realization that rapid response of trained community members to emergency situations could significantly improve patient outcomes. Over time, local communities began to develop more sophisticated EMS capacity, although there was significant variation nationwide. Increased recognition of the importance of EMS in the 1970s led to strong federal leadership and funding that resulted in considerable advances, including the nationwide adoption of the 9-1-1 system, the development of a professional corps of emergency medical technicians (EMTs), and the establishment of more organized local EMS systems.

Federal funding for EMS, however, declined abruptly in the early 1980s. Since then, the push to develop more organized systems of EMS delivery has diminished, and EMS systems have been left to develop haphazardly across the United States. There is now enormous variability in the design of EMS systems among states and local areas. Nearly half of these systems are fire-based, meaning that EMS care is organized and delivered through the local fire department. Other systems are operated by municipal or county governments or may be delivered by private companies, including for-profit ambulance providers and hospital-based systems. Adding to this diversity, there are more than 6,000 9-1-1 call centers across the country, each run differently by police, fire, county or city government, or other entities.

Given the wide variation in EMS system models, there is broad speculation about which systems perform best and why. However, there is little evidence to support alternative models. For the most part, systems are left to their own devices to develop the arrangement that appears to work best for them.

Fire-based systems across the United States are in transition. The number of fires is decreasing while the number of EMS calls is increasing, raising questions about system design and resource allocation. An estimated 80 percent of fire service calls are now EMS related. While there is little evidence to guide localities in designing their EMS systems, there is even less information on how well any system performs and how to measure that performance.

A key objective of any EMS system is to ensure that each patient is directed to the most appropriate setting based on his or her condition. Coordination of the regional flow of patients is an essential tool in ensuring the quality of prehospital care, and also plays an important role in addressing systemwide issues related to hospital and trauma center crowding. Regional coordination requires that many elements within the regional system—community hospitals, trauma centers, and particularly prehospital EMS—work together effectively to achieve this common goal. Yet only a handful of systems around the country coordinate transport effectively. There is often very little information sharing between hospitals and EMS regarding emergency



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