2
History and Current State of EMS

Across the country, emergency medical services (EMS) agencies face numerous challenges with regard to their funding, management, workforce, infrastructure, and research base. Though the modern EMS system was instituted and funded in large part by the federal government through the Highway Safety Act of 1966 and the EMS Act of 1973, federal support for EMS agencies declined precipitously in the early 1980s. Since that time, states and localities have taken more prominent roles in financing and designing EMS programs. The result has been considerable fragmentation of EMS care and wide variability in the type of care that is offered from state to state and region to region. This chapter traces the development of the modern EMS system and describes the current state of EMS at the federal, state, and local levels.

A BRIEF HISTORY OF EMS

EMS dates back centuries and has seen rapid advances during times of war. At least as far back as the Greek and Roman eras, chariots were used to remove injured soldiers from the battlefield. In the late 15th century, Ferdinand and Isabella of Spain commissioned surgical and medical supplies to be provided to troops in special tents called ambulancias. During the French Revolution in 1794, Baron Dominique-Jean Larrey recognized that leaving wounded soldiers on the battlefield for days without treatment dramatically increased morbidity and mortality, weakening the fighting strength of the army. He instituted a system in which trained medical per-



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Emergency Medical Services at the Crossroads 2 History and Current State of EMS Across the country, emergency medical services (EMS) agencies face numerous challenges with regard to their funding, management, workforce, infrastructure, and research base. Though the modern EMS system was instituted and funded in large part by the federal government through the Highway Safety Act of 1966 and the EMS Act of 1973, federal support for EMS agencies declined precipitously in the early 1980s. Since that time, states and localities have taken more prominent roles in financing and designing EMS programs. The result has been considerable fragmentation of EMS care and wide variability in the type of care that is offered from state to state and region to region. This chapter traces the development of the modern EMS system and describes the current state of EMS at the federal, state, and local levels. A BRIEF HISTORY OF EMS EMS dates back centuries and has seen rapid advances during times of war. At least as far back as the Greek and Roman eras, chariots were used to remove injured soldiers from the battlefield. In the late 15th century, Ferdinand and Isabella of Spain commissioned surgical and medical supplies to be provided to troops in special tents called ambulancias. During the French Revolution in 1794, Baron Dominique-Jean Larrey recognized that leaving wounded soldiers on the battlefield for days without treatment dramatically increased morbidity and mortality, weakening the fighting strength of the army. He instituted a system in which trained medical per-

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Emergency Medical Services at the Crossroads sonnel initiated treatment and transported the wounded to field hospitals (Pozner et al., 2004). This model was emulated by Americans during the Civil War. General Jonathan Letterman, a Union military surgeon, created the first organized system in the United States to treat and transport injured patients. Based on this experience, the first civilian-run, hospital-based ambulance service began in Cincinnati in 1865. The first municipally based EMS began in New York City in 1869 (NHTSA, 1996). In 1910, the American Red Cross began providing first-aid training programs across the country, initiating an organized effort to improve civilian bystander care. During World Wars I and II, further advances were made in EMS, although typically these were not replicated in the civilian setting until much later (Pozner et al., 2004). Following World War II, city EMS activities were for the most part run by municipal hospitals and fire departments. In smaller communities, funeral home hearses often served as ambulances because they were the only vehicle capable of transporting patients quickly in stretchers. With the advent of federal involvement in EMS in the early 1970s and the articulation of standards at the state and regional levels, these EMS providers were gradually replaced by others, including third-service providers, fire departments, rescue squads, and private ambulances (NHTSA, 1996). By the late 1950s, prehospital emergency care in the United States was still little more than first aid (IOM, 1993). Around that time, however, advances in medical care began to spur the rapid development of modern EMS. While the first recorded use of mouth-to-mouth ventilation had been in 1732, it was not until 1958 that Dr. Peter Safar demonstrated it to be superior to other modes of manual ventilation. In 1960, cardiopulmonary resuscitation (CPR) was shown to be efficacious. These two clinical advances led to the realization that rapid response of trained community members to cardiac emergencies could improve outcomes. The introduction of CPR and the development of portable external defibrillators in the 1960s provided the foundation for advanced cardiac life support (ACLS) that fueled much of the development of EMS systems in subsequent years. In 1965, the President’s Committee for Traffic Safety published the report Health, Medical Care and Transportation of the Injured. The report recommended a national program to reduce highway deaths and injuries. The following year, the National Academy of Sciences (NAS) and National Research Council (NRC) released Accidental Death and Disability: The Neglected Disease of Modern Society (NAS/NRC, 1966). That report emphasized that the health care system needed to address injuries, which at the time were the leading cause of death for those aged 1–37. It noted that in most cases, ambulances were inappropriately designed, ill-equipped, and often staffed with inadequately trained personnel. For example, the report

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Emergency Medical Services at the Crossroads called attention to the fact that at least 50 percent of ambulance services nationwide were being provided by morticians. The report contained a total of 29 recommendations, 11 of which applied directly to prehospital EMS (Delbridge et al., 1998). These included recommendations to (1) develop federal standards for ambulances (design, construction, equipment, supplies, personnel training and supervision); (2) adopt state ambulance regulations; (3) ensure provision of ambulance services applicable to the conditions of the local government; (4) initiate pilot programs to evaluate automotive and helicopter ambulance services in sparsely populated areas; (5) assign radio channels and equipment suitable for voice communications between ambulances and emergency departments (EDs) and other health-related agencies; and (6) develop a single nationwide telephone number for summoning an ambulance. The report also laid out a vision for the establishment of trauma systems as we know them today. In addition to the momentum that had been provided by the President’s Commission, support for the NAS/NRC report was fueled by surgeons with military experience in Korea and World War II who recognized that the trauma care available to soldiers overseas was better than the care available in local communities. In 1966, Congress passed the Highway Safety Act, which led to the formation of the National Highway Traffic Safety Administration (NHTSA) within the Department of Transportation (DOT). NHTSA was given authority to fund improvements in EMS. Among those improvements, NHTSA developed a national EMS education curriculum and model state EMS legislation. NHTSA’s 70-hour basic EMT curriculum became the first standard EMT training in the United States. The department developed more extensive advanced life support (ALS) training several years later. Also as part of the 1966 act, DOT offered grant funding to states with the goal of improving the provision of EMS. 1970s: Rapid Expansion of Regional EMS Systems In the early 1970s, additional research and policy planning focused on the unmet needs of EMS. In 1972, the NAS/NRC released another report on EMS entitled Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services (NAS and NRC, 1972). The report expressed concern that the federal effort to upgrade EMS had not kept pace with what was needed. It urged integration of all federal EMS efforts into the Department of Health, Education and Welfare (DHEW, which later became the Department of Health and Human Services [DHHS]). The report also stated that the focal point for local EMS should be at the state rather than the federal level, and that all efforts should be coordinated through regional programs.

