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86 SECTION XI Reducing Death and Injury Consequences Through Improved Rural EMS Services This section of the guide provides general details on the is desirable is crash data. Crash data can be used to identify process of choosing treatments that will improve Emergency high crash locations. Identifying areas of high concentration Medical Services (EMS) in rural areas, thereby minimizing the of serious injury and fatal crashes can be useful for prioritiz- effects of injuries sustained from motor vehicle crashes. The ing the allocation of funds to implement EMS treatments in process of choosing treatments and target populations is gen- specific areas of the state (or within a local jurisdiction) with erally performed through the use of one of four procedures: the highest concentrations of crashes. The second type of data that is desirable for improving rural Procedure 1 Choosing treatments and target populations EMS is data for evaluating the efficacy and effectiveness of when treatment effectiveness is known, and both crash and EMS systems. The evolution and establishment of an EMS non-crash data are available. data collection system from which outcome measures can be Procedure 2 Choosing treatments and target popula- derived has progressed slowly and sporadically. A compound- tions when treatment effectiveness is known and crash ing factor is the lack of standard nomenclature within EMS to data are available, but detailed inventory data are not describe patient conditions or to document patient care. available. However, a national standard on nomenclature is being Procedure 3 Choosing treatments and target populations developed to address this issue under the National Emergency when treatment effectiveness in terms of crash/injury re- Medical Services Information System (NEMSIS see http:// duction is not known. www.nemsis.org/). It is also desirable to supplement the EMS Procedure 4 Choosing treatments and target populations data with trauma center data concerning the actions of patient for which some candidate treatments have known effec- treatment after reaching the hospital. tiveness estimates and other treatments do not. The third type of data would include coverage area for EMS agencies, types of equipment available, and capabilities Choosing treatments to improve rural EMS will generally of responders, as well as response times. be done using Procedure 3, primarily because the treatments identified in the Guide for Enhancing Rural Emergency Med- Procedure ical Services (15) do not have defined levels of effectiveness ex- pressed in terms of well defined CRFs or AMFs. (Like seatbelt The two basic steps for Procedure 3 are as follows: strategies, EMS strategies will not result in an overall reduc- tion in crashes, but will hopefully reduce the level of injury of 1. Choose the "best treatments" from among the set of all the most severe crashes.) Thus, Procedures 1 and 2 cannot be treatments presented in the applicable NCHRP Report 500 specifically applied to this emphasis area, and Procedure 4 is guides. a hybrid of the first three procedures so it is not applicable to 2. Choose the routes or locale where the selected treatments this emphasis area either. should be applied. When applying Procedure 3 to enhance EMS in rural areas, Data Needs the general order of the steps should probably be reversed. The There are three types of data recommended for choosing first step should be identifying the location or locations (i.e., treatments to improve rural EMS. The first type of data that geographical area) with the greatest potential for making

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87 improvements. The most logical areas for improving rural The next level of this step is to develop resource and EMS are those rural areas with the highest concentration of in- performance standards unique to your local rural EMS juries resulting from motor vehicle crashes. This step can be system. It must be recognized that the primary measures performed at all levels of administration (i.e., state, regional, used to determine the success of an EMS system (i.e., the county, and local). response to patients in cardiac arrest prior to biological Having identified the locations (i.e., geographical areas) with death and the transport of trauma patients to the appro- the greatest potential for making improvements to the rural priate level of trauma center) are based upon national EMS system, the next step is to choose the "best treatments" standards, and in most cases these national standards do applicable for the area. The choice of the best treatments as not account for the barriers and challenges facing rural listed in the Guide for Enhancing Rural Emergency Medical EMS systems compared to their counterparts in urban Services (15) can be based on the following factors: areas. Therefore, it is critical for local rural EMS agencies to determine realistic resource and performance standards The potential treatments judged to be the most effective, for their given area, taking into consideration the stan- even given that the effectiveness is unknown dards set by the various national organizations. The costs of implementing the potential treatments This first step can be viewed as an evaluation process, or Other technical or policy considerations in another way, it can be viewed as a planning process. First, an agency needs to assess the status of their current These factors must be combined in some fashion to decide system. Second, an agency needs to assess where they which treatment to choose. ought to be by establishing resource and performance The general procedure for deciding which treatment to standards for the future. choose can be divided into two phases. The first phase relates Step 2: Identify, provide, and mandate efficient and effec- to identifying areas for improvement within your local EMS tive methods for collection of necessary EMS data. system. The second phase relates to selecting treatments that A complete assessment of any EMS system requires that improve deficiencies in (a) system integration, (b) quality of an analysis be completed on the performance of the sys- care, and/or (c) response time. tem. All personnel at EMS agencies need to understand the importance of consistent, long-term collection of data for system evaluation and improvement. National stan- Phase I Identify Areas for Improvement dards have been developed in regards to collection of EMS in Your Local EMS System data. Each agency has the responsibility to collect the min- The primary purpose of this phase is to identify potential imum set of data. A minimum data set must support ways to improve your local EMS system. One of the objectives analyses of response standards, patient care, treatments for improving EMS in rural areas in the Guide for Enhancing administered, and patient outcomes. Rural Emergency Medical Services (15) provides guidance on Step 3: Identify and evaluate model rural EMS operations. how to achieve this goal. The objective is to provide