Christine Kilgore

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

"We're asking ourselves: What should we take on in the next 3-5 years, and how can we as medical school leaders maximize our value and contribution?" Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

"Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity," said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of over 3 million jobs. "That's 1 out of 48 wage earners in the U.S.," said Dr. Reece.

In their meetings with legislators and national leaders, Dr. Reece and his colleagues from other medical schools emphasized the "ripple effect" of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research and slows the amount and pace of such research.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and more than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before a retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans involve "maximizing the impact of research" and better preparing graduates for the future.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

"We're asking ourselves: What should we take on in the next 3-5 years, and how can we as medical school leaders maximize our value and contribution?" Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

"Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity," said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of over 3 million jobs. "That's 1 out of 48 wage earners in the U.S.," said Dr. Reece.

In their meetings with legislators and national leaders, Dr. Reece and his colleagues from other medical schools emphasized the "ripple effect" of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research and slows the amount and pace of such research.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and more than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before a retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans involve "maximizing the impact of research" and better preparing graduates for the future.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

"We're asking ourselves: What should we take on in the next 3-5 years, and how can we as medical school leaders maximize our value and contribution?" Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

"Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity," said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of over 3 million jobs. "That's 1 out of 48 wage earners in the U.S.," said Dr. Reece.

In their meetings with legislators and national leaders, Dr. Reece and his colleagues from other medical schools emphasized the "ripple effect" of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research and slows the amount and pace of such research.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and more than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before a retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans involve "maximizing the impact of research" and better preparing graduates for the future.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece, chair of the AAMC Council of Deans, said upgrading primary care's status and emphasis is “definitely on the agenda.” ©RICHARD LIPPENHOLZ

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece, chair of the AAMC Council of Deans, said upgrading primary care's status and emphasis is “definitely on the agenda.” ©RICHARD LIPPENHOLZ

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece, chair of the AAMC Council of Deans, said upgrading primary care's status and emphasis is “definitely on the agenda.” ©RICHARD LIPPENHOLZ

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Deans have played a “very active role” in securing more biomedical research funding, Dr. John E. Prescott, chief academic officer at the AAMC, said in an interview. They are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Deans have played a “very active role” in securing more biomedical research funding, Dr. John E. Prescott, chief academic officer at the AAMC, said in an interview. They are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine—a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000 to 2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Deans have played a “very active role” in securing more biomedical research funding, Dr. John E. Prescott, chief academic officer at the AAMC, said in an interview. They are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers being responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners” in the United States, said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act (formally, the American Recovery and Reinvestment Act of 2009) directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine, a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention. A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group. Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers being responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners” in the United States, said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act (formally, the American Recovery and Reinvestment Act of 2009) directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine, a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention. A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group. Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to convince Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care utilization and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview. The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation—a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion during 2005, according to the AAMC, with academic medical centers being responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners” in the United States, said Dr. Reece, also the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the “ripple effect” of declining funding—how it thwarts the careers of young scientists and physicians interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act (formally, the American Recovery and Reinvestment Act of 2009) directed $10 billion in new funds to the NIH—equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine, a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said that other questions for the medical school deans—questions that could drive the choice of issues for new or renewed focus—involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention. A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group. Other studies—including one published recently in Health Affairs—also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, chief academic officer at the AAMC.

Deans have played a “very active role” in securing more biomedical research funding, he said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care use and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview.

The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation–a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion in 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, who also serves as the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the ripple effect of declining funding–the way in which it thwarts the careers of young scientists and physicians who are interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funding to the NIH–equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine–a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans–questions that could drive the choice of issues for new or renewed focus–involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies–including one published recently in Health Affairs–also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, who serves as chief academic officer at the AAMC.

Medical school deans have played a “very active role” in securing more biomedical research funding, Dr. Prescott said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece is concerned about the ripple effect of declining funding. ©Richard Lippenholz

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care use and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview.

The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation–a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion in 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, who also serves as the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the ripple effect of declining funding–the way in which it thwarts the careers of young scientists and physicians who are interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funding to the NIH–equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine–a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans–questions that could drive the choice of issues for new or renewed focus–involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies–including one published recently in Health Affairs–also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, who serves as chief academic officer at the AAMC.

Medical school deans have played a “very active role” in securing more biomedical research funding, Dr. Prescott said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece is concerned about the ripple effect of declining funding. ©Richard Lippenholz

Fresh from their successful efforts to persuade Congress and the president to dramatically increase federal biomedical research funding, the nation's medical school deans are now working to prioritize which issues to tackle over the next several years.

The menu of issues is huge: There are crises in access to and cost of health care, an inadequate emphasis on preventive and primary care services, wide variations in health care use and quality of care, and a pace of translational research that many believe is much too slow.

“We're asking ourselves, what should we take on in the next 3–5 years, and how can we as medical school leaders maximize our value and contribution?” Dr. E. Albert Reece, who chairs the Association of American Medical Colleges' Council of Deans, said in an interview.

The council identifies issues affecting academic medicine and develops strategies to deal with them.

When Dr. Reece assumed the council chairmanship last October, biomedical research funding was the top issue. Since 2004, the budget of the National Institutes of Health had been reduced by 13% after factoring in inflation–a trend that leaders at the AAMC argued was slowing progress on critical research programs and creating a backlog of unfunded and underfunded biomedical research projects.

“Our approach with Congress and with the Obama transition team, and then the administration, was to point out how academic medical centers create a huge amount of economic activity,” said Dr. Reece, vice president for medical affairs at the University of Maryland and dean of the university's school of medicine in Baltimore.

The combined economic impact of the nation's 130 academic medical centers exceeded $450 billion in 2005, according to the AAMC, with academic medical centers responsible for the creation of more than 3 million jobs. “That's 1 out of 48 wage earners in the U.S.,” said Dr. Reece, who also serves as the John Z. and Akiko K. Bowers Distinguished Professor at the university.

In their meetings with legislators and other national leaders, Dr. Reece and his colleagues from other medical schools emphasized the ripple effect of declining funding–the way in which it thwarts the careers of young scientists and physicians who are interested in bench-to-bedside research, slows the amount and pace of such translational research, and ultimately adversely affects patient care.

The $787 billion Recovery Act, formally called the American Recovery and Reinvestment Act of 2009, directed $10 billion in new funding to the NIH–equivalent to a third of the institute's $29.5 billion annual budget and an amount higher than the deans and other supporters of increased funding had expected. Sen. Arlen Specter (R-Pa.) championed the new funding.

Now, said Dr. Reece, in addition to sustaining ongoing research, the deans will continue to explore and implement other ways of attracting more physician-scientists to academic medicine–a need identified by the Institute of Medicine's Clinical Research Roundtable (CRR) that, from 2000–2005, studied the challenges facing clinical research.

Easing loan repayments was among the many ideas examined by the CRR, said Dr. Reece, who served on the roundtable.

