At the Intersection of Health, Health Care and Policy Cite this article as: Nicole Lurie, Gregg S. Margolis and Kristin L. Rising The US Emergency Care System: Meeting Everyday Acute Care Needs While Being Ready For Disasters Health Affairs, 32, no.12 (2013):2166-2171 doi: 10.1377/hlthaff.2013.0771

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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2013 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.

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Preparedness By Nicole Lurie, Gregg S. Margolis, and Kristin L. Rising 10.1377/hlthaff.2013.0771 HEALTH AFFAIRS 32, NO. 12 (2013): 2166–2171 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.

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Nicole Lurie (Nicole.lurie@ hhs.gov) is assistant secretary for preparedness and response at the Department of Health and Human Services (HHS), in Washington, D.C. Gregg S. Margolis is director of the Division of Healthcare Systems and Health Policy, Office of the Assistant Secretary for Preparedness and Response, HHS. Kristin L. Rising is a research fellow in the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Hospital of the University of Pennsylvania, in Philadelphia.

VIEWPOINT

The US Emergency Care System: Meeting Everyday Acute Care Needs While Being Ready For Disasters The emergency care system is an essential part of the US health care system. In addition to providing acute resuscitation and life- and limb-saving care, the emergency care system provides considerable support to physicians outside the emergency department and serves as an important safety-net provider. In times of disaster, the emergency care system must be able to surge rapidly to accommodate a massive influx of patients, sometimes with little or no notice. Extreme daily demands on the system can promote innovations and adaptations that are invaluable in responding to disasters. However, excessive and inappropriate utilization is wasteful and can diminish “surge capacity” when it is most needed. Certain features of the US health care system have imposed strains on the emergency care system. We explore policy issues related to moving toward an emergency care system that can more effectively meet both individuals’ needs for acute care and the broader needs of the community in times of disaster. Strategies for the redesign of the emergency care system must include the active engagement of both patients and the community and a close look at how to align incentives to reward quality and efficiency throughout the health care system. ABSTRACT

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n April 15, 2013, two improvised explosive devices were detonated at the finish line of the Boston Marathon, killing three bystanders instantly and injuring 264 people.Within moments, local, state, and federal response teams were activated, and hundreds of untrained bystanders began providing initial assistance to those in need. Boston hospital emergency departments (EDs) began preparing for a large influx of critically injured patients. Once on the scene, health care professionals triaged and treated the injured, many of whom were then transported to six Level I trauma centers. None of the 264 people who were injured subsequently died—an outcome indicative of a well2166

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coordinated response from an emergency care system capable of responding to a catastrophic event. That system was created and refined over many years by the cooperative efforts of thousands of health care providers, public health and public safety officials, and emergency management professionals. The day before the Boston Marathon bombings, the city’s EDs were engaged in typical daily routines, treating thousands of patients. Many of those patients had emergency conditions such as heart attacks, strokes, seizures, and traumatic injuries that were potentially life threatening. Most of the patients did not know that they would have to rely on the emergency care system that day.

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Other patients arrived for myriad unscheduled acute care needs. Some of them may have been unsure about the severity of a concerning symptom, unable to get an appointment with their doctor quickly enough to address their concerns, advised to go to the ED by a care provider, or lacking any other source of care. In the majority of these cases, health professionals involved in their care worked in dozens of facilities around the city and provided care mostly independently, with limited need for coordination and integration. The juxtaposition of these two days in April illustrates the importance of the nation’s emergency care systems, both day to day and during disasters. Americans have a collective interest in ensuring that emergency care both is accessible to people with acute care needs and can be quickly “scaled up” to meet the demands of disasters that can affect thousands of people in a short time. Just as no individual knows exactly when he or she will have to call upon the emergency care system, no community can predict when a catastrophe will cause its emergency care needs to surge. Thus, emergency care systems must be prepared for all hazards, many of which occur with little or no notice. The best way for communities to be prepared for such events is to ensure that they can build on the strengths of their emergency care systems. Individual health care facilities must be able to coordinate with other health care, public health, public safety, and emergency management entities to ensure they can surge appropriately. This may include distributing patients to multiple hospitals, as was done after the marathon bombings, or transferring patients with less acute needs to a facility that can provide a lower level of safe and appropriate care. Not all emergency care systems operate as well as that of Boston, either daily or in the face of a disaster. Some EDs experience high levels of daily strains in their efforts to address the otherwise unmet needs of patients in their communities because of limited surrounding medical and social services. This increased daily strain leaves less capacity for providers and facilities as a whole to surge in case of disaster. Other systems, although efficient on the individual facility level, have limited integration between facilities. The challenge for each community is to design a system that continues to meet the needs of each individual patient for unscheduled acute care while preserving the capacity of the system as a whole to surge when needed. Articles in this special issue of Health Affairs consider the future of US emergency care. The response of Boston’s emergency care system to

the marathon bombings and the contrasting routine activities of the previous day at EDs across the region serve as backdrops against which we can review the major components of the US emergency care system; discuss their dual functions, both day to day and during catastrophic events; and consider how aspects of these two functions can both complement one another and come into conflict. We explore some of the forces that contribute to the growing demand for emergency services and the impact that this demand has on the system. We then present issues for policy makers to consider in moving toward an emergency care system that is patient and community centered and also ready to surge during disasters.