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Emergency Medical Services at the Crossroads In 1973, Congress enacted the EMS Systems Act, which created a new grant program to further the development of regional EMS systems. The intent of the law was to improve and coordinate care throughout the country through the creation of a categorical grant program run by the new Division of Emergency Medical Services within DHEW. This program became a decisive factor in the nationwide development of regional EMS systems. Millions of dollars were earmarked for EMS training, equipment, and research. In total, more than $300 million was appropriated for EMS feasibility studies, planning, operations, expansion and improvement, and research. (In 2004 dollars, this investment equates to $1.3 billion.) Also, in 1974 The Robert Wood Johnson Foundation appropriated $15 million to fund 44 regional EMS projects ($64 million in 2004 dollars). To this day, this remains the largest private grant for EMS system development ever awarded. An important feature of the grant program was its emphasis on the need for effective planning at the state, regional, and local levels to ensure coordination of prehospital and hospital emergency care. Across the country, state EMS offices began to emerge. With the federal support, states established a total of about 300 EMS regions—most covering several counties—each eligible to receive up to 5 years of funding (NHTSA, 1996). The law also identified 15 essential elements that should be included in an EMS system: manpower, training, communications, transportation, facilities, critical care units, public safety agencies, consumer participation, access to care, patient transfer, coordinated patient record keeping, public information and education, review and evaluation, disaster plan, and mutual aid. The EMS Systems Act helped guide the development of models of service delivery; informed system functions such as medical direction, triage protocols, communication, and quality assurance; and set the tone of the EMS system’s interaction with the larger health care and public health systems. While the act identified ideal components of an EMS system from the federal government’s perspective, however, the organization of systems on the ground, including their scope of practice and overall structure, was fundamentally driven by local needs, characteristics, and concerns. A patchwork quilt of systems began to emerge. A 1978 report by the NAS/NRC, Emergency Medical Services at Mid-passage, expressed criticism of DHEW and focused on the coordination problem between DOT and DHEW at the federal level (NAS and NRC, 1978). The report criticized the conflicting education standards developed by the two departments and recommended more research and evaluation of EMS system development. By 1981, an agreement between DOT and DHEW to coordinate efforts had been canceled, and the EMS program and DHEW grants had been eliminated.

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Emergency Medical Services at the Crossroads 1980s: Withdrawal of Federal Support and Leadership in EMS In 1981, the Omnibus Budget Reconciliation Act (OBRA) eliminated the categorical federal funding to states established by the 1973 EMS Systems Act in favor of block grants to states for preventive health and health services. This change shifted responsibility for EMS from the federal to the state level. Once states had greater discretion regarding the use of funds, most chose to spend the money in areas of need other than EMS. Thus the immediate impact of the shift to block grants was a sharp decrease in total funding for EMS (U.S. Congress, Office of Technology Assessment, 1989). Moreover, states were left to develop their systems in greater isolation. Some increased their involvement in EMS, but others chose to cede more authority to cities and counties. Political, geographic, and fiscal disparities contributed to fragmented and diverse development of EMS systems at the local level. In addition, a lack of objective scientific evidence regarding the best models for EMS organization and delivery left many systems in the dark regarding appropriate steps to take. The structure provided to local EMS systems by state governments varied. Lead state EMS agencies remained in all states, but with varying degrees of authority and funding. Maryland, for example, chose to maintain an active role and retained significant authority at the state level. The Maryland Institute for Emergency Medical Services Systems was established in 1972 and continued to take a strong leadership role in subsequent years. The state elected to provide emergency air and ground transportation as a public service and created a sophisticated trauma system that designates trauma centers on the basis of compliance with standards and demonstrated need (IOM, 1993). By contrast, California and many other states elected to take a less active role. By default as much as by design, regional and county EMS systems took the lead in designing and managing their EMS programs. California state government maintained responsibility for such issues as investigating EMS system complaints and setting EMS training standards, but otherwise had a diminished role in the overall direction of EMS systems. During the 1980s, some states maintained vestiges of the regional systems that were developed in the 1970s, but other systems were fractured along smaller and smaller local lines. The result was even greater diversity among systems. In the early to mid-1980s, the role of voluntary national EMS organizations increased. These included the National Association of State EMS Officials (NASEMSO, formerly the National Association of State EMS Directors [NASEMSD]), the National Association of Emergency Medical Technicians (NAEMT), the National Association of EMS Physicians (NAEMSP), the American College of Surgeons Committee on Trauma (ACS COT), and the American College of Emergency Physicians (ACEP) EMS Committee. In 1984, the Emergency Medical Services for Children (EMS-C) program was

