Index

A

Accidental Death and Disability: The Neglected Disease of Modern Society, 18, 32, 75, 81

Accountability

fragmentation of EMS system and, 6, 83

importance of, 83

model systems, 91, 93, 94, 95

recommendations for performance indicator development, 1112, 85

shortcomings of current system, 73, 83

Accreditation

of EMS system components, 85

national standardization of EMS personnel training, 125, 144

of paramedic education, 9

Acute Injury Care Research Agenda, 217

Advanced cardiac life support, 32

Advanced emergency medical technicians, 123

Advanced life support (ALS)

ambulance equipment, 158159

effectiveness, 164

field application, 21, 80, 209210

fleet characteristics, 55

research efforts, 218

research needs, 164, 209210

training curriculum, 33, 124

transport reimbursement, 47

Agency for Healthcare Research and Quality, 100, 105

research program, 208, 214215

Air medical services

accreditation, 85

capacity and access, 161

coordination of emergency response, 10, 162

current system, 11, 61

dispatch decisions, 157158

effectiveness, 6162

government oversight, 11, 161162, 170

Hurricane Katrina response, 188

interfacility transport, 162163

Iraq War experiences, 191192

lack of coordination, 74

origins and development, 160161

recommendations, 11, 162, 170

regional disparities, 24

roles and responsibilities, 161

safety concerns, 61, 161

Ambulance services

accreditation, 85

ambulance crashes, 20, 159160

ambulance design, 159

design and capabilities, 27, 33

disaster preparedness funding for, 176

diversion, 2223, 4041, 86

driver training, 159160



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Emergency Medical Services at the Crossroads Index A Accidental Death and Disability: The Neglected Disease of Modern Society, 18, 32, 75, 81 Accountability fragmentation of EMS system and, 6, 83 importance of, 83 model systems, 91, 93, 94, 95 recommendations for performance indicator development, 11–12, 85 shortcomings of current system, 73, 83 Accreditation of EMS system components, 85 national standardization of EMS personnel training, 125, 144 of paramedic education, 9 Acute Injury Care Research Agenda, 217 Advanced cardiac life support, 32 Advanced emergency medical technicians, 123 Advanced life support (ALS) ambulance equipment, 158–159 effectiveness, 164 field application, 21, 80, 209–210 fleet characteristics, 55 research efforts, 218 research needs, 164, 209–210 training curriculum, 33, 124 transport reimbursement, 47 Agency for Healthcare Research and Quality, 100, 105 research program, 208, 214–215 Air medical services accreditation, 85 capacity and access, 161 coordination of emergency response, 10, 162 current system, 11, 61 dispatch decisions, 157–158 effectiveness, 61–62 government oversight, 11, 161–162, 170 Hurricane Katrina response, 188 interfacility transport, 162–163 Iraq War experiences, 191–192 lack of coordination, 74 origins and development, 160–161 recommendations, 11, 162, 170 regional disparities, 24 roles and responsibilities, 161 safety concerns, 61, 161 Ambulance services accreditation, 85 ambulance crashes, 20, 159–160 ambulance design, 159 design and capabilities, 27, 33 disaster preparedness funding for, 176 diversion, 22–23, 40–41, 86 driver training, 159–160

