CONTENTS
NHTSA realized the need for agencies, organizations, and individuals involved in EMS to evaluate their roles and chart a course to the future. The EMS Agenda for the Futureprovides an opportunity for all health care providers to examine what has been learned during the past 30 years. Its purpose is to outline the most important directions for future EMS development. During the process of creating this document, the EMS Agenda for the Future Steering Committee sought and incorporated input from a broad, multidisciplinary spectrum of EMS stakeholders.
As the Steering Committee points out, this agenda comes at an important time, when the nation’s health care system is undergoing constant and rapid evolution. Resulting health care system changes will affect EMS and its health care delivery roles.
As we look to the future it is clear that EMS must be integrated with other services and systems that are intended to maintain and improve community health and ensure its safety. We must also focus on aspects of EMS that improve its science, strengthen its infrastructure, and broaden its involvement in enhancing the health of our communities. The Agenda describes 14 EMS attributes and proposes continued development of them, enabling all of us to strive for a vision that emphasizes a critical role for EMS in caring for our nation’s health.
Our EMS experiences over the past 30 years provide us with a basis on which to create the future. It is important, however, not to be held hostage to the past, but to look freely to the future. The EMS Agenda for the Future is an important tool for doing that. It will be a valuable resource for government officials and all health care providers and administrators, including EMS administrators, medical directors, managers, and all EMS providers. NHTSA is proud to have co-sponsored the project that led to completion of this document, and is indebted to the Steering Committee and all those who participated. As both NHTSA’s administrator and an emergency physician, I wholeheartedly endorse the vision and the convictions to be found within the pages that follow.
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During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive development and growth. Yet initiatives to create a system to provide emergency medical care for the nation’s population began with limited knowledge about what constituted the most efficient processes for delivering ideal resources to the spectrum of situations encountered by contemporary EMS.
The EMS Agenda for the Future provides an opportunity to examine what has been learned during the past three decades and create a vision for the future. This opportunity comes at an important time, when those agencies, organizations, and individuals that affect EMS are evaluating its role in the context of a rapidly evolving health care system.
The EMS Agenda for the Future project was supported by the National Highway Traffic Safety Administration and the Health Resources and Services Administration, Maternal and Child Health Bureau. This document focuses on aspects of EMS related to emergency care outside traditional health care facilities. It recognizes the changes occurring in the health care system of which EMS is a part. EMS of the future will be community-based health management that is fully integrated with the over-all health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. EMS will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net.
To realize this vision, the EMS Agenda for the Future proposes continued development of 14 EMS
attributes. They are:
This document serves as guidance for EMS providers, health care organizations and institutions, governmental agencies, and policy makers. They must be committed to improving the health of their communities and to ensuring that EMS efficiently contributes to that goal. They must invest the resources necessary to provide the nation’s population with emergency health care that is reliably accessible, effective, subject to continuous evaluation, and integrated with the remainder of the health system.
The EMS Agenda for the Future provides a vision for out-of-facility EMS. Achieving such a vision
will require deliberate action and application of the knowledge gained during the past 30 year EMS
experience. If pursued conscientiously, it will be an achievement with great benefits for all of society.
Staffing the acute care response vehicle are Nancy Quam, Community Health Advanced Medical Practitioner (CHAMP) and Ed Perez, Community Health Intermediate Practitioner (CHIP). Nancy became a CHAMP because she recognized a declining need for physicians. She was credentialed following a four-year college degree program. Many of her colleagues were previous paramedics and nurses who became credentialed through career-bridging programs. Ed Perez was credentialed as a CHIP after a one-year academic program. He currently goes to school part-time, on a scholarship, working toward becoming a CHAMP. As Quam and Perez proceed toward Joe’s home, a transponder in their vehicle changes all traffic signals in their favor. Also, digital displays in all area vehicles are alerted that there is an emergency vehicle in their vicinity. The PSAC computer informs Quam and Perez that neither a personal risk analysis (PRA) nor a domicile risk analysis (DRA) has been performed in the past five years.
As Quam and Perez arrive at the home, four minutes after the initial linkage with CHM, they notice substandard lighting on the home’s outside walkways and front-porch steps in need of repair. They also note that a maintenance light is illuminated on the CHM annunciator panel. As they greet the patient, they realize that he does not speak English well. Perez puts the translator module into his PDA, then he speaks to the PDA which translates his voice to Russian.
The all-systems monitor is applied to the patient’s arm and across his chest. Physiologic data is acquired by the monitor’s computer chip, then it is analyzed on the scene and transmitted via burst technology to the medical command center 100 miles away. By communicating through their PDAs, Quam and Perez are able to acquire the patient’s history. Through Quam’s PDA video screen, she establishes a video connect with the MCC. The MCC EMS physician requests additional Level III monitoring which reveals the patient’s carbon monoxide level to be 14%.
Analysis of all the data by the MCC computer and EMS physician suggests a 96% probability of acute myocardial ischemia. Quam and the EMS physician confer and the patient subsequently is administered short -acting thrombolytics and IV antioxidants. The nearest cardiac care center that is part of Joe’s health network is identified and alerted by computer. Joe is transported there, even though other hospitals may be closer. He is examined very briefly in the emergency department and taken directly to the cardiac catheterization laboratory. There he undergoes complete laser debridement of his coronary arteries. Joe suffers no myocardial enzyme leak, there is no permanent cardiac damage, and he is discharged in two days.
Following Quam’s and Perez’s report, a PRA and a DRA are requested. Joe’s health care network contracts with their agency to return to the home where they learn that the family did not completely understand the CHM’s operations. Thus, when its carbon monoxide sensor had failed they were unaware. The health care network subsequently offers a matching grant to repair an aging furnace, the CHM, and the other environmental hazards noted by Quam and Perez. In follow up, it was determined that Joe had been noncompliant with his previous medication instructions due to lack of understanding. A new caseworker is assigned who ensures that Joe understands his health care instructions and begins to minimize all his risk factors.
Joe lives to 94 years old.
The roots of emergency medical services (EMS)are deep in history. The EMS chronology provides an overview of some important EMS developments (please refer to Appendix A for more detailed historical perspectives). During the past 30 years, EMS in the United States has experienced an explosive evolution. The predisposing factors for such development have been multifactorial, including an appreciation that better response might improve patient outcomes for some medical conditions. The initial EMS growth spurt began with a lack of knowledge about what constituted the most efficient processes for delivering the ideal resources to the spectrum of situations addressed by today’s EMS systems.
We are now able to examine what has been learned during the past three decades, in order to refine contemporary EMS. This opportunity comes at a time when EMS systems and agencies and individuals responsible for EMS structure, processes, and outcomes are evaluating their roles within a rapidly evolving health care system and during an era of fiscal restraint. Recognizing its need and potential impact, the National Highway Traffic Safety Administration (NHTSA) and the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) provided funding to support completion of the EMS Agenda for the Future.
EMS CHRONOLOGY
| 1797 | Napoleon’s chief physician implements a prehospital system designed to triage and transport the injured from the field to aid stations |
| 1860s | Civilian ambulance services begin in Cincinnati and New York City |
| 1915 | First known air medical transport occurs during the retreat of the Serbian army from Albania |
| 1920s | First volunteer rescue squads organize in Roanoke, Virginia, and along the New Jersey coast |
| 1958 | Dr. Peter Safar demonstrates the efficacy of mouth-to-mouth ventilation |
| 1960 | Cardiopulmonary resuscitation (CPR) is shown to be efficacious |
| 1966 | The National Academy of Sciences, National Research Council publishes Accidental Death and Disability: The Neglected Disease of Modern Society |
| 1966 | Highway Safety Act of 1966 establishes the Emergency Medical Services Program in the Department of Transportation |
| 1972 | Department of Health, Education, and Welfare allocates 16 million dollars to EMS demonstration programs in five states |
| 1973 | The Robert Wood Johnson Foundation appropriates 15 million dollars to fund 44 EMS projects in 32 states and Puerto Rico |
| 1973 | The Emergency Medical Services Systems (EMSS) Act provides additional federal guidelines and funding for the development of regional EMS systems; the law establishes 15 components of EMS systems |
| 1981 | The Omnibus Budget Reconciliation Act consolidates EMS funding into state preventive health and health services block grants, and eliminates funding under the EMSS Act |
| 1984 | The EMS for Children program, under the Public Health Act, provides funds for enhancing the EMS system to better serve pediatric patients |
| 1985 | National Research Council publishes Injury in America: A Continuing Public Health Problem describing deficiencies in the progress of addressing the problem of accidental death and disability |
| 1988 | The National Highway Traffic Safety Administration initiates the Statewide EMS Technical Assessment program based on ten key components of EMS systems |
| 1990 | The Trauma Care Systems and Development Act encourages development of inclusive trauma systems and provides funding to states for trauma system planning, implementation, and evaluation |
| 1993 | The Institute of Medicine publishes Emergency Medical Services for Children which points out deficiencies in our health care system’s ability to address the emergency medical needs of pediatric patients |
| 1995 | Congress does not reauthorize funding under the Trauma Care Systems and Development Act |
| PURPOSE |
| ASSUMPTIONS |
EMS of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will serve as the public emergency medical safety net.