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Emergency Medical Services at the Crossroads established at the Health Resources and Services Administration (HRSA) within DHHS. In 1985, the NRC report Injury in America: A Continuing Health Problem described the limited progress that had been made in addressing the problem of accidental death and disability (IOM, 1985). The report described the need for a federal agency to focus on injuries as a public health problem. In response, an injury program was established at the Centers for Disease Control and Prevention (CDC) that approached injury prevention and control from a public health perspective. This program was later elevated to the status of a center at CDC—the National Center for Injury Prevention and Control (NCIPC). During this period, rural EMS development lagged behind. The loss of federal funding and the limited financial resources available in states with large rural populations exacerbated this problem. In 1989, the Office of Technology Assessment released a report detailing the challenges faced by rural EMS (U.S. Congress, Office of Technology Assessment, 1989) (see the discussion of rural EMS below). NHTSA implemented a statewide EMS technical assessment program in 1988. During these assessments, statewide EMS systems are evaluated on the basis of 10 essential components: regulation and policy, resource management, human resources and training, transportation, facilities, communications, public information and education, medical direction, trauma systems, and evaluation. 1990s to the Present: EMS—Looking Toward the Future In 1995, through the urging of then NHTSA Administrator Ricardo Martinez, NHTSA and HRSA commissioned a strategic plan for the future EMS system. The resulting report, Emergency Medical Services Agenda for the Future (NHTSA, 1996), outlined a vision of an EMS system that is integrated with the health care system, proactive in providing community health, and adequately funded and accessible (see Table 2-1). TABLE 2-1 New Vision for the Role of Emergency Medical Services EMS Today (1996) EMS Tomorrow Isolated from other health services Reacts to acute illness and injury Financed for service to individuals Access through fixed-point phone Integrated with the health care system Acts to promote community health Funded for service to the community Supports fixed and mobile phones SOURCE: Martinez, 1998.

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Emergency Medical Services at the Crossroads In 1997, NHTSA gathered members of the EMS community to develop an implementation guide for making the recommendations in Agenda for the Future a reality. The implementation guide focused on three strategies: improving linkages between EMS and other components of the health care system, creating a strong infrastructure, and developing new tools and resources to improve the effectiveness of EMS. Agenda for the Future, now a decade old, has been effective in drawing attention to EMS and placing a spotlight on the vital role played by EMS within the emergency and trauma care system. Several of the goals it set forth, however, have not yet been realized. Its vision, such as placing a focus on the care provided to entire communities rather than individuals and thinking proactively rather than reactively, still represents a significant conceptual leap for most EMS systems. The types of changes envisioned by the Agenda are discussed in the relevant context in the chapters that follow. More recently, in 2001, the U.S. General Accounting Office (GAO) released a comprehensive study of local EMS system needs and of the state regulatory agencies responsible for improving EMS outcomes. The report characterized the needs as substantial and wide-ranging, and grouped the problems identified under four categories: personnel, training, equipment, and medical direction. The report noted that the extent of local needs was difficult to determine since little standard and quantifiable information exists for use in comparing performance across systems. The report also noted that most of the available information is localized and anecdotal (GAO, 2001b). The terrorist attacks of September 11, 2001, focused attention on the heroism of public safety personnel (fire, police, and EMS), but also exposed many of the technical and logistical challenges that confront the nation’s public safety systems. Communications capabilities were shown to be grossly deficient among the units that responded to the World Trade Center attacks, and a lack of interoperability and inadequate communications with rescuers within the towers probably contributed to the deaths of many rescue personnel (National Commission on Terrorist Attacks upon the United States, 2004). In the aftermath of the disaster, the federal government took a number of steps to improve response capabilities, including development of the National Response Plan and the National Incident Management System (NIMS) (discussed in Chapter 6). Boxes 2-1 and 2-2 detail the development and recent experience of EMS systems in two U.S. cities. THE TROUBLED STATE OF EMS EMS operates at the intersection of health care, public health, and public safety and therefore has overlapping roles and responsibilities (see

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Emergency Medical Services at the Crossroads BOX 2-1 Seattle, Washington Thirty years ago, Seattle had no organized EMS system and no paramedics. Several progressive individuals developed the concept that firefighters could be taught some of the medical skills that were normally reserved for physicians acting within a hospital. The goal was to provide these services at the earliest point of illness or injury. In 1970, the Seattle Fire Department, in cooperation with a small group of physicians at HarborviewMedical Center and the University of Washington, trained the first class of firefighters as paramedics. With strong community support supplemented by grants from the National Highway Traffic Safety Administration, paramedic programs flourished in subsequent years. Research, much of it conducted within the Seattle “Medic One” EMS system, has shown that paramedics can provide high-quality care to patients outside of the hospital. The prehospital emergency medical care system pioneered in Seattle has become famous around the world and remains a model that many others attempt to emulate. Further, Seattle has taken its unique approach to its citizens. In 1998, the Washington State Legislature enacted a lawto facilitate the implementation of and compliance with a citizen defibrillation program. This city leads the nation in providing early care for victims of cardiac arrest as a result of the active involvement and training of civilians within the community. Citizens in Seattle are trained to recognize when a fellow citizen needs medical care, activate the 9-1-1 system, and help the victim until the EMS unit arrives. Seattle’s Medic One system exemplifies what can be achieved with political leadership, strong and sustained physician medical direction, community support, and data-driven decision making. Figure 2-1). Often, local EMS systems are not well integrated with any of these groups and therefore receive inadequate support from each of them. As a result, EMS has a foot in many doors, but no clear home. Prehospital EMS faces a number of special challenges. First and foremost, EMS systems throughout the country are often highly fragmented. Although they are frequently required to work side by side, turf wars between EMS and fire personnel are not uncommon (Davis, 2003a, 2004). In addition, as noted above, the events of September 11, 2001, demonstrated that public safety agencies (including fire, police, emergency management, and EMS) often use incompatible equipment and are unable to communicate with each other during emergencies. Many of these problems are