The Evolving Roles Of The Emergency Care System Although the US emergency care system can boast of many successes, overall it is in trouble. In 2007 the Institute of Medicine concluded that emergency care in the United States is overburdened, underfunded, and highly fragmented.1 Use of the ED continues to grow, while the number of EDs declines.2 It is widely known that ED crowding and boarding, as well as ambulance diversion, have an adverse impact on the quality and safety of care, yet these practices continue to pose major problems to the daily delivery of care and to public health.3,4 They reflect health care issues that extend well beyond the walls of the ED, including hospital crowding, patients’ limited access to outpatient care and lack of timely access to on-call specialists, and high rates of uninsurance. Many challenges faced by EDs today arise from the multiple roles they play in the health care system. The original goal of emergency care was to provide acute resuscitation and life- and limbsaving treatment, but the ED has evolved to fill other roles. EDs now provide nearly one-third of the unscheduled acute care in the United States.5 A recent RAND Corporation study indicated that 82 percent of patients who contacted their care provider for an acute concern were advised to go to the ED.6 The ED has also become a major source of care for the medically underserved. Policy makers and payers often criticize this use of the ED as an expensive and inappropriate source of primary care delivery.7,8 However, assessment of the appropriateness or cost of this use is complicated because many of the people who seek care in the ED have no other source of care.9 Finally, the ED is increasingly being used by Dece mber 2013

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Preparedness both patients and outpatient providers as a venue for rapid access to diagnostic testing and advanced imaging.10 Such tests and imaging performed in the ED may speed the process of obtaining a diagnosis. However, their use may also contribute to increased crowding in the ED and to longer overall patient wait times.10

Components Of The Emergency Care System

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Only 18 percent of ED visits result in admission to the hospital.

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One way to conceptualize the emergency care system is to track the continuum of services that a patient might use when seeking acute unscheduled care. First, bystanders in the community play a critical initial role in the emergency care system by recognizing emergencies, activating the emergency care system, and providing first aid. They may clear a patient’s airway, pull victims from wreckage, staunch bleeding, perform cardiopulmonary resuscitation (CPR), or provide comfort until additional help arrives. The critical role of laypeople in the community is often overlooked, yet research has shown that patients receiving early CPR from bystanders have significantly better survival rates after cardiac arrest.11,12 Furthermore, experience during international disasters suggests that many people are rescued by trained and untrained citizens when response systems are overwhelmed or incapacitated.13 The people who take 911 calls are often the second critical part of the emergency care system. Through well-developed protocols and scripts, 911 emergency dispatchers determine the nature and severity of medical calls and send out the appropriate resources. In addition, dispatchers can provide reassurance as well as instructions to callers on how to provide first aid before emergency medical services (EMS) personnel arrive. During a disaster, these dispatchers play an essential role in triaging calls and coordinating responses to ensure that scarce resources are being used most efficiently. In response to a 911 call, EMS professionals provide on-scene assessment, care, and transportation to the ED. They play a critical role in determining the most appropriate hospital destination, taking into account distance, time, and the capabilities of potential receiving facilities. During routine operations, they provide an essential link between the scene and the hospital, especially for patients with severe and sudden illnesses or injuries. During a crisis, EMS professionals may also provide additional onscene care if EDs become overwhelmed. Hospital EDs are the hub of the emergency care system, providing care to 129 million pa-

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Many challenges faced by EDs today arise from the multiple roles they play in the health care system.

tients annually.14 EDs are generally staffed with physicians, nurses, and other health professionals who have been specially trained to identify and treat potentially life-threatening conditions. Testing and treatment for conditions that are determined to be less acute are often assigned a lower triage priority or are deferred to an outpatient setting, ensuring that the sickest patients are seen first. It is not necessary or efficient for all EDs to have the same specialty capabilities. Many EDs transfer low-frequency or highly specialized, time-sensitive conditions—such as trauma, pediatric emergencies, burns, and poisoning—to specialty centers. These specialty referral networks have evolved as regions recognize the inefficiency of providing highly specialized services at every hospital.15 The past decade has seen an increase in the types of services being touted as emergency specialty care, with centers to treat stroke,16 ST-segment-elevation myocardial infarction,17 and postcardiac arrest18 emerging as some of the newest specialty care centers.

