delayed. It is estimated that 501,000 ambulances were diverted in 2003 (Burt et al., 2006).


The health sector in general and emergency and trauma care services in particular lag behind other industries in adopting engineering principles and information technologies that can improve process management, lower costs, and enhance quality. Inefficiency in EMS care takes various forms:

  • Little is known about the cost-effectiveness of EMS interventions. As with EMS research in general, sparse information exists to help guide the field in this area. Reimbursement policies and federal regulations also contribute to inefficiencies. In many cases, providers are not reimbursed unless they transport a patient to the ED, even though it may be more efficient and just as effective to treat the patient on site.

  • Services are often poorly coordinated. In some situations, for example, multiple vehicles respond to a single small event. Significant problems are often encountered near municipal, county, and state border areas. When a street delineates the boundary between two city or county jurisdictions, responsibility for care—as well as the protocols and procedures employed—depends on the side of the street on which the incident occurred.

  • The Emergency Medical Treatment and Active Labor Act may require that certain EMS agencies perform a medical screening exam when in fact a patient should be transported immediately to a trauma center for definitive care.

  • Outdated and poorly planned technologies also contribute to inefficiencies. For example, many of the 9-1-1 calls placed today are from cellular phones, but dispatchers often lack the capability to trace the location of such callers. In the event of a disaster, most EMS communications systems are not compatible with those of other responders, such as police and fire departments.


Disparities in access to EMS systems are evident, particularly between urban and rural communities. For example, there are still small pockets of the country that do not offer even basic 9-1-1 coverage, and these are located exclusively in rural or frontier areas. Moreover, only 45 percent of counties nationwide have the more advanced 9-1-1 systems that can track the location of cellular callers, even though this information can be vitally important in responding to various emergency situations.

Ground and air ambulance coverage is also uneven across the country.

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