSPITAL EHER&ENCY ROOH SERVICES HSA 3 - NORTH CENTRAL GA

FACILITY NAHE ROCKDALE COUNTY HOSPITAL GRIFFIN-SPALDING CO. HOSP. WEST GEORGIA HEDICAL CENTER UPSON COUNTY HOSPITAL WALTON COUNTY HOSPITAL

CAP. BEDS
tee 222 286 , t9 t&' 9,9&9

24HR JCAH E.R. LEVEL

YES

2

YES

4

YES

3

YES

3

YES

2

TOTAL

IADH

PATIENTS HOSP.

t t ,8U 22,819
t9,4&& t5,442 t3,&85 972,763

t ,895 2,454
4,e74 2, t62
~, t42 t t7 ,667

PAGE

4

.,
ITRTHT RATIO STA'S PAT/Sf

9

t,Jt6

4

5,72&

8

2,425

te

t ,544

5

2,6t7

4&5

2,4&2

X ADH HOSP.
t6.6 t&.7 2t.6 t4.e t6.4 '2. ,

\.0 W

4/01/86

E"ERGENCY ROOH SERVICES IN ALL GENERAL tmSPITAlS, GEORGIA '985 SPECIAL SURVEY OF HOSPITAL E"ERGENCY ROOH SERVICES HSA 4 - EAST CENTRAL GA

PAGE

5

COUNTY

FACILITY NAHE

CAP. 24HR JCAH

To'rAl

BEDS E.R. lEVEL PATIENTS

tADH ITRl"T RATIO HOSP. SlA'S PAVST

t"lOASDP."

PARROW

DARROW HEDICAL CENTER

44 YES

4

1,321

133

4

, ,.832 '0.8

BURKE

BURKE COUNTY HOSPITAL

51 YES

J

3,388

401

2

, ,694 '2.0

Cl.ARKE Cl.ARKE El.BERT
EHANUEL GREENE JACKSON JEFFERSON JENKINS HCIUJFFlE

ATHENS GENERAL HOSPITAL SAINT HARY'S HOSPITAL~ATHENS ELDERTON-ELBERT CO. t SPITAL EHANUEl- COUN'T HOSPITAL HINNIE G. BOSWELL HEHORIAL BANK S-JACK.JON-COHHERCE HOSP. JEFFERSON 'HOSPITAL JENKINS ~OUNTY HOSPITAL HCDUFFIE COUNTY HOSPITAL

328 YES

2

"6 YES

2

64 'iES

3

13 68 ge lei 4e 41

~YE
Y YS YS
S

3 4 3 3 3 3

35,oee 24,465 5,eee 6,oeo
3,500

1,ooe 2,441 , ,eee , ,200
420

""3,1

3, '82 2,224
1t4 2,eoo 3,50e

20.0
'0.0 20.0 20.e
'2.0

9,555

, ,624

3

3, '85 H.O

4,131

372

5

B21

9.0

3,348

804

2

, ,614 24.0

1,128

85e

5

1,546 11.0

HORGAN

HORGAN HEHORIAL HOSPITAL

26 YES

4

3, lee

589

2

, ,550 t9.0

1.0

RICHMOND

HUHANA HOSPITAL OF AUGUSTA

374 YES

:2

te,959

2,52'

'2

913 23.0

.J::>

RICHHOND

HEDICAL COLLEGE Of GEORGIA

111 YES

I

",91e

3,513

'2

993 30.0

RICtlHot4D

SAINT JOSEPH'S - AUGUSTA

24e YES

2

14,611

2,63'

8

1,821 IB.0

RICtlHOND

UNIVERSITY HOSPITAL

'ge YES

t

18,681

9,118

54

t,301 '3.0

SCREVEN

SCREVEN COUNTY HOSPITAL

16 YES

4

2,ge9

81

2

1,455

J.O

WILKES

WILLS HEHORIAL ttOSPlTAL

66 YES

3

4,698

94

2

2,349

2.0

USA TOTALS

3,357

228,242 35,538 146

1,563 15.6

4/07/86

EHERGENCY ROOH SERVICES IN ALL GENERAL HOSPITALS, GEORGIA t985 SPECIAL SURVEY OF HOSPITAL EHERGENCY ROOH SERVICES HSA 5 - CENTRAL GEORGIA

PAGE

6

COUNTY

FACILITY NAHE

CAP. 24HR JCAH

TOTAL

BEDS E.R. LEVEL PATIENTS

'ADH URTHT RAT.JO ttosP. STA'S PAT/ST

X ADH ttOSP.