In an interview before an early April retreat of the Council of Deans, Dr. Reece said other questions for the medical school deans–questions that could drive the choice of issues for new or renewed focus–involve “maximizing the impact of research” and better preparing graduates for the future.

Upgrading primary care's status and emphasis is “definitely on the agenda,” he added.

Health care reform will likely favor primary care along with wellness and prevention.

A study by the AAMC has warned that demand for physicians will outpace supply faster for primary care than for any other specialty group.

Other studies–including one published recently in Health Affairs–also have projected a growing shortage of primary care physicians.

“The deans at most medical schools are making concerted efforts to improve the role that primary care physicians play in the delivery of care and medical education,” said Dr. John E. Prescott, who serves as chief academic officer at the AAMC.

Medical school deans have played a “very active role” in securing more biomedical research funding, Dr. Prescott said in an interview, and are now “leading efforts” on access to treatment and the quality of care.

For primary care physicians and advocates, Dr. Prescott added, “I think 2009 will be a significant one.”

Dr. E. Albert Reece is concerned about the ripple effect of declining funding. ©Richard Lippenholz

WASHINGTON — Preliminary analyses of a national registry of patients with the “understudied” condition of acute severe hypertension paint a picture of surprisingly high morbidity and mortality, and striking differences in physician management practices.

The STAT (Studying the Treatment of Acute Hypertension) registry, now closed, collected data from more than 1,580 patients in 25 hospitals—up to 120 consecutive patients in each hospital—in an effort to better understand the condition of acute hypertension that is managed in a critical care setting and treated with intravenous antihypertensive drugs, reported Dr. Kurt C. Kleinschmidt at the annual meeting of the Society of Academic Emergency Medicine.

Estimates are that up to 25% of patients in busy urban emergency departments (EDs) suffer from acute hypertension. Other than small retrospective studies, however, there are limited data available to guide physicians in the evaluation and management of these patients, said Dr. Kleinschmidt of the emergency medicine department at the University of Texas Southwestern Medical School, Dallas.

The STAT registry includes nonpregnant patients with at least one blood pressure reading greater than 180 mm Hg systolic and/or greater than 110 mm Hg diastolic, as well as patients with subarachnoid hemorrhage if they had a BP reading greater than 140 mm Hg systolic and/or greater than 90 mm Hg diastolic. All patients had to have been treated with an intravenous agent given as at least two boluses within 24 hours of hospital arrival and/or as a continuous infusion.

Initial analyses of the registry shed light on the patient population, patterns of care, and outcomes.

“It's a much sicker population than we'd anticipated … and there is an amazing collection of management strategies,” Dr. Kleinschmidt said.

Patients enrolled in the registry, managed by the Center for Outcomes Research at the University of Massachusetts, Worcester, had a mean age of 58 years. Most had a history of chronic hypertension (89%), and many (25%) were nonadherent to medications (25%). Almost 27% had had a prior admission for acute hypertension. The patients were almost equally men and women; 56% were black.

In nearly 80% of cases, intravenous antihypertensives were started in the ED. Management practices varied substantially with respect to the initial agent selected, the use of subsequent antihypertensives, and the timing of therapy.

Labetalol was the most commonly used first-line intravenous antihypertensive (31.5%), followed by metoprolol (17.4%), nitroglycerin (15.2%), hydralazine (14.8%), other antihypertensives (8.2%), nicardipine (7.6%), and sodium nitroprusside (5.2%). None of these medications was effective alone; all were followed by the addition of at least two other intravenous antihypertensives, “suggesting that none of the initial IV medications is particularly effective,” Dr. Kleinschmidt said in an interview.

Nicardipine was the least likely to be followed by other agents, he said, while sodium nitroprusside was most frequently followed by other medications. Therapy was initiated within 1 hour after acute severe hypertension was detected in about 47% of cases. In almost 11.5% of the cases, it took more than 6 hours. The median duration of intravenous therapy was 7.7 hours.

For patients without subarachnoid hemorrhage (1,419 of the more than 1,580 patients), the median time to achieve a systolic BP of less than 160 mm Hg was 4 hours. About 53% of patients had a re-elevation to greater than 180 mm Hg after initial control, and roughly 4% developed hypotension that required intervention.

For those patients who presented with subarachnoid hemorrhage, a systolic BP less than 140 mm Hg was reached in a median of 1.8 hours, and about 4% developed hypotension.

Overall, there was “considerable variability” in BP response over time, based on the initial antihypertensive agent selected, reported Dr. Kleinschmidt, also associate medical director of emergency services at Parkland Memorial Hospital, Dallas.

Nearly 60% of patients had evidence of target-organ injury associated with their hypertensive episodes. In-hospital mortality was almost 7%—a rate that is largely attributed to those patients with intracerebral hemorrhage.

WASHINGTON — Preliminary analyses of a national registry of patients with the “understudied” condition of acute severe hypertension paint a picture of surprisingly high morbidity and mortality, and striking differences in physician management practices.

The STAT (Studying the Treatment of Acute Hypertension) registry, now closed, collected data from more than 1,580 patients in 25 hospitals—up to 120 consecutive patients in each hospital—in an effort to better understand the condition of acute hypertension that is managed in a critical care setting and treated with intravenous antihypertensive drugs, reported Dr. Kurt C. Kleinschmidt at the annual meeting of the Society of Academic Emergency Medicine.

Estimates are that up to 25% of patients in busy urban emergency departments (EDs) suffer from acute hypertension. Other than small retrospective studies, however, there are limited data available to guide physicians in the evaluation and management of these patients, said Dr. Kleinschmidt of the emergency medicine department at the University of Texas Southwestern Medical School, Dallas.

The STAT registry includes nonpregnant patients with at least one blood pressure reading greater than 180 mm Hg systolic and/or greater than 110 mm Hg diastolic, as well as patients with subarachnoid hemorrhage if they had a BP reading greater than 140 mm Hg systolic and/or greater than 90 mm Hg diastolic. All patients had to have been treated with an intravenous agent given as at least two boluses within 24 hours of hospital arrival and/or as a continuous infusion.

Initial analyses of the registry shed light on the patient population, patterns of care, and outcomes.

“It's a much sicker population than we'd anticipated … and there is an amazing collection of management strategies,” Dr. Kleinschmidt said.

Patients enrolled in the registry, managed by the Center for Outcomes Research at the University of Massachusetts, Worcester, had a mean age of 58 years. Most had a history of chronic hypertension (89%), and many (25%) were nonadherent to medications (25%). Almost 27% had had a prior admission for acute hypertension. The patients were almost equally men and women; 56% were black.

In nearly 80% of cases, intravenous antihypertensives were started in the ED. Management practices varied substantially with respect to the initial agent selected, the use of subsequent antihypertensives, and the timing of therapy.

Labetalol was the most commonly used first-line intravenous antihypertensive (31.5%), followed by metoprolol (17.4%), nitroglycerin (15.2%), hydralazine (14.8%), other antihypertensives (8.2%), nicardipine (7.6%), and sodium nitroprusside (5.2%). None of these medications was effective alone; all were followed by the addition of at least two other intravenous antihypertensives, “suggesting that none of the initial IV medications is particularly effective,” Dr. Kleinschmidt said in an interview.

