easy. States vary in their ability to collect data, and there are no ongoing and systematic nationwide or nationally representative surveillance systems (U.S. DHHS, 1991).

The greatest growth appears to be in prehospital care. All but nonexistent in the 1960s, prehospital care has become ubiquitous today. In the early 1990s, the Journal of Emergency Medical Services (JEMS) began an annual survey of prehospital providers in the 200 most populous cities, the so-called JEMS 200 City Survey, which captures 25 percent of the U.S. population. Although the sample is not nationally representative and the methods and results are not peer reviewed, the survey is one of the only indicators of growth and trends. The 1995 survey found 9-1-1 access to be available in more than 99 percent of the cities surveyed, and 82 percent of surveyed cities have so-called enhanced 9-1-1 service, in which the caller's street address is automatically provided to the dispatcher (W. Stanton, National Emergency Number Association, personal communication, 1998).

The nationwide status of regional trauma system development has been evaluated about every five years since 1987 through voluntary surveys of state EMS directors or health departments. Before 1987, state efforts waxed and waned depending on the vicissitudes of federal, state, and local support (Bazzoli et al., 1995). By 1987, West and colleagues (1988) found only two states that had fulfilled eight components judged essential by the authors to constitute a regional trauma system (see Table 6.2); 19 states and the District of Columbia missed meeting one or more of the criteria; and 29 states had not yet started the process of trauma center designation. By 1992, when the survey was updated by Bazzoli and colleagues (1995), five states were judged to have met the eight criteria. More states would have qualified except that they had failed to limit the number of trauma centers, depending on community need. The survey also found that states lacked standardized policies for interhospital transfer and systemwide evaluation. The authors advocated that more research on useful and valid outcome measures be included in trauma systems registries in order to assess system effectiveness. Subsequent nationwide updates were conducted in 1996 by Goodspeed (1997) and in 1997 by Bass (1997). Both studies found 27 states reported an established trauma system (although the defining criteria for a system were left to state discretion by Goodspeed). Thus, there is evidence to suggest that the past decade has witnessed an increase in trauma systems. The increase is thought to be related to the availability of federal funding, especially through the catalytic role of the Federal Trauma Care Systems Planning and Development Act, which required state matching funds. However, the authorization for this legislation lapsed in 1995, and it remains to be seen whether states will continue to invest in trauma systems development and maintenance without federal assistance.

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