system’s authority comes from the state to the local level, all prehospital and emergency hospital services are coordinated through one lead agency. This arrangement provides continuity of services, standardized triage, treatment and transport protocols, and an opportunity to improve the system as issues are identified.

The county is divided into five service areas, each of which has at least a level II trauma center. Adult trauma patients are triaged and transported to the appropriate trauma center, while the children’s trauma center provides care to all seriously injured children below the age of 14. Serious burn cases are taken to the University of California-San Diego Burn Center. The county is considering regionalization for other conditions, such as stroke and heart attack, based on the trauma model. The system includes the designation of regional trauma centers, designation of base hospitals to provide medical direction to EMS personnel, establishment of regional medical policies and procedures, and licensure of EMS services.

Accountability is driven by a quality improvement program in which a medical audit committee meets monthly to review systemwide patient deaths and complications. The committee includes trauma directors; trauma nurse managers; the county medical examiner; the chief of EMS; and representatives of key specialty organizations, including orthopedic surgeons and neurosurgeons, as well as a representative for nondesignated facilities. A separate prehospital audit committee that includes ED physicians and prehospital providers also meets monthly and discusses any relevant prehospital issues.

States and regions face a variety of situations, and no one approach to building EMS systems will achieve the goals discussed in this chapter. There is, for example, substantial variation across states and regions in the level of development of trauma systems; the effectiveness of state EMS offices and regional EMS councils; and the degree of coordination and integration among fire departments, EMS, hospitals, trauma centers, and emergency management. The baseline conditions and needs also vary. For example, rural areas face very different problems from those of urban areas, and an approach that works for one may be counterproductive for the other.