A Patient- And Community-Centered System According to the Institute of Medicine, patientcentered care is respectful of and responsive to individual patients’ preferences, needs, and values; and it ensures that patients’ values guide all clinical decisions.19 Patient-centered care is not the same as giving patients whatever they want. Instead, it involves a respectful dialogue between patients and providers, with the goal of shared decision making that takes into account the needs of the whole person. Overuse of the ED is inefficient and leads to overtesting and overtreatment for many patients, as well as increased wait times and diminished availability of resources for all patients. From a patient-centered perspective, people who arrive in the ED without what would be considered an emergency condition have usually made a decision that there is no better place for

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In addition to serving individual patients, the emergency care system is an essential community resource.

them to go. Efforts to address ED crowding and overuse should include expanded options for both addressing the needs of these patients and providing them with sufficient information so they can make informed decisions about where to receive optimal care. Seeking care in the ED may be convenient for patients from a scheduling perspective. However, care provided there for low-acuity problems tends to result in excessive testing and minimal coordination with patients’ other providers. Only 18 percent of ED visits overall result in admission to the hospital; the majority of patients are discharged and referred to other health care resources for follow-up care.20 Furthermore, many patients come to the ED because they lack access to a regular source of care, and their ability to obtain follow-up care is often limited or nonexistent.5 This leads to a vicious circle of uncoordinated and fragmented care, especially for patients with multiple chronic diseases that require ongoing management— patients who are becoming more typical as the mean age of the US population increases. The ABIM Foundation’s Choosing Wisely initiative21 encourages physicians and patients to talk about medical tests and procedures that may be unnecessary. This initiative could provide a basic framework for discussions with patients about the proper setting for care, even after the patient has arrived in the ED. Part of this work could include collaboration between the primary care and emergency care communities to develop guidelines for which situations and circumstances should be managed in an outpatient setting (perhaps within a twenty-four-hour timeframe) and which should be referred to an ED. Such evidencebased guidelines would be invaluable in the development of policies, practices, quality metrics, and incentives to help ensure that patients get the right care at the right time and in the right setting. In addition to serving individual patients, the emergency care system is an essential communi-

ty resource. At the most fundamental level, it must be able to respond to emergencies and large-scale disasters. Just as communities differ, so does what they need from their emergency care system. Thus, there is no “one size fits all” system design. Developing a community-centered emergency care system requires that significant decisions be made at the community level about the role of the ED in providing nonurgent care and the development of innovative partnerships to link patients to a regular source of care. Kelly Doran and coauthors recently performed a trial in which patients visiting the ED with low-acuity complaints were offered same-day primary care clinic visits as an alternative to an ED visit. The authors found that 85 percent of low-acuity ED patients accepted the offer of treatment in a primary care clinic instead of the ED. They also found that 9 percent more of the patients in the intervention group had at least one followup primary care visit within the following year, as compared to patients in the control group who visited the ED and had no primary care provider.22 This study describes one example of how systems might develop processes to direct patients to the most appropriate sources of care. Mechanisms to provide alternative prehospital care can also have a meaningful impact. Kaiser Permanente Colorado established an after-hours call line to assist in the triage of pediatric patients and found that 48 percent of those who reached the call center received recommendations for home care, with only 0.2 percent of patients requiring a higher level of care than initially recommended.23 Further work needs to be done to assess the long-term outcomes and potential cost savings of this model. However, the results support the use of call centers as a safe mechanism for early triage of patients. Community paramedicine and mobile integrated health care are evolving delivery models in which specially trained EMS providers increase access to basic health services. Pilot programs are evaluating the ability of EMS personnel to perform patient assessments and procedures already within their skill set as an alternative to transporting patients to hospitals, with the goal of expanding the use of primary care and public health services in underserved communities and by vulnerable patients.24 Another strategy involves providing counseling and preventive treatment to frequent EMS and emergency department users. MedStar in Fort Worth, Texas, provides patient education and care coordination to frequent 911 callers.25 In the twelve months following the enrollment of the first fifty patients in the Community Health Program, MedStar avoided nearly a thousand D e c em b e r 2 0 1 3