BALDWIN

BALDWIN COUNTY HOSPITAL

t68 YES

2

22,225

2,553

6

3,704 tt,5

BIBB

CQLISEUH PARK HOSPITAL

258 NO

.9

BI88

HEDICAL CENTER Of CENTRA~ GA

562 YES

t

58,911

6,969

tS

3,222 t2.9

BIBB

HIDDLE GEORGIA HOSP.TAL

t66 NO

.9

BI(lB

RIVERSIDE CLINIC HOSPITAL

52

.e

BI.ECKLEY

BLECKLEY COUNTY HOSPITAL

64 YES

4

3,624

125

5

125 29.9

CLAY

CLAY CO.-FT. GAINES HOSPITAL

35 YES

4

2, t62

23B

t

2, t62 tL9

DODGE

DODGE COUNTY HOSPITAL

tn YES

4

7,491

t ,332

4

t ,859 t8.9

~ (J'l

HOUSTON

HEDICAL CTR OF HOUSTON CO.

258 YES

2

29.998

3.239

1

4,285 te.s

HOUSTON JASPER

PERRY-HOUSTON CO. HOSPITAl. JASPER HEHORIAL HOSPITAL

45 YES 2B YES

3.

1,818 t .632

945

3

2,626 t2.9

,211

2

8t6 fl.e

LAURENS

FAIRVIEW PARK HOSPITAl

t91 YES

2

t5,2~t

3, t95

9

t.696 29.9

HACON

HACON COUNTY HEDICAL CENTER

5. YES

3

3,325

636

4

83t t 9. t

HARION HONROE

HARION HEHORIAL HOSPITAL HONROE COUNTY HOSPITAl

38 YES 41 YES

.4.

t .569 t8, U5

-6@

2

185

J.B

1.2'

,2

5.9B8

1.e

HUSCOGEE HUSCOGEE

DOCTORS HOSPITAL-COLUHBUS HEDICAL CENTER OF COLUM.US

252 YES

2

4tl YES

2

2.325

538

4

'- 51lt 22.8

J9,495

4,335

t3

3,93t tt.9

HUSCOGEE

SAINT FRANCIS HOSPITAL

292 YES

2

1t.66B

t ,929

4

2.661 t8.e

PEACH

PEACH COUNTY HOSPITAL

76 YES

2

B,9B5

t.2t3

4

2.12t t5.e

PULASKI

R.J. TAYlOR HEHORIAL

56 YES

3

5.59t

996

t

5,59t U.B

PUTNAH

PUTNAH GENERAl HoSPITAl

51 YES

3

4,46t

t t t5

3

t .4Bl 25.9

RANDOLPH

PATTERSON HOSPITAL

4. NO

.1

STEWART

STEWART-WEBSTER HOSPITAL

32 YES

4

t ,659

4Jt

t

t ,659 26.1

TELFAIR

TttREE RIVERS HOSP It HED CTR

52 YES

4

2.B13

281

5

515 t9.e

WASHINGTON HEHORIAL-WASHINGTON CO.

56 YES

3

5. tB6

199

6

B64 t5.4

WttEELER

WHEELER COUNTY HOSPITAL

22 YES

2

2.649

t .589

t

2.649 68.9

USA TOTALS

3,3B8

246.t5t J4.e81 tes

2,344 U.8

4/07/B6

E"ERGENCY ROO" SERVICES IN ALL GENERAL HOSPITALS, GEORGIA 1985 SPECIAL SURVEY OF HOSPITAL E"ERGENCY ROO" SERVICES HSA 6 - SOUTHWEST GEORGIA

PAI~E

7

COUNTY

FACILITY NAHE

CAP. 24HR JCAH

TOTAL

BEDS E.R. lEVEL PATIENTS

IADH ITRT"T RATIO HOSP. STA'S PAT/Sf

% AD" HOSP.