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Emergency Medical Services at the Crossroads magnified when incidents cross jurisdictional lines. Significant problems are often encountered near municipal, county, and state borders. Where 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. One county in Michigan has 18 different EMS systems with a range of service models and protocols. In addition, EMS providers have found that coordinating services across state lines is particularly challenging. In addition, coordination between EMS and hospitals is often inadequate. While hospital ED staff often provide direct, on-line medical direction to EMS personnel during transport, time pressures, competing demands, and a lack of trust can at times hinder these interactions. In addition, cultural differences between EMS and hospital staff can impede the exchange of information. Upon arrival at the hospital, busy ED staff who are strug- BOX 2-2 San Francisco, California Prior to 1997, San Francisco’s EMS system fell under the jurisdiction of the public health department, with the fire department providing first-responder support. During the late 1990s and early 2000s, a seven-phase merger process was initiated to place EMS under the jurisdiction of the fire department. However, this process experienced difficulties from the beginning and later resulted in a partial separation. The merger called for the cross-training of EMS personnel and firefighters, the placement of paramedics on city fire trucks, and institution of a “one and one” response program, with ambulances staffed by one paramedic and one EMT. However, the cross-training of firefighters as paramedics was delayed because of lengthy union negotiations. EMS workload constraints delayed EMTs’ fire-suppression cross-training. This in turn delayed the changes in personnel configuration. In addition, a requirement that EMS personnel work 24-hour shifts rankled paramedics and raised concerns about the impact on patient care. These and other issues revealed a clash between the firefighting and EMS cultures and raised questions about the advisability of the merger. An audit later determined that, despite the increased resources devoted by the fire department to EMS during the first 4 years of the merger, average response times had increased (City and County of San Francisco, Office of the Budget Analyst, 2002). The city later instituted a newplan in which a lower-paid group of paramedics and EMTs was hired and located outside of fire stations, partially ending the merger attempt.

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Emergency Medical Services at the Crossroads FIGURE 2-1 The overlapping roles and responsibilities of EMS. SOURCE: NHTSA, 1996. gling to manage a very crowded ED often greet arriving EMS units with, at best, a lack of enthusiasm. As a result, clinically important information is sometimes lost in patient handoffs between EMS and hospital staff. Second, there is little doubt that ED crowding has had a very adverse impact on prehospital care. When an ED is crowded, ED staff may be unable to find the physical space needed to off-load patients. Under these circumstances, EMS units may be stuck in the ED for prolonged periods of time, leaving them out of service for other emergency calls. In addition, ED diversion has become commonplace in many major cities, further hindering the performance of EMS. In major metropolitan areas, it is not uncommon for all of the city’s trauma centers to request ambulance diversion at the same time. When hospital EDs go on diversion status, ambulances may have to drive longer distances and take patients to less appropriate facilities (GAO, 2003). Fully 45 percent of EDs reported going on diversion at some point in 2003, and the problem was especially pronounced in urban areas. Overall, it is estimated that 501,000 ambulances were diverted during that year (Burt et al., 2006). Although it is likely that ambulance diversions endanger patients, there are no data directly linking ambulance diversions with higher mortality rates. No agency has sponsored a systematic study to examine this question, and fears of legal liability inhibit candid disclosure of adverse events (IOM, 2000). However, a study by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2002) revealed that more than

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Emergency Medical Services at the Crossroads half of all “sentinel” ED events—defined as “an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof”—were caused by delayed treatment. While this study was not centered on ambulance diversion, its findings are consistent with the argument that delays in treatment resulting from diversion can have deleterious effects on patients. Third, the cost of maintaining an EMS system in a state of readiness is extremely high, and it is rarely compensated. The EMS reimbursement model used by the Centers for Medicare and Medicaid Services (CMS) and emulated by many payers reimburses on the basis of transport to a medical facility. This model ignores the increasingly sophisticated care provided by EMS personnel, as well as the growing proportion of elderly patients with multiple chronic conditions who frequently utilize EMS. Medicaid typically pays a fixed rate—as low as $25 in some states—for an EMS transport, regardless of the complexity of the case or the resources utilized. The fact that payers generally withhold reimbursement in cases where transport is not provided is a major impediment to the implementation of processes that allow EMS to “treat and release,” to transport patients directly to a dialysis unit or another appropriate site, or to terminate unsuccessful cardiac resuscitation in the field. In addition, many systems of all types provide both 9-1-1 call services and medical transportation. To make up for funding shortfalls, these systems often offset the cost of the former services with revenues from the latter. EMS is widely viewed as an essential public service, but it has not been supported through effective federal and state leadership and sustainable funding strategies. Unlike other such services—electricity, highways, airports, and telephone service, for example—all of which were created and are actively maintained through major national infrastructure investments, access to timely and high-quality emergency and trauma care has largely been relegated to local and state initiatives. As a result, EMS care remains extremely uneven across the United States. Even when EMS is located within a publicly funded agency such as the fire service, it may receive a disproportionately small amount of fire service funding (including grants and line item disbursements), despite the fact that a large majority of calls to fire departments are medical in nature. Fourth, EMS agencies face a number of personnel challenges. The training of EMTs and paramedics is uneven across the United States, and as a result, EMS professionals exhibit a wide range of skill levels. There are currently no national requirements for training, certification, or licensure, nor is there required national accreditation of schools that provide EMS training. In addition, recruitment and retention are significant challenges for EMS systems. The work of prehospital providers can be challenging and dangerous. EMS personnel face potential violence from patients; risks