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Emergency Medical Services at the Crossroads dynamic load-responsive deployment, 65 emerging technologies for, 163–164 equipment, 158–159 fleet characteristics, 55–56 hospital-based EMS, 58 information technologies for, 163, 164, 170 interfacility transport, 162–163 legal requirements, 48–49 licensing, 158, 159 light and siren use, 160, 220 Medicare reimbursement, 47 national capacity, 158 origins and development, 32–33 performance measurement, 86 private EMS systems, 58–59 problems of hospital emergency department crowding, 40 regional disparities, 23–24 in rural areas, 65 utilization, 83 See also Prehospital care; Transportation of patient American Board of Emergency Medicine, 9, 144 American College of Emergency Physicians (ACEP), 35, 78–79, 208 American College of Surgeons, 35, 78–79, 85 Anthrax, 181 Automated external defibrillators (AEDs), 16, 140–141, 218–219 Automatic crash notification, 16, 27, 63, 149, 155–157 Avian influenza, 178 B Basic life support (BLS) transport features, 158 fleet characteristics, 55 Medicare reimbursement, 47 training curriculum, 124 Battlefield Medical Information System Tactical (BMIST), 169 Biochemical weapons, 181–182, 193–194, 199–200 Bioterrorism Hospital Preparedness Program, 12, 100, 197 Blood substitute, 163 Bystander care, 65–66, 140–141 C California EMS system management, 35 model EMS and trauma system, 94–95 San Francisco EMS system, 39 Capacity, EMS air medical services, 161 ambulance services, 158 goals for system, 5 local disaster preparedness, 194–196 national, 15 9-1-1 systems, 53, 63, 151 Cardiac arrest incidence, 16 Public Access Defibrillation trial, 218–219 Cardiac Arrest Registry to Enhance Survival (CARES), 87, 217 Cardiopulmonary resuscitation (CPR) citizen first responders, 65–66, 140 origins of EMS system, 1, 32 prehospital care research, 219, 220 Categorization of emergency providers, 8, 79–80, 114–115 of trauma care capabilities, 78, 114–115 Causes of ED visits, 16–17 Centers for Disease Control and Prevention (CDC) EMS-related programs, 44 National Center for Injury Prevention and Control, 36, 44, 46, 99–100, 217 research efforts, 208, 217 Centers for Medicare and Medicaid Services EMS reimbursement, 41 performance measurement activities, 88 recommendations for, 7–8, 114, 116 See also Medicaid; Medicare Centers for Public Health Preparedness, 181 Civil War, U.S., 32 Commission on Accreditation of Ambulance Services, 85 Commission on Accreditation of Medical Transport Systems, 85 Committee on the Future of Emergency Care in the United States Health System, 5, 24–25

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Emergency Medical Services at the Crossroads Communications technologies and systems automatic crash notification, 16, 27, 63, 149, 155–157 for coordination of care, 76–77 current model systems, 90 current shortcomings, 3, 10, 38, 164 disaster response, 182, 198–199 interoperability among EMS systems, 23, 27, 164–167, 171, 199 obstacles to improvement, 166 recommendations for, 10–11, 164–165, 171 September 11, 2001, terrorist attack responses, 183 telephone location tracing, 23 transmission of clinical information, 10 Voice over Internet Protocol, 154 Wireless Public Safety Interoperable Communications Program, 167 See also 9-1-1 systems Confidentiality issues Health Insurance Portability and Accountability Act requirements, 49–50, 113, 213 research and, 210, 213, 222, 223 Congress, recommendations for, 6–7, 13–14, 96, 115, 198, 202, 223, 224, 226 Coordination of care air medical services, 10, 162 communication requirements, 76–77 conceptual development, 34 current model systems, 90–91, 92, 93, 94 current shortcomings, 3, 10, 39–40, 73, 74–75 demonstration projects to promote, 97 disaster response, 201–202 efficiency of care and, 23 establishment of national agency for regulation and support, 6–7, 105–111 goals, 5, 9–10, 75–76 obstacles to, 6, 49 in pediatric intensive care system, 76 regional disaster response planning, 176, 196–198 role of Federal Interagency Committee on EMS, 44 in trauma system, 76 See also Regionalization of EMS system Costs benefits of regionalization, 8 Emergency Medical Services Cost Analysis Project, 215 enhanced 9-1-1 technology, 153, 154 Health Insurance Portability and Accountability Act compliance, 50 scope of EMS costs, 7 See also Economics Crash Injury Research and Engineering Network (CIREN), 215, 216 Crossing the Quality Chasm: A New Health System for the 21st Century, 19 Crowding, hospital emergency department disaster effects, 183–184 payment incentives to reduce, 89 quality of care and, 40 D Data Elements for Emergency Department Systems (DEEDS), 84 Defibrillators, automated external, 16, 140–141, 218–219 Delayed treatment ambulance diversion and, 40–41 field stabilization and, 21, 80 response times in rural areas, 63 use of ambulance lights and sirens, 220 Demonstration projects funding levels, 98 granting agency, 98–99 purpose of grants for, 96–97 rationale, 95–96 recipients of grants for, 96 recommendations for, 13–14, 96, 115 Department of Health, Education and Welfare (DHEW) evolution of emergency medical care system, 33, 34 See also Department of Health and Human Services Department of Health and Human Services (DHHS), 105 disaster planning and operations, 12, 196–197, 202 disaster preparedness funding, 105, 176 establishment of new lead agency in, 6–7, 107, 108, 115