BEN HILL

DORHINY HEHORIAL HOSPITAL

15 YES

3

6,e58

lSI

6

1,8GB

2.5

BERRIEN BROOKS

BERRIEN COUNTY HOSPITAL BROOKS COUNTY HOSPITAL

l' YES

3

45 YES

3

2,561 4, t94

487

3

854 19.8

419

2

2,897 10.G

CAUtOUN

CALHOUN HEHORIAL HOSPITAL

48 YES

3

1,978

256

2

985 IJ.8

COLQUIT

COLQUITT COUNTY HEHORIAL

155 YES

2

t6,338

4,899

6

2,722 J8.G

COOK

HEHORIAL HOSPITAl OF ADEL

48 YES

3

1,665

1,353

5

1,53J t7.7

CRISP DECATUR

CRISP COUNTY HOSPITAL HE"ORIAL HOSP-DECATUR CO.

le YES

3

82 YES

3

9,18e 9,8e8

2,738 1,245

J

J,83J 3G.G

3

3,8G8 IJ.8

lO 0'\

DOOLY DOUGHERTY

DOOLY HEDICAL CENTER PALHYRA PARk HOSPITAL

47 YES

3

223 YES

3

3.245 t4,888

487 2,632

2

1,623 15.8

8

t,758 tB.8

DOUGHERTY PHOEBE PUTNEY HEHORIAL

458 YES

2

44,122

4,413

18

2,485 18.G

EARLY

EARLY HEHORIAl HOSPITAL

49 YES

3

2,998

897

6

498 Je.G

GRADY IRWIN

GRADY GENERAL HOSPITAl IRWIN COUNTY HOSPITAL

68 YES 34 YES

3.

6,618 1,138

881

2

3,JJ9 12.G

313

t

1,138 18.G

LANIER LOWNDES LOWNDES
"ILLER HITCHELL

LOUIS SHITH HEHORIAl SHITH HOSPITAL SOUTH GEORGIA HEDICAL CENTER HILLER COUNTY HOSpiTAL HITCHELL COUNTY HOSPITAL

l'4. .YES NO 288 YES' 3. YES

3
.2.

54 YES

3

t ,4" t,798 24,5J8 hUt 4,126

353
3,643 365 523

t

1,4tt 25.G

1,198

.G

8

3,G66 14.9

I

I, t61 3t.4

3

t ,515 I t. I

SEHINOLE

DONALSONVILLE HOSPITAL

66 YES

4

3,888

728

2

1,54G 23.6

SUHTER

AHERICUS-SUHTER CO. HOSPITAL

t88 YES

2

t2,t13

t.454

4 3,828 12.G

TERRELL

TERRELL COUNTY HOSPITAl

34 YES

3

2,e"

3tJ

2

l,e48 14.9

THOHAS

JOHN D. ARCHBOLD HEHORIAL

246 YES

2

25,88e

3,58e

7

3,571 14.G

TIFT

TIFT GENERAL HOSPITAL

UB YES 2

25,984

3,tt2

9

2,B7B 12.G

l"URNER WORTH

TURNER COUNTY HOSPITAL WORTH COH"UNITY HOSPITAL

48 YES 58 YES

.4

t ,899 4,914

35

2

6BB

5

SSG

3.2

9BJ 14.8

USA TOTALS

2.724

238,874 35,851 ttl

2.145 15.1

4101186

EHERGENCY ROOH SERVICES IN ALL GENERAL HOSPITALS, GEORGIA 1985. SPECIAL SURVEY OF HOSPITAL EHERGENCY ROOH SERVICES

F:AGE

B

HSA 7 - SOUTHEAST GEORGIA
,

COUNTY

FACILITY NAHE

CAP. 24HR JCAtt

TOTAL

BEDS E.R. LEVEL PATIENTS

tADH tTRTHT RATIO ttOSP. SlA'S PATIST

X ADM ttOSP.