or The purpose of this step is to evaluate several peer systems improve management and decision-making tools to enable (i.e., those having similar demographics and service de- system managers to make more informed decisions on ways mands) to learn from their experiences. This should provide to improve their services. The logical steps in this process are better access to information about procedures/strategies/ provided below. treatments that have worked well, and others that have been less successful. Therefore the new system can provide Step 1. Evaluate the status of your current system and guidance for jurisdictions that are faced with enhancing develop resource and performance standards unique to their current system, or in some cases, developing a com- your local rural EMS system. prehensive EMS program. This step will provide a better To make an informed decision on how best to improve basis for establishing resource and performance standards your local rural EMS system, it is necessary to under- as well as guidelines for improving the operation of your stand how your current system operates. This can be local rural EMS system. done either through an internal evaluation or an Step 4: Provide evaluation results to elected and adminis- expanded evaluation which may include perspectives trative officials at the county and local levels. from other stakeholders such as area hospitals and med- Rural EMS systems often operate with minimal over- ical assistance facilities, governing bodies, schools, sight, control, or responsibility to governing bodies. Given service clubs, the business community, and the public at the lack of direct control of EMS systems in many rural large. This process can help evaluate the place of the EMS areas, the representatives of the citizens may not be aware agency in the community. of response issues and problems until a tragic event is cov-

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88 ered by the media. Providing elected and administrative hospital can all reduce the elapsed time until definitive officials with measures and standards that have been de- care begins. veloped from evaluations would give them a better un- derstanding of the levels of service offered in their com- While there are multiple ways of selecting the best treatments munity, and the nature of any improvements needed. By for implementation, the following represents one such understanding the myriad of issues, community leaders procedure. will be able to determine the gap between the actual level of service provided in the community, what level of serv- Step 5: Prioritize the type of deficiencies to be improved. ice they desire for their community, and the issues related EMS systems around the country exist at various levels of to meeting that level of response. sophistication and in various stages of development. State EMS Directors, system managers, and policy makers at the In many ways these four steps pertaining to Phase I are long- local level are best suited to determine which objectives are term procedures/steps for choosing the best treatments ap- best to pursue, based on their existing levels of service and plicable for an area. In the short-term, it may be desirable for resources. State EMS Directors and local EMS system man- an agency to perform an initial internal evaluation as part of agers should also work with State and local highway agen- Step 1 and to identify deficiencies in (a) system integration, cies during the process of prioritization. In making these (b) quality of care, and/or (c) response time. Thus, in the decisions, State EMS Directors, system managers, and pol- short-term an agency can begin the Phase II process of se- icy makers should try to answer the following questions, lecting treatments that improve deficiencies in the selected based upon the current levels of services and resources: areas. However, agencies should have a longer-term goal to Where are the bottlenecks in existing processes? develop a more systematic approach to system evaluation Does the existing level of life-saving skills negatively im- and identifying areas for improvement within their local pact the quality of service provided to injured patients? EMS system. Is the average time from injury to appropriate definitive care acceptable? By answering these questions, State EMS Directors, system Phase II Select Treatments That Improve managers, and policy makers can judge the magnitude of Deficiencies in System Integration, Quality of Care, the problems/deficiencies and judge the room for im- and/or Response Time provement in each area. The primary purpose of this phase is to choose the best Step 6: Identify possible treatments for each high priority treatments applicable for improving deficiencies in system problem/deficiency. integration, quality of care, and/or response time. Three of The user will review the Guide for Enhancing Rural the four objectives in the Guide for Enhancing Rural Emer- Emergency Medical Services (15) and list treatments that gency Medical Services (15) pertain to deficiencies in system would be most appropriate for each of the high priority integration, quality of care, and response time. By imple- problem areas identified in the above step. The choice menting strategies/treatments related to the respective should be limited to those treatment strategies that are objective, EMS agencies in rural areas will be able to work classified as tried in the guides. more efficiently toward their goal of providing the best avail- Step 7: Rate the possible treatments based on estimated able care for injured patients involved in motor vehicle effectiveness. crashes in the following ways: Since this procedure deals with treatment strategies with unknown effectiveness, this appears to be impossible. By integrating services, EMS agencies will be able to utilize However, for a given set of possible treatments for a capabilities of other organizations and be able to streamline particular problem/deficiency, it may be possible to make processes and develop new and unique functionality that a judgment concerning which treatment strategy would be previously did not exist. expected to be most effective. Providing better educational opportunities will improve Step 8: Choose the best treatment(s) by considering the the life-saving skills of EMS personnel and others who may estimated effectiveness, cost of implementation, and not have previously been involved in EMS. other technical and policy considerations. By reducing the time from injury to appropriate defini- The user will then combine the output of the steps tive care, many patients will have a greater probability of above with at least two other factors in making a final de- survival. Reduction of the time required for notification, cision on which treatment(s) to implement the cost of dispatching, travel time to the crash site, time spent at the implementation and other technical and policy consider- crash site, and travel time from the crash site to the ations. Unfortunately, there are no good guidelines for