Nicardipine was the least likely to be followed by other agents, he said, while sodium nitroprusside was most frequently followed by other medications. Therapy was initiated within 1 hour after acute severe hypertension was detected in about 47% of cases. In almost 11.5% of the cases, it took more than 6 hours. The median duration of intravenous therapy was 7.7 hours.

For patients without subarachnoid hemorrhage (1,419 of the more than 1,580 patients), the median time to achieve a systolic BP of less than 160 mm Hg was 4 hours. About 53% of patients had a re-elevation to greater than 180 mm Hg after initial control, and roughly 4% developed hypotension that required intervention.

For those patients who presented with subarachnoid hemorrhage, a systolic BP less than 140 mm Hg was reached in a median of 1.8 hours, and about 4% developed hypotension.

Overall, there was “considerable variability” in BP response over time, based on the initial antihypertensive agent selected, reported Dr. Kleinschmidt, also associate medical director of emergency services at Parkland Memorial Hospital, Dallas.

Nearly 60% of patients had evidence of target-organ injury associated with their hypertensive episodes. In-hospital mortality was almost 7%—a rate that is largely attributed to those patients with intracerebral hemorrhage.

WASHINGTON — Preliminary analyses of a national registry of patients with the “understudied” condition of acute severe hypertension paint a picture of surprisingly high morbidity and mortality, and striking differences in physician management practices.

The STAT (Studying the Treatment of Acute Hypertension) registry, now closed, collected data from more than 1,580 patients in 25 hospitals—up to 120 consecutive patients in each hospital—in an effort to better understand the condition of acute hypertension that is managed in a critical care setting and treated with intravenous antihypertensive drugs, reported Dr. Kurt C. Kleinschmidt at the annual meeting of the Society of Academic Emergency Medicine.

Estimates are that up to 25% of patients in busy urban emergency departments (EDs) suffer from acute hypertension. Other than small retrospective studies, however, there are limited data available to guide physicians in the evaluation and management of these patients, said Dr. Kleinschmidt of the emergency medicine department at the University of Texas Southwestern Medical School, Dallas.

The STAT registry includes nonpregnant patients with at least one blood pressure reading greater than 180 mm Hg systolic and/or greater than 110 mm Hg diastolic, as well as patients with subarachnoid hemorrhage if they had a BP reading greater than 140 mm Hg systolic and/or greater than 90 mm Hg diastolic. All patients had to have been treated with an intravenous agent given as at least two boluses within 24 hours of hospital arrival and/or as a continuous infusion.

Initial analyses of the registry shed light on the patient population, patterns of care, and outcomes.

“It's a much sicker population than we'd anticipated … and there is an amazing collection of management strategies,” Dr. Kleinschmidt said.

Patients enrolled in the registry, managed by the Center for Outcomes Research at the University of Massachusetts, Worcester, had a mean age of 58 years. Most had a history of chronic hypertension (89%), and many (25%) were nonadherent to medications (25%). Almost 27% had had a prior admission for acute hypertension. The patients were almost equally men and women; 56% were black.

In nearly 80% of cases, intravenous antihypertensives were started in the ED. Management practices varied substantially with respect to the initial agent selected, the use of subsequent antihypertensives, and the timing of therapy.

Labetalol was the most commonly used first-line intravenous antihypertensive (31.5%), followed by metoprolol (17.4%), nitroglycerin (15.2%), hydralazine (14.8%), other antihypertensives (8.2%), nicardipine (7.6%), and sodium nitroprusside (5.2%). None of these medications was effective alone; all were followed by the addition of at least two other intravenous antihypertensives, “suggesting that none of the initial IV medications is particularly effective,” Dr. Kleinschmidt said in an interview.

Nicardipine was the least likely to be followed by other agents, he said, while sodium nitroprusside was most frequently followed by other medications. Therapy was initiated within 1 hour after acute severe hypertension was detected in about 47% of cases. In almost 11.5% of the cases, it took more than 6 hours. The median duration of intravenous therapy was 7.7 hours.

For patients without subarachnoid hemorrhage (1,419 of the more than 1,580 patients), the median time to achieve a systolic BP of less than 160 mm Hg was 4 hours. About 53% of patients had a re-elevation to greater than 180 mm Hg after initial control, and roughly 4% developed hypotension that required intervention.

For those patients who presented with subarachnoid hemorrhage, a systolic BP less than 140 mm Hg was reached in a median of 1.8 hours, and about 4% developed hypotension.

Overall, there was “considerable variability” in BP response over time, based on the initial antihypertensive agent selected, reported Dr. Kleinschmidt, also associate medical director of emergency services at Parkland Memorial Hospital, Dallas.

Nearly 60% of patients had evidence of target-organ injury associated with their hypertensive episodes. In-hospital mortality was almost 7%—a rate that is largely attributed to those patients with intracerebral hemorrhage.

For a copy of the EMTALA technical advisory group's final report, visit www.magpub.com/emtala/EMTALA%20Final%20Report_final.pdf

As the technical advisory group examining the Emergency Medical Treatment and Labor Act wraps up its work, some of its 55 recommendations are already finding their way into federal regulators' approaches to emergency on-call policies and specialty hospitals' responsibilities.

Despite those advances, the panel cautioned that larger issues within EMTALA remain to be addressed.

The panel put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

“One of our overarching goals was to encourage attending physician participation in the on-call system, to make it easier and more practical for physicians and hospitals to work together and fulfill their obligations,” said Dr. David M. Siegel, an emergency physician and lawyer who chaired the technical advisory group (TAG). “A lot of the clarifications and definitions we provided should have some impact if adopted.”

The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation.

CMS Considers On-Call Crisis

Several of the panel's recommendations to improve on-call systems already have been implemented or are under serious consideration.

The CMS changed its interpretive guidelines, for instance, to clarify that a treating physician has final say on whether an on-call physician should come to the emergency department, and that he or she may use a variety of methods, including telemedicine, to communicate.

CMS also has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The TAG's other recommendations cover a broad swath of issues, from improvement in EMTALA enforcement to review of “triage out” practices and improvement in medical screening exams and care for psychiatric patients, said Dr. Siegel, senior vice president at Meridian Health in Neptune, N.J.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians.

“They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means,” she added.

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

The panel also filed its report with a letter urging HHS to not only adopt the recommendations, but to give “serious consideration” to the larger, systemic issues that are fueling on-call problems across the country.

“No matter what we put together, the TAG recommendations will not solve the ongoing on-call crisis,” said panel member Dr. Mark Pearlmutter, chief of the Caritas Emergency Medical Group at St. Elizabeth's Medical Center, Boston.

Can Community Call Deliver?

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

The panel received testimony from leaders of various regional call pilot projects around the country “that [the projects] really worked,” Dr. Pearlmutter said. “It was very clear this was something we needed to recommend.”