APPLING

APPLING GENERAL HOSPITAL

41 YES

4

1,988

635

I

1,900 33.4

BACON

BACON COUNTY HOSPITAL

47 YES

3

3,824

153

5

165

4.0

BULLOCtt

BULLOCH HEHORIAL HOSPITAL

"4 YES

3

t5,382

154

t2

1.282

1.0

CAHDEN

GILMAN HOSPITAL

J9 YES

3

:3.692

554

3

t.231 15.0

CANDLER

CANDLER COUNTY HOSPITAL

68 YES

J

5.e88

608

3

1.661 12.0

CHARLTON

CHARLTON HEMORIAL HOSPITAL

5& YES

2

4.5ee

315

2

2,250

1.0

CHATHAM

CANDLER GENERAL tWSPITAL

U5 YES

2

21,615

3,286

9

3,068 I I .9

CHATHAM

MEMORIAL HEDICAL CENTER

465 YES

t

48,934

3,425

5

9,181

1.0

CHAtttAM

SAINT JOSEPH'S - SAVANNAH

J88 YES

2

U,644

2,456

10

1.364 18.0

I.....D...

CLINCH COFFEE

CLINCH HEMORIAL HOSPITAL COFFEE REGIONAL HOSPITAL

49 YES

4

t51 NO

2,528

211

3

840 11.0
.0

EFFINGttAH EFFINGHAM COUNTY HOSPITAL

45 NO

3,451

519

I

3,451 15.0

EVANS

EVANS MEHORIAL HOSPITAL

13 YES

3

8.854

1.289

2

4,021 16.0

GLYNN

GLYNN-BRUNSWICK HEHORIAL

34e YES

2

21,594

4,t39

14

t ,971 15.0

JEFF DAVIS JEFF DAVIS HOSPITAL

68 YES

J

1.212

865

I

7,212 12.0

LI9ERTY

LIBERTY MEHORIAL HOSPITAL

58 YES

3

5,872

588

I

5,872

9.9

PIERCE

PIERCE COUNTY HOSPITAL

62' YES

4

2,921

351

2

1,464 12.e

TATTNALL

TATTNALL MEMORIAL HOSPITAL

48 YES

4

'J,688

36e

I

3,6ee to.O

TOOl19S

JOHN M. MEADOWS HEHORIAL

92 YES

J

11,869

388

9

1,238

3.4

WARE

MEHORIAL HOSPITAL-WARE CO.

251 YES

2

24,Ut

3,B54

12

2,011 16.8

WAYNE

WAYNE HEHORIAL HOSPITAL

tJ8 YES

2

12,8J1

2, "7

4

J.8e9 IB.O

HSA TOTAl.S

2,B64

232,964 26,359 tee

2,33e II.J

FINAL TOTALS

24.891

2,281 ,ee6 295.416 t ,e02

2, t97 13.4

I1t RECORDS TOTALED SOllRf.:E: GEORGIA STATE HEALTH PLANNING AGENCY, FEBRUARY, t986.

APPENDIX 3 Treatment Modules for Categorizing Burns

TREATMENT MODULES for CATEGORIZING BURNS
"
Ma ,or Burn In jury
-All bu~./ZO~ BSA)children < 10 y.arl old.
-All b~./ZO~ BSA/adulcs > 40 yearl old.
-All bu~./Z5~ BSAIale. 10 to 40 -Pull thickness burn. 10~ BSA or greacer. -All burn. involvinl fac., eye., ears, handa, feec, or perineua. -All burn. thac are likely to result in fUDcCioual or co.mecic im~airmanc. -All hilh volcale eleccrical bu~ -All burna co~licaced by inhalacion injury. -All burns cC8plicaCed by crauma/chrOGic healch probl.... Moderace Burn In jUry
-Kixed parcial/full-chickne bu~./lO-Z~ BSA)children < 10 years old.
-Kized parcial/full-ChickD bUrDa/10-Z~ BSAIadulcs > 40 years old.
-Kized parcial/full-ChickD burDa/1S-Z5~/a... 10-40. *Specifically excluded frena this cacelory are amy burma meeeina the criceria
for Kajar Buru Injury. !!iDOl' Bun In 1un
-Burn./< 10: vtch DO .are chaa Z~ full-ChickDa/children < 10 years ol~.
-Burn./< 10: vteh DO .are chaa Z~ full-chickD /adulc. > 40 years old.
-B~./< 151 wich DO .are chaD Z~ full-chickDe/a... 10-40. "'Specifically excluci.d frena this caeelory are my burm. . .seinl ths criceria
for Kajar or KocI.rac:e Bun Injury.
98