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Emergency Medical Services at the Crossroads severely injured and that they often did not deliver patients to the hospital more rapidly than ground ambulances (Levin and Davis, 2005). On the other hand, a number of other studies suggest benefits of air ambulance service relative to ground transport. Davis and colleagues (2005) found that patients with moderate to severe traumatic brain injury who received care through air ambulance had improved outcomes. In addition, the study found that out-of-hospital intubation among air-transported patients resulted in better outcomes than ED intubation among ground-transported patients. Patients with more severe injuries appeared to derive the greatest benefit from air medical transport. And Gearhart and colleagues (1997) reviewed the literature and reported 1–12 additional survivors per 100 patients flown. EMS in Rural Areas According to the 2000 U.S. Census, 21 percent of the nation’s population lives in rural and frontier areas. Residents of these areas experience significant health disparities relative to their urban counterparts (Pollock, 2001). A large portion of these disparities results from the distinctive cultural, social, economic, and geographic characteristics that define rural America, but the situation also reflects the difficulty of applying medical systems designed for urban environments to rural and frontier communities. Rural EMS Challenges Rural EMS systems face a multitude of challenges. A particularly daunting challenge is providing adequate access to care given the distances involved and the limited assets available. Ensuring the delivery of quality EMS to rural populations is also complicated by the makeup and skill level of prehospital EMS personnel and associated issues of management, funding, and medical direction for rural EMS systems. In 1989, the Office of Technology Assessment estimated that three-quarters of rural prehospital EMS personnel were volunteers (U.S. Congress, Office of Technology Assessment, 1989). A more recent national assessment found that 77 percent of EMS personnel in rural areas were volunteers, compared with 33 percent in urban areas (Minnesota Department of Health, Office of Rural Health Primary Care, 2003). State health directors list access to quality EMS care as a major rural health concern (O’Grady et al., 2002). In a 2003 survey of national and state rural health experts, 73 percent identified access to health care as a priority issue, and EMS access was cited as a primary concern (Gamm et al., 2003; Rawlinson and Crewes, 2003). In its 2004 report Quality Through

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Emergency Medical Services at the Crossroads Collaboration: The Future of Rural Health, the Institute of Medicine cited EMS as one of four essential health care services for rural residents, along with primary, dental, and mental health care (IOM, 2004). As noted in Chapter 1, EMS response times from the instigating event to arrival at the hospital are significantly longer in rural than in urban areas. These prolonged response times occur at each step in EMS activation and response, including time to EMS notification, time from EMS notification to arrival at the scene, and time from arrival at the scene to arrival at the hospital. A 2002 survey found that 30 percent of rural patients fatally injured in a crash (compared with 8.3 percent in urban areas) arrived at the hospital more than 60 minutes after the crash, after the “golden hour” had expired (NHTSA, 2005). These prolonged response times are attributable to the increased distances involved, but also to other factors, such as the limits of 9-1-1 availability in sparsely populated areas. While the availability of 9-1-1 extends to the vast majority of the U.S. population, 4 percent of the nation’s counties still do not have access to basic 9-1-1 (see Chapter 5). Moreover, enhanced 9-1-1, which provides geographic data to the dispatch center so the location of an incident can be pinpointed, is difficult to implement when a large portion of the rural population uses rural routes and post office boxes to designate addresses (Gausche and Seidel, 1999). In addition, the small number of ambulances available in some rural regions and the inability to priority dispatch these ambulances if there is only one unit available remain a challenge (Key, 2002). One of the first obstacles to timely EMS activation in rural areas is the delay that commonly occurs in the discovery of crash scenes. On infrequently traveled rural roads, a long time may elapse before victims are discovered. This delay may be the single largest contributor to prolonged times until transport to a hospital (Esposito et al., 1995). In a study of rural Missouri, only 39 percent of calls alerting EMS came within 5 minutes of the collision, compared with 90 percent in urban study areas (Brodsky, 1992). Automated collision notification systems offer the potential for significant improvement in this area (see Chapter 5). In a rural demonstration project conducted by NHTSA during 1995–2000, this technology was demonstrated not only to work, but also to reduce response times (NHTSA, 2001). When prehospital EMS is activated, there is significant local variation in the type and quality of services provided. Rural EMTs working in an isolated environment while treating a critically ill or injured patient will spend more time with the patient and use fewer resources than urban EMTs or paramedics. Certain clinical scenarios may actually require a greater skill level and more multitasking on the part of rural EMTs as compared with their urban counterparts. As noted, however, EMS systems in rural areas are staffed largely by volunteers with highly variable levels of expertise, training, and experience. A rural EMT may encounter highly critical cases

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Emergency Medical Services at the Crossroads very infrequently as a result of the small size of the local population and the number of volunteers required to cover a schedule. For the limited number of EMS personnel in a largely volunteer system, formal training and critical care experience are often lacking, and even when such training is attained, the low volume of calls contributes to the degradation of critical care skills. Moreover, access to continuing education may be scarce in rural areas (Key, 2002). Additionally, volunteer organizations experience a higher level of provider turnover, which may reduce the number of experienced volunteers. Taken together, these factors mean that rural EMS providers may be less proficient than urban providers. A high percentage of rural EMS personnel may be trained only in BLS, and indeed, many rural programs offer only BLS services (Minnesota Department of Health, Office of Rural Health Primary Care, 2003). Even when rural EMTs are trained to perform critical tasks, such as endotracheal intubation, their success rate is poor (Sayre et al., 1998), in part because of the infrequent need to exercise such skills noted above. In one study, despite training, rural EMS personnel were able to intubate only 49 percent of their patients successfully. Cited as possible explanations for this low success rate were training deficiencies, infrequent intubation opportunities, and inconsistent supervision (Bradley et al., 1998). Likewise, Spaite (1998) pointed out that rural EMS personnel with defibrillator training may defibrillate a patient only two or three times in a decade, emphasizing a pivotal role for the use of automated external defibrillators. In addition, even when ALS is available in rural areas, the services have repeatedly been demonstrated to be provided at much lower levels of quality than in urban settings (Gausche et al., 1989; Svenson et al., 1996; Seidel et al., 1999). The availability and qualifications of EMS medical directors are also an issue. Many of these individuals have little or no experience in EMS medical direction. A survey of state EMS directors indicated that recruitment of medical directors is frequently very difficult and that providers serving in that role are often primary care physicians with little or no emergency medicine training. While on-line continuing medical education is becoming more available, it has been slow to take hold; moreover, such training can impart cognitive information, but typically does not teach technical and procedural skills. Nevertheless, the use of telemedicine and distance learning allows previously inaccessible training to penetrate remote areas, while new, more realistic and dynamic patient simulators enable case-based honing of critical skills and decision-making abilities. These tools may be able to offset some of the problems with skill deterioration due to the limited experience attained in rural areas (McGinnis, 2004).