The focus of this document is the component of the EMS system which provides emergency care remote from a health care facility. This health care mission is accomplished utilizing principles of public health and public safety systems.
EMS certainly does not exist in isolation, but is integrated with other services and systems intended to maintain and enhance community health and ensure its safety. Therefore, EMS is affected by changes that occur within those arenas. Opportunities and challenges will be created by interacting with those responsible for overall maintenance of community health, including providers of continuous health care. Currently, the term “managed care organization” (MCO) describes the combination of insurer and health care provider. Although the future of the term “MCO” is unclear, the concept of large regional providers and underwriters of health care is becoming more pervasive. Opportunities exist for EMS systems to develop model relationships with other components of the health care system, while maintaining a commitment to public safety services to improve community health.
Emergency medical services have and will continue to raise the standards for community health care by implementing innovative techniques and systems to deliver the emergency care that is needed by the entire population. The following sections focus on important EMS attributes, and provide direction and guiding principles for future EMS development that will facilitate EMS systems’ abilities to fulfill their health care mission.
The EMS Agenda for the Future presents a perspective from a single point in time. As the environment in which EMS exists is dynamic, this document is intended to serve as a guiding reference only until the next periodic re-evaluation of EMS issues. Planning for such evaluation should commence as implementation of the Agenda is contemplated.
Discussion of EMS attributes in any particular
sequence, as in the text of this document, is not
a statement regarding their relative importance.
The vignettes of the future in each section are intended
to be illustrative and thought-provoking.
They are not meant to advocate specific actions
or terminology.
"Out-of-facility care is an integral component of the health care system. EMS focuses on out-of-
facility care and also supports efforts to implement cost-effective community health care. By integrating
with other health system components EMS improves health care for the entire community, including children,
the elderly, and others with special needs."
Integration of health care services helps to ensure that the care provided by EMS does not occur in isolation, and that positive effects are enhanced by linkage with other community health resources and integration within the health care system.
EMS provides out-of-facility medical care to those with perceived urgent needs. It is a component of the overall health care system. EMS delivers treatment as part of, or in combination with, systematic approaches intended to attenuate morbidity and mortality for specific patient subpopulations.
The future: Ella is 78 years old, and she trips and falls in her living room. Although initially she is unable to get herself up, she summons EMS via a voice recognition habitat monitor. The EMS providers do not find serious injuries, but suspect an ankle sprain. They schedule an appointment for Ella later that day with her primary care source, via a palmsize computer. They also are able to request transportation for her after consultation with the medical command center. While at Ella’s, the EMS providers note that her home is oppressively hot due to a malfunctioning air conditioner, and that there are numerous risk factors for future falls. Using their computer, they arrange for social services to follow-up, they notify her primary care provider, notify her building maintenance supervisor, and they schedule an EMS return visit to check on progress. Ella avoids an emergency department visit, is treated for her ankle sprain, and she receives attention that reduces her numerous risk factors for future health problems.
| WHERE WE ARE |
As a component of the health care delivery system, EMS addresses all possible injuries and illnesses, and treats all ages. It is a component of, and is also comprised by, systems intended to provide care for specific diseases and population segments. Contemporary EMS systems were created to meet the immediate needs of the acutely ill and injured; to provide “stabilization” and transportation. EMS, in general, meets these objectives in relative isolation from other health care and community resources. Reports have been published regarding public health surveillance by EMS personnel and referral to social services agencies.50,51,69 However, most EMS systems are disconnected from other community resources, except perhaps other public safety agencies, and are not involved in the business of ensuring follow-up by social service agencies or other community agencies/resources potentially able to intervene when patients need support. Thus, the potential positive effects of EMS, in terms of improved health for individual patients and the community, remain unrealized.
EMS providers, in general, do not provide or ensure medical follow- up for patients who are not transported. Failure to obtain such care in a timely fashion may be an issue responsible for suboptimal patient outcomes and litigation involving EMS systems and personnel. Lack of integration with other health care providers limits the ability of EMS to coordinate aftercare for its patients.
Except for familiarity with medical direction facilities and emergency departments, EMS personnel in general, do not have substantial working knowledge of the practices of other community health care providers and the policies of regional health care organizations. Thus, they are unable to integrate their care with sources for patients’ continuing health care.
A model for incorporating EMS systems and health monitoring referral systems has been described. 61 Some EMS systems are conducting pilot projects to determine the benefits of collaboration and routine communication with patients’ health care providers, organizations and networks. Other projects are exploring an expanded role for EMS regarding the clinical care it provides.115
| WHERE WE WANT TO BE |
For its patients and the community as a whole, EMS provides care and service that is integrated with other health care providers and community health resources. Thus, EMS patients are assured that their care is considered part of a complete health care program, connected to sources for continuous and/or follow-up care, and linked to other potentially beneficial health resources.
Out-of-facility care is considered to be an integral component of the health care system. The attributes or elements of out-of-facility care are shared by the other health care components. Each EMS attribute applies to all groups of potential EMS patients, addressing the needs of all community members. Furthermore, the borders among patient groups, system attributes, and health care components are not discrete and are shared (Figure 1).
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EMS focuses on out-of-facility care and, at the same time, it supports efforts to implement cost-effective community health care. Out-of-facility care is a component of the comprehensive health care system, and EMS shares structural and process elements common to all health care system components. Furthermore, EMS is a resource for community health care delivery.
EMS maintains liaisons, including systems for communication with other community resources, such as other public safety agencies, departments of public health, social service agencies and organizations, health care provider networks, community health educators, and others. This enables EMS to be proactive in affecting people’s long-term health by relaying information regarding potentially unhealthy situations (e.g., potential for injury), providing referrals to agencies with a vested interest in maintaining the health of their clients. Multiple dispositions are possible when a call is received at a public safety answering point; additional multiple dispositions are available following patient evaluation by EMS personnel. EMS is a community health resource, able to initiate important follow-up care for patients, whether or not they are transported to a health care facility.
EMS is integrated with other health care providers, including health care provider organizations and networks, and primary care physicians. As a health care provider, EMS, with medical direction, facilitates access for its patients to appropriate sources of medical care. Integration ensures that EMS patients receive appropriate follow-up medical care, and that the episodic care provided by EMS is considered a component of each patient’s medical history that affects the plan for continuing health care.
EMS integrates with other health system components to improve its care for the entire community, including children, the elderly, those who are chronically dependent on medical devices, and others. This ensures that the population is better served, and that the special needs of specific patients are addressed adequately.
Efforts to improve EMS care for specific segments of the population recognize the need for, and advocate implementation of, system enhancements that benefit the entire population. These efforts often include attention to functional system design, health care personnel education, and equipment and facility resources.
| HOW TO GET THERE |
EMS must expand its public health role and develop ongoing relationships with community public health and social services resources. Such relationships should result in systems of communication that enable referrals and subsequent follow-up by those agencies. Relationships should benefit all parties by improved understanding of factors contributing to issues being addressed. Reports of the effectiveness of these relationships should be disseminated.
EMS must become involved in the business of community health monitoring, including participation in data collection and transmittal to appropriate community and health care agencies. Long-term effects of such efforts must be widely reported.
EMS systems must seek to become integrated with other health care providers and provider organizations and networks. Integration should benefit patients by enhancing and maintaining the continuum of care. Communications systems, including confidential transmittal of patient-related data, should be developed. These should explore the utility of continuing communications technological advances. Mutually acceptable clinical guidelines regarding patient treatment and transport also must be developed.
Health care provider organizations and networks must incorporate EMS within their structures to deliver quality health care. They must not impede the community’s immediate access to EMS when a perceived emergency exists.
EMS medical direction must be cognizant of the special medical needs of all population segments and, through continuous processes, ensure that EMS is integrated with health care delivery systems striving to optimally meet these needs. An EMS physician, collaborating with other community physicians (including pediatricians, surgeons, family practitioners, internists, emergency physicians, and others) and health care professionals (including nurses, nurse practitioners, physician’s assistants, paramedics, administrators, and others), should ultimately be responsible and have authority for EMS medical direction and, in partnerships with system administrators, effect system improvements.