APPENDIX 4
Maps

EMERGENCY MEDICAL SERVICES REGIONS
LOCATION of HOSPITALS reporting Full-time Emergency Departments
Self-designated Level of E.D and Bed Capacity
FULTON COUNTY
470-II 523-1 1038-1 124-II 175-II 363-II 184-III 449-II 360-II
88-1

I

I2-II!,~._--'"-.; \..4,7..' .3.. -n~_.--

~
\

/

_.1_.~ ...~-.._L.

"";~ G~ '" '"- '40-IV ...... ~

\ -335-

.

.
/

/.5/ 2-I
TlVOI.

v



..
\

..'.\ ,j
O-I

I

- 1 " - -
JI

-' -...'.I.._...,al'TUL"L-".'._.'.-,:.,,5.", >0"-,'I-I.I_.I-. ."\?'.0~' 6')~6.-'5;",-J";T.""~,(Y-.')'_'!.0~"....?,...:........

J 3.5..-,. oa_UlI 34-11'1 LI.

\

,;-7"5'~- IIII."\L

SO'" 1 .4IVe9lA"1r.Y-"',I Iv-3I'<8I-0-C-~-IAV-I1l'.-..r1.~...~1--./1r1'f.j2-,-~o24O:'""U!3;,G5J-;-..=.M'.0?~"1-L"-1l~1II".~tI~l'~ B..._I.S-~SO'I-TV--~lII!lI1I_-V- 6-."8.}n:+i"i~4"jO!'1J-\."~,-"_4I',1"'-_:1"_II.-rV1.".;I'.-'

"" oav.. .I -

I
;

rli'.,

1.._,

.

41-IV _''''I

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SOURCE: Special EMS Survey of Hospitals. 1985

')0

State Health Planning Agency 99

(

PATIENT ORIGIN/HUMANA HOSPITAL-AUGUSTA INPATIENT BURN SERVICES - 1984

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STATE OF
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North Carolina: 3

Florida:

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SOURCE: SHPA Special Survey 1985 100

PATIENT ORIGIN/GRADY MEMORIAL HOSPITAL INPATIENT BURN SERVICES - 1984

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SOURCE: SHPA Special Survey 1985

101

PATIENT ORIGIN/MEDICAL COLLEGE of GEORGIA HOSPITAL

INPATIENT BURN SERVICES - 1984

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Other States (S. Carolina): 11 Grand Total: 61

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102

APPENDIX 5 Membership of the EMERGENCY MEDICAL SERVICES TECHNICAL ADVISORY TASK FORCE
August 1985

EMERGENCY MEDICAL SERVICES TECHNICAL ADVISORY TASK FORCE

Membership

NAME
Chairman: Richard C. Treat, M.D., F.A.C.S Director, Trauma & Burn Services Augusta, Georgia

ORGANIZATION Medical College of Georgia

Carl Boyd, M.D. Director, Emergency Medical Services Savannah, Georgia

Georgia Trauma Committee

Roger" Chapman, M.D. Chairman, EMS Committee Atlanta, Georgia

Medical Association of Georgia

Al Christie Chief & Director Douglas County EMS Douglasville, Georgia

Emergency Services Advisory Council

Jim Creel, M.D. Director, EMS Fort Oglethorpe, Georgia

American College of Em~rgency Physicians (Georgia Chapter)

Dallas Jankowski Director, ERS Atlanta, Georgia
Judge Arthur Kaplan *
EMT/EMT Trainer Atlanta, Georgia

Department of Human Resources Emergency Health Section
Emergency Services Advisory Council