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The TAG's final report also is sprinkled with high-priority recommendations aimed at making it clear that patients may not be transferred unnecessarily, and that hospitals must have—and review annually—plans for on-call coverage for services they regularly offer to the public. That includes specialty hospitals without dedicated emergency departments.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

Inpatient Transfers Hotly Debated

The advisory group closed with heated debate, when questions were raised near the end of the panel's seventh and final meeting last September about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized.

The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

“We heard testimony about hospitals getting on the phone and trying to transfer that patient to a receiving facility that refused, citing they had no obligation to do so,” Dr. Pearlmutter recalled.

After several votes, the panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance.

“Deciding what to recommend,” Dr. Pearlmutter said, “was a difficult, deliberate process.”

In the end, the contentious recommendation became one that CMS ran with. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

In a series of recommendations on psychiatric issues in the emergency setting, the group again “spoke to the issue that EMTALA requirements have not recognized the need for local responses,” Ms. Tomar said.

The advisory panel said, for instance, that physicians and hospitals can use community protocols, services, and resources to help determine whether psychiatric emergency medical conditions exist, and how and where patients should be placed and cared for.

Proposed EMTALA Policy Changes

Other high-priority recommendations in the EMTALA TAG's final report include:

▸ HHS should improve the consistency of EMTALA interpretations and enforcement across CMS regions, establish intermediate sanctions for less serious violations, and establish an appeals process for hospitals and providers.

▸ While taking calls selectively may violate EMTALA, taking calls for patients with whom the physician has a preexisting relationship should not be considered “selective call.”

▸ An emergency medical condition does not need to be resolved to be considered stabilized for the purpose of discharge—as long as it is determined that the patient's care can be reasonably performed as an outpatient or later as an inpatient, and as long as the patient receives a plan for follow-up care.

▸ HHS should monitor and evaluate, however, the consequences of deferred care and of patients being “triaged out.”

▸ A psychiatric medical screening exam should attempt to determine whether an individual is suicidal, homicidal, or gravely disabled (poses a danger to oneself because of extremely poor judgment or inability to care for oneself)—though such a determination does not necessarily mean the patient has an emergency medical condition.

▸ Hospitals with specialized behavioral health capabilities should be required to accept the transfer of patients who are gravely disabled and have an emergency medical condition, if these hospitals have the necessary resources and capacity and the transferring hospital does not.

▸ The use of chemical or physical restraints may provide a temporary safe environment by minimizing risk during patient transport, but it does not in itself stabilize a psychiatric emergency medical condition. Unless the hospital or physician can demonstrate that a patient is stabilized regardless of the restraints, EMTALA still applies.

For a copy of the EMTALA technical advisory group's final report, visit www.magpub.com/emtala/EMTALA%20Final%20Report_final.pdf

As the technical advisory group examining the Emergency Medical Treatment and Labor Act wraps up its work, some of its 55 recommendations are already finding their way into federal regulators' approaches to emergency on-call policies and specialty hospitals' responsibilities.

Despite those advances, the panel cautioned that larger issues within EMTALA remain to be addressed.

The panel put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

“One of our overarching goals was to encourage attending physician participation in the on-call system, to make it easier and more practical for physicians and hospitals to work together and fulfill their obligations,” said Dr. David M. Siegel, an emergency physician and lawyer who chaired the technical advisory group (TAG). “A lot of the clarifications and definitions we provided should have some impact if adopted.”

The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation.

CMS Considers On-Call Crisis

Several of the panel's recommendations to improve on-call systems already have been implemented or are under serious consideration.

The CMS changed its interpretive guidelines, for instance, to clarify that a treating physician has final say on whether an on-call physician should come to the emergency department, and that he or she may use a variety of methods, including telemedicine, to communicate.

CMS also has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The TAG's other recommendations cover a broad swath of issues, from improvement in EMTALA enforcement to review of “triage out” practices and improvement in medical screening exams and care for psychiatric patients, said Dr. Siegel, senior vice president at Meridian Health in Neptune, N.J.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians.

“They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means,” she added.

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

The panel also filed its report with a letter urging HHS to not only adopt the recommendations, but to give “serious consideration” to the larger, systemic issues that are fueling on-call problems across the country.

“No matter what we put together, the TAG recommendations will not solve the ongoing on-call crisis,” said panel member Dr. Mark Pearlmutter, chief of the Caritas Emergency Medical Group at St. Elizabeth's Medical Center, Boston.

Can Community Call Deliver?

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

The panel received testimony from leaders of various regional call pilot projects around the country “that [the projects] really worked,” Dr. Pearlmutter said. “It was very clear this was something we needed to recommend.”

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The TAG's final report also is sprinkled with high-priority recommendations aimed at making it clear that patients may not be transferred unnecessarily, and that hospitals must have—and review annually—plans for on-call coverage for services they regularly offer to the public. That includes specialty hospitals without dedicated emergency departments.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

Inpatient Transfers Hotly Debated

The advisory group closed with heated debate, when questions were raised near the end of the panel's seventh and final meeting last September about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized.

The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

“We heard testimony about hospitals getting on the phone and trying to transfer that patient to a receiving facility that refused, citing they had no obligation to do so,” Dr. Pearlmutter recalled.

After several votes, the panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance.

“Deciding what to recommend,” Dr. Pearlmutter said, “was a difficult, deliberate process.”

In the end, the contentious recommendation became one that CMS ran with. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

In a series of recommendations on psychiatric issues in the emergency setting, the group again “spoke to the issue that EMTALA requirements have not recognized the need for local responses,” Ms. Tomar said.

The advisory panel said, for instance, that physicians and hospitals can use community protocols, services, and resources to help determine whether psychiatric emergency medical conditions exist, and how and where patients should be placed and cared for.

Proposed EMTALA Policy Changes

Other high-priority recommendations in the EMTALA TAG's final report include:

▸ HHS should improve the consistency of EMTALA interpretations and enforcement across CMS regions, establish intermediate sanctions for less serious violations, and establish an appeals process for hospitals and providers.

▸ While taking calls selectively may violate EMTALA, taking calls for patients with whom the physician has a preexisting relationship should not be considered “selective call.”

▸ An emergency medical condition does not need to be resolved to be considered stabilized for the purpose of discharge—as long as it is determined that the patient's care can be reasonably performed as an outpatient or later as an inpatient, and as long as the patient receives a plan for follow-up care.

▸ HHS should monitor and evaluate, however, the consequences of deferred care and of patients being “triaged out.”

▸ A psychiatric medical screening exam should attempt to determine whether an individual is suicidal, homicidal, or gravely disabled (poses a danger to oneself because of extremely poor judgment or inability to care for oneself)—though such a determination does not necessarily mean the patient has an emergency medical condition.

▸ Hospitals with specialized behavioral health capabilities should be required to accept the transfer of patients who are gravely disabled and have an emergency medical condition, if these hospitals have the necessary resources and capacity and the transferring hospital does not.

▸ The use of chemical or physical restraints may provide a temporary safe environment by minimizing risk during patient transport, but it does not in itself stabilize a psychiatric emergency medical condition. Unless the hospital or physician can demonstrate that a patient is stabilized regardless of the restraints, EMTALA still applies.

