nership with professional organizations, convene a panel of individuals with multidisciplinary expertise to develop evidence-based categorization systems for emergency medical services, emergency departments, and trauma centers based on adult and pediatric service capabilities (3.1). The categorization systems should be developed within 18 months of the release of this report. The two federal agencies should fund the process and convene the panel of emergency care experts and medical professionals to review the literature and develop the categorization systems. The multidisciplinary nature of the process should help ensure that the categories reflect the viewpoints of the various stakeholders and facilitate familiarity with the categories, as well as their adoption. The results of this process should be a complete inventory of emergency care assets for each community, which should be updated regularly to reflect the rapid changes in delivery systems nationwide.
The information generated by the implementation of recommendation 3.1 could be used to develop protocols that would guide EMTs in the transport of patients. But more research and discussion are needed to develop transport protocols. For example, it is unclear whether pediatric dispatch cards, which vary across jurisdictions, are appropriate. More research and discussion are needed to determine under what circumstances patients should be brought to the closest hospital for stabilization and transfer as opposed to being transported directly to the highest level of care, even if that facility is farther away. A debate remains over whether EMS providers should perform ALS procedures in the field or whether rapid transport to definitive care is best (Wright and Klein, 2001). The answer to this question likely depends, at least in part, on the type of emergency condition. It is evident, for example, that whether a patient will survive out-of-hospital cardiac arrest depends almost entirely on actions taken at the scene, including rapid defibrillation, provision of cardiopulmonary resuscitation (CPR), and perhaps other ALS interventions. Delaying these actions until the unit reaches a hospital results in dismal rates of survival and poor neurological outcomes. Conversely, there is little that prehospital personnel can do to stop internal bleeding from major trauma. In this instance, rapid transport to definitive care in an operating room offers the victim the best odds of survival. For example, a recent study showed that bypassing a level II trauma center in favor of a more distant level I trauma center may be optimal for head trauma patients (McConnell et al., 2005).
EMS responders who provide stabilization before the patient arrives at a critical care unit are sometimes subject to criticism because of a strongly held bias among some physicians that out-of-hospital stabilization only delays definitive treatment without adding value; however there is little evidence