David Lofton Director, EMS Region I Rome, Georgia

EMS Project, Region I

Commodore T. Mobley, Jr., M.D. Emergency Physician Douglasville, Georgia

State Health Policy Council

Honorable Roy D. Moultrie Member House Health & Ecology Committee Hamilton, Georgia

Georgia House of Representatives

103

John B. Oneal, M.D. Medical,irector/Consultant Elberton, Georgia
Paul Shanor Legislative Aide Atlanta, Georgia
Cory Slovis, M.D. Director, Medical Emergency Assistant Professor of Medicine Atlanta,'Georgia
Margie Smith Acting Director Atlanta, Georgia
Bob Spesser Coordinator, EMS Region 7 Columbus, Georgia
Bill G. Waters Chi~f Executive Officer Floyd Medical Center Rome, Georgia

Department of Human Resources Emergency Health Section
Georgia Senate Human Resources Committee
Emory University
Department of Human Resources Office of Regulatory Services
Representative, Regional EMS Coordinators
Georgia Hospital Association

Staff: Edna B. Tate Health Systems Analyst
* Judge Kaplan was the recipient of the 1986 Humanitarian Award
for his work as a volunteer Emergency Medical Technician.

104

APPENDIX 6 Excerpts from The New England Journal of Medicine
(Reprinted with permission)
105

372

THE :-iEW E..'lGLAND JOUR."lAL OF MEDICINE

Feb. 7, 1985

ECONOMIC CONSIDERATIONS IN EMERGENCY CARE
What Are HoapicaJs for?
Two items in this issue have some lessons to teach
us about the social responsibilities of hospitals in a
health care system now obsessed with cost control and increasingly inBuenced by economic competition. The
first article is a Sounding Board contribution from Dr.
Keith Wrenn, a primary care internist in rural North Carolina, who recounts his difficulty in getting an uninsured patient with an acute traumatic neurosurgical problem admitted to a tertiary care referral. center. The article is printed virtually unedited, because it so vividly describes the author's distress as he vainly tries to persuade a stair neurosurgeon at a regional university hospital to accept the patient in transfer, only to be told that the hospital administration will not allow it for economic reasons.
I focus on this disturbing event not to accuse any particular hospital, but to make a general point about
hospitals everywhere. Dr. Wrenn says, "I think it is
likely that the institution in questioa is not unique and that this attitude of professional 'copping out' will become increasingly prevalent in the future as hospitals move to secure tbemse!ves economically and, try to ward oft" 'dump..'" He is correct. Newspapers have recently been reponing similar incidents around the country, and physicians are aware of many more that never make the headlines. As economic pressures on hospitals grow and hospital managers are encour-
aged - or forced - to act like businessmen concerned
primarily with profit margins, more and more patients will be denied access to urgendy needed care simply because they cannot pay for it. In theory, all private hospitals, whether invatol'-Owaed or voluntary, acknowledge an obligacion to provide emergency care for any acutely ill indigent patients brought to their doors - at least until such patients can be "stabilized" (whatever that means) and safely transferred to a public hospital That sounds reassuring, but in practice maay very sick patients are denied adequate care.
As an example, consider the indigent emergency patient who.is not yet at the hospital door but is awaiting transfer from some other facility that is not able to provide the necessary care. Such was the case with Dr. Wrenn's patient. She had been taken to a small rural hospital lacking neurosurgical capability, and clearly needed to be transferred elsewhere very prompdy. What are the obligations ofa regional tertiary care hospital under those circumstances? Surely economic considerations should be subordinated to the patient's interest. Unfortunately, that no longer always happens. Medical judgment, compassion, and common sense are nowadays too often overruled by the economic concerns ofhospital managers. Unwanted emel'Kency patients not at the hospital can usually be fended off by an alen cost-eonscious hospital man-