For a copy of the EMTALA technical advisory group's final report, visit www.magpub.com/emtala/EMTALA%20Final%20Report_final.pdf

As the technical advisory group examining the Emergency Medical Treatment and Labor Act wraps up its work, some of its 55 recommendations are already finding their way into federal regulators' approaches to emergency on-call policies and specialty hospitals' responsibilities.

Despite those advances, the panel cautioned that larger issues within EMTALA remain to be addressed.

The panel put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

“One of our overarching goals was to encourage attending physician participation in the on-call system, to make it easier and more practical for physicians and hospitals to work together and fulfill their obligations,” said Dr. David M. Siegel, an emergency physician and lawyer who chaired the technical advisory group (TAG). “A lot of the clarifications and definitions we provided should have some impact if adopted.”

The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation.

CMS Considers On-Call Crisis

Several of the panel's recommendations to improve on-call systems already have been implemented or are under serious consideration.

The CMS changed its interpretive guidelines, for instance, to clarify that a treating physician has final say on whether an on-call physician should come to the emergency department, and that he or she may use a variety of methods, including telemedicine, to communicate.

CMS also has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The TAG's other recommendations cover a broad swath of issues, from improvement in EMTALA enforcement to review of “triage out” practices and improvement in medical screening exams and care for psychiatric patients, said Dr. Siegel, senior vice president at Meridian Health in Neptune, N.J.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians.

“They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means,” she added.

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

The panel also filed its report with a letter urging HHS to not only adopt the recommendations, but to give “serious consideration” to the larger, systemic issues that are fueling on-call problems across the country.

“No matter what we put together, the TAG recommendations will not solve the ongoing on-call crisis,” said panel member Dr. Mark Pearlmutter, chief of the Caritas Emergency Medical Group at St. Elizabeth's Medical Center, Boston.

Can Community Call Deliver?

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

The panel received testimony from leaders of various regional call pilot projects around the country “that [the projects] really worked,” Dr. Pearlmutter said. “It was very clear this was something we needed to recommend.”

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The TAG's final report also is sprinkled with high-priority recommendations aimed at making it clear that patients may not be transferred unnecessarily, and that hospitals must have—and review annually—plans for on-call coverage for services they regularly offer to the public. That includes specialty hospitals without dedicated emergency departments.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

Inpatient Transfers Hotly Debated

The advisory group closed with heated debate, when questions were raised near the end of the panel's seventh and final meeting last September about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized.

The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

“We heard testimony about hospitals getting on the phone and trying to transfer that patient to a receiving facility that refused, citing they had no obligation to do so,” Dr. Pearlmutter recalled.

After several votes, the panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance.

“Deciding what to recommend,” Dr. Pearlmutter said, “was a difficult, deliberate process.”

In the end, the contentious recommendation became one that CMS ran with. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

In a series of recommendations on psychiatric issues in the emergency setting, the group again “spoke to the issue that EMTALA requirements have not recognized the need for local responses,” Ms. Tomar said.

The advisory panel said, for instance, that physicians and hospitals can use community protocols, services, and resources to help determine whether psychiatric emergency medical conditions exist, and how and where patients should be placed and cared for.

Proposed EMTALA Policy Changes

Other high-priority recommendations in the EMTALA TAG's final report include:

▸ HHS should improve the consistency of EMTALA interpretations and enforcement across CMS regions, establish intermediate sanctions for less serious violations, and establish an appeals process for hospitals and providers.

▸ While taking calls selectively may violate EMTALA, taking calls for patients with whom the physician has a preexisting relationship should not be considered “selective call.”

▸ An emergency medical condition does not need to be resolved to be considered stabilized for the purpose of discharge—as long as it is determined that the patient's care can be reasonably performed as an outpatient or later as an inpatient, and as long as the patient receives a plan for follow-up care.

▸ HHS should monitor and evaluate, however, the consequences of deferred care and of patients being “triaged out.”

▸ A psychiatric medical screening exam should attempt to determine whether an individual is suicidal, homicidal, or gravely disabled (poses a danger to oneself because of extremely poor judgment or inability to care for oneself)—though such a determination does not necessarily mean the patient has an emergency medical condition.

▸ Hospitals with specialized behavioral health capabilities should be required to accept the transfer of patients who are gravely disabled and have an emergency medical condition, if these hospitals have the necessary resources and capacity and the transferring hospital does not.

▸ The use of chemical or physical restraints may provide a temporary safe environment by minimizing risk during patient transport, but it does not in itself stabilize a psychiatric emergency medical condition. Unless the hospital or physician can demonstrate that a patient is stabilized regardless of the restraints, EMTALA still applies.

The technical advisory group examining the Emergency Medical Treatment and Labor Act put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

The report recommends “community call” plans that share resources to fulfill EMTALA responsibilities, and emphasizes the obligations of specialty hospitals in meeting the on-call crisis. The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation. Several of the panel's recommendations to improve on-call systems already have been implemented.

The CMS has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians. “They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means.”

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

The advisory group closed with heated debate, when questions were raised about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized. The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

The panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance. And in the end, the CMS ran with the contentious recommendation. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

The technical advisory group examining the Emergency Medical Treatment and Labor Act put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

The report recommends “community call” plans that share resources to fulfill EMTALA responsibilities, and emphasizes the obligations of specialty hospitals in meeting the on-call crisis. The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation. Several of the panel's recommendations to improve on-call systems already have been implemented.

The CMS has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians. “They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means.”

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

The advisory group closed with heated debate, when questions were raised about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized. The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

The panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance. And in the end, the CMS ran with the contentious recommendation. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

The technical advisory group examining the Emergency Medical Treatment and Labor Act put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

The report recommends “community call” plans that share resources to fulfill EMTALA responsibilities, and emphasizes the obligations of specialty hospitals in meeting the on-call crisis. The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation. Several of the panel's recommendations to improve on-call systems already have been implemented.

The CMS has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians. “They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means.”

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

The advisory group closed with heated debate, when questions were raised about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized. The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

The panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance. And in the end, the CMS ran with the contentious recommendation. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

Palliative care for children and adolescents with chronic or advanced respiratory and critical illnesses is a significant part of a new clinical policy statement issued by the American Thoracic Society.

In issuing the 15-page policy on palliative care, the ATS joins a growing number of national bodies, including the American Academy of Pediatrics, that have addressed the importance of this care and the need for professional competence in providing it.

Today's model of palliative care refers to the relief of suffering during any stage of illness and not only the end stages, the ATS and others have emphasized.

The ATS statement lists and describes a number of overarching and timeless “values and principles” relating to palliative care for children and adults: the need for an individualized approach and a focus on the patient and his or her family, for instance, as well as the need to begin care when patients become symptomatic and the importance of a comprehensive and multidisciplinary approach.

The policy also provides practical information on managing dyspnea and pain, on the decision making process, and on issues such as withholding and withdrawing life support (Am. J. Respir. Crit. Care Med. 2008;177:912–27).

Studies of end-of-life care for children and adults with cystic fibrosis suggest that providers often do not discuss palliative care early enough or at all, the statement says.

