protocols to ensure that the patient is taken to the optimal facility given the severity and nature of the illness or injury, the status of the various care facilities, and the travel times involved. Ideally, this decision should take into account a number of complex and fluctuating factors, such as hospital ED closures and diversions and traffic congestion that hinders transport times for the EMS unit (The SAFECOM Project, 2004).

In addition to using ambulance units and the EMS system to direct patients to the optimum location for emergency and trauma care, hospital emergency and trauma care designations should be posted prominently to improve patients’ self-triage decisions. Such postings can educate the public about the types of emergency services available in their community and enable patients who are not using EMS to direct themselves to the optimal facility.


Fostering accountability is perhaps the most important of the committee’s three goals because it is necessary to achieve the other two. Lack of accountability has contributed to the failure of the emergency and trauma care system to adopt needed changes in the past. Without accountability, participants in the system need not accept responsibility for their failures and can avoid making changes necessary to avoid them in the future.

Accountability has failed to take hold in EMS systems because responsibility is dispersed across many different components of the system; thus it is difficult for policy makers to determine when a system breakdown occurs, much less where it is located or how it can be adequately addressed. EMS diversion is a good example. When a city recognizes it has an unacceptably high frequency of diversions, the locus of responsibility for the problem remains unclear. EMS can blame the ED for crowded conditions and excessively long off-loading times; EDs can blame their hospital for not transporting admitted patients to inpatient units promptly; hospitals can blame on-call specialists or the discharging physician, as well as long-term care facilities that are unwilling to take additional referrals; and all players in the system can blame the state public health department for inadequate funding of community-based alternatives or community physicians for failing to manage their patients adequately so as to keep them out of the ED.

The unpredictable and infrequent nature of emergency and trauma care contributes to the lack of accountability. Most people have limited exposure to the emergency and trauma care system and consider it unlikely that they will ever require an ambulance transport. Consequently, public awareness of specific problem areas in the system is limited. In fact, however, Americans visit EDs more than 114 million times a year, and more than 16 million of these visits involve transport by ambulance (Burt et al., 2006).

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