ager, thereby avoiding the possibility of a large unpaid bill.
When the economically unwanted patient is actually in the emergency room, however, it becomes harder for such business considerations to prevail. Even if a suitable public facility is available to receive the patient in transfer, a medical judgment must be made about the "stability" of the patient's condition before the transfer can decendy be carried out. This is what the second article is about. Professor William Curran tells us in his Law-Medicine Note this week about a case appealed to the Arizona Supreme Court in which a young boy injured in an accident was transferred (after his condition had been "stabilized") from a private voluntary hospital to the local county hospital before definitive surgical treatment could be carried out. The boy's family was indigent, and the transfer was purely for "economic reasons"; he could have had the necessary surgery at the private hospital had not the hospital management ordered otherwise. As it happened, pennaaeac impairment resulted, and the boy's mother sued the private hospital as we!l as the physicians involved, alleging that the transfer had been inappropriate and had led directly to the permanent injury.
The court concluded that thehospital, not the phy-
sicians, was liable for the injury, because it was the
hospital that had insisted on the transfer. The court also confirmed an earlier Arizona decision holding that a private hospital has the same legal obligation as a public hospital to render all needed care to emergency patients.
The Arizona court has the right idea: Hospitals exist primarily to serve the needs ofpatients. But government and other third-party payers now seem to be telling ow!' private hospitals that they must act like competitive cost-eonscious businesses. In such a climate we cannot expect the emergency care ofindigent and uninsured patients always to be given a very high priority - and it is not.
The lessons from these two articles are plain. We need regional referral systems for the tertiary care of all acutely ill and injured patients, regardless of their ability to pay. When business considerations dominate the behavior of hospital management, the poor will inevitably be neglected. Government and regional health planning agencies should designate tertiary care facilities to receive emergency referrals from defined regions and should ensure that no medically appropriate referrals from those regions are refused simply for economic reasons.
We also need more state laws and coun rulings that require all hospitals, regardless of ownership, to treat all emergency patients brought to their doors provided that they have the appropriate medical facilities and staff. Hospitals should be allowed to transfer indigent patients who have urgeD\. problems only with the approval ofattending physicians, and acceptable reasons should be limited to medical need. "Stabilization" of emergency cases is a notion used by hospital managers

Vol. 312 No.6

;JVUJ,.'Uj,J. ... ", U'-'4 ......_

to .i.!:!!WY .tral)Sfers fgr economic reasons, but it is an table lateral skull film. While the patient was stabi-

elusive and dangerous concept. Transfers, and delays lized, attempts were made to transfer her to a neuro-

in the definitive treatment of seriously ill or injured surgeon. A neurosurgeon 120 miles northeast accepted

patients, are rarely without some risk. They can be the patient r~adily, but because transport by helicop-

medically justified only.when the move is intended to ter was deemed advisable and a low cloud cover in the.

provide better care. When medical justification is intervening,! mountains prohibited this transport, we

lacking, transfers of emergency patients should be again atte~pted to refer the patient to the neuro-

APin, prohibited.

surgical service at the tertiary care center mentioned

The steps necessary to ensure adequate emergency above.

after hearing about the problem, the

care of the indigent and uninsured are, unfortUnately, first question related to the patient's insurance cover-

at odds with the. currendy fashionable philosophy in age. Whc;h it was learned that the patient had no cov-

Washington. We cannot expect to see much action erage, qie transfer was refused on those grounds,

until enough policy makers lose their fascination with ostensiQly because the neurosurgeon to whom I talked

the view that hospitals are basically businesses. They had go,iten into trouble with the administration for ac-

aren't, of coune, or at least they shouldn't be. They cep~g a similar patient in the recent past. All the

are community resources and, as a first priority, telep~one calls caused at least a 45-minute delay in

they should be responsive to the ~th care needs of getting the helicopter oft' the ground. Eventually, the

the communities they serve.

patient was ~ferred to a secondary referral center

ARNOLD S. REI.M..u, M.D. 100/ miles west.
To place the incidents in perspective, it should be

mentioned that our local hospital is a 5O-bed acute

care hospital with a staff of general internists, fami-

SOUNDING BOARD

ly practitioners, one obatetrlcian-gynecologist, and
one.generals~n. Obviously,prompt~erralin

NO 1NSt1RANCE, NO ADMISSION

both cases was imperative. Our referral patterns are historically to the northeast and south for many rea-

I WOULD like to address what seems to me to be a SODS, not the least of which is the belief that the serv-

very disturbing trend from my vantage point as a pri- - ices provided are of the highest caliber in these two

mary care internist in a relatively isolated rural area places. Transport times in any direction by helicopter

approximately two houn in any direction from a refer- or ambulance are essentially the same, and the heli-

ral center. To illustrate my problem, I report the fol- copter service originates from the city where the refus-

lowing two cases.

ing institution is located.

