EMS focuses on out-of-facility care and, at thesame time, it supports efforts to implement cost-effectivecommunity health care. Out-of-facility careis a component of the comprehensive health caresystem, and EMS shares structural and process elementscommon to all health care system components.Furthermore, EMS is a resource for communityhealth care delivery.EMS maintains liaisons, including systems forcommunication with other community resources,such as other public safety agencies, departmentsof public health, social service agencies and organizations,health care provider networks, communityhealth educators, and others. This enablesEMS to be proactive in affecting people’s long-termhealth by relaying information regarding potentiallyunhealthy situations (e.g., potential for injury),providing referrals to agencies with a vestedinterest in maintaining the health of their clients.Multiple dispositions are possible when a call isreceived at a public safety answering point; additionalmultiple dispositions are available followingpatient evaluation by EMS personnel. EMS is a communityhealth resource, able to initiate importantfollow-up care for patients, whether or not theyare transported to a health care facility.EMS is integrated with other health care providers,including health care provider organizationsand networks, and primary care physicians.As a health care provider, EMS, with medical direction,facilitates access for its patients to appropriatesources of medical care. Integration ensuresthat EMS patients receive appropriate follow-upmedical care, and that the episodic care providedby EMS is considered a component of each patient’smedical history that affects the plan for continuinghealth care.EMS integrates with other health system componentsto improve its care for the entire community,including children, the elderly, those who arechronically dependent on medical devices, andothers. This ensures that the population is betterserved, and that the special needs of specific patientsare addressed adequately.Efforts to improve EMS care for specific segmentsof the population recognize the need for,and advocate implementation of, system enhancementsthat benefit the entire population. These effortsoften include attention to functional system design,health care personnel education, and equipmentand facility resources.HOW TO GET THEREEMS must expand its public health role anddevelop ongoing relationships with community publichealth and social services resources. Such relationshipsshould result in systems ofcommunication that enable referrals and subsequentfollow-up by those agencies. Relationships shouldbenefit all parties by improved understanding offactors contributing to issues being addressed. Reportsof the effectiveness of these relationshipsshould be disseminated.EMS must become involved in the business ofcommunity health monitoring, including participationin data collection and transmittal to appropriatecommunity and health care agencies.Long-term effects of such efforts must be widelyreported.EMS systems must seek to become integratedwith other health care providers and provider organizationsand networks. Integration should benefitpatients by enhancing and maintaining the continuumof care. Communications systems, includingconfidential transmittal of patient-related data,should be developed. These should explore the utilityof continuing communications technological advances. Mutuallyacceptable clinical guidelines regardingpatient treatment and transport also mustbe developed.Health care provider organizations and networksmust incorporate EMS within their structures todeliver quality health care. They must not impedethe community’s immediate access to EMS whena perceived emergency exists.EMS medical direction must be cognizant of thespecial medical needs of all population segmentsand, through continuous processes, ensure that EMSis integrated with health care delivery systems strivingto optimally meet these needs. An EMS physician,collaborating with other communityphysicians (including pediatricians, surgeons, familypractitioners, internists, emergency physicians, andothers) and health care professionals (includingnurses, nurse practitioners, physician’s assistants,paramedics, administrators, and others), shouldultimately be responsible and have authority forEMS medical direction and, in partnerships withsystem administrators, effect system improvements.EMS must incorporate health systems thataddress the special needs of all population segmentsserved (e.g., pediatric, geriatric, medicaldevice-dependent; and other patients in urban, suburban,rural, and frontier areas). Such systems orplans should include education, system design, andresource components. They must be developed withinput from members of the community. Groupsunable to represent themselves, such as children,must be represented by others who are familiarwith their needs.Emergency medical services leaders must continueto identify issues of interest to policy makersto address specific aspects of EMS, and improvethe system as a whole. Attention paid to EMS componentsshould be done with consideration of theentire system.Research and pilot projects should be conductedwith regard to expanded services that may beprovided by EMS. Efforts to enhance services shouldfocus foremost on improving those currently deliveredby EMS, and might also lead to servicesthat enable patients to seek follow-up care in a lessurgent manner and/or facility. These projects shouldaddress objective meaningful patient outcomes, EMSstaffing requirements, personnel education issues,quality evaluations, legal issues, and cost-effectiveness.They must also include logistical evaluationssuch as the ongoing capabilities of EMS torespond to critical emergencies (e.g., cardiac arrests).These studies must precede widespread adoptionof such practices and results should bedisseminated and subjected to scrutiny.INTEGRATION OF HEALTH SERVICES:Expand the role of EMS in public healthInvolve EMS in community health monitoringactivitiesIntegrate EMS with other health care providersand provider networksIncorporate EMS within health care networks’structure to deliver quality careBe