EMS must incorporate health systems that address the special needs of all population segments served (e.g., pediatric, geriatric, medical device-dependent; and other patients in urban, suburban, rural, and frontier areas). Such systems or plans should include education, system design, and resource components. They must be developed with input from members of the community. Groups unable to represent themselves, such as children, must be represented by others who are familiar with their needs.
Emergency medical services leaders must continue to identify issues of interest to policy makers to address specific aspects of EMS, and improve the system as a whole. Attention paid to EMS components should be done with consideration of the entire system.
Research and pilot projects should be conducted with regard to expanded services that may be provided by EMS. Efforts to enhance services should focus foremost on improving those currently delivered by EMS, and might also lead to services that enable patients to seek follow-up care in a less urgent manner and/or facility. These projects should address objective meaningful patient outcomes, EMS staffing requirements, personnel education issues, quality evaluations, legal issues, and cost-effectiveness. They must also include logistical evaluations such as the ongoing capabilities of EMS to respond to critical emergencies (e.g., cardiac arrests). These studies must precede widespread adoption of such practices and results should be disseminated and subjected to scrutiny.
INTEGRATION OF HEALTH SERVICES:
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“The future of EMS is indelibly linked to the future of EMS research. This reality provides EMS with its greatest opportunities, its greatest risks, and its greatest single need to depart from the ways of the past. EMS must grasp this quickly closing window of opportunity.”
Research involves pursuit of the truth. In EMS, its purpose is to determine the efficacy, effectiveness, and efficiency of emergency medical care. Ultimately, it is an effort to improve care and allocation of resources.
The future: A new pharmacologic agent becomes available and might potentially decrease the morbidity of stroke. Theoretically, the sooner the medication is administered after symptom on-set, the more effective it is likely to be. However, it is expensive and has accompanying risks. Therefore, a multi-EMS system study is funded by the National Institutes of Health (NIH). Over the course of two years, information is collected from the participating EMS systems about control patients and those who were treated with the new medication in the field. The information includes out-of-facility EMS data that is linked with hospital and rehabilitation data. Subsequently, the cost-effectiveness and risks of administering the medication in the field are determined and EMS practices are adjusted accordingly.
| WHERE WE ARE |
EMS has evolved rapidly over the past 30 years despite slow progress in developing EMS-related research. System changes frequently prompt research efforts to prove they make a difference, instead of the more appropriate sequence of using research findings as a basis for EMS improvements.
Most of what is known about EMS has been generated by researchers at a small number of medical schools, generally in midsized cities, that have ongoing relationships with municipal EMS systems. The volume of EMS research is low and the quality often pales in comparison with other medical research.
Most published EMS research is component-based, focusing on a single intervention or health problem, and rarely addressing the inherent complexities of EMS systems.119 With few exceptions, there has been little emphasis on systems analysis. Development of the “chain of survival” concept for cardiac emergencies provides the best evidence of completed systems research.22,94 Trauma-related research comprises the only other EMS research emphasis.119 However, study methods have not been as extensively developed, and experimental designs often limit abilities to compare studies and reach meaningful conclusions.65 Other clinical conditions have not been scientifically studied with a systems approach. Component-based analyses often lead to conclusions that are incorrect, or at least cannot be supported, when they are considered in the context of the entire EMS system.119,120 Thus, in many cases, our poor understanding of systems research models has led to the development of wrong assumptions with regard to EMS care.
Currently there are five major impediments to the development of quality EMS research:
Without dramatic progress on these five fronts, there will not be a significant increase in the quantity of well-done, meaningful EMS research.
Significant barriers to collecting relevant, meaningful, and accurate EMS data exist.120 EMS data often are not collected in a rigorous fashion that allows academic evaluation. Linkage with hospital and other data sets, which is required to determine EMS effectiveness, is difficult and infrequently accomplished.
A national agenda for EMS-related research does not exist, and there is no central source for EMS research funding. The EMS-C program has invested in system development and research affecting not only pediatric issues, but all of EMS.39 Other federal agencies, including the Health Resources Services Administration, Agency for Health Care Policy and Research, and NHTSA have also sponsored EMS-related investigations. Additional support often is sought from private and corporate interests. However, funding frequently is directed only toward component-based studies. Overall, financial support for EMS-related research is inadequate to address the many systems issues requiring study.
Overly restrictive informed consent interpretations create additional barriers to conducting EMS research. They do not consider the clinical and environmental circumstances of field EMS investigations, and impede institutional review board approval of meaningful resuscitation research and other field trials.
EMS education curricula do not include adequate research-related objectives. Thus, very few EMS personnel, including system administrators and managers, have a sufficient baseline understanding and appreciation of the critical role of EMS research. Unlike most other clinical fields, EMS research often is conducted without significant participation by its own practitioners, relying instead on others.
The rationale for many routine EMS interventions is based on in-hospital studies, and not on scientific investigation of their out-of-hospital effectiveness. The effectiveness of most EMS interventions and of EMS systems, in general, has not been well established with outcome criteria.35 Furthermore, the outcome criterion most studied is death, which, although important, is not pertinent to most EMS clinical situations.35,45
| WHERE WE WANT TO BE |
The essential nature of quality EMS research is recognized. A sufficient volume of quality research is undertaken to determine the effectiveness of EMS system design and specific interventions.
EMS evolves with a scientific basis. Adequate investigations of EMS interventions/treatments and system designs occur before they are advocated as EMS standards. The efficacy, effectiveness and cost-effectiveness of such interventions and system designs are determined. This includes the identification of patients who are appropriate for transport, and evaluation of the effects of alternative dispositions for patients when they are not transported to health care facilities.
As much as possible, EMS research employs systems analysis models. These models use multidisciplinary approaches to answer complex questions. They consider many issues that impact a system to help ensure that findings are accurate within the context of multifaceted EMS systems.
The National Institutes of Health (NIH) are committed to EMS-related research. NIH participates in setting a national agenda and provides EMS-related research funding.
Integrated information systems provide linkages between EMS and other public safety services and health care providers. They facilitate the data collection necessary to determine EMS effectiveness.
Several academic centers have long-term commitments to EMS research. They serve as a nucleus of activity that involves many EMS systems with different characteristics and all personnel levels, including field providers, managers, administrators, nurses, and physicians.
Informed consent rules account for the clinical and environmental circumstances of EMS research. They enable credible resuscitation and other out-of-facility investigations to be conducted.
EMS personnel of all levels and credentials appreciate the role of EMS research in terms of creating a scientific basis for EMS patient care. All individuals with some responsibility for EMS structure, process, and/or outcomes are involved, to some extent, with EMS research.
EMS research examines multiple outcome criteria. Thus, it is pertinent to most EMS clinical situations, which do not involve a likelihood of death.
| HOW TO GET THERE |
Public and private organizations responsible for EMS structures, processes, and/or outcomes must collaborate to establish a national EMS research agenda. They should determine general research goals and assist with development of research funding sources.
The major impediments to EMS research must be addressed:
EMS must be designated as a subspecialty for physicians and other health professionals. The development of well-trained EMS researchers must be an integral component of the EMS subspecialty, just as it is in other subspecialties. Those with sub-specialty credentials should be integrally involved in advancing the knowledge base of EMS.
EMS field providers and managers, as part of their routine education, must learn the importance and principles of conducting EMS-related systems research. The objectives need not be to develop EMS researchers, but to help personnel understand the research that is being conducted and enable them to participate and be supportive.
EMS researchers must enhance the quality of published research. Study methods should employ systems analysis methods and meaningful outcome criteria, and determine cost-effectiveness. Research meetings should include forums to educate those wanting to improve their research skills.
EMS systems, medical schools, other academic institutions, and private foundations must develop collaborative relationships. Such relationships should facilitate implementation of significant EMS research projects required to determine, among other things, efficacy, effectiveness and cost-effectiveness.
State EMS lead agencies must evolve from being primarily regulatory to providing technical assistance. They should be involved in promoting public health services research, and facilitating the development of relationships and resources necessary for such studies.
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“Injuries and illnesses requiring an EMS response represent a public health problem that can only be addressed through the combined efforts of all levels of government and private organizations. Government must maintain its traditional role of assuring the existence of an EMS safety net, and at the same time partner with others to build new models for improving EMS.”