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Emergency Medical Services at the Crossroads recommendations for, 7, 8, 11–12, 13, 79–80, 85, 107, 113–115, 169, 171, 196–197, 202, 224, 226 research role, 13, 224, 226 structure of EMS system support, 44, 99–100 See also Department of Health, Education and Welfare Department of Homeland Security (DHS) disaster preparedness funding, 12, 176, 192–193, 197–198 EMS funding and support, 43, 44, 46, 100, 176 establishment, 184 recommendations for, 12, 196–197, 202 Department of Transportation (DOT) evolution of EMS system, 33, 34, 43, 99 recommendations for, 12, 196–197, 202 See also National Highway Traffic Safety Administration Disaster Medical Assistance Teams (DMATs), 100, 186–187 Disaster response accidental man-made disasters, 179 biochemical threats, 181–182, 193–194, 199–200 certification and licensure for EMS personnel, 13, 201 challenges, 182, 192, 202 communications and information systems for, 182, 198–199 coordination of, 201–202 current readiness, 4, 43, 192–194 definition of “disaster,” 175 emergency support functions, 185 EMS involvement in regional planning, 176, 196–198 establishment of new lead agency for oversight and support, 108–109, 115 funding distribution, 12–13, 176, 192–193, 197–198, 202 goals for EMS systems, 27 homeland security funding, 43, 176 local capacity, 194–196 National Incident Management System, 184 natural disasters, 178–179, 193–194 recent events, 177, 183–192 recommendations for, 12–13, 196–197, 198, 200, 202 research funding, 221 risks for EMS workers, 182 shortcomings of current EMS and trauma systems, 175–176, 202 strategies for improving, 194–202 training, 13, 43, 176, 195–196, 200, 202 types of threats, 177, 192, 193–194 volunteer screening and coordination, 188 Dispatch of emergency services compensation for dispatchers, 141 dynamic load-responsive deployment, 65 model of EMS delivery, 53–62 need for coordination, 9–10 prearrival instruction for bystanders, 140 recognizing nonemergency calls, 141–142, 157 roles and responsibilities, 141 selection of equipment and personnel for response, 157–158 training for, 141 See also 9-1-1 systems Dumping of uninsured patients, 48 E Earthquakes, 178 Economics challenges for EMS system, 41 cost-effectiveness of EMS interventions, 23 demonstration project grant funding, 98, 115 disaster preparedness funding, 12–13, 176, 192–193, 197–198, 202 dispatcher compensation, 141 EMS workforce salaries, 4, 42, 136 evolution of EMS funding, 2, 18, 31, 33, 34, 35, 41 fire-based EMS funding, 57 funding of new lead agency for EMS system, 110–111 homeland security funds, 43 9-1-1 systems funding, 151 patient transport costs, 48 possible negative consequences of regionalization, 78