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Emergency Medical Services at the Crossroads Addressing Rural EMS Challenges A number of strategies for optimizing EMS resources have been proposed to deal with the paucity of funding, response units, and other resources in rural areas. One such proposal is the dynamic load-responsive deployment of ambulance units. With this approach, ambulances are positioned strategically throughout an area and are dispatched centrally in an effort to reduce response times. Determination of where to position individual units is based on the demand in each area combined with the distance to be traveled, using an established average response time. In one study, load-responsive deployment in a rural area resulted in a 32 percent increase in the number of calls responded to within the established time allowance of 8 minutes (Peleg and Pliskin, 2004). While promising, however, this approach is not possible in very isolated rural communities where EMS units are staffed by volunteers who respond from home. Another method found to increase the efficiency of EMS systems in rural areas is the establishment of regionally based systems. Such systems may be organized in countywide or larger areas, with ambulances being prepositioned in strategic locations and dispatched centrally (Key, 2002). Basic EMS providers and fire departments scattered throughout the area can act as first responders, with fully equipped units responding after dispatch. Such a system has been used successfully on San Juan Island, a rural island off the coast of Washington State. Killien and colleagues (1996) demonstrated a survival to discharge rate for out-of-hospital cardiac arrest of 22 percent employing this type of system, whereas most studies in rural areas have found survival rates of less than 10 percent (Killien et al., 1996). One of the largest rural regional EMS systems in the United States is that of the East Texas Medical Center. This system serves nearly 17,000 square miles over 17 counties, with 85 ambulance units and two helicopters. Units are dispatched through a central 9-1-1 dispatcher using a modern global positioning system for geographic information (East Texas Medical Center Regional Healthcare System, 2004). In this way, a large rural area encompassing many counties can be served by an EMS system with up-to-date equipment and resources that could not be sustained financially by any one county alone. Another issue pertinent to rural settings is the involvement of citizens or lay first responders who can provide first aid, start CPR, and take other measures while awaiting the arrival of EMS. The 2005 World Health Organization report Prehospital Trauma Care Systems strongly recommends such citizen engagement, particularly in resource-poor communities that cannot afford costly or sophisticated EMS systems (Sasser et al., 2005). Training dispatchers to give prearrival instructions can help reinforce citizen involvement, with or without prior CPR and first-aid training. Although the current standard for CPR training is a 4-hour class taught by a paid instruc-

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Emergency Medical Services at the Crossroads tor, research has shown that citizens can teach themselves CPR with a video and inexpensive manikin in 30 minutes (see Chapter 4). Numerous benefits can result, including more consistent provision of first aid, rapid access to bystander CPR, enhanced community response to disasters and mass-casualty events, and possibly more rational use of EDs and EMS assets. Role of EMS in Rural Public Health Individuals in rural communities have less access to the full range of essential public health services than their urban counterparts (U.S. Congress, Office of Technology Assessment, 1989). Many such areas have no local county or city public health agency, and those public health departments that do serve rural areas have few if any staff with formal public health training (Pollock, 2001). As a result, the rural EMS system often assumes a broader role in the community than the typical urban system with regard to both the medical needs of individuals and the public health and safety of the community overall. Because of the lack of physicians and nurses and other medical facilities, it is not unusual in rural communities for EMS to provide informal evaluation, advice, and care that are never reflected in an EMS patient’s record and do not involve transportation (McGinnis, 2004). The lack of public health departments may require rural EMS personnel to assume leadership roles in tasks performed traditionally by public health departments, such as immunizations (Pollock, 2001). Finally, the lack of capacity of rural public health departments and a limited rural public safety infrastructure result in greater reliance on rural EMS personnel to participate in disaster preparedness relative to their urban counterparts (Spaite et al., 2001). REFERENCES AAA (American Ambulance Association). 2004. Community Guide to Ensure High-Performance Emergency Ambulance Service. McLean, VA: AAA. AAA. 2006. Ambulance Facts. [Online]. Available: http://www.the-aaa.org/media/Ambulance-Facts.htm [accessed January 5, 2006]. AEMS (Advocates for Emergency Medical Services). 2005a. FICEMS Bill. [Online]. Available: http://www.advocatesforems.org/default.cfm/PID=1.9.24/ [accessed October 1, 2005]. AEMS. 2005b. EMS Related Fiscal Year 2006 Federal Funding. [Online]. Available: http://www.advocatesforems.org/Library/upload/EMS_funding_summary_chart3.pdf [accessed October 1, 2005]. Arfken CL, Shapiro MJ, Bessey PQ, Littenberg B. 1998. Effectiveness of helicopter versus ground ambulance services for interfacility transport. Journal of Trauma-Injury Infection & Critical Care 45(4):785–790. Baker SP, Grabowski JG, Dodd RS, Shanahan DF, Lamb MW, Li GH. 2006. EMS helicopter crashes: What influences fatal outcome? Annals of Emergency Medicine 47(4):351–356. Bledsoe BE. 2003. Air medical helicopter accidents in the United States: A five-year review. Prehospital Emergency Care 7(1):94–98.

