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Safety Data and Analysis in Developing Emphasis Area Plans (2008)

Chapter: Section XI - Reducing Death and Injury Consequences Through Improved Rural EMS Services

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Suggested Citation:"Section XI - Reducing Death and Injury Consequences Through Improved Rural EMS Services." National Academies of Sciences, Engineering, and Medicine. 2008. Safety Data and Analysis in Developing Emphasis Area Plans. Washington, DC: The National Academies Press. doi: 10.17226/14170.
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Suggested Citation:"Section XI - Reducing Death and Injury Consequences Through Improved Rural EMS Services." National Academies of Sciences, Engineering, and Medicine. 2008. Safety Data and Analysis in Developing Emphasis Area Plans. Washington, DC: The National Academies Press. doi: 10.17226/14170.
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Page 87
Page 88
Suggested Citation:"Section XI - Reducing Death and Injury Consequences Through Improved Rural EMS Services." National Academies of Sciences, Engineering, and Medicine. 2008. Safety Data and Analysis in Developing Emphasis Area Plans. Washington, DC: The National Academies Press. doi: 10.17226/14170.
×
Page 88
Page 89
Suggested Citation:"Section XI - Reducing Death and Injury Consequences Through Improved Rural EMS Services." National Academies of Sciences, Engineering, and Medicine. 2008. Safety Data and Analysis in Developing Emphasis Area Plans. Washington, DC: The National Academies Press. doi: 10.17226/14170.
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Page 89

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

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

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

how to “weight” the different factors. While problem size (total crash cost) and assumed treatment effectiveness are key factors, there may be technical, policy, and cost con- siderations that will remove certain treatments from con- sideration even if they are felt to be effective. The user will have to choose the final treatments based on best judg- ment. The procedure outlined above will at least ensure that the major factors in the decision are clearly defined. Step 9: Target the chosen treatments to areas with high crash concentrations. Since this procedure concerns treatment strategies without known effectiveness, it will not be possible to tar- get the treatments based on any type of economic analysis such as those in Procedures 1, 2A and 2B. Instead, the treatment will be targeted to EMS agencies and commu- nities located in geographical areas with the highest total crash cost or frequency, coupled with user judgment con- cerning other characteristics of the potential target groups, and technical and political issues. Step 10: Repeat the process for each problem/deficiency. Step 11: Add either new treatments or new target areas until the available funding is used. Without effectiveness measures for the treatments, it is not possible to verify whether or not a specific set of treat- ment types and treatments will meet the established goal. Therefore, the best that can be done is to proceed in select- ing treatment types and treatments until the available budget for safety improvement has been fully committed. The total benefit of the selected program will not be fore- castable, but the success of the program can be determined if a sound evaluation is conducted after its implementation. Closure Choosing treatments and targeting those treatments to the unsafe driving populations covered in this section is difficult. The programs are complex, there is limited crash-based information on treatment effectiveness for the strategies cov- ered in the two guides, and there is limited information on program costs. However, choices have to be made given that available budgets will always be limited to some degree. Because programs aimed at improving EMS responsiveness are not traditional engineering treatments, the application of these types of programs is usually more flexible in nature and costs for implementation can be more easily adapted to a budget of any size. It is hoped that the procedures presented in this section at least provide some insight into how budget- ary choices can be made. 89

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TRB's National Cooperative Highway Research Program (NCHRP) Report 500, Vol. 21: Guidance for Implementation of the AASHTO Strategic Highway Safety Plan: Safety Data and Analysis in Developing Emphasis Area Plans provides guidance on data sources and analysis techniques that may be employed to assist agencies in allocating safety funds.

In 1998, the American Association of State Highway and Transportation Officials (AASHTO) approved its Strategic Highway Safety Plan, which was developed by the AASHTO Standing Committee for Highway Traffic Safety with the assistance of the Federal Highway Administration, the National Highway Traffic Safety Administration, and the Transportation Research Board Committee on Transportation Safety Management. The plan includes strategies in 22 key emphasis areas that affect highway safety. The plan's goal is to reduce the annual number of highway deaths by 5,000 to 7,000. Each of the 22 emphasis areas includes strategies and an outline of what is needed to implement each strategy.

Over the next few years the National Cooperative Highway Research Program (NCHRP) will be developing a series of guides, several of which are already available, to assist state and local agencies in reducing injuries and fatalities in targeted areas. The guides correspond to the emphasis areas outlined in the AASHTO Strategic Highway Safety Plan. Each guide includes a brief introduction, a general description of the problem, the strategies/countermeasures to address the problem, and a model implementation process.

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