578 COMMENTARIES Boyd • ED CATEGORIZATION

Emergency Department Categorization:Solid First Steps

The conceptual and practicalbasis for the need to cate-

gorize hospitals is fairly straight-forward: 1) hospitals are notequal in size, capability, or com-mitment; 2) the only way to un-derstand and rationally arrangescarce and/or expensive hospitalresources is via an objective eval-uation process; 3) patient popu-lation planning for both generaland disease-specific demand re-quirements can be reasonablybased on these assessments; 4)professional standards and per-formance expectations are es-tablished from these ratings;5) institutions do not providethe necessary resources to meetthese standards unless they are‘‘required’’ to do so; 6) hospi-tal administrators overestimatetheir institutional capabilitiesand performances; and 7) an ap-propriately categorized, desig-nated emergency medical ser-vices (EMS) system can expectcost and performance improve-ments regionally and within par-ticipating hospitals. In fact, hos-pital categorization is theobjective and rational way tosound EMS planning and opera-tions. It’s the only way to ‘‘un-scramble the omelette.’’

The SAEM Board of Directorsand the EC Categorization TaskForce are to be congratulated fortheir courage and willingness toembark on this crucial and im-portant venture to reexamineand upgrade the standards forthe categorization of the Level 1ED. This process is typically slowand methodical during the devel-opmental period, with scant in-terest beyond the organizingcommittee. It requires touchingbase with all relevant profes-sional and institutional inter-ests, getting input from all, mak-ing sure every one has had his or

her say, and formulating the ba-sic survey documents. Trust me,the interest and tempo in thisproject will dramatically in-crease as the consensus docu-ments start circulating, gaincredibility, and become imple-mented.

I have been keenly interestedin the subject of hospital emer-gency facility categorization for anumber of years. My experiencestarted with the original EMSsystem ‘‘categorization’’ program,i.e. ‘‘The Illinois Trauma Center’’program,1 and later the ‘‘TotalStatewide EMS System forIllinois’’ 2,3 (1971–1974). Fromthese beginnings, the opera-tional terms of ‘‘horizontal’’ and‘‘vertical’’ categorization of hos-pital emergency capabilities andarea-wide designation of spe-cialty advanced care centerswere introduced. The Illinoistrauma program is still the mostrepresentative example of ‘‘selec-tive designation’’ using a verticalassessment of a hospital’s totalcapabilities for a specific diseaseentity. Echelon designations on aregional basis were initially formajor trauma, but are readilyfashioned for burns, spinal cordinjury, limb reimplantation, andadvanced cardiac, pediatric crit-ical care, perinatal, and behav-ioral emergencies.

As the Illinois Trauma/EMSprogram logically developed, theobvious need to evaluate all hos-pitals for their everyday horizon-tal capabilities for the generalemergency patient became ap-parent. These essential Trauma/EMS program tasks were accom-plished through a combination ofprogram policies, national guide-lines, and state hospital regula-tions. Success in Illinois can beattributed to the credibility ofthe ‘‘EMS lead agency’’ in the

state health department, the ob-jectivity of the categorizationtools, and the acceptance of theintent and process by the hospi-tal and professional community.A most important factor was ourassurance that the categoriza-tion process would be imple-mented on a regional/areawidebasis. The final result was the to-tal involvement statewide ofevery licensed hospital in: 1)areawide EMS planning (28 ar-eas), 2) general horizontal emer-gency categorization (general,basic, or standby), and 3) selec-tive center vertical designationson a regional and macroregionalbasis for trauma (regional, area-wide, and local), burns, spinalcord injury, etc.

Because of the prime impor-tance that hospital categoriza-tion holds for serious EMS sys-tems planning, as the EMSDirector of the Department ofHealth and Human Services(DHHS), I embarked on a nation-wide horizontal/vertical hospitalcategorization effort during thefirst years of the EMS SystemsAct of 1973 and as amended in1976 and 1979.4 All federallyfunded EMS systems regionalprojects (303) were required toassess all of their hospitals’emergency medical capabilitiesusing the available nationallyrecognized general and disease-specific categorization guide-lines.

I have had the opportunity toreview the categorization docu-ments being presented by theSAEM EC Categorization TaskForce.5 These include the poli-cies, procedures, and criteria forthe designation of Level 1 emer-gency care centers. I find these tobe basically sound in content andin the currently accepted format.These criteria will set goals forleadership emergency facilitiesand set their requirements forestablishing services, education,and research. Paradoxically as itmay seem, the proper approachto EMS system planning is to es-

ACADEMIC EMERGENCY MEDICINE • June 1999, Volume 6, Number 6 579

tablish the highest attainable lo-cus in the system and work out-ward from this. By establishingthe Level 1 ED criterion for ac-ademic centers, the stabilizingthree components of excellencein care, education, and researchare emphasized. The rationalcategorization of other levels ofemergency care based on thesethree essential components, butwith appropriate emphasis, canthen develop for the large andsmall, private and public, teach-ing and nonteaching, and urban,suburban, and rural EDs. Thiscontinuing process will by ra-tional necessity involve a widerspectrum of provider and orga-nizational interests.