Issues relating to legislation, and its resulting regulations, are central to the provision of EMS in the public’s behalf. Legislation and regulations affect EMS funding, system designs, research, and EMS personnel credentialing and scope of practice.
The future: In the town of Gaston, out-of-facility emergency care is provided exclusively by Medstat EMS, a non-profit corporation. Medstat merges with a larger company that, for numerous reasons, abruptly decides to cease operations in Gaston. Fortunately, the state EMS agency uses its authority to compel the service to continue its operations, at least for emergency care, until adequate temporary arrangements are made with neighboring local EMS systems to provide Gaston with quality EMS. The agency then works with Gaston community leaders to develop a long-term solution. During the interim period, when Medstat would have otherwise ceased to operate in Gaston and temporary arrangements were initiated, Medstat EMS personnel were able to resuscitate a three-year-old near-drowning victim due, in part, to their rapid response to the scene.
| WHERE WE ARE |
All states have legislation that provides a statutory basis for EMS activities and programs. States have found that it is within the public’s interest to assure that EMS is readily available, coordinated, and of acceptable quality. However, during 35 state evaluations by NHTSA technical assessment teams, only 40% of states reported comprehensive enabling EMS legislation for development of a statewide EMS system.118 Only 20% of states had an identified lead agency, meeting the standard of the assessment teams, that provided central coordination for EMS system activities.118 State laws vary greatly in the way they describe EMS system components. Some laws permit greater flexibility on the part of the lead or regulatory agencies than others.
In some cases, local governments also have passed ordinances to delineate EMS standards for their communities. These may relate to system components or define process standards.
Legislation leads to rules and regulations designed to carry out the intent of the law. State and regional authorities responsible for implementing regulations, are, in general, extensively involved in personnel licensing, training program certification, EMS vehicle licensing, and record keeping.
| WHERE WE WANT TO BE |
There is a federal lead EMS agency. The agency is mandated by law, sufficiently funded and credible, and is recognized by the health care and public safety systems. It directs nationwide EMS development, provides coordination among federal programs/agencies affecting EMS, serves as a central source for federal EMS-related research and infrastructure creation funding, provides an information clearinghouse function, and oversees development of national guidelines.
All states have a single EMS lead agency, established in law, responsible for developing and overseeing a statewide EMS system. Each state’s agency is adequately funded to ensure its effectiveness. Lead agency enabling legislation allows flexibility; the ability to adapt and be responsive to the health care and public safety environment. It is a facilitator, a clearinghouse for information, a developer of guidelines, and a promotor and educator. This helps ensure that statewide EMS system development continues, that its development and oversight are efficient, and that EMS of acceptable quality is available to the entire population.
State legislation provides a broad template that allows local medical directors to determine the specific parameters of practice for their EMS systems and to conduct credible research and pilot projects. This ensures substantial uniformity within states, but provides the degree of flexibility necessary to ensure that EMS systems, given their resources, are able to optimally meet the health care needs of their communities. Justification for practice parameters are required, as is maintaining minimum quality standards.
In addition to regulating EMS, state lead agencies provide technical assistance to EMS systems. They provide coordination and geographic integration among local EMS systems, and provide technical expertise that may not be available within individual systems. They facilitate credible EMS research and innovative pilot projects. Lead agencies rely, to an increased extent, on national certifying and accrediting bodies to ensure adequate quality of some EMS system components, thus enabling enhancement of their roles as facilitators.
State and local EMS lead agencies have the authority and means to ensure the reliable availability of EMS to the entire population. Such authority is exercised to act on the public’s behalf when eventualities occur, such as potential changes in the health care system or EMS structural or financial circumstances, and threaten its quality or availability to the entire population.
| HOW TO GET THERE |
Collectively, those responsible for EMS must convince legislators in the U.S. Congress to authorize and sufficiently fund a lead federal EMS agency. This agency should be health care based and credible to public safety interests, responsible for coordinating all federal initiatives for national EMS development, overseeing development of national guidelines, and serving as a national EMS clearinghouse.
All states must pass, and periodically review, enabling legislation that supports innovation and integration, and establishes and sufficiently funds an EMS lead agency. This agency should be responsible for developing and maintaining a comprehensive statewide EMS system.
State EMS agencies must enhance their abilities to provide facilitation and technical assistance to local EMS systems. Although states may retain responsibility for licensing, they should increase reliance on available national resources for certification and accreditation of EMS providers and some EMS system components.
Each state must establish and fund the position of State EMS Medical Director, delineate the authority of all EMS medical directors within the state, and establish qualifications for various medical director positions in the state. Medical directors, within broad guidelines, should be responsible for determining the parameters of EMS practice within their systems.
State and local EMS authorities must be authorized to act on the public’s behalf in cases of threats to the availability of quality EMS to the entire population. Actions should ensure that some segments of the population are not underserved, or denied immediate access to EMS due to socioeconomic or other factors.
States should implement laws that provide protection from liability for EMS field and medical direction personnel when dealing with unexpected and/or unusual situations falling outside the realm of current protocols. These should include provisions for in-depth review of such cases, and not alter liability for grossly negligent conduct.
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“The future of EMS is indivisibly linked to how it is funded. In order to optimize the positive influence of EMS on community health we must move to a system of finance that is proactive, accounting for the costs of emergency safety net preparedness and aligning EMS financial incentives with the remainder of the health care system.”
Emergency medical services systems, similar to all public and private organizations, must be financially viable. In an environment of constant economic flux, it is critical to continuously strive for a solid financial foundation.
The future: A consortium of regional hospitals form the Optimal Health Network, a managed care provider/ insurer organization. As its membership increases, the network establishes collaborative relationships with EMS agencies in the members’ communities. Based on a formula that accounts for patient care standards, EMS system preparedness, and expectations of both the network and the EMS systems, the network’s support for EMS is proactively determined and EMS assumes a role in the access of the network’s members to efficient health care.
| WHERE WE ARE |
Providing the nation with EMS is a multibillion dollar effort each year. While all the costs are not exactly known, Hawaii’s EMS system provides a basis for estimation. Out-of-facility EMS in Hawaii is completely state-funded. The annual cost of EMS for the state’s 1.2 million residents is $32,460,605. 76 This includes funding for training, communications, ambulance services, quality improvement, data collection, and other aspects of the system, and amounts to approximately $27 per capita per year. Extrapolating that cost to the entire U.S. population (249,632,692 in 1990) yields an estimate of $6.75 billion per year. Of course, such an estimate might not account for some costs or fail to factor in cost-savings (e.g., volunteers). However, EMS clearly represents a large investment.
The overall cost of EMS for a discreet geographic area includes the costs of all the infrastructure and activities required to provide service. For example, communications systems, vehicle/equipment acquisition and maintenance, personnel training and continuing education, first response and ambulance operations, medical direction, and licensing and regulation activities all contribute to EMS costs. Also, process (e.g., response time) standards and staffing requirements greatly influence these costs. In total, the combined costs of all EMS components and activities, the overall cost of EMS, is equivalent to the cost of preparedness, and it is greatly affected by community requirements.
EMS systems are funded by a combination of public and/or private funds. Primary revenue streams include governmental subsidy via tax dollars, subscription revenue, and fees generated by providing service. For those EMS systems supported directly by tax dollars, subsidies vary greatly and may exceed $20 per capita in some areas. Additionally, many states fund EMS development from specific revenue sources, such as vehicle or driver licensing, motor vehicle violations, and other taxes.128
Subscription programs allow the public to pre-purchase EMS system services in one of two forms. A subscription, depending on the program, is a contract to provide EMS without additional charges to the consumer, or fixes the price and pre-pays any potential insurance deductible. With the latter, third party payors may be billed, but there are still no additional charges to the consumer.
Fee for service revenue comes from five main sources: Medicare, Medicaid, private insurance companies, private paying patients, and special service contracts.125 Of these, Medicare, Medicaid, and private insurance company revenues are probably the most important. Rates of payment, in general, are based on customary charges and the prevailing charge in the area. However, rules vary significantly among insurance carriers, and payment can be affected by what neighboring systems charge.
Those EMS systems relying on third party payors for significant revenue must, in general, provide transportation in order to charge for their services. In other words, if the EMS system provides treatment, but does not actually transport a person to a hospital, third party payors are not obliged to pay for the service provided. Furthermore, payment is often based on the level of care required during transport. It ignores that more advanced resources may have been initially required by the patient, based on the first available information, but that less advanced resources were required for transport.