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Emergency Medical Services at the Crossroads recommendations for research, 7–8, 114, 116 research funding, 13, 208, 210, 214–217, 218, 220–221 state funding for EMS services, 52 structure of federal support for EMS, 43–48 See also Costs Education. See Training of EMS personnel Effectiveness of current EMS system, 20–21 Efficiency of care, 23 Elderly emergency transport, 7, 16 EMS utilization, 46 future demand for EMS, 134 Electrocardiography, 16, 163 Emergency care, defined, 25 Emergency Management Assistance Compact (EMAC), 187–188 Emergency medical services (EMS) definition, 25 scope of, 25 See also Emergency medical services system Emergency Medical Services Agenda for the Future, 6, 24, 36–37, 75–76, 100, 120, 167–170, 208 Emergency Medical Services Agenda for the Future: Implementation Guide, 120, 122, 208 Emergency Medical Services at Midpassage, 19, 34 Emergency Medical Services Cost Analysis Project (EMSCAP), 215 Emergency Medical Services Education Agenda for the Future: A Systems Approach, 120, 122, 124, 125, 126–127 Emergency Medical Services for Children, 35–36, 98, 106, 216–217 Emergency Medical Services Outcomes Project (EMSOP), 215, 216 Emergency medical services system characteristics, 55–56 definition, 25, 55 development, 1–2, 6, 18, 31–37, 73–74 effectiveness, 20–21 essential elements, 34 goals, 5, 26–27, 36–37, 73 patient characteristics, 16–17 recommendations for establishment of national agency for, 6–7, 105–111 shortcomings of current system, 3–5, 14, 31, 37–43, 73 strengths of current system, 3, 16 Emergency medical technicians (EMTs), 2 compensation, 42 credentialing and certification, 124 disaster preparedness, 176, 200 education curriculum, 123–124 national certification, 126 registration status, 133, 134 roles and responsibilities, 127 scope of practice model, 123 training, 211 Emergency Medical Treatment and Active Labor Act (EMTALA), 23, 48–49, 112–113 recommendations for, 113–114, 115 Emergency Medicine Foundation, 208 Emergency support functions, 185 Emergency Systems for Advance Registration of Volunteer Health Professionals, 188 EMS. See Emergency medical services EMS Performance Measures Project, 84 EMS Systems Act (1973), 31, 34 Endotracheal intubation, 209–210, 219 England, 2005 terrorist attacks in London, 189–190 ENHANCE 9-1-1 Act, 151 Equipment and supplies, EMS biochemical event response, 199–200 current supply and access, 149–150 emergency support functions, 185 local disaster preparedness, 194–196 needs, 149 technological advances, 149 See also Air medical services; Ambulance services; Communications technologies and systems; Information technologies and systems Equitable care, 23–24 F Federal Aviation Administration (FAA), 161, 162 Federal Communications Commission (FCC), 152–153, 154, 167 Federal Emergency Management Agency (FEMA), 100, 185–186, 187

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Emergency Medical Services at the Crossroads Federal government air ambulance oversight, 161–162 demonstration project granting agency, 98–99 disaster preparedness funding, 176, 192–193, 197–198 disaster response, 184–185, 201–202 EMS research funding, 208 establishment of new agency for emergency care system integration, 6–7, 98, 105–111, 115 evolution of emergency medical care system, 18, 31, 32–37, 41, 99 fragmentation of EMS support and regulation, 99, 102 interagency collaboration in EMS, 100–101 leadership in emergency care, 3 legislative framework of EMS system, 48–53, 112–114 to promote communications interoperability among EMS systems, 166, 167 research support, 208, 214–217 structure of EMS oversight and funding, 43–48, 99–100 See also specific governmental entity Federal Interagency Committee on EMS (FICEMS) future of EMS system leadership and, 6, 104–105 membership, 101 new lead agency for EMS system and, 109–110 purpose, 6, 44, 100–102 Federalwide Assurance program, 213–214, 223, 226 Fire-based EMS, 2, 132 advantages, 57 current system, 55, 56 disadvantages, 57–58 funding, 57 structure and operations, 56–57 Fire department first responders, 127, 158 Floods, 178 Florida EMS and trauma system, 93–94 Fragmentation of EMS system current state, 3, 6, 18, 31, 38–39, 41, 73 disaster response, 176 federal support and regulation, 6, 99, 102 origins, 6, 34, 35 structure of federal oversight, 43 G Grant payments to emergency care system Centers for Disease Control and Prevention block grants, 44–46 demonstration programs for enhancing emergency care, 14, 96–99 disaster preparedness funding, 12, 46, 193–194, 198 federal block grants to states, 18 origins and early development, 34, 35, 36 private funding, 34 research grants, 221–222 H Health Insurance Portability and Accountability Act (HIPAA) impediments to EMS in, 49–50, 113 implications for research, 20, 113, 210, 213, 222, 223 purpose, 49, 113 recommendations for, 113–114, 115 Health Level Seven, 84 Health, Medical Care and Transportation of the Injured, 32 Health Plan Employer Data and Information Set (HEDIS), 88 Health Resources and Services Administration as demonstration project granting agency, 98–99 EMS system programs and offices, 35–36, 43–44, 44 performance measurement activities, 85 recommendations for, 13–14, 96, 115 research support, 208–209, 215, 216–217 Trauma-EMS Systems Program, 181 Healthy People 2010 initiative, 44–46 Highway Safety Act (1966), 31, 33, 43 Hospital-based EMS bioterrorism preparedness, 44 disadvantages, 58 emergency department crowding, 40 employment, 132 establishment of new lead agency for oversight and support, 108–109, 115 numbers of, 55