“In children, cystic fibrosis is probably the paradigm case, and is a model in terms of its being family centered. The literature suggests, though, that communication about the goals of care in CF and how to best meet them could be improved,” said Dr. Paul N. Lanken, professor of medicine and medical ethics at the Hospital of the University of Pennsylvania, Philadelphia, and cochair of the task force that developed the policy.

“Children may be getting certain types of curative care up to the very end, even though the goals of care have turned to 100% palliative,” he said in an interview.

Parents of children with any chronic progressive disease should, the statement says, be “sensitively informed about the likely trajectory” of the child's disease, so that they can adequately plan for the child's goals of care and palliative support needs.

Children become mature enough to actively participate in decision making at all different ages, so their role should be assessed on an individual basis. With adolescents, however, shared decision making with their parents “should be promoted,” the policy says. The ATS policy statement also warns that pain in young children often results “as much from diagnostic and therapeutic procedures as from the disease itself” and calls for adequate treatment of pain during initial procedures.

It encourages physicians to access certain up-to-date, resource-rich Web sites, such as that of the Center to Advance Palliative Care (www.capc.org

Palliative care for children and adolescents with chronic or advanced respiratory and critical illnesses is a significant part of a new clinical policy statement issued by the American Thoracic Society.

In issuing the 15-page policy on palliative care, the ATS joins a growing number of national bodies, including the American Academy of Pediatrics, that have addressed the importance of this care and the need for professional competence in providing it.

Today's model of palliative care refers to the relief of suffering during any stage of illness and not only the end stages, the ATS and others have emphasized.

The ATS statement lists and describes a number of overarching and timeless “values and principles” relating to palliative care for children and adults: the need for an individualized approach and a focus on the patient and his or her family, for instance, as well as the need to begin care when patients become symptomatic and the importance of a comprehensive and multidisciplinary approach.

The policy also provides practical information on managing dyspnea and pain, on the decision making process, and on issues such as withholding and withdrawing life support (Am. J. Respir. Crit. Care Med. 2008;177:912–27).

Studies of end-of-life care for children and adults with cystic fibrosis suggest that providers often do not discuss palliative care early enough or at all, the statement says.

“In children, cystic fibrosis is probably the paradigm case, and is a model in terms of its being family centered. The literature suggests, though, that communication about the goals of care in CF and how to best meet them could be improved,” said Dr. Paul N. Lanken, professor of medicine and medical ethics at the Hospital of the University of Pennsylvania, Philadelphia, and cochair of the task force that developed the policy.

“Children may be getting certain types of curative care up to the very end, even though the goals of care have turned to 100% palliative,” he said in an interview.

Parents of children with any chronic progressive disease should, the statement says, be “sensitively informed about the likely trajectory” of the child's disease, so that they can adequately plan for the child's goals of care and palliative support needs.

Children become mature enough to actively participate in decision making at all different ages, so their role should be assessed on an individual basis. With adolescents, however, shared decision making with their parents “should be promoted,” the policy says. The ATS policy statement also warns that pain in young children often results “as much from diagnostic and therapeutic procedures as from the disease itself” and calls for adequate treatment of pain during initial procedures.

It encourages physicians to access certain up-to-date, resource-rich Web sites, such as that of the Center to Advance Palliative Care (www.capc.org

Palliative care for children and adolescents with chronic or advanced respiratory and critical illnesses is a significant part of a new clinical policy statement issued by the American Thoracic Society.

In issuing the 15-page policy on palliative care, the ATS joins a growing number of national bodies, including the American Academy of Pediatrics, that have addressed the importance of this care and the need for professional competence in providing it.

Today's model of palliative care refers to the relief of suffering during any stage of illness and not only the end stages, the ATS and others have emphasized.

The ATS statement lists and describes a number of overarching and timeless “values and principles” relating to palliative care for children and adults: the need for an individualized approach and a focus on the patient and his or her family, for instance, as well as the need to begin care when patients become symptomatic and the importance of a comprehensive and multidisciplinary approach.

The policy also provides practical information on managing dyspnea and pain, on the decision making process, and on issues such as withholding and withdrawing life support (Am. J. Respir. Crit. Care Med. 2008;177:912–27).

Studies of end-of-life care for children and adults with cystic fibrosis suggest that providers often do not discuss palliative care early enough or at all, the statement says.

“In children, cystic fibrosis is probably the paradigm case, and is a model in terms of its being family centered. The literature suggests, though, that communication about the goals of care in CF and how to best meet them could be improved,” said Dr. Paul N. Lanken, professor of medicine and medical ethics at the Hospital of the University of Pennsylvania, Philadelphia, and cochair of the task force that developed the policy.

“Children may be getting certain types of curative care up to the very end, even though the goals of care have turned to 100% palliative,” he said in an interview.

Parents of children with any chronic progressive disease should, the statement says, be “sensitively informed about the likely trajectory” of the child's disease, so that they can adequately plan for the child's goals of care and palliative support needs.

Children become mature enough to actively participate in decision making at all different ages, so their role should be assessed on an individual basis. With adolescents, however, shared decision making with their parents “should be promoted,” the policy says. The ATS policy statement also warns that pain in young children often results “as much from diagnostic and therapeutic procedures as from the disease itself” and calls for adequate treatment of pain during initial procedures.

It encourages physicians to access certain up-to-date, resource-rich Web sites, such as that of the Center to Advance Palliative Care (www.capc.org

WASHINGTON — Cardiopulmonary resuscitation is often poorly performed by paramedics, physicians, and other well-trained hospital staff, and several problems—mainly frequent pauses and slow compression rates, shallow compression depths, and hyperventilation—are significantly reducing survival from cardiac arrest, emergency medicine leaders said.

“We can triple survival to hospital discharge by [addressing these problems] and doing good basic life support,” said Dr. Ahamed H. Idris, director of emergency medicine research at Southwestern Medical Center, Dallas, during a panel discussion on resuscitation at the annual meeting of the Society of Academic Emergency Medicine.

Research presented earlier at the meeting by Dr. Henry Wang of the University of Pittsburgh was emblematic of the growing body of data. His study of out-of-hospital cardiac arrests treated by paramedics documented frequent and prolonged interruptions in chest compressions due to endotracheal intubation (ETI) efforts.

Of 129 cases of cardiac arrest, they identified ETI-associated chest compression interruptions in 64 cases. The median duration of all ETI-associated interruptions was 78 seconds, Dr. Wang reported, and 35% of the interruptions exceeded 120 seconds.

Published reports of in-hospital cardiac arrest care have similarly documented widely variable and suboptimal chest compression rates, among other problems.

“We need to better monitor the quality of CPR” in and out of our hospitals, said Dr. Benjamin Abella, clinical research director of the Center for Resuscitative Science at the University of Pennsylvania Health System, Philadelphia, during the panel discussion.

Among the most recent studies published on cardiac arrest care is one published in January 2008 showing that delayed defibrillation is common and is associated with lower rates of survival.