Treatment followed by transport (by the EMS system) to a hospital is not always necessary or the most efficient means of delivering needed care. However, current EMS financial incentives may not be aligned with efforts of the health care system as a whole to optimize out-of-facility care and enhance health care efficiency. With current payment policies, decreasing the percentage of transports per patient assessed or treated results in decreased EMS system revenue, reduced operating margin, and impaired ability to shift costs.
The primary determinants of EMS cost relate to system preparedness, or the cost of maintaining the resources necessary to meet a benchmark for emergency response. On the other hand, the primary determinant of payment (one source of revenue) is patient transport. Thus, the driving forces for cost and payment are not aligned.
In some cases health care insurers or providers stipulate to their subscriber patients that authorization must precede utilization of EMS. Refusal to pay EMS for services provided may be based on lack of preauthorization or claims that the patient condition did not represent an emergency. Furthermore, regional health care providers (e.g., managed care organizations) frequently require their patients to seek care at specific facilities. EMS systems are then requested to provide transport to locations that are not always geographically convenient. Accommodation of these requests may require additional resources, with their associated costs, to be deployed by EMS systems.
| WHERE WE WANT TO BE |
In as much as EMS is a component of the health care delivery system, and provides health care services, it is consistently funded by mechanisms that fund other aspects of the system. These mechanisms are proactive and recognize the value of treatment that is provided without transport. Transport is not a prerequisite for funding. Payment for EMS is preparedness-based (i.e., the cost of maintaining a suitable state of readiness), and depends on service area size and complexity, utilization, and pre-determined quality standards (i.e., staffing, level of care, response time, and others). This provides EMS with financial incentives that encourage, as appropriate, provision and/or direction of EMS patients to efficient care or other resources. It links finance to value, as determined by community consumers, and aligns cost and payment drivers.
The continued development of EMS systems on regional, state-wide, and national bases is facilitated by regional, state, and federal governments. Sufficient funds are allocated to ensure EMS preparedness, including its first response functions.
| HOW TO GET THERE |
EMS systems must continually determine and improve their cost-effectiveness and evaluate trends within the health care system as a whole. Evaluations should enable optimization of financial resources to provide improved care.
EMS systems must develop proactive relationships with health care insurers and other providers. Such relationships should include implementing pilot projects that determine ways for EMS and other health care organizations to collaborate to increase the efficiency of patient care delivery. These could address such issues as patient and system outcomes when patients are not transported to an emergency department. The results of such pilot projects must be widely disseminated.
Health care insurers and provider organizations must compensate EMS as a component of the health care system caring for their clients/subscribers/ members/ patients/consumers. Model formulas for use among these entities should be developed. Criteria for payment, that are preparedness-based, do not necessarily require patient transport, and are not volume driven, must be developed between EMS systems and insurers/provider organizations.
Health care insurers/provider organizations must allow immediate access to EMS for their patients who believe that a medical emergency exists. They must recognize an emergency medical condition as a medical condition, with a sudden onset, that manifests itself by symptoms of sufficient severity, such that a prudent layperson, possessing an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the person’s health in serious jeopardy. Such a condition should serve as sufficient cause to access EMS.
Governmental agencies responsible for health care finance policy must incorporate divisions that address issues relevant to EMS. Such issues should include reimbursement for services when transport does not occur, and development of preparedness-based or other alternative, proactive criteria for EMS reimbursement/finance.
Local, state, and federal governments must commit to funding agencies primarily responsible for facilitating coordinated EMS development and evolution. Such funding should be from stable sources that enable future planning to occur. It should provide resources for infrastructure development, EMS evaluation and research, and pilot project implementation.
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The future: Hannah is a paramedic in the north-east U.S. She becomes interested in a new position in a Georgia city. The new position, paramedic- community health specialist,- involves all of her current duties, but also requires some knowledge and skills Hannah does not currently use. She is accepted for the job, and through routine mechanisms involving credential checks, is authorized by Georgia’s lead EMS agency to work there. Her new employer verifies clinical competency through medical direction and provides access to the educational programs Hannah needs to be comfortable and proficient in her new role. Her credentials are part of a permanently accessible record in the event she chooses to relocate in the future.
| WHERE WE ARE |
Many people with greatly diverse backgrounds contribute to the efficient operations of EMS systems. In addition to citizen bystanders, these include public safety communicators and emergency medical dispatchers, first responders, emergency medical technicians (EMTs) of various certification levels, nurses, physicians, firefighters, law enforcement officers, other public safety officials, administrative personnel, and others. Among local EMS systems, specific contributions by different categories of personnel may vary significantly.
The vast majority of out-of-hospital EMS care is provided by paramedics and other levels of EMTs. Estimates of the total number of EMS providers vary, but one indicated that there are more than 70,000 paramedics and 500,000 other levels of EMTs.66 Across the country, more than 40 different levels of EMT certification exist. However, the National EMS Education and Practice Blueprint has established standard knowledge and practice expectations for four levels of EMS providers: First Responder, EMT-Basic, EMT-Intermediate, and EMT-Paramedic. 89 Much of the nation’s EMS is provided by volunteers with diverse occupational backgrounds. They serve more than 25% of the population. The economic value of their contribution is immeasurable.79 However, for many possible reasons, the number of EMS volunteer organizations is decreasing.40
Nurses continue to be involved in EMS systems in educational, administrative, and care delivery capacities. The most frequently employed crew configurations for air medical services include at least one nurse.124 Nursing education regarding out-of-facility emergency care is variable. However, many nurses engaged in out-of-facility EMS patient care activities also are certified as EMTs at some level.1 Several states have created curricula specifically for the purpose of educating, and thus credentialing, nurses who wish to be EMS field providers. Additionally, the Emergency Nurses Association has developed national standard guidelines for prehospital nursing curricula. 106
Many other groups of health care workers also collaborate to effect the patient care provided by EMS. They include physicians (emergency physicians, family practitioners, pediatricians, surgeons, cardiologists, and others), nurses with various areas of special expertise, nurse practitioners, physician’s assistants, respiratory therapists, and others. Their roles may involve EMS personnel education, system planning, evaluation, research and/or direct provision of care.
Perennial EMS personnel-related issues include the difficulties of recruitment and retention. Occupational risks, often limited mobility (e.g., credential reciprocity), suboptimal recognition, and inadequate compensation contribute to these problems. Both volunteer and career (i.e, paid personnel) systems are affected.
EMS personnel experience stressors and risks that are unique to other health care workers and, no doubt, to other public safety workers. Among these stressors is exposure to highly traumatic events or experiences. Emergency personnel are at least twice as likely as the general population to suffer from post traumatic stress disorders.81, 82 However, there is a paucity of literature describing systematic approaches intended to further understand the spectrum of EMS workforce stressors.11,23,95,105 Instead, most descriptions of EMS personnel stress and subsequent “burnout” are anecdotal.
Exposure to bloodborne pathogens is a significant risk for EMS personnel. Exposure to HIV and hepatitis viruses are the greatest concerns.42 Reports indicate that between 6 and 19 per 1,000 “ALS” EMS responses involve a contaminated needle stick injury to EMS personnel.58,103 The average hepatitis B virus seroprevalance rate among EMS personnel is 14%, which is 3-5 times higher than the general population.80 Furthermore, the wide-spread resurgence of tuberculosis poses an additional threat of serious occupation related infection to EMS workers.42
Other work related injuries also are common. EMS personnel, especially those in urban areas, are subject to assault.48 Back injury is the single largest category of occupational injuries, and frequent mechanisms of injury include lifting, falling, assaults, and motor vehicle crashes.49,60,111
EMS workers often suffer from lack of full recognition as members of the health care delivery system. They frequently lack a satisfactory career ladder. Providers are also limited in terms of their mobility, as there is no uniform system of credential reciprocity among all states. Barriers also exist between regions in some states. Furthermore, the environment in which EMTs and, in particular, paramedics may practice is in many cases limited by state statutes and regulations.
Among EMS systems, the numbers and types of personnel who staff EMS vehicles vary greatly. Some literature addresses the value of a physician in specific circumstances and as part of an air medical transport team.9,54,112 However, evaluations of other desirable personnel attributes, in terms of numbers and combined levels of education and experience to provide specific services/ interventions, have not been systematically performed and reported.
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People attracted to EMS service are among society’s best, and desire to contribute to their community’s health. The composition of the EMS workforce reflects the diversity of the population it serves. The workforce receives compensation, financial or otherwise, that supports its needs and is comparable to other positions with similar responsibilities and occupational risks.