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Emergency Medical Services at the Crossroads Blumen IJ, UCAN Safety Committee. 2002. A Safety Review and Risk Assessment in Air Medical Transport. Salt Lake City, UT: Air Medical Physician Association. Bradley JS, Billows GL, Olinger ML, Boha SP, Cordell WH, Nelson DR. 1998. Prehospital oral endotracheal intubation by rural basic emergency medical technicians. Annals of Emergency Medicine 32(1):26–32. Branas CC, MacKenzie EJ, Williams JC, Schwab CW, Teter HM, Flanigan MC, Blatt AJ, ReVelle CS. 2005. Access to trauma centers in the United States. Journal of the American Medical Association 293(21):2626–2633. Brodsky H. 1992. Delay in ambulance dispatch to road accidents. American Journal of Public Health 82(6):873–875. Brown WE Jr, Dawson DE, Levine R. 2003. Compensation, benefits, and satisfaction: The Longitudinal Emergency Medical Technical Demographic Study (LEADS) project. Prehospital Emergency Care 7(3). Burt CW, McCaig LF, Valverde RH. 2006. Analysis of Ambulance Transports and Diversions Among U.S. Emergency Departments. Hyattsville, MD: National Center for Health Statistics. Center for Catastrophe Preparedness and Response NYU. 2005. Emergency Medical Services: The Forgotten First Responder—A Report on the Critical Gaps in Organization and Deficits in Resources for America’s Medical First Responders. New York: Center for Catastrophe Preparedness and Response, New York University. City and County of San Francisco, Office of the Budget Analyst. 2002. Management Audit of the San Francisco Fire Department: Introduction. [Online]. Available: http://www.sfgov.org/site/budanalyst_page.asp?id=4844 [accessed April 20, 2006]. Cunningham P, Rutledge R, Baker CC, Clancy TV. 1997. A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported from the scene. Journal of Trauma-Injury Infection & Critical Care 43(6):940–946. Davis DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, Rosen P. 2003. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. Journal of Trauma-Injury Infection & Critical Care 54(3):444–453. Davis DP, Peay J, Serrano JA, Buono C, Vilke GM, Sise MJ, Kennedy F, Eastman AB, Velky T, Hoyt DB. 2005. The impact of aeromedical response to patients with moderate to severe traumatic brain injury. Annals of Emergency Medicine 46(2):115–122. Davis R. 2003a, July. Many lives are lost across USA because emergency services fail. USA Today. P. 1 A. Davis R. 2003b. The Method: Measure How Many Victims Leave the Hospital Alive. [Online]. Available: http://www.usatoday.com/news/nation/ems-day1-method.htm [accessed January 27, 2007]. Davis R. 2004, August 26. D.C. EMS chief’s firing illustrates conflicts over lifesaving reform: Turf wars hamper efforts across USA. USA Today. P. B14. Delbridge TR, Bailey B, Chew JL Jr, Conn AK, Krakeel JJ, Manz D, Miller DR, O’Malley PJ, Ryan SD, Spaite DW, Stewart RD, Suter RE, Wilson EM. 1998. EMS agenda for the future: Where we are … where we want to be. Prehospital Emergency Care 2(1):1–12. DHHS (Department of Health and Human Services). 2003. Emergency Medical Treatment and Labor Act (EMTALA) Interim Guidance. Center for Medicare and Medicaid Services’ Center for Medicaid and State Operations, Survey and Certification Group. Baltimore, MD: DHHS. Dula DJ, Palys K, Leicht M, Madtes K. 2000. Helicopter versus ambulance transport of patients with penetrating trauma. Air Medical Journal 36(4):S76. East Texas Medical Center Regional Healthcare System. 2004. ETMC EMS. [Online]. Available: http://emsservices.etmc.org [accessed September 2004].

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Emergency Medical Services at the Crossroads Elting K, Toddy M. 2003. New Rules Clarify EMTALA Obligations. [Online]. Available: http://www.jonesday.com/pubs/pubs_detail.aspx?pubID=S1820 [accessed May 24, 2006]. EMS Insider. 2005. EMS Employers Struggle with Paramedic Shortages. [Online]. Available: http://www.jems.com/insider/4_04.html [accessed April 4, 2005]. Esposito TJ, Sanddal ND, Hansen JD, Reynolds S. 1995. Analysis of preventable trauma deaths and inappropriate trauma care in a rural state. The Journal of Trauma 39(5):955–962. Franks PE, Kocher N, Chapman S. 2004. Emergency Medical Technicians and Paramedics in California. San Francisco, CA: University of California, San Francisco Center for the Health Professions. Gamm L, Hutchison L, Dabney BJ, Dorsey A, eds. 2003. Rural Healthy People 2010: A Companion Document to Healthy People 2010 (Volume 1). College Station, TX: Southwest Rural Health Research Center. GAO (U.S. Government Accountability Office). 2001a. Emergency Care. EMTALA Implementation and Enforcement Issues. Washington, DC: Government Printing Office. GAO. 2001b. Emergency Medical Services: Reported Needs Are Wide-Ranging, with a Growing Focus on Lack of Data (GAO-2-28). Washington, DC: Government Printing Office. GAO. 2003. Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities. Washington, DC: Government Printing Office. Gausche M, Seidel JS. 1999. Out-of-hospital care of pediatric patients. Pediatric Clinics of North America 46(6):1305–1327. Gausche M, Seidel JS, Henderson DP, Ness B, Ward PM, Wayland BW, Almeida B. 1989. Pediatric deaths and emergency medical services (EMS) in urban and rural areas. Pediatric Emergency Care 5(3):158–162. Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD, McCollough MD, Henderson DP, Pratt FD, Seidel JS. 2000. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurologic outcome: A controlled clinical trial. Journal of the American Medical Association 283(6):783–790. Gearhart PA, Wuerz R, Localio AR. 1997. Cost-effectiveness analysis of helicopter EMS for trauma patients. Annals of Emergency Medicine 30(4):500–506. Hauert SA. 1990. The MPDS and Medical-Legal Danger Zones. [Online]. Available: http://www.emergencydispatch.org/articles/medicallegal1.htm [accessed February 24, 2006]. Helicopter Association International. 2005. White Paper: Improving Safety in Helicopter Emergency Medical Services (HEMS) Operations. Alexandria, VA: Helicopter Association International. IOM (Institute of Medicine). 1985. Injury in America. Washington, DC: National Academy Press. IOM. 1993. Emergency Medical Services for Children. Washington, DC: National Academy Press. IOM. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press. IOM. 2004. Quality through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press. Isakov AP. 2006. Souls on board: Helicopter emergency medical services and safety. Annals of Emergency Medicine 47(4):357–360. JCAHO (Joint Commission for the Accreditation of Healthcare Organizations). 2002. Delays in treatment. Sentinel Event Alert (26):1–3. Kaiser Commission on Medicaid and the Uninsured. 2003. Medicaid Benefits. [Online]. Available: http://www.kff.org/medicaid/benefits/index.cfm [accessed August 20, 2004]. Keim SM, Spaite DW, Maio RF, Garrison HG, Desmond JS, Gregor MA, O’Malley PJ, Stiell IG, Cayten CG, Chew JL Jr, Mackenzie EJ, Miller DR. 2004. Risk adjustment and outcome measures for out-of-hospital respiratory distress. Academic Emergency Medicine 11(10):1074–1081.