Investigators identified 6,789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at approximately 370 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. They found that delayed defibrillation (more than a minute) was associated with a significantly lower probability of surviving to hospital discharge (22% vs. 39%) than was defibrillation that was not delayed (N. Engl. J. Med. 2008;358:9-17).

Dr. Abella said studies at his institution have shown that the chance of successful shock plummets with every 5, 10, or 15 seconds of additional pausing.

“If we can get the shock out in less than 10 seconds vs. 20 or 30 seconds, it makes a huge difference in terms of shock efficacy,” he said.

“We now know … that pauses [in CPR] are lethal,” Dr. Abella said in an interview, citing the landmark study published in 2000 that compared standard CPR (then cycles of 15 compressions and two breaths) with chest compression alone. The study utilized a dispatcher-assisted CPR program in Seattle, in which individuals who called 911 could be instructed in CPR. Investigators found that about 15% of the patients whose rescuers were instructed only in chest compression survived, compared with about 10% of those whose rescuers were instructed in rescue breathing and compression (Crit. Care Med. 2000;28:N190-2).

The study had significant limitations, but “at the time, this was shocking,” he said, “We all thought that breaths should be important.”

With respect to compression depth, animal studies have also shown that a coronary perfusion pressure of approximately 15 mm is necessary for resuscitation. In one study, that pressure (and a good survival rate) was achieved with compressions that were 2 inches deep, but not with compressions of 1.5 inches. In fact, all of the animals that received 2-inch-deep compressions survived, while very few of the animals that received 1.5-inch compressions survived.

Hyperventilation during CPR is also a problem. Changes to the American Heart Association's CPR guidelines published in 2005—namely, the change in the recommended ratio of compressions to breaths from 15:2 to 30:2—were intended to address this point.

With regard to the optimal rate of chest compression during CPR for cardiac arrest, new data come partly from prospective observational studies that Dr. Abella and his associates have performed of in-hospital cardiac arrests. The studies have revealed an inconsistent quality of CPR that often does not meet published guideline recommendations.

One of the studies, which covered 67 patients, documented chest compression rates of less than 90/min in 28% of recorded 30-second segments of CPR. Current guidelines recommend a rate of 100 compressions/min. The study also documented a shallow compression depth of less than 38 mm for 37% of compressions, as well as high ventilation rates, with more than 20 breaths/min given during 61% of CPR segments (JAMA 2005;293:305-10).

Another of the studies similarly showed compression rates of less than 80/min in 37% of CPR segments, and rates of less than 70/min in 22% of segments. Such suboptimal rates were associated with poor return of spontaneous circulation, Dr. Abella explained (Circulation 2005;111:428-34).

The most important message from his own research, Dr. Idris said, is not that there is a specific ideal compression rate, but that the more chest compressions per minute a patient receives, the better the outcome. “If a patient receives 80-100 compressions/min, the survival rate more than triples, compared to 20 chest compressions/min,” he explained.

Dr. Abella and his colleagues at the University of Pennsylvania, Philadelphia, have recently increased their rates of survival to hospital discharge for cardiac arrest patients by using defibrillators that monitor CPR, recording and providing feedback on the depth and rate of compressions. They also have initiated a “debriefing” program in which leaders routinely meet with rescue teams to review CPR data immediately after care is given.

EMS programs in Seattle and other locations, in the meantime, have begun telling their paramedics “to start compressions immediately and not intubate—to bag only—for the first 10 minutes,” Dr. Idris said.

With 80-100 compressions/min, the survival rate more than triples, compared with 20 compressions/min. DR. IDRIS

Some EMS programs have begun telling paramedics to start compressions immediately and not intubate—to bag only—for the first 10 minutes. ©Nancy Louie/iStockphoto, Inc.

WASHINGTON — Cardiopulmonary resuscitation is often poorly performed by paramedics, physicians, and other well-trained hospital staff, and several problems—mainly frequent pauses and slow compression rates, shallow compression depths, and hyperventilation—are significantly reducing survival from cardiac arrest, emergency medicine leaders said.

“We can triple survival to hospital discharge by [addressing these problems] and doing good basic life support,” said Dr. Ahamed H. Idris, director of emergency medicine research at Southwestern Medical Center, Dallas, during a panel discussion on resuscitation at the annual meeting of the Society of Academic Emergency Medicine.

Research presented earlier at the meeting by Dr. Henry Wang of the University of Pittsburgh was emblematic of the growing body of data. His study of out-of-hospital cardiac arrests treated by paramedics documented frequent and prolonged interruptions in chest compressions due to endotracheal intubation (ETI) efforts.

Of 129 cases of cardiac arrest, they identified ETI-associated chest compression interruptions in 64 cases. The median duration of all ETI-associated interruptions was 78 seconds, Dr. Wang reported, and 35% of the interruptions exceeded 120 seconds.

Published reports of in-hospital cardiac arrest care have similarly documented widely variable and suboptimal chest compression rates, among other problems.

“We need to better monitor the quality of CPR” in and out of our hospitals, said Dr. Benjamin Abella, clinical research director of the Center for Resuscitative Science at the University of Pennsylvania Health System, Philadelphia, during the panel discussion.

Among the most recent studies published on cardiac arrest care is one published in January 2008 showing that delayed defibrillation is common and is associated with lower rates of survival.

Investigators identified 6,789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at approximately 370 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. They found that delayed defibrillation (more than a minute) was associated with a significantly lower probability of surviving to hospital discharge (22% vs. 39%) than was defibrillation that was not delayed (N. Engl. J. Med. 2008;358:9-17).

Dr. Abella said studies at his institution have shown that the chance of successful shock plummets with every 5, 10, or 15 seconds of additional pausing.

“If we can get the shock out in less than 10 seconds vs. 20 or 30 seconds, it makes a huge difference in terms of shock efficacy,” he said.

“We now know … that pauses [in CPR] are lethal,” Dr. Abella said in an interview, citing the landmark study published in 2000 that compared standard CPR (then cycles of 15 compressions and two breaths) with chest compression alone. The study utilized a dispatcher-assisted CPR program in Seattle, in which individuals who called 911 could be instructed in CPR. Investigators found that about 15% of the patients whose rescuers were instructed only in chest compression survived, compared with about 10% of those whose rescuers were instructed in rescue breathing and compression (Crit. Care Med. 2000;28:N190-2).

The study had significant limitations, but “at the time, this was shocking,” he said, “We all thought that breaths should be important.”

With respect to compression depth, animal studies have also shown that a coronary perfusion pressure of approximately 15 mm is necessary for resuscitation. In one study, that pressure (and a good survival rate) was achieved with compressions that were 2 inches deep, but not with compressions of 1.5 inches. In fact, all of the animals that received 2-inch-deep compressions survived, while very few of the animals that received 1.5-inch compressions survived.

Hyperventilation during CPR is also a problem. Changes to the American Heart Association's CPR guidelines published in 2005—namely, the change in the recommended ratio of compressions to breaths from 15:2 to 30:2—were intended to address this point.

With regard to the optimal rate of chest compression during CPR for cardiac arrest, new data come partly from prospective observational studies that Dr. Abella and his associates have performed of in-hospital cardiac arrests. The studies have revealed an inconsistent quality of CPR that often does not meet published guideline recommendations.