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Emergency Medical Services at the Crossroads problems in coordination with prehospital care, 39–40 structure and operations, 58 Hurricane Katrina, 175, 176, 178, 182, 185–189, 193, 194, 199, 201 I Infectious disease pandemics and outbreaks, 178–179 public health surveillance, 75 risks for EMS personnel, 20, 41–42, 137, 159 Influenza pandemics, 178–179 Information technologies and systems for ambulance services, 163, 164, 170 for disaster response, 198–199 EMS system data, 168–169, 170 goals, 167–170, 170 Health Insurance Portability and Accountability Act and, 49, 50, 113, 210, 213, 222, 223 interoperability among EMS systems, 164–165 National Health Information Infrastructure, 11, 169, 171 9-1-1 caller identification and location, 151–154 patient data, 169, 170 for performance measurement, 86 Wireless Public Safety Interoperable Communications Program, 167 See also Communications technologies and systems Informed consent, EMS research and, 212–213, 222–223 Injury, accidental data sets, 169 preventive interventions, 75, 217 as public health problem, 36 research needs, 19 Injury in America: A Continuing Health Problem, 36 Interagency Committee on EMSC Research (ICER), 100 Iraq War, 191–192 Israel, 2001 building collapse in Jerusalem, 190–191 J Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 85 Jurisdictions of responders, 10, 23, 38–39 K Korean War, 33 L Language barriers, 21–22 Leadership current federal, 43, 52, 99–102 disaster response, 201–202 establishment of new agency for emergency care system, 6–7, 105–111, 115 Federal Interagency Committee on EMS for, 104–105 Hurricane Katrina response, 185, 187 to promote communications interoperability among EMS systems, 166 strategies for improving EMS system, 102–104 See also Medical directors, EMS Licensure and credentialing air medical services, 161 ambulance services, 158, 159 Disaster Medical Assistance Teams, 187 disaster response training, 13, 200–201, 202 emergency medical technician training requirements, 124 EMS personnel registration status, 130 EMS subspecialty certification, 9, 143–144 national EMS certification, 126–127 national scope of practice model, 122–123 reciprocity among jurisdictions, 123, 137 recommendations for, 9, 144, 202 shortcomings of current EMS training system, 41 state government oversight, 51, 123 volunteers in disaster response, 188

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Emergency Medical Services at the Crossroads Longitudinal Emergency Medical Technician Attribute and Demographic Study (LEADS), 215 M Maryland EMS and trauma system, 35, 90–92 Medicaid EMS reimbursement, 41, 46–48 EMS utilization, 52 payment incentives for performance improvement, 89 state agencies, 52 See also Centers for Medicare and Medicaid Services Medical directors, EMS payment incentives, 89 potential problems, 143 qualifications, 64, 143 roles and responsibilities, 142–143 system performance research, 220 Medicare emergency transport reimbursement, 7, 114 influence on EMS services, 48 payment incentives for performance improvement, 89 See also Centers for Medicare and Medicaid Services Metropolitan Medical Response System, 100, 188–189 Military medicine, 31–32, 33, 160–161, 169, 191 Missouri, 60 Models of emergency care dispatch centers, 53–62 fire-based EMS systems, 56–58 historical and conceptual development, 34 hospital-based EMS systems, 58 local level, 53 municipal service, 59–60 private systems, 58–59 recommendations for demonstration program, 13–14, 95–96 research needs, 42 rural EMS systems, 62–66 staffing models, 60 systems currently in operation, 90–95 trauma system, 78–79 Mortality air ambulance crashes, 61 ambulance crashes, 20, 159–160 ambulance diversion and, 40–41 automobile accident, 24 EMS workforce occupational fatalities, 137 Mouth-to-mouth ventilation, 1, 32 Municipal EMS services, 59–60 Mustard gas, 181 N National Association of Emergency Medical Technicians, 35 National Association of EMS Physicians, 35 National Association of State EMS Officials (NASEMO), 35, 50–51, 52, 126–127 National Center for Injury Prevention and Control, 36, 44, 46, 99–100, 217 National Disaster Medical System, 186–187 National EMSC Data Analysis Resource Center (NEDARC), 217 National EMS Education and Practice Blueprint, 120, 122 National EMS Information System (NEMSIS), 168–169, 215 National EMS Research Agenda, 208–209, 215, 223, 224 National EMS Scope of Practice Model, 9, 201, 215 National Governors Association, 201–202 National Health Information Infrastructure, 11, 169, 171 National Highway Traffic Safety Administration development of EMS systems, 36, 43, 99 EMS funding and technical assistance, 6, 52 EMS research, 208–209 9-1-1 systems management, 151, 155 origins, 6, 33 performance measurement activities, 85 recommendations for, 8, 79–81, 114–115 research activities, 215 system integration goals, 75–76