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Preparedness transports to the ED, saving more than $2.5 million.26 It seems likely that consensus can be reached on what the elements of a basic national emergency care system should be. However, individual communities will ultimately need to determine the best mix of emergency care system resources to serve their populations, both for daily care and for disasters. The national Hospital Preparedness Program works to support health care system preparedness for disasters through coalitions that involve all of the health care organizations in a community.27 The premise of the program is that organizations that work together, even if they also compete with each other in the marketplace, can create a stronger response system than they would have been able to produce working independently. The primary mission of these community coalitions is emergency preparedness. However, they are ideal venues for ongoing community and stakeholder engagement in identifying and disseminating best practices for daily operations. They can also contribute to defining the roles of accountable care organizations in providing emergency care to enrollees and communities. In the long run, coverage expansion through the continuing implementation of the Affordable Care Act will take some pressure off the ED as a safety-net provider. This expansion alone, however, will not fix the problem of increasing strain and overcrowding in the ED. Examining financial incentives in other parts

of the emergency care system may reveal additional opportunities to relieve pressure on EDs, support uncompensated care, and facilitate a transition to value-based purchasing for emergency care. For example, in 2006 the Office of Inspector General at the Department of Health and Human Services found that 25 percent of ambulance transports were either unnecessary or inappropriate.28 Additional research has shown that 11–61 percent of patients transported by ambulance to EDs could have been safely treated elsewhere.29–33 Under current policies for reimbursing EMS agencies, however, ambulances are reimbursed only if they provide transportation to the ED. Thus, EMS agencies have no financial incentive to offer patients alternative destination options, even if doing so would provide a more patient-centered and cost-sensitive approach. Other opportunities to examine EDs’ financial incentives and improve quality of care can be found in telehealth and telemonitoring programs. In addition, the increased exchange of electronic health data between in- and out-ofhospital emergency care providers could allow for improved coordination of patient care throughout the health care system. As is the case with other aspects of the health care system, emergency care must be transformed in conjunction with the development of meaningful, actionable, and transparent measures of quality that enable the individual and the community to understand how the system is performing day to day, and how it is likely to serve them in a disaster. ▪

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Department of Health and Human Services or its components.

NOTES 1 Institute of Medicine. Hospitalbased emergency care: at the breaking point. Washington (DC): National Academies Press; 2007. 2 Hsia RY, Kellermann AL, Shen YC. Factors associated with closures of emergency departments in the United States. JAMA. 2011; 305(19):1978–85. 3 Epstein SK, Huckins DS, Liu SW, Pallin DJ, Sullivan AF, Lipton RI, et al. Emergency department crowding and risk of preventable medical errors. Intern Emerg Med. 2012;7(2):173–80. 4 Sun BC, Hsia RY, Weiss RE, Zingmond D, Liang LJ, Han W, et al. Effect of emergency department crowding on outcomes of admitted

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patients. Ann Emerg Med. 2013; 61(6):605–11. 5 Pitts SR, Carrier ER, Rich EC, Kellermann AL. Where Americans get acute care: increasingly, it’s not at their doctor’s office. Health Aff (Millwood). 2010;29(9):1620–9. 6 Morganti KG, Bauhoff S, Blanchard JC, Abir M, Iyer N, Smith AC, et al. The evolving role of emergency departments in the United States [Internet]. Santa Monica (CA): RAND Corporation; 2013 [cited 2013 Oct 28]. (Research Report No. RR280-ACEP). Available from: http:// www.rand.org/content/dam/rand/ pubs/research_reports/RR200/ RR280/RAND_RR280.pdf 7 McWilliams A, Tapp H, Barker J,

Dulin M. Cost analysis of the use of emergency departments for primary care services in Charlotte, North Carolina. N C Med J. 2011;72(4): 265–71. 8 Katz MH. Emergency department care: when needed—not when better choices are unavailable. Arch Intern Med. 2012;172(8):609–10. 9 Kellermann AL, Weinick RM. Emergency departments, Medicaid costs, and access to primary care—understanding the link. N Engl J Med. 2012;366(23):2141–3. 10 Pitts SR. Higher-complexity ED billing codes—sicker patients, more intensive practice, or improper payments? N Engl J Med. 2012; 367(26):2465–7.