cognizant of the special needs of the entirepopulationIncorporate health systems within EMS that addressthe special needs of all segments of thepopulationReturn to ContentsEMS RESEARCH“The future of EMS is indelibly linked to the future of EMS research. This reality provides EMSwith its greatest opportunities, its greatest risks, and its greatest single need to depart from the waysof the past. EMS must grasp this quickly closing window of opportunity.”Daniel W. Spaite, MDResearch involves pursuit of the truth. In EMS,its purpose is to determine the efficacy, effectiveness,and efficiency of emergencymedical care. Ultimately, it is an effort to improvecare and allocation of resources.The future: A new pharmacologic agent becomesavailable and might potentially decrease the morbidityof stroke. Theoretically, the sooner the medicationis administered after symptom on-set,the more effective it is likely tobe. However, it is expensive and hasaccompanying risks. Therefore, amulti-EMS system study is fundedby the National Institutes of Health(NIH). Over the course of two years,information is collected from the participatingEMS systems about controlpatients and those who weretreated with the new medication inthe field. The information includesout-of-facility EMS data that is linkedwith hospital and rehabilitation data.Subsequently, the cost-effectivenessand risks of administering the medication in the fieldare determined and EMS practices are adjusted accordingly.WHERE WE AREEMS has evolved rapidly over the past 30 yearsdespite slow progress in developing EMS-relatedresearch. System changes frequently prompt researchefforts to prove they make a difference, instead ofthe more appropriate sequence of using researchfindings as a basis for EMS improvements.Most of what is known about EMS has beengenerated by researchers at a small number ofmedical schools, generally in midsized cities, thathave ongoing relationships with municipal EMSsystems. The volume of EMS research is low andthe quality often pales in comparison with othermedical research.Most published EMS research is component-based,focusing on a single intervention or healthproblem, and rarely addressing the inherent complexitiesof EMS systems.119 With few exceptions,there has been little emphasis on systems analysis.Development of the “chain of survival” conceptfor cardiac emergencies provides the bestevidence of completed systems research.22,94 Trauma-relatedresearch comprises the only other EMS researchemphasis.119 However, study methods havenot been as extensively developed, and experimentaldesigns often limit abilities to compare studies andreach meaningful conclusions.65Other clinical conditions have notbeen scientifically studied with asystems approach. Component-basedanalyses often lead to conclusionsthat are incorrect, or atleast cannot be supported, whenthey are considered in the contextof the entire EMS system.119,120Thus, in many cases, our poorunderstanding of systems researchmodels has led to the developmentof wrong assumptions with regardto EMS care.Currently there are five major impediments to the development of quality EMS research:inadequate fundinglack of integrated information systems thatprovide for meaningful linkage with patient out-comespaucity of academic research institutions withlong-term commitments to EMS systems researchoverly restrictive informed consent interpretationslack of education and appreciation by EMS personnelregarding the importance of EMS research.Without dramatic progress on these five fronts,there will not be a significant increase in the quantityof well-done, meaningful EMS research.Significant barriers to collecting relevant,meaningful, and accurate EMS data exist.120 EMSdata often are not collected in a rigorous fashionthat allows academic evaluation. Linkage withhospital and other data sets, which is required todetermine EMS effectiveness, is difficult and infrequentlyaccomplished.A national agenda for EMS-related research doesnot exist, and there is no central source for EMSresearch funding. The EMS-C program has investedin system development and research affecting notonly pediatric issues, but all of EMS.39 Other federalagencies, including the Health Resources ServicesAdministration, Agency for Health Care Policy andResearch, and NHTSA have also sponsored EMS-relatedinvestigations. Additional support oftenis sought from private and corporate interests.However, funding frequently is directed only towardcomponent-based studies. Overall, financial supportfor EMS-related research is inadequate toaddress the many systems issues requiring study.Overly restrictive informed consent interpretationscreate additional barriers to conducting EMSresearch. They do not consider the clinical and environmentalcircumstances of field EMS investigations,and impede institutional review boardapproval of meaningful resuscitation research andother field trials.EMS education curricula do not include adequateresearch-related objectives. Thus, very few EMSpersonnel, including system administrators andmanagers, have a sufficient baseline understandingand appreciation of the critical role of EMSresearch. Unlike most other clinical fields, EMSresearch often is conducted without significantparticipation by its own practitioners, relying insteadon others.The rationale for many routine EMS interventionsis based on in-hospital studies, and not onscientific investigation of their out-of-hospitaleffectiveness. The effectiveness of most EMS interventionsand of EMS systems, in general, hasnot been well established with outcome criteria.35Furthermore, the outcome criterion most studiedis death, which, although important, is not pertinentto most EMS clinical situations.35,45WHERE WE WANT TO BEThe essential nature of quality EMS researchis recognized. A sufficient volume of quality researchis undertaken to determine the effectivenessof EMS system design and specificinterventions.EMS evolves with a scientific basis. Adequateinvestigations of EMS interventions/treatments andsystem designs occur before they are advocatedas EMS standards. The efficacy, effectiveness andcost-effectiveness of such interventions and systemdesigns are determined. This