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Emergency Medical Services at the Crossroads National Incident Management System (NIMS), 37, 184 National Institutes of Health (NIH), 44, 208, 214, 221, 224 National Quality Forum, 85 National Registry of Emergency Medical Technicians, 124, 126, 130 National Response Plan, 37 National Standard Curricula, 123–124, 125 National Trauma Data Bank, 169 9-1-1 systems automatic crash notification, 155–157 caller identification and location, 23, 151–154 capacity and utilization, 2, 53, 63, 151 cell phone calls, 151–154 enhanced, 151, 152–154 establishment of new lead agency for oversight and support, 108–109, 115 funding, 151 next generation, 154–155 nonemergency calls, 141–142, 157 origins and development, 2, 150–151 performance measurement, 86 prearrival instructions, 54–55, 140, 219 regional disparities, 23, 150 strengths of current system, 16 structure and operations, 27, 53–54, 151 Voice over Internet Protocol, 154 O Obese patients, 22 Omnibus Budget Reconciliation Act (OBRA) (1981), 35 Ontario Prehospital Advanced Life Support study, 218 Outcomes research air ambulance effectiveness, 61–62 Emergency Medical Services Outcomes Project, 215, 216 Health Insurance Portability and Accountability Act and, 50 performance measurement, 86 prehospital interventions, 21, 163–164, 209 regionalization rationale, 77 P Paramedics compensation, 42, 136 disaster preparedness, 176, 200 recommendations for training standardization, 125–126, 144 roles and responsibilities, 127, 129–130 scope of practice model, 123 supply problems, 134–135 training for research, 211 Patient-centered care, 21–22 Patient characteristics challenges of special populations, 22–23 demographics, 16–17 Medicaid utilization, 52 See also Elderly; Pediatric care Pediatric care, 24–25 challenges in EMS care, 22 coordination in intensive care system, 76 emergency transport patients, 16 EMS-C, 35–36, 98, 106, 216–217 prehospital endotracheal intubation, 209–210, 219 research, 216–217 Pediatric Emergency Care Applied Research Network (PECARN), 216–217 Performance measurement access to data, 12, 88 Cardiac Arrest Registry to Enhance Survival, 87 current efforts, 84–85 current EMS effectiveness, 20–21 demonstration project, 97 information technologies for, 86 key indicators, 86 National Highway Traffic Safety Administration assessments, 52 need for EMS system review, 18–19 patient-level data for, 86 private EMS system evaluation, 59 public perception of EMS system performance and, 84 quality aims for health care system, 19 recommendations for, 11–12, 85–86, 115 research needs for, 42 statewide EMS system evaluations, 36 See also Public reporting Personal protective equipment, 199–200 Police first responders, 127