One of the studies, which covered 67 patients, documented chest compression rates of less than 90/min in 28% of recorded 30-second segments of CPR. Current guidelines recommend a rate of 100 compressions/min. The study also documented a shallow compression depth of less than 38 mm for 37% of compressions, as well as high ventilation rates, with more than 20 breaths/min given during 61% of CPR segments (JAMA 2005;293:305-10).

Another of the studies similarly showed compression rates of less than 80/min in 37% of CPR segments, and rates of less than 70/min in 22% of segments. Such suboptimal rates were associated with poor return of spontaneous circulation, Dr. Abella explained (Circulation 2005;111:428-34).

The most important message from his own research, Dr. Idris said, is not that there is a specific ideal compression rate, but that the more chest compressions per minute a patient receives, the better the outcome. “If a patient receives 80-100 compressions/min, the survival rate more than triples, compared to 20 chest compressions/min,” he explained.

Dr. Abella and his colleagues at the University of Pennsylvania, Philadelphia, have recently increased their rates of survival to hospital discharge for cardiac arrest patients by using defibrillators that monitor CPR, recording and providing feedback on the depth and rate of compressions. They also have initiated a “debriefing” program in which leaders routinely meet with rescue teams to review CPR data immediately after care is given.

EMS programs in Seattle and other locations, in the meantime, have begun telling their paramedics “to start compressions immediately and not intubate—to bag only—for the first 10 minutes,” Dr. Idris said.

With 80-100 compressions/min, the survival rate more than triples, compared with 20 compressions/min. DR. IDRIS

Some EMS programs have begun telling paramedics to start compressions immediately and not intubate—to bag only—for the first 10 minutes. ©Nancy Louie/iStockphoto, Inc.

WASHINGTON — Cardiopulmonary resuscitation is often poorly performed by paramedics, physicians, and other well-trained hospital staff, and several problems—mainly frequent pauses and slow compression rates, shallow compression depths, and hyperventilation—are significantly reducing survival from cardiac arrest, emergency medicine leaders said.

“We can triple survival to hospital discharge by [addressing these problems] and doing good basic life support,” said Dr. Ahamed H. Idris, director of emergency medicine research at Southwestern Medical Center, Dallas, during a panel discussion on resuscitation at the annual meeting of the Society of Academic Emergency Medicine.

Research presented earlier at the meeting by Dr. Henry Wang of the University of Pittsburgh was emblematic of the growing body of data. His study of out-of-hospital cardiac arrests treated by paramedics documented frequent and prolonged interruptions in chest compressions due to endotracheal intubation (ETI) efforts.

Of 129 cases of cardiac arrest, they identified ETI-associated chest compression interruptions in 64 cases. The median duration of all ETI-associated interruptions was 78 seconds, Dr. Wang reported, and 35% of the interruptions exceeded 120 seconds.

Published reports of in-hospital cardiac arrest care have similarly documented widely variable and suboptimal chest compression rates, among other problems.

“We need to better monitor the quality of CPR” in and out of our hospitals, said Dr. Benjamin Abella, clinical research director of the Center for Resuscitative Science at the University of Pennsylvania Health System, Philadelphia, during the panel discussion.

Among the most recent studies published on cardiac arrest care is one published in January 2008 showing that delayed defibrillation is common and is associated with lower rates of survival.

Investigators identified 6,789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at approximately 370 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. They found that delayed defibrillation (more than a minute) was associated with a significantly lower probability of surviving to hospital discharge (22% vs. 39%) than was defibrillation that was not delayed (N. Engl. J. Med. 2008;358:9-17).

Dr. Abella said studies at his institution have shown that the chance of successful shock plummets with every 5, 10, or 15 seconds of additional pausing.

“If we can get the shock out in less than 10 seconds vs. 20 or 30 seconds, it makes a huge difference in terms of shock efficacy,” he said.

“We now know … that pauses [in CPR] are lethal,” Dr. Abella said in an interview, citing the landmark study published in 2000 that compared standard CPR (then cycles of 15 compressions and two breaths) with chest compression alone. The study utilized a dispatcher-assisted CPR program in Seattle, in which individuals who called 911 could be instructed in CPR. Investigators found that about 15% of the patients whose rescuers were instructed only in chest compression survived, compared with about 10% of those whose rescuers were instructed in rescue breathing and compression (Crit. Care Med. 2000;28:N190-2).

The study had significant limitations, but “at the time, this was shocking,” he said, “We all thought that breaths should be important.”

With respect to compression depth, animal studies have also shown that a coronary perfusion pressure of approximately 15 mm is necessary for resuscitation. In one study, that pressure (and a good survival rate) was achieved with compressions that were 2 inches deep, but not with compressions of 1.5 inches. In fact, all of the animals that received 2-inch-deep compressions survived, while very few of the animals that received 1.5-inch compressions survived.

Hyperventilation during CPR is also a problem. Changes to the American Heart Association's CPR guidelines published in 2005—namely, the change in the recommended ratio of compressions to breaths from 15:2 to 30:2—were intended to address this point.

With regard to the optimal rate of chest compression during CPR for cardiac arrest, new data come partly from prospective observational studies that Dr. Abella and his associates have performed of in-hospital cardiac arrests. The studies have revealed an inconsistent quality of CPR that often does not meet published guideline recommendations.

One of the studies, which covered 67 patients, documented chest compression rates of less than 90/min in 28% of recorded 30-second segments of CPR. Current guidelines recommend a rate of 100 compressions/min. The study also documented a shallow compression depth of less than 38 mm for 37% of compressions, as well as high ventilation rates, with more than 20 breaths/min given during 61% of CPR segments (JAMA 2005;293:305-10).

Another of the studies similarly showed compression rates of less than 80/min in 37% of CPR segments, and rates of less than 70/min in 22% of segments. Such suboptimal rates were associated with poor return of spontaneous circulation, Dr. Abella explained (Circulation 2005;111:428-34).

The most important message from his own research, Dr. Idris said, is not that there is a specific ideal compression rate, but that the more chest compressions per minute a patient receives, the better the outcome. “If a patient receives 80-100 compressions/min, the survival rate more than triples, compared to 20 chest compressions/min,” he explained.

Dr. Abella and his colleagues at the University of Pennsylvania, Philadelphia, have recently increased their rates of survival to hospital discharge for cardiac arrest patients by using defibrillators that monitor CPR, recording and providing feedback on the depth and rate of compressions. They also have initiated a “debriefing” program in which leaders routinely meet with rescue teams to review CPR data immediately after care is given.

EMS programs in Seattle and other locations, in the meantime, have begun telling their paramedics “to start compressions immediately and not intubate—to bag only—for the first 10 minutes,” Dr. Idris said.

With 80-100 compressions/min, the survival rate more than triples, compared with 20 compressions/min. DR. IDRIS

Some EMS programs have begun telling paramedics to start compressions immediately and not intubate—to bag only—for the first 10 minutes. ©Nancy Louie/iStockphoto, Inc.