In May 1983 a mildly intoxicated 26-year-old

I do not think that these patients would have been

man was in an automobile acc:ident, sustaining a refused 10 years agO or even 5 years ago at the institu-

bump on his head without loss of consciousness. He tion mentioned, because I trained there. I think that it

was brought to the emergency room as a precaution is no coincidence that the first <:ale was reluctandy

and was initially lucid and in no distress. While accepted and the second <:ale summarily refused over

waiting to be seen, be began to have signs of trans- the time span from May of 1983 to December of 1984.

tentorial herniation, presumably due to an acute During this time, a major upheaval in medical ec0-

subdural hematoma. and while treatment with dexa- nomics and practice took place and has been exten-

methasone, mannitol, and phenytoin wu instituted, sively reviewed in the lay and professional press. I do

attempts were made to contact a neurosurgeon at a not presume to speak to the appropriateness ofcurrent

private tertiary care center in a well-endowed uni- reimbursement procedures or the "cutbacks" as they

versity setting in a city 130 miles to the south, exist. I am even grudgingly willing to adopt a wait-

because the patient lived in that area and his family and-see. attitude. I can, however, speak to the danger-

was there. After the cale was presented to the neuro- ous trend of letting economic matters take precedence

surgeon attending, the first question was "Does the over maners of humanity.

patient have insurance?" At that time, no family

I am disappointed and angry at an institution in

members were present and no information other than which I trained and feel degraded by my association

his name was available. After much pleading, the with a profession that seems to be losing sight of its

patient was accepted in transfer and later died. As primary purpose - providing the service of health

it turned out. he did have insurance.

care. I also feel betrayed because the ethical principles

On December 27, 1984. a 35-year-old woman was in that were imparted during training (and for that mat-

an automobile accident, sustaining massive facial ter in growing up) seem to be just words blithely ut-

and head trauma. On arrival at the emergency room, tered in lip service to the Hippocratic oath.

she' was hypoxic, had an obvious midline mandibu-

It may be foolish to neglect health insurance cover-

lar fracture as well as .se\'ere bilateral orbital and age, but the cost of good coverage in our time is cer-

eyelid hematomas. and had multiple lacerations of tainlya burden to people on the poverty-level end of

her face. She was combative and her mental status our economic spectrum. Whether the institution in

waxed and waned. A skull fracture was seen on a por- question is unique in its unethical disregard for pa-

3;"

THE :-fEW E..'lGLU'fD JOURNAL OF MEDICINE

tienu' needs is not clear, because I have very little
experience with other institutions. I think it is likely chat the institution inq~estion is not unique and chat this attitude ofprofessioDal "copping out" will become increasingly prevalent in the future as hospitals move
to secure themselves economically and try to ward oft"
04dumps." The fact is, however, that certain patients
require transfer to major medical centerS for care beyond the capacity of small rura! hospitals, the social and economic climate notwithstanding.
Hospital administrators, admission clerks, or busi-
ness managers should not have the final say in determining who gelS health care, becaue the less fortunate will always suft"er. Physicians aDd hospitals who
cannot or will not cb.aDF their practice styles in c0-
day's climate ofchange are miaing the boat, but physicians who woWd refuse care to the above patients on the basil of seemiDgiy purely economic grounds are cowards in a moral, ethical, and personal sase. I think ail of WI need to recoasider why we are practicing medic:iDe, and if the bottom IiDe is DOt to provide good care to ail who need it regardless ofthe situatioa,
then a change in proCaaioa is iDdicated.

*"*', ,..... ..... ~CD* NC 2110I

K&ITII WUlQI, M.D.

Feb. i. 1985