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11 Wissenberg M, Lippert FK, Folke F, Weeke P, Hansen CM, Christensen EF, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA. 2013;310(13):1377–84. 12 Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and metaanalysis. Circ Cardiovascular Qual Outcomes. 2010;3(1):63–81. 13 Moore M, Trujillo HR, Stearns BK, Basurto-Davila R, Evans DK. Learning from exemplary practices in international disaster management: a fresh avenue to inform U.S. policy? J Homeland Secur Emerg Manage. 2009;6(1):Article 35. 14 National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2010 emergency department summary tables [Internet]. Hyattsville (MD): NCHS; [cited 2013 Oct 28]. Available from: http:// www.cdc.gov/nchs/data/ahcd/ nhamcs_emergency/2010_ed_ web_tables.pdf 15 Mechem CC, Goodloe JM, Richmond NJ, Kaufman BJ, Pepe PE, U.S. Metropolitan Municipalities EMS Medical Directors Consortium. Resuscitation center designation: recommendations for emergency medical services practices. Prehosp Emerg Care. 2010;14(1):51–61. 16 Adams R, Acker J, Andrews L, Atkinson R, Fenelon K, Furlan A, et al. Recommendations for improving the quality of care through stroke centers and systems: an examination of stroke center identification options: multidisciplinary consensus recommendations from the Advisory Working Group on Stroke Center Identification Options of the American Stroke Association. Stroke. 2002;33(1):e1–7. 17 Jollis JG, Granger CB, Henry TD, Antman EM, Berger PB, Moyer PH, et al. Systems of care for ST-segmentelevation myocardial infarction: a report from the American Heart As-

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sociation’s Mission: Lifeline. Circ Cardiovasc Qual Outcomes. 2012; 5(4):423–8. Van Diepen S, Abella BS, Bobrow BJ, Nichol G, Jollis JG, Mellor J, et al. Multistate implementation of guideline-based cardiac resuscitation systems of care: description of the HeartRescue Project. Am Heart J. 2013;166(4):647–53. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press; 2001. Pines JM, Mutter RL, Zocchi MS. Variation in emergency department admission rates across the United States. Med Care Res Rev. 2013; 70(2):218–31. ABIM Foundation. Choosing Wisely [home page on the Internet]. Philadephia (PA): ABIM Foundation; [cited 2013 Nov 6]. Available from: http://www.abimfoundation .org/Initiatives/Choosing-Wisely .aspx Doran KM, Colucci AC, Hessler RA, Ngai CK, Williams ND, Wallach AB, et al. An intervention connecting low-acuity emergency department patients with primary care: effect on future primary care linkage. Ann Emerg Med. 2013;61(3):312–21. Kempe A, Bunik M, Ellis J, Magid D, Hegarty T, Dickinson LM, et al. How safe is triage by an after-hours telephone call center? Pediatrics. 2006;118(2):457–63. Patterson DG, Skillman SM. National consensus conference on community paramedicine: summary of an expert meeting. Seattle (WA): University of Washington, WWAMI Rural Health Research Center; 2013 Feb. Johnson K. Responding before a call is needed. New York Times. 2011 Sep 18. MedStar Mobile Healthcare. Program overview—high utilizer 9-1-1/ emergency department patients [Internet]. Fort Worth (TX): MedStar Mobile Healthcare; [cited 2013 Nov 18]. Available from: http://

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www.medstar911.org/Websites/ medstar911/files/Content/1089414/ MedStar_CHP_Program_Overview .pdf Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. Healthcare preparedness capabilities: national guidance for healthcare system preparedness [Internet]. Washington (DC): HHS; 2012 Jan [cited 2013 Nov 6] Available from: http://www.phe.gov/ preparedness/planning/hpp/ reports/documents/capabilities.pdf Department of Health and Human Services, Office of Inspector General. Medicare payments for ambulance transports [Internet]. Washington (DC): HHS; 2006 Jan [cited 2013 Nov 6]. (Pub No. OEI-05-02-00590). Available from: http://oig.hhs.gov/ oei/reports/oei-05-02-00590 .pdf Billittier AJ, Moscati R, Janicke D, Lerner EB, Seymour J, Olsson D. A multisite survey of factors contributing to medically unnecessary ambulance transports. Acad Emerg Med. 1996;3(11):1046–52. Cone DC, Schmidt TA, Mann NC, Brown L. Developing research criteria to define medical necessity in emergency medical services. Prehosp Emerg Care. 2004;8(2):116–25. Gratton MC, Ellison SR, Hunt J, Ma OJ. Prospective determination of medical necessity for ambulance transport by paramedics. Prehosp Emerg Care. 2003;7(4):466–9. Millin MG, Brown LH, Schwartz B. EMS provider determinations of necessity for transport and reimbursement for EMS response, medical care, and transport: combined resource document for the National Association of EMS Physicians position statements. Prehosp Emerg Care. 2011;15(4):562–9. Weaver MD, Moore CG, Patterson PD, Yealy DM. Medical necessity in emergency medical services transports. Am J Med Qual. 2012;27(3): 250–5.

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The US emergency care system: meeting everyday acute care needs while being ready for disasters.

The emergency care system is an essential part of the US health care system. In addition to providing acute resuscitation and life- and limb-saving ca...
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