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Emergency Medical Services at the Crossroads Prehospital care bystander care, 65–66, 140–141 categorization of services, 79, 114–115 historical and technical development, 32–37 jurisdictional issues, 10, 23, 38–39 need for coordination, 9–10, 74 participation in National Health Information Infrastructure, 11 patient stabilization out of hospital, 21, 80 recommendations for protocol development, 8, 80–83, 115 recommendations for research, 13, 221, 224 research efforts, 218–220 research needs, 42, 163–164, 209–210 research rationale, 207 in rural areas, 63–64 safety risks, 19 scope of, 15 strengths of current system, 16 transmission of clinical information, 10 See also Air medical services; Ambulance services; Dispatch of emergency services; Emergency medical services system; 9-1-1 systems Preventive Health and Health Services, 44 Preventive interventions accidental injury, 36 coordination of EMS with public health agencies, 75 Private EMS systems, 58–59 Public Access Defibrillation (PAD) trial, 218–219 Public health agencies, coordination between EMS and, 75 Public involvement citizen first responders, 65–66, 140–141 goals for EMS system, 5–6 self-triage, 83 Public perception of EMS system performance, 18, 83–84 Public reporting of aggregate performance data, 12, 88 current state, 88 forms of, 87 goals, 87–88 importance of, 87 Public safety answering points, 53, 141, 151, 154. See also 9–1–1 systems Q Quality of care ambulance diversion and, 40–41 current system, 4 financial incentives for performance improvement, 88–89 measurement, 4 out-of-hospital stabilization, 21, 80 regionalization of services and, 77 R Radioactive materials exposure, 181 Red Cross, 32 Regional flow of patients, 2 Regional variation in EMS systems causes of, 95 medical oversight and review, 9 9-1-1 systems, 23, 150, 153–154 origins of, 2, 35, 41 response time, 22 role of demonstration projects, 95–96 scope of practice, 122–123 shortcomings of current system, 2, 53 strategies for enhancing emergency care and, 13 as strength, 53 structure of state government EMS oversight, 50–51 training of EMS personnel, 9, 125 workforce qualifications, 119 See also Rural areas Regionalization of EMS system benefits of, 77–78 categorization of emergency departments for, 8 characteristics, 99 current model systems, 91, 93–95 definition of “region,” 26 implications of Emergency Medical Treatment and Active Labor Act, 112–113 possible negative consequences of, 78 rationale, 2–3, 8, 77–78 recommendations for, 8 in rural areas, 65 Reimbursement efficiency of care and, 23 federal system, 46–48

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Emergency Medical Services at the Crossroads incentives for unnecessary transport, 88–89 Medicare and Medicaid, 44, 46–48 payment incentives for performance improvement, 89 recommendations for research, 7–8, 114, 116 state role, 52 Research barriers to, 18, 210–217, 220, 222 current EMS knowledge base, 207, 208–210 data sources for, 210–211, 212–214, 223 demonstration program for enhancing emergency care, 13–14, 95–96 development of EMS system, 34 disaster preparedness, 221 establishment of new lead agency for EMS system and, 109 federal entities for, 208, 214–217 funding, 13, 208, 210, 214–217, 218, 220–221, 224 goals, 207, 210 grant review process, 221–222 informed consent issues, 212–213, 222–223 infrastructure for, 210 needs. See Research needs practice applications, 211 prehospital care knowledge base, 218–220 priority topics, 223–224 protections for human subjects, 213–214, 222 recommendations for, 13, 220–221, 223, 224, 226 regulatory environment, 210, 212–214, 222–223 strategies for improving, 27, 220–224 training for, 210, 211–212 trauma care, 207–208 Research needs cost-effectiveness of EMS interventions, 23 effectiveness of EMS, 20–21 EMS system finances, 7–8 EMS system review, 18–19 outcomes data, 21 prehospital interventions, 163–164, 209–210 shortcomings of EMS knowledge base, 4–5, 18, 27, 42, 208–210 Response times ambulance diversion and, 22–23 causes of delay, 22 current system, 4, 16 determinants of, 4 performance measurement, 86 in rural areas, 63 variation among EMS systems, 22 Rhode Island, 2003 nightclub fire in West Warwick, 190 Ricin, 181 Robert Wood Johnson Foundation, 34 Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services, 19, 33 Rural areas air medical services, 161 challenges for EMS systems, 42, 62–64 crash fatalities, 24 development of EMS system, 36 disaster response readiness, 200 disparities in care, 23–24, 62 EMS workforce characteristics, 132, 138 need for new workforce staffing models, 138–139 9-1-1 systems, 63 population trends, 138 regionalization of services, 65 response times, 63 role of EMS in, 66 strategies to enhance EMS, 65–66 transport costs, 48 volunteer-based EMS systems, 60, 62 S Safar, Peter, 32 Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU), 6, 101 Safety air medical services, 61, 161 ambulance crashes, 20, 159–160 of EMS personnel, 19–20, 41–42, 136–137 risks in disaster response, 182 risks in prehospital emergency care, 19 Sarin, 181 Scope of emergency medical services, 1, 15

