terial. But not only that, they find that in many cases it enables them to provide same-day service or service the following morning on orders received which, of course, makes it possible for the hospitals to vastly reduce the amount of drugs, the amount of equipment that they have to have on hand, because they have the assurance that they can order it today and have it tomorrow.

Senator HATFIELD. As you know, one of the basic problems we face in the whole health field is the problem of rising costs, particularly as it involves hospital care. I think it is very significant in this potential that you describe here for hospital administration, could represent a significant reduction in costs of operation for hospitals. Is this not true?

Mr. CALLAHAN. Yes, sir; and with the introduction of Touch-Tone telephone service which we will be describing later on, that cost reduction will be even further developed, because-well, a typical price of a Touch-Tone telephone card dialer such as I have here is around $4.50 a month. It has the capability of transmitting ordering information directly to the computer in the way that the Salem people are planning, and replaces an arrangement that presently costs nearly $40 a month in total. Of course, at the same time, it serves the purpose of a regular telephone also.

So there is real potential here for reducing hospital administrative

costs.

Senator HATFIELD. Thank you, Mr. Chairman.

Senator NELSON. Go ahead.

Mr. CALLAHAN. In pursuing the cardiac emergency one more step, I would like to raise the question of what happens when a cardiac arrest occurs, when a heart stops. Today thousands are being restored to life through cardiopulmonary resuscitation, an emergency measure in which a stopped heart is brought back to life by rhythmic pressure on the chest. These hearts have been temporarily stilled by strokes, heart attacks, drug reactions, or accidents.

According to the American Heart Association Committee on External Cardiopulmonary Resuscitation, the tragedy is that for every life saved by this technique, probably a dozen are lost because it is not used. Resuscitation is possible in many of the over 500,000 heart disease deaths, the many thousand heart arrests in surgery, and the many thousands of deaths from drowning, suffocation, electric shocks, and other accidents. Tests show that salvage from these deaths can perhaps average more than 100,000 lives per year. The key difficulty is the need to reach the heart victim within 2 minutes; that is, before the brain dies or is irreparably damaged for lack of oxygen.

When an attack occurs in a hospital, the staff can only respond if they are aware of the situation. How do you notify everyone who needs to know-doctors, nurses, technicians spread throughout a large complex? Obviously proper communications are vital, for even within a hospital, it is estimated that 30 percent of patients having attacks die. The problem is compounded by the fact that if a patient is not in the intensive-care ward, staff coordination becomes even more critical, since vital equipment is located in other sections of the hospital. It is therefore necessary to have some form of communications that will alert emergency team members wherever they may be in the medi

L cal complex; also, to advise other personnel involved in the preparation of operating rooms and vital equipment.

What we would like to show you now is a command alert telephone system that was specially designed to meet this need in any hospital with dial switching telephone service. The backbone of this system is dial switching equipment that provides the regular telephone service in a hospital.

Let me briefly describe the actions that ensue in a matter of seconds. A patient in room 324 has suffered a cardiac arrest. A nurse can initiate an alert from any dial telephone in the hospital-the one right next to the patient's bed, for instance. There is no special telephone needed for this purpose. The nurse simply dials a special number that has been designated for this particular purpose. Let's say 1212 is this emergency number. The telephone is immediately connected to an announcement machine and a tone is returned to the telephone which tells the nurse, we are ready for message.

The nurse now simply says, "Code Blue, Room 324," and hangs up. Now, this is a typical code used to indicate an emergency condition in a hospital, "Code Blue." This has only taken the nurse a few seconds and it is all the action that is required by her to bring the patient the support she needs. She now can devote her full attention to the patient. While the nurse is recording the message, the switching equipment is ringing preselected hospital telephones with a distinctive ringing signal. These can be any telephones associated with the hospital system and can vary according to the established emergency procedures. Anyone answering these telephones will hear the alert message, "Code Blue, Room 324."

In the event the telephone is busy at the time of the alert, spurts of tone will be heard on the line signaling that an emergency condition exists. As soon as the person hangs up the telephone, it will ring with the distinctive signal. Upon answering, they will get the alarm, "Code Blue, Room 324."

At the same time, the dial switching equipment can also seize control of the paging system, stop all public address announcements, and broadcast the alert message. Also simultaneously, signaling devices such as pocket radios, horns, bells, or lights can be activated. Any members of the resuscitation team seeing or hearing the signal will dial a predetermined number from any telephone in the hospital to receive the alert message. The emergency code would activate emergency vehicles, shutting off the 110-volt power supply that charges the self-contained batteries and activating the electronic apparatus contained in the cart, such as electrocardiographic and electroencephalographic equipment. This places all the equipment in a ready condition for service the instant the cart reaches the patient.

An elevator is a key factor in moving the resuscitation equipment to the patient and can also be activated by the dial equipment. Upon receiving a signal, the elevator will close its doors and move automatically to the floor where the resuscitation cart or equipment is stored. On arrival, the doors will open and the electric power will be cut off to prevent the car's use by anyone else during the emergency. This cuts vital seconds off the time needed to move the equipment to the patient. The elevator will then be waiting to move the patient to the operating

room.

All of this has taken place immediately and automatically as a result of the nurse making a simple telephone call of only a few seconds' duration.

During this period, the system can also be monitored by the switchboard attendant, although no action has been required on her part to coordinate any part of the procedure. The system is not limited to cardiopulmonary emergencies. A separate code could be established for an obstetrical emergency-say, 3333 instead of 1212, and a different set of hospital telephones would be activated. Likewise, surgical or civil emergencies could have their own separate codes.