A career ladder exists for EMS personnel, and it includes established connections to parallel fields. EMS personnel may use accumulated knowledge and skills in a variety of EMS-related positions, and neither advancing age or disability prevent EMS providers from using their education and expertise in meaningful ways.
Standard categories of EMS providers are recognized on a national basis. Such levels provide the basis for augmentation of knowledge and patient care skills that may be desirable for specific regional circumstances.
Reciprocity agreements between states for standard categories of EMS providers eliminates unreasonable barriers to mobility. This enhances career options for EMS workers and their ability to relocate whether for personal or professional reasons.
There is an understanding of the occupational issues, including both physical and psychological, unique to EMS workers. All EMS personnel receive available immunizations against worrisome communicable diseases, appropriate protective clothing and equipment, and pertinent education. They also have ready access to counseling when needed. The value of supporting the well-being of the workforce is recognized, and workforce diversity is considered during the design of strategies to address occupational issues.
EMS personnel are prepared to provide the level of service and care expected of them by the population served. Preparation includes physical resources, adequate personnel resources, and requisite knowledge and skills. This helps ensure that the quality of care provided meets an acceptable community standard.
EMS personnel are readily recognized as members of the health care delivery team. This is congruent with recognition of the role EMS plays in providing out-of-facility care to the population, and its function as an initial treatment provider and facilitator of access to further care at times of acute injury or illness.
Health care workers with special competency in EMS are readily identifiable. This includes physicians, nurses, administrators, and others whose practices involve EMS. Recognition of special competency helps ensure quality of knowledge and expertise for health care workers who are sought to affect EMS and its ability to provide quality care for its patients.
Provider skills and patient care interventions are evaluated continuously to determine which skills and interventions positively impact EMS patient coutcomes. This ensures that providers are appropriately educated and distributed within EMS systems so that they are able to deliver optimal care to the population.
| HOW TO GET THERE |
Adequate preparation, in terms of both knowledge and skills acquisition, must precede changes in the expectations of services to be provided by EMS personnel. EMS systems administrators, managers and medical directors are responsible for ensuring such preparation. Requisite knowledge and skills should be estimated a priori and continuously evaluated.
Those responsible for EMS structures, processes and outcomes, including EMS education, must adopt the principles of the National Emergency Medical Services Education and Practice Blueprint.89 This will provide greater national uniformity among EMS workers and enhance recognition of their expertise and roles within health care.
State EMS directors must work together to develop a system of reciprocity for credentialing EMS professionals who relocate from one state to another (e.g., the National Registry of Emergency Medical Technicians). Although states may have specific criteria for authorizing EMS providers to practice, it is not acceptable to require professionals to repeat education that has already been acquired. This will ensure that EMS providers may take advantage of professional opportunities to which they are otherwise entitled.
EMS systems should develop relationships with academic institutions. This will facilitate access to resources necessary to conduct occupational health studies and provide education opportunities for personnel. Education opportunities sought should include recognized management course work for EMS system managers/administrators.
Researchers in EMS systems should collaborate to conduct occupational health studies regarding EMS personnel (e.g., long-term surveillance studies, national database, and others). Such studies must be designed to yield an improved understanding of occupational hazards for EMS workers and strategies for minimizing them.
EMS systems must become affiliated with or implement a system for critical incident stress management. The potential effects of overwhelmingly tragic events on EMS workers cannot be ignored, and must be addressed to the greatest extent possible.
EMS must be developed as a subspecialty for physicians, nurses, and other health care professionals with an EMS focus. This will facilitate recognition of health care professionals with spe-cial competency in EMS.
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The future: In Quinton, the EMS medical director, after input from other community physicians, wishes to add follow-up visits for certain discharged emergency department patients to her system’s practice parameters. The medical direction staff- and other physicians are formally consulted, and justification is provided to the state EMS lead agency. After extensive education and granting of clinical privileges to a number of system personnel, the plan goes into effect. The medical command center coordinates communication between field personnel- and patients’ primary care providers. The medical direction staff conducts a continuous evaluation of the new activity and its effects on the system’s emergency response capabilities.
| WHERE WE ARE |
Administrative and medical direction management components, working in concert, are required to ensure quality state-of-the-art EMS. Physicians affiliated with EMS systems serve at varying extents, from informal system medical advisors to full-time medical directors and system administrators. With respect to EMS events, medical direction includes activities that are prospective (e.g., planning, protocol development), contemporaneous, and retrospective.
In most states, medical direction of EMS systems that provide advanced levels of care is mandated by law. Many basic level EMS systems (i.e., those without EMT-Intermediates or EMT-Paramedics) do not maintain continuous medical direction, but a growing number are now being required to establish formal relationships with responsible physician medical directors.118 The Emergency Medical Technician: Basic, National Standard Curriculum emphasizes the role of medical direction during EMT-B education and practice.34
In many states, the majority of on-line medical direction, referring to the moment-to-moment contemporaneous medical supervision of EMS personnel caring for patients in the field, is provided by emergency physicians.118 It occurs via radio, telephone, or on-scene physicians. Within any given EMS system, on-line medical direction may emanate from a central communications facility or one or more designated hospitals or other health care facilities. Some areas utilize staff other than physicians, such as mobile intensive care nurses (MICN) to communicate with field EMS personnel and affect patient management.
Although on-line medical direction may be important for selected patients, its systematic application for the majority of EMS patients remains controversial. Several investigators have examined the issue of prolonged out-of-hospital times when radio contact with a physician was required.36,52,62,100 The results have been mixed. However, linkage to objective, relevant outcomes has been incomplete. In the majority of cases on-line medical direction does not result in orders for care beyond what has been directed via protocol, but such communication is nevertheless felt to be helpful by EMS personnel. 36,59,131,142
Medical direction activities that do not involve contemporaneous direction of EMS personnel in the field include development and timely revision of protocols and medical standing orders, implementation and maintenance of quality improvement systems, personnel education, development and monitoring of communications protocols, attention to the health and wellness of personnel, and addressing equipment and legislative issues. Such activities are critical for ensuring optimal EMS.
The task of medical direction involves many people in addition to the EMS medical director. Medical direction staffs, medical control authorities and other oversight agencies or boards often include other physicians (emergency physicians, pediatricians, surgeons, internists, family practitioners, and others), nurses and nurse practitioners, physician’s assistants, paramedics and other EMTs, administrative staff, and others. Medical direction results from a collaborative effort of all to positively affect the patient care delivered by EMS systems.
The medical director ’s role is to provide medical leadership for EMS. Those who serve as medical directors are charged with ultimate responsibility for the quality of care delivered by EMS, must have the authority to effect changes that positively affect quality, and champion the value of EMS within the remainder of the health care system. The medical director has authority over EMS medical care regardless of providers’ credentials. He or she is responsible for coordinating with other community physicians to ensure that their patients’ issues and needs are understood and adequately addressed by the system.
Medical directors evolve from several medical disciplines. In some areas, emergency physicians provide the majority of medical direction. During their residency training, emergency physicians are exposed to the principles of providing medical direction. A model curriculum for EMS education within emergency medicine residency programs has been published.129 However, not all emergency physicians are EMS physicians, nor are all EMS physicians emergency physicians. Furthermore, not all EMS physicians are EMS medical directors. Nevertheless, no matter what other clinical expertise they possess, these physicians are knowledgeable regarding EMS systems and clinical issues. They provide input to their communities’ EMS systems, affect the care that is delivered by EMS, and participate in local, state, and/or national EMS issues resolutions. A growing number of EMS fellowships are being created to facilitate development of special competency in EMS among physicians, but no subspecialty certification by the American Board of Medical Specialties yet exists.
Currently, medical direction is often provided by physicians and staffs on behalf of hospitals who donate, to some extent, their resources. As the structure of the health care delivery system as a whole evolves, and financial incentives for medical care providers change, hospitals’ incentives for engaging in EMS medical direction are diminishing. The potential of a crisis may exist for medical direction in its current form, involving physician expertise that is often volunteered or compensated by hospitals.
| WHERE WE WANT TO BE |
All EMS providers and activity have the benefit of qualified medical direction. This is true regardless of the level of service provided, and helps ensure that EMS is delivering appropriate and quality health services that meet the needs of individual patients and the entire population.
The effects of on-line medical direction are understood, including identification of situations that are significantly influenced by on-line medical direction, and the effects of various personnel providing it. This helps ensure that on-line medical direction is available and obtained for those situations when it is likely to have a positive effect for EMS patients.