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Emergency Medical Services at the Crossroads Scope of practice, EMT and paramedic definition, 9 national model, 122–123 recommendations, 9, 123, 144 September 11, 2001, terrorist attacks, 37, 38, 176, 183–185, 192, 198–199 Severe acute respiratory syndrome (SARS), 178 Smallpox, 181 Society for Academic Emergency Medicine, 208 Spain ambulancias, 31 2004 terrorist attacks in Madrid, 190 State governments air ambulance regulation, 161–162, 170 ambulance regulation, 159 Centers for Disease Control and Prevention block grants, 44–46 demonstration programs for enhancing emergency care, 14, 96 disaster planning and operations, 12, 201–202 Emergency Management Assistance Compact, 187–188 EMS oversight, 50–53 EMS personnel credentialing and certification, 122–123, 124, 126–127, 201 evolution of EMS system, 35 licensing reciprocity between, 123, 137, 201 model EMS systems, 90–95 recommendations for, 9, 11, 12, 123, 126, 144, 162, 170 Structure of EMS systems barriers to research, 210–211 categorization of emergency providers, 79–80 communications and, 10, 164 establishment of new lead agency, 106, 107, 108, 115 federal oversight and funding, 6, 43–50, 99–101 fire department–based, 56–57 goals, 78–79 hospital-based, 58 local decision making, 53 9-1-1 systems, 53–54 prehospital care research, 219–220 regional variation in EMS systems, 2, 164 research role, 207 state government oversight, 50–53 See also Fragmentation of EMS system Surveillance, public health, 75 T Terrorist attacks disaster preparedness, 12, 192–193 hospital bioterrorism preparedness, 44 Jerusalem (2001), 190–191 London (2005), 189–190 Madrid (2004), 190 National Response Plan, 184–185 research funding, 221 threat types and characteristics, 179–182 training for EMS personnel, 43 See also September 11, 2001, terrorist attacks Texas EMS and trauma system, 92–93 Tornadoes, 178 Training of EMS personnel, 27 accreditation, 9 ambulance drivers, 159–160 disaster response readiness, 4, 13, 43, 176, 195–196, 200, 202 dispatchers, 141 efforts to standardize, 120–121 EMS subspecialty certification, 9, 143–144 first responders, 127 graduation trends, 135 historical development, 33 medical directors, 64, 143 model components, 120–121 national certification, 126–127, 144 national core content, 120, 121–122 national standard curricula, 123–124 origins and development, 32 recommendations for, 9, 125–126, 143–144, 144, 200, 202 regional variation, 119, 125 for research, 210, 211–212 scope of practice model, 120, 121, 122–123 settings for, 125 shortcomings of current system, 41 Transportation of patient cost per transport, 48 disaster response, 182

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Emergency Medical Services at the Crossroads Emergency Medical Treatment and Active Labor Act requirements, 112–113 incentives for unnecessary transport, 88–89 interfacility, 162–163 Medicaid reimbursement, 41, 52 Medicare reimbursement, 7, 47, 48 patient characteristics, 16–17 recommendations for protocol development, 8, 80–83, 115 shortcomings of current system, 3, 10 strengths of current system, 16 See also Air medical services; Ambulance services; Prehospital care Trauma care definition, 25 research, 207–208 Trauma center definition, 25 Trauma system, coordination of care in, 76, 78–79 Trauma Systems Consultation, 79 Triage, 77, 81, 141, 190–192 U Uniform Prehospital EMS Dataset, 168 Uninsured patients, 48 Urban Area Security Initiatives, 193, 194 URGENCY Decision Assist software, 156–157 V Ventricular fibrillation, 21 Voice over Internet Protocol, 154 Volunteer-based EMS systems, 60, 62, 188 W Washington state, Seattle EMS system, 38 Wireless Public Safety Interoperable Communications Program (SAFECOM), 167 Workforce, 27 ambulance working conditions, 159 calls per week, 132 career development, 136 challenges for EMS system, 41–42 compensation, 4, 42, 136 demographics, 130–132 dispatchers, 141–142 efforts to standardize qualifications and requirements, 120–121 employment, 132, 134 future challenges, 119, 135 job satisfaction, 135 licensing reciprocity between jurisdictions, 123, 137 occupational fatalities, 137 professional identity, 4, 42 projected growth, 134, 135 registration status, 130, 133, 134, 137–138 roles and responsibilities, 127–130 rural EMS systems, 42, 63–64, 138–139 safety concerns, 19–20, 41–42, 136–137 size, 15, 132–135 staffing models, 60 supply problems, 134–135 variations in education and training, 119 volunteer-based EMS systems, 60, 137–139 See also Emergency medical technicians; Medical directors, EMS; Scope of practice, EMT and paramedic; Training of EMS personnel World Wars I and II, 32

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