We have invited Dr. Joel J. Nobel, director of the Graduate Pain Research Foundation in Philadelphia, who has done considerable work in conjunction with this system, to describe the impact of the command telephone system on hospital emergency service.

Dr. Nobel is with us today and I would like to present him at this time.

Senator NELSON. Dr. Nobel, the committee appreciates your coming here today. Would you furnish the reporter your full name and

identification for the record?

STATEMENT OF DR. JOEL J. NOBEL, DIRECTOR, GRADUATE PAIN RESEARCH FOUNDATION, PHILADELPHIA, PA.

Dr. NOBEL. Thank you, Mr. Chairman. It is my privilege.

I am Joel J. Nobel, director of the Graduate Pain Research Foundation in Philadelphia.

Senator NELSON. Go ahead, Dr. Nobel.

Dr. NOBEL. Thank you.

The limiting factor in the survival of many patients requiring emergency medical care within the hospital or on arrival in the emergency room is the time required to mobilize emergency care resources. The patient with cardiac arrest is irretrievable if resuscitation is not begun within a few seconds or minutes and the accident victim may die if emergency surgery is delayed.

Despite the current tendency to concentrate more critically ill patients in specialized intensive or coronary care units, emergencies are and will remain a hospitalwide phenomena. Our capability for predicting which patient is a likely candidate for emergency care is still rather limited. From the staffing viewpoint, it is impossible to have a three or four person team with no other duties, standing by 24 hours a day awaiting an emergency. Team members normally have routine hospital duties which they interrupt for emergencies. Team members, like emergencies themselves, can therefore be in any location. The goal of emergency mobilization is, of course, to deliver a competent, well-equipped team to the patient's bedside as quickly as possible. The time required to bring personnel and equipment to the patient is directly related to delays in communications, elevators, and characteristics of equipment and the physical plant of the hospital.

In large or high-rise urban hospitals, it may require from 3 to 10 minutes to get personnel and equipment to the bedside. Rarely is emergency surgery underway in less than 20 or 25 minutes once a patient has reached the emergency room. The two greatest problems are communications and elevator delays.

Over the past 3 years we have conducted time motion studies of emergency car and concluded that any mobilization system which relies on an entirely human-operated communications sequence is unsatisfactory.

If, for example, a switchboard operator must individually call and awaken four or five people for a night emergency, we can expect unacceptable time delays. Frequently the room number of the emergency location is given in error, either because of the nurse reporting the emergency or, much more frequently, because the operator panics, confuses the message, and mispages the location. This error, due to the operator, actually occurs about 12 percent of the time.

Following a study of many human and technical factors in emergency care mobilization, we identified the problem areas and designed a system which, we feel, will add a new measure of effectiveness to emergency care within the hospital.

We are developing a hospital emergency command system with the support of the Research and Demonstration Grants Branch, Division of Hospital and Medical Facilities of the U.S. Public Health Service. The hospital emergency command system incorporates what was previously described, the command system communications system, with one of its subsystems or components. The total system will permit simultaneous and immediate mobilization of communications, personnel, equipment, and elevators by a single initiating call from any hospital dial telephone.

(The hospital emergency command system illustration referred to follows:)

HOSPITAL EMERGENCY COMMAND SYSTEM

Dr. NOBEL. Furthermore, it provides a selective mobilization response to the varying requirements of cardiopulmonary arrest, or emergency surgery, or obstetrical emergencies or civil disasters causing a large number of injured persons.

What happens at the present time?

An accident ward nurse must make from five to 10 individual telephone calls to set up emergency surgery at the very time her assistance is most needed at the patient's side. Usually the operating room, admissions, anesthesia, hematology, blood bank, surgical resident, and intern staff physician must all be notified. A nurse at the bedside of a patient requiring resuscitation must wait from 10 to 80 seconds for the switchboard operator to respond to her need for help with a busy daytime switchboard. This is the very time when she must provide physiological support of the patient. She has to breathe for the patient and perform other immediately necessary duties. Communications is critical, but physiological support of the patient is even more desperate.

When the operator does respond, she often mispages the room location. Once knowing where to go, the emergency team members must then wait a lengthy period for an elevator. Elevator delays in hospitals I am sure you have experienced these delays can be astronomical in terms of timing for emergency mobilization.

With the hospital emergency command system under development, the nurse at the bedside picks up the telephone, dials a specific number, for example 1212. Keep in mind again, this is the very time the critical support of the patient is required and we do not want the nurse preoccupied with administrative problems in communications.

She says "Code Blue, Room 705" and hangs up. There is no switchboard operator lag period. The nurses' voice is recorded. At the same time, a series of vital telephones ring simultaneously with a very distinct ring. Vital phones might include heart station, anesthesia, and night on-call rooms. If the phone is in use, there is a priority interrupt and the message is still transmitted. The system also transmits the message over the public address system and triggers pocket page receivers. The command system also activities a special emergency cart. This mobile emergency life support system was developed by us 3 years ago to decrease the time required for critical medical emergency procedures, to reduce the number of persons required on the team, to eliminate many common errors in technique, and because of selfcontained power and oxygen to sustain the moribund patient in transit to the operating room or intensive care unit. Briefly, it reduces the time required for critical procedures tenfold and reduces the size of the team by half. It is now in general use throughout the United States, in Europe and Vietnam.

(The mobile emergency life support system illustration referred to appears on facing page.)

Dr. NOBEL. The hospital emergency command system transmits an electrical signal to this emergency cart which energizes its elapsed time meter and electronic equipment. The elapsed time meter indicates, of course, the time since the initial alerting telephone call and thus provides a continuous timing reference to the team.

How long has it been since the original event occurred, since there was transmission of the message, what time has gone by, should we