includes the identificationof patients who are appropriate fortransport, and evaluation of the effects of alternativedispositions for patients when they are nottransported to health care facilities.As much as possible, EMS research employssystems analysis models. These models usemultidisciplinary approaches to answer complexquestions. They consider many issues that impacta system to help ensure that findings are accuratewithin the context of multifaceted EMS systems.The National Institutes of Health (NIH) are committedto EMS-related research. NIH participatesin setting a national agenda and provides EMS-relatedresearch funding.Integrated information systems provide linkagesbetween EMS and other public safety servicesand health care providers. They facilitate the datacollection necessary to determine EMS effectiveness.Several academic centers have long-term commitmentsto EMS research. They serve as a nucleusof activity that involves many EMS systems withdifferent characteristics and all personnel levels,including field providers, managers, administrators,nurses, and physicians.Informed consent rules account for the clinicaland environmental circumstances of EMS research.They enable credible resuscitation and otherout-of-facility investigations to be conducted.EMS personnel of all levels and credentialsappreciate the role of EMS research in terms of creatinga scientific basis for EMS patient care. Allindividuals with some responsibility for EMS structure,process, and/or outcomes are involved, tosome extent, with EMS research.EMS research examines multiple outcome criteria.Thus, it is pertinent to most EMS clinical situations,which do not involve a likelihood of death.HOW TO GET THEREPublic and private organizations responsible forEMS structures, processes, and/or outcomes mustcollaborate to establish a national EMS researchagenda. They should determine general researchgoals and assist with development of research fundingsources.The major impediments to EMS research must be addressed:Federal and state policy makers must allocatefunds for a major EMS systems research thrust.This should include involvement of the NIH insetting a national EMS research agenda and providingresearch funding.Integrated information systems must be developedto provide linkage between EMS and variouspublic safety services and other health careproviders to facilitate the data collection thatis necessary to determine EMS effectiveness.Academic institutions and medical schools mustconsider making long- term commitments to EMS-relatedresearch. They should support EMS-interestedfaculty members, collaborate with EMSsystems, and involve EMS personnel of all levelsin conducting credible systems research.The Department of Health and Human Servicesand the Food and Drug Administration must continueto revise their interpretations of informedconsent rules so that they enable credible resuscitationand other out-of-facility research to beconducted. Informed consent interpretationsshould account for the clinical and environmentalcircumstances inherent in conducting EMS research.All individuals with some responsibility for EMSstructures, processes, and outcomes must beinvolved in and/or support quality EMS systemsresearch. They must recognize the need for qualityinformation that demonstrates the effects of EMSfor the patient population served, and providesthe scientific basis for EMS patient care.EMS must be designated as a subspecialty forphysicians and other health professionals. The developmentof well-trained EMS researchers mustbe an integral component of the EMS subspecialty,just as it is in other subspecialties. Those with sub-specialtycredentials should be integrally involvedin advancing the knowledge base of EMS.EMS field providers and managers, as part oftheir routine education, must learn the importanceand principles of conducting EMS-related systemsresearch. The objectives need not be to develop EMSresearchers, but to help personnel understand theresearch that is being conducted and enable themto participate and be supportive.EMS researchers must enhance the quality ofpublished research. Study methods should employsystems analysis methods and meaningful outcomecriteria, and determine cost-effectiveness. Researchmeetings should include forums to educate thosewanting to improve their research skills.EMS systems, medical schools, other academicinstitutions, and private foundations must developcollaborative relationships. Such relationships shouldfacilitate implementation of significant EMS researchprojects required to determine, among other things,efficacy, effectiveness and cost-effectiveness.State EMS lead agencies must evolve from beingprimarily regulatory to providing technical assistance.They should be involved in promoting publichealth services research, and facilitating the developmentof relationships and resources necessaryfor such studies.EMS RESEARCH:Allocate federal and state funds for a major EMSsystems research thrustDevelop information systems that provide linkagebetween various public safety services and otherhealth care providersDevelop academic institutional commitments toEMS-related researchInterpret informed consent rules to allow forthe clinical and environmental circumstancesinherent in conducting credible EMS researchDevelop involvement and/or support of EMSresearch by all those responsible for EMS structure,processes, and/or outcomesDesignate EMS as a physician subspecialty, anda subspecialty for other health professionsInclude research related objectives in theeducation processes of EMS providers andmanagersEnhance the quality of published EMS researchDevelop collaborative relationships between EMSsystems, medical schools, other academic institutions,and private foundationsReturn to ContentsLEGISLATION AND REGULATION“Injuries and illnesses requiring an EMS response represent a public health problem that can only beaddressed through the combined efforts of all levels of government and private organizations. Governmentmust maintain its traditional role of assuring the existence of an EMS safety net, and at the same timepartner with others to build new models for improving EMS.”Dan ManzIssues relating to