An appropriate question iswho should lead in this process?In the originating national effortcredible professionals initiatedthese activities, using acceptedconsensus-developed guidelines,through the auspices of the na-tional and state public healthservices. These activities werepresented through a ‘‘due pro-cess’’ and as ‘‘voluntary,’’ howeverfew hospitals selected out of theprocess once it was in play. TheSAEM effort will need to main-tain its credibility in the aca-demic sphere as it moves for-ward in this process. If otherlevels of EDs are to be catego-rized, appropriate professional/political alignment with theAmerican College of EmergencyPhysicians (ACEP) and otheremergency medicine organiza-tions is advisable. Accommoda-tion with the Joint Commissionon Accreditation of HealthcareOrganizations (JCAHO) is un-necessary as they have smallbearing on academic areas. Attheir best, they set minimalstandards.

The opposition and antici-pated resistance to this catego-rization process have alwaysbeen and predictably will beagain from the hospital associa-tions. While in their constitu-ents’ best interest, in the inter-

view skeptically activities affect-ing their members and in whichthey have little input and con-trol. Physicians and other pro-viders passionately representingtheir ‘‘unique’’ situations willprotest the harmful effects ontheir institutions. Other facili-ties not yet being considered willprotest being left out (i.e., com-munity and rural hospitals).Other professional associationswill complain of lack of input and‘‘treading on their turf ’’ andother manifestations of per-ceived loss of power. The publichealth EMS agencies of todaywill not provide active support.

I trust these comments willbe of some assistance to theSAEM Level 1 emergency centercategorization program. I wishthe program well and the best ofluck in this important effort.Success will be measured bySAEM’s credibility, objectivity,and determination to stay thecourse. I would like to see thisbecome a solid first step to EMScommunity reaffirmation of thisessential system component andthe recategorization of all hospi-

tals for the new millennium.—DAVID BOYD, MDCM, (For-merly) National EMS System Di-rector, Public Health Service, De-partment of Health and HumanServices, Washington, DC; (Cur-rently) Surgery Service, BlackfeetIndian Health Service Hospital,Browning, MT

Key words. emergency depart-ments; categorization; SAEM; emer-gency medical services.

References

1. Boyd DR (ed). A symposium on the Il-linois trauma program: a systems ap-proach to the care of the critically in-jured. J Trauma. 1973; 13:275–320.2. Boyd DR. Efforts to improve emer-gency medical service: the Illinois expe-rience. J Am Coll Emerg Physicians.1977; 6:209–17.3. Boyd DR. A total emergency medicalservices system for Illinois. Illinois MedJ. 1972; 142:486–8.4. Law of the 93rd Congress, EMS Sys-tems Development Act of 1973, PublicLaw 93-154, Washington, DC, Nov 16,1973. Amended, Public Law 94-573(1976) and Public Law 96-142 (1979).5. Goldfrank L, Henneman PL, Ling LJ,Prescott JE, Rosen C, Sama A, for theEC Categorization Task Force. Emer-gency center categorization standards.Acad Emerg Med. 1999; 6:638–55.

Are Outpatient Admission Sources Truly aRisk Factor for Appendiceal Rupture?

In this issue of AcademicEmergency Medicine, Buckley

and colleagues1 identify risk fac-tors predicting appendiceal rup-ture among patients hospitalizedwith a final diagnosis of acuteappendicitis. In particular, theyexamined whether patients withappendicitis admitted from out-patient settings are more likelyto suffer rupture than are thoseadmitted from a hospital ED. Anexplicit reason for targeting ad-mission source as a potentialrisk factor for ruptures was notstated, although it was impliedthat appendiceal rupture and itsrisk factors may serve as senti-nel markers for the quality of

health care for acute time-depen-dent diseases. Using a multivar-iate analysis of an existing da-tabase, the authors did indeedfind that patients hospitalizedfrom routine outpatient admis-sion sources were 1.6 times morelikely to experience an appendi-ceal rupture than are patientsadmitted from the ED.

The authors acknowledgedthat their retrospective study de-sign was limited in its ability toexplain the reasons that outpa-tient settings were an indepen-dent predictor of rupture. None-theless, they speculated thatoutpatient offices and clinicsmay place patients with appen-