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Emergency Medical Services at the Crossroads Key CB. 2002. Operational issues in EMS. Emergency Medicine Clinics of North America 20(4):913–927. Killien SY, Geyman JP, Gossom JB, Gimlett D. 1996. Out-of-hospital cardiac arrest in a rural area: A 16–year experience with lessons learned and national comparisons. Annals of Emergency Medicine 28(3):294–300. Levin A, Davis R. 2005, July 18. Surge in crashes scars air ambulance industry. USA Today. P. 1A. Lewis RJ, Berry DA, Cryer H III, Fost N, Krome R, Washington GR, Houghton J, Blue JW, Bechhofer R, Cook T, Fisher M. 2001. Monitoring a clinical trial conducted under the food and drug administration regulations allowing a waiver of prospective informed consent: The diaspirin cross-linked hemoglobin traumatic hemorrhagic shock efficacy trial. Annals of Emergency Medicine 38(4):397–404. Li G, Baker SP, Grabowski JG, Rebok GW. 2001. Factors associated with pilot error in aviation crashes. Aviation, Space, and Environmental Medicine 72(1):52–58. Margolis G, Studnek J. 2006. How many volunteers are there really? Journal of Emergency Medical Services 31(3). Martinez R. 1998. New vision for the role of emergency medical services. Annals of Emergency Medicine 32(5):594–599. McGinnis K. 2004. Rural and Frontier Emergency Medical Services Agenda for the Future. Kansas City, MO: National Rural Health Association. Mears G. 2004. 2003 Survey and Analysis of EMS Scope of Practice and Practice Settings Impacting EMS Services in Rural America: Executive Brief and Recommendations. Chapel Hill, NC: University of North Carolina at Chapel Hill Department of Emergency Medicine. MedPAC (Medicare Payment Advisory Committee). 2003. Appendix A: How Medicare Pays for Services: An Overview. Washington, DC: MedPAC. Meier B. 2005, February 28. Fatal crashes provoke debate on safety of sky ambulances. The New York Times. P. A1. Minnesota Department of Health, Office of Rural Health Primary Care. 2003. Profile of Rural Ambulance Services in Minnesota. [Online]. Available: http://www.health.state.mn.us/divs/chs/rhpc/Worddocs/RHProfile-EMS.doc [accessed December 18, 2005]. Monosky KA. 2004. The JEMS 2003 200 city survey. Journal of Emergency Medical Services 29(2):38–53. Moront ML, Gotschall CS, Eichelberger MR. 1996. Helicopter transport of injured children: System effectiveness and triage criteria. Journal of Pediatric Surgery 31(8):1183–1186; discussion 1187–1188. Murray JA, Demetriades D, Berne TV, Stratton SJ, Cryer HG, Bongard F, Fleming A. 2000. Prehospital intubation in patients with severe head injury. The Journal of Trauma 49(6):1065–1070. NAS, NRC (National Academy of Sciences, National Research Council). 1966. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: NAS. NAS, NRC. 1972. Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services. Washington, DC: NAS. NAS, NRC. 1978. Emergency Medical Services at Midpassage. Washington, DC: NAS. NASEMSD (National Association of State EMS Directors). 2005. Special Report: Implementation Status of the EMS Agenda for the Future. Falls Church, VA: NASEMSD. National Commission on Terrorist Attacks upon the United States. 2004. The 9/11 Commission Report. Washington, DC: National Commission on Terrorist Attacks upon the United States. National Emergency Number Association. 2004. The Development of 9-1-1. [Online]. Available: http://www.nena.org/PR_Pubs/Devel_of_911.htm [accessed September 28, 2004].

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Emergency Medical Services at the Crossroads Svenson JE, Spurlock C, Nypaver M. 1996. Factors associated with the higher traumatic death rate among rural children. Annals of Emergency Medicine 27(5):625–632. U.S. Congress, Office of Technology Assessment. 1989. Rural Emergency Medical Services–– Special Report. Washington, DC: U.S. Government Printing Office. U.S. Fire Administration. 2005. Federal Interagency Committee on Emergency Medical Services (FICEMS). [Online]. Available: http://www.usfa.fema.gov/subjects/ems/ficems.shtm [accessed January 5, 2006]. Wanerman R. 2002. The emtala paradox. Emergency medical treatment and labor act. Annals of Emergency Medicine 40(5):464–469. Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM. 2004. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Annals of Emergency Medicine 44(5):439–450. Williams D. 2005. 2004 JEMS 200-city survey. Journal of Emergency Medical Services 30(2):42–60.

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