Many experts date the development of modern EMS systems in the United States back to the publication of the landmark report Accidental Death and Disability: The Neglected Disease of Modern Society (NAS and NRC, 1966). Following the publication of this report and subsequent congressional action, EMS systems began to develop rapidly across the country. However, this momentum was lost in 1981 when direct federal funding for the planning and development of EMS systems ended and was replaced by block grants to states. Over the past 25 years, EMS systems have developed haphazardly nationwide, regulated by state EMS offices that have been highly inconsistent in their level of sophistication and control. The result has been a fragmented and sometimes balkanized network of underfunded EMS systems that often lack strong quality controls, cannot or do not collect data to evaluate and improve system performance, fail to communicate effectively within and across jurisdictions, allocate limited resources inefficiently, and lack effective strategies and resources for recruiting and retaining personnel.

A significant lack of funding and infrastructure for EMS research has sharply limited studies of the safety and efficacy of many common EMS practices. Pressing questions remain regarding a number of central issues, such as the value of ALS services, the safety and efficacy of many common EMS procedures, the optimal approach to managing multisystem trauma, and the cost-effectiveness of public-access defibrillation programs. Barriers to data collection, a lack of standardized terms, and a limited pool of researchers trained and interested in EMS all pose significant challenges to research in the field. As a result, the prehospital emergency care system provides a stark example of how standards of care and clinical protocols can take root despite an almost total lack of evidence to support their use.

Because of this lack of supporting evidence, EMS systems often must operate blindly in addressing such questions as how available EMS personnel should be deployed, what services should be provided in the out-of-hospital setting, and what approach to organizing the EMS system is best. Multiple models of EMS organization have evolved over time, including fire department–based systems, hospital-based systems, and other public and private models. However, there is little research to demonstrate whether any one of these approaches is more effective than the others.

Within the last several years, complex problems facing the emergency care system have come into public view. Press coverage has highlighted instances of slow EMS response times, ambulance diversions, trauma center closures, and ground and air crashes during patient transport. This heightened public awareness of problems that have been building over time has made clear the need for a comprehensive review of the U.S. emergency care system. Although emergency care represents a vital component of the U.S.

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