Medical direction is provided by qualified physicians and staffs with special competency in EMS. Recognition of competency, by virtue of acquisition of knowledge and skills relevant to the delivery of EMS care and administration of EMS systems as population-based health care systems, is available in the form of subspecialty certification for physicians, nurses and administrators. This helps ensure that medical direction, which ultimately affects the care provided to patients in the community, is provided by knowledgeable and qualified individuals.
Every state has a state EMS Medical Director who is an EMS physician. This helps ensure appropriate medical direction for states’ EMS systems. It acknowledges EMS as a component of the health care system serving patients’ needs and requiring physician leadership. States recognize that out-of-facility medical care must be supervised by a qualified physician.
Resources available to the medical director(s) are commensurate with the responsibilities and size of the population served. This ensures that resources (e.g., personnel, equipment, funding, and others) are sufficient to carry out the responsibilities and authorities incumbent upon the medical director and medical direction staff. The cost of such resources is included with those of system preparedness.
EMS medical directors, in consultation with other medical direction participants, are responsible for determining EMS systems’ practice parameters. They maintain authority for all care provided by EMS, and they have responsibility for granting clinical privileges to EMS providers. The medical director and other medical direction personnel ensure that EMS providers are prepared, in terms of education and skills, to deliver the system’s patient care.
Medical direction provides leadership for EMS systems and personnel. The medical director ensures collaboration between EMS and other health care partners, and actively seeks contributions from other community physicians so that the interests and needs of the entire population served (e.g., children, senior citizens, and others with special health care needs) are addressed. EMS medical directors are in a position to positively influence systems and the care delivered through their knowledge of the complexities of EMS, the spectrum of issues related to population-based care, the occupational health concerns of EMS personnel, the optimal care for the spectrum of EMS patients, and the principles of clinical research.
| HOW TO GET THERE |
EMS provider agencies, of all levels of sophistication, must formalize a relationship with a medical director(s) for the purpose of obtaining medical direction. Medical direction must be available and provided to all EMS processes, including emergency medical dispatching and education. In some cases, local or state legislation may be appropriate to compel such relationships.
EMS systems must ensure that medical direction is appropriated sufficient resources to justify its accountability to the systems, communities, and patients served. The cost of such resources should be included with those of system preparedness.
All individuals who provide on-line medical direction must be appropriately credentialed. This should be accomplished, in part, through formal orientation to the principles of on-line medical direction and specific characteristics of local EMS systems.
EMS physicians and researchers must conduct investigations of adequate quality to elucidate the effects of on-line medical direction. Effects studied should address objective, relevant patient outcomes and systems costs.
Interested organizations must continue their work to develop the basis for EMS as a physician subspecialty. Such work should include encouragement of institutions to develop resources necessary to implement EMS fellowships, so that the number of qualified EMS physicians will grow.
EMS authorities and systems should designate a physician(s) responsible for overall medical direction within the jurisdiction. Such an appointment should be made with the intent of facilitating uniformity of medical oversight policies and practices throughout the jurisdiction. Additionally, medical director(s) should be charged with the responsibility of, and accountable for, collaborating with other community physicians to ensure the best possible care for the population.
All states must appoint a statewide EMS medical director. This physician ultimately will be responsible for statewide EMS medical direction, providing leadership and guidance for the state’s EMS system that is based on sound medical practice.
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As EMS care continues to evolve and become more sophisticated, the need for high quality education for EMS personnel increases. Education programs must meet the needs of new providers and of seasoned professionals, who have a need to maintain skills and familiarity with advancing technology and the scientific basis of their practice.
The future: Tom Klowska is a paramedic in a municipal EMS system. He started his career as an EMT-Basic after completing a standard accredited course at the community college. He received academic credit for his one-year paramedic program, which he completed two years ago. Currently, he has a partial scholarship- and is pursuing a degree in community health, which will qualify him as a Community Health Advanced Medical Practitioner, and result in his ability- to assume a new position (with higher compensation) within the EMS system. Many of his classmates have similar experiences. Some are nurses and other health professionals transitioning to out-of-facility positions.
| WHERE WE ARE |
Currently, EMS education programs primarily prepare those who are interested for certification as an EMT at various levels. The National EMS Education and Practice Blueprint describes the standard knowledge and practice expectations for four levels of EMS providers.89 However, there are currently more than 40 different types of EMT certification, in terms of requisite knowledge and skills, available across the United States. Such variation among states and local jurisdictions impedes efforts to develop agreements for credentialing reciprocity. The National Registry of Emergency Medical Technicians (NREMT) offers certification examinations for First Responder, EMT-Basic, EMT-Intermediate, and Paramedic levels, which are accepted by many states as evidence of competency.
Settings for EMS education include hospitals, community colleges, universities, technical centers, private institutions, and fire departments.130 Program quality and improvement efforts can be achieved in all settings. Ninety-four paramedic education programs currently are accredited by the Joint Review Committee on Educational Programs for the EMT-Paramedic. Additionally, increasing numbers of colleges offer bachelor ’s degrees in EMS.101 However, overall there is inadequate availability of EMS education opportunities in management, public health, and research principles.
Curricula developed by the U.S. Department of Transportation (DOT) provide the bases for education of first responders, EMT-Basics, EMT-Intermediates, and EMT-Paramedics. Education of military EMS personnel also follows these curricula, and they often may provide a resource pool for civilian EMS systems.
Standardized brief educational programs, with specific objectives that address treatment of segments of the population, also have been developed. They include courses in cardiac, trauma, and pediatric life support. Such programs are frequently incorporated into, or used to supplement, EMS education plans. Many reports discuss education of EMS providers to perform specific skills.6, 16, 43, 70, 71, 102, 133, 140, 141 However, there have not been systematic analyses of the suitability of EMS education with regard to expectations for EMS personnel to provide a spectrum of public safety and health care services. Additionally, issues related to knowledge and skill degradation have not been addressed extensively. While some EMS providers seek further educational opportunities, others, for various reasons, do not wish to do so.130
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EMS education employs sound educational principles and sets up a program of lifelong learning for EMS professionals. It provides the tools necessary for EMS providers to serve identified health care needs of the population. Education is based on research and employs adult learning techniques. It is conducted by qualified instructors.
Educational objectives for EMS providers are congruent with the expectations of health and public safety services to be provided by them. This ensures that acquired knowledge and skills are those that adequately prepare providers to meet expectations for personnel of their stature.
Education programs are based on the national core contents for providers at various levels. Core contents provide infrastructure for programs, which might be augmented as appropriate for local circumstances (e.g., wilderness rescue). They provide national direction and standardization of education curricula, which facilitates recognition by credentialing agencies while allowing adequate opportunity for customization as indicated by local necessity.
Higher level EMS education programs are affiliated with academic institutions. EMS education that is academically-based facilitates further development of EMS as a professional discipline. It increases the availability of educational opportunities that acknowledge previous EMS educational/ academic achievements, provides more academic degree opportunities for EMS personnel, augments the management skills among EMS professionals, and protects the value of personal and societal resources invested in education.
Interdisciplinary and bridging programs provide avenues for EMS providers to enhance their credentials or transition to other health care roles, and for other health care professionals to acquire EMS field provider credentials. They facilitate adaptation of the work force as community health care needs, and the role of EMS, evolve.
Institutions of higher learning recognize EMS education as an achievement worthy of academic credit. They welcome affiliations with EMS education programs, and assist them to strengthen the academic basis of EMS education.
| HOW TO GET THERE |
Any change in the vision of EMS should prompt an analysis of new tasks required by that vision, providing the basis for determining the education needs of the EMS workforce. Alterations of EMS education core contents should then follow accordingly.
EMS education researchers must investigate curricula adequacy and alternative education techniques. Such investigations should be designed to provide improved understanding of the education that is optimal for serving various EMS roles. The results of such investigations should be widely disseminated.
Objectives of education programs must be updated sufficiently and frequently so that the needs of EMS patients are met. Modifications should ensure that objectives serve the current needs of EMS patients and the personnel who care for them, so community standards of practice can be achieved. Higher level EMS education programs must incorporate learning objectives regarding research, quality improvement, and management. The scientific basis of EMS practice, basic principles of clinical research, the importance of ongoing EMS research, and the principles of quality improvement and management should be included.
All EMS education must be conducted with the benefit of qualified medical direction. The physician medical director(s) should be involved in education program planning, presentation, and evaluation, including evaluation of faculty, and participants.
The federal EMS lead agency should commission the development of national core contents for various levels of EMS providers. Core contents should replace current curricula. These should be updated on a predetermined schedule to ensure their ongoing utility.
EMS education programs should seek accreditation by a nationally recognized accrediting agency. Accreditations should be sought to demonstrate that the educational programs provided meet a predefined national standard of quality.
