safety profiles in hospital- or office-based settings are implemented in the out-of-hospital setting without adequate examination of patient outcomes (Gausche-Hill, 2000; Gausche et al., 2000).

Another example is the debate over whether EMS personnel should perform ALS procedures in the field, or rapid transport to definitive care is best (Wright and Klein, 2001). EMS responders who provide stabilization before the patient arrives at a critical care unit are sometimes subject to criticism because of a strongly held belief among many physicians that out-of-hospital stabilization only delays definitive treatment without adding value. However, there is little evidence that the prevailing “scoop and run” paradigm of EMS is optimal (Orr et al., 2006) except in certain circumstances, such as reducing time to reperfusion for heart attack patients (Waters et al., 2004).

In addition to the significant gaps in knowledge regarding appropriate treatments, there are important gaps in recording patient outcomes. Many cities do not track outcomes, so the performance of their EMS systems cannot be evaluated or benchmarked against that of the systems of other cities. The limited evidence that is available shows wide variation nationwide. For example, results of investigative research by USA Today indicate that the percentage of people suffering ventricular fibrillation who survive and are later discharged from the hospital with good brain function ranges from 3 to 45 percent depending on the municipality (Davis, 2003). This broad variation illustrates the tremendous challenge involved in making the EMS system overall more effective.

Recent EMS research has been able to contribute to the knowledge base regarding appropriate and effective EMS care. For example, the Ontario Prehospital Advanced Life Support study demonstrated that an optimized EMS system with rapid defibrillation capabilities may not benefit from the addition of ALS interventions. In addition, the Public Access Defibrillation trial found that providing AEDs in the community, along with adequate CPR training, can improve survival from cardiac arrest due to ventricular fibrillation. Studies have also shown that CPR involving only chest compressions can be effective, and a number of large U.S. cities have changed the way their 9-1-1 dispatchers provide CPR prearrival instructions as a result.

Patient-Centeredness

EMS systems are geared toward meeting the needs of patients with specific acute conditions, such as heart attack, stroke, and injuries resulting from automobile crashes and other types of accidents. However, they are not always well equipped to meet the needs of special populations or of patients with less acute medical conditions. For example, language bar-



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