Public funds for education should be directed preferentially toward EMS education programs that are accredited. This includes student financial aid (e.g., state and federal).
Providers of EMS education should seek to establish relationships with academic institutions (e.g., colleges, universities, academic medical centers). Such relationships should enhance the academic basis of EMS education and facilitate recognition of advanced level EMS education as an accomplishment worthy of academic credit.
EMS education providers and academic institutions should develop innovative solutions that address cultural variation, rural circumstances, and travel and time constraints. These should include programs that incorporate, for example, distance learning and advancing technology. Reports of such programs should be made widely available. In some cases, these institutions should develop their own EMS education programs that offer academic credit.
EMS educators must develop bridging and transitioning programs. These programs should offer mechanisms for EMS providers to enhance their credentials or transition to new health care roles. They should also provide other health care personnel the ability to transition to out-of-hospital EMS roles.
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Public education, as a component of health promotion, is a responsibility of every health care provider and institution. It is an effort to provide a combination of learning experiences designed to facilitate voluntary actions leading to health.
The future: Nine-year-old Sara and her friends are swimming at the neighborhood pool when they hear a siren. They run to the parking lot to discover an ambulance, not responding to an emergency call, but “on-scene” to brief kids about bicycle safety. At the end of the program each child receives a family safety checklist. Once completed with their parents, it is redeemable for food and drinks at the pool snack bar. Children also receive information about how they and their parents can use their home computers to learn more about safety, first aid, and EMS in their town, and at the same time win coupons redeemable for ice cream cones and other treats. Later that week Sara crashes her bicycle as she tries to avoid a squirrel in her path. Although she strikes her head, she is fortunately wearing her new helmet and suffers no injuries.
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Public education is an essential activity for every EMS system. Yet, as a tool for providing public education, EMS is woefully underdeveloped. A great deal of what the public knows about its EMS system and about dealing with medical emergencies originates from the media, including television programs intended for entertainment and not education. The media does not prepare the public to evaluate or ensure the quality of EMS.
Education, with all its various dimensions, is the linchpin for health promotion. As a component of health promotion, education facilitates development of knowledge, skills, and motivation that lead to reduction of behavioral risks and more active involvement of people in community affairs. This includes greater participation in effecting health and social policy and advocacy for improved health systems.53 Public education is often a focus of other public safety divisions. Examples include fire service campaigns regarding the importance of smoke detectors, and police educational efforts regarding impaired driving, traffic and highway safety, and personal safety. In general, EMS has not optimally engaged itself in providing education that improves community health through prevention, early identification, and treatment.
Certainly there are examples of EMS public education initiatives. In some areas EMS-C funds have been utilized to develop programs regarding childhood illness and injury. 39 The U.S. Fire Administration (USFA)/National Highway Traffic Safety Administration (NHTSA)/Maternal and Child Health Bureau (MCHB) “Make the Right Call” campaign and other community-wide efforts have focused on timely access and appropriate utilization of the EMS system.57, 84 Additionally, numerous EMS systems have assumed a leadership role in disseminating CPR and “bystander care” education to the public. The NHTSA Public Information and Education Relations (PIER) program seeks, in part, to augment EMS provider public education skills.
However, planned and evaluated EMS public education initiatives remain sporadic. This is despite the interest and role of EMS in improving community health, its stature and visibility within the community, and its potential ability to educate individual patients and family members during periods of care and follow-up.
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Public education is acknowledged as an essential ongoing activity of EMS. Such programs support the role of EMS to improve community health and provide valuable information regarding prevention of injuries and illnesses, appropriate access and utilization of EMS and other health care services, and bystander care. It realizes the advantages of EMS as a community-based resource with broad expertise and capacity for contributing to community health monitoring and education dissemination.
EMS and public education programs address the needs of all members of the community. This includes school-age children, adults, senior citizens, and other members of the community with special needs.
EMS systems educate the public as consumers. The importance of the public’s knowledge of EMS-related issues, including funding, level of care provided, equipment, and system expectations and standards is acknowledged. Purchasers of health care services, whether individual, corporate, or public, are well-informed about EMS issues, including evaluating and ensuring optimal EMS.
EMS systems explore innovative techniques to conduct their public education missions. These include, among others, follow-up visits to patients and their families, exploration of new technologies (e.g., computers, worldwide web), and media formats.
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EMS should collaborate with other community resources and agencies to determine public education needs. Such assessments will enable development of education programs with specific objectives appropriate for the community.
EMS must engage in continuous public education. Such efforts should focus on areas of prevention, early identification and health care service access, and initial treatment.
EMS must educate the public as consumers. Targets for such efforts should include at-large community members, other members of the health care system, policy makers, lawmakers, and health care service purchasers.
EMS must explore new techniques and technologies to effect public education. Efforts should be made to reach the broadest possible population in the community.
Public education efforts must be scrutinized by an evaluation process. Such evaluation helps ensure that program objectives are being met and provides guidance for program modification.
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Prevention provides an opportunity to realize significant reductions in human morbidity and mortality—all with a manageable investment. Engaging in prevention activities is the responsibility of every health care practitioner, including those involved with the provision of EMS.
The future: EMS personnel analyzing uniform patient care records realize that a disproportionate number of motor vehicle crash victims originate from a particular road intersection. Many of the crashes occurred during the morning rush hours as motorists exited their neighborhood. The information is relayed to the local law enforcement agency and community groups, which form a coalition to evaluate the problem. At civic association meetings, neighborhood residents are advised of a safer route that avoids the dangerous intersection, and congestion there decreases.. Speed limit enforcement on the main highway is increased. Also, new signs near the intersection and radio traffic reporters remind drivers of the potential danger spot so that they exercise caution and stay attentive. Soon thereafter, crash incidence and resulting injuries decrease at that intersection.
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As a whole, the health care system is evolving from an emphasis on providing highly technologic, curative care to improving health through prevention and wellness. The objective is to prevent people from ever requiring costly medical care.
In this era, injury prevention has taken on a new dimension for both improving the nation’s health and truly controlling health care costs.77 Injury is the third leading cause of death and disability in all age groups and accounts for more years of potential life lost (YPLL) than any other health problem.8 Following consideration of such information, a consensus panel has advocated addition of injury prevention modules to the National EMS Education and Practice Blueprint. 47
Other public safety services have demonstrated their effectiveness at public education and prevention activities. These include fire service efforts to effect engineering, enforcement, and education that decrease the number of fires and fire-related burns and deaths. Police departments have implemented deliberate efforts to decrease traffic-related injuries and deaths through aggressive enforcement of impaired driving laws.
EMS is not commonly linked to the public’s prevention consciousness. However, the potential role of EMS in prevention has previously been recognized.73 EMS providers are widely distributed throughout the population, often reflect the composition of the community, and generally enjoy high credibility. 47 In some regions, EMS personnel currently are taught principles of injury prevention. 117 EMS-initiated prevention programs have been successful in reducing drownings in Pinellas County, Florida, and Tucson, Arizona, and falls from height in New York.39,55,96 EMS patients also may benefit from linkage between the EMS system and other community services able to provide specific education and prevention initiatives.39,50,55,61 Such linkages remain rare, however.
Early efforts are underway to implement Safe Communities projects.110 The Safe Communities concept involves undertaking a systematic approach to address all injuries, and emphasizes the need for coordination among prevention, acute care, and rehabilitation efforts. The Centers for Disease Control and Prevention is developing the concept of “Safe America” and is working with NHTSA to integrate prevention, acute care and rehabilitation for all types of injuries among the many public and private partners involved in injury control.107 EMS systems are crucial to these efforts as collectors of important injury-related data, as community partners that help study the injury problem and design risk reduction strategies, and as health practitioners who provide acute care.
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EMS systems and providers are continuously engaged in injury and illness prevention programs. Prevention efforts are based on regional need; they address identified community injury and illness problems.
EMS systems develop and maintain prevention-oriented environments for their providers, individually and collectively. An atmosphere of safety and well- being, established through EMS system initiatives, provides the foundation for EMS prevention efforts within the community.
EMS providers receive education regarding prevention principles (e.g., engineering, enforcement, education, economics). They develop and maintain an understanding of how prevention activities relate to themselves (e.g., while performing EMS-related duties and at other times) and to their outreach efforts.
EMS systems continuously enhance their abilities to document and analyze circumstances contributing to injuries and illnesses. This information is provided to other health care and community resources able to help evaluate and attenuate injury and illness risk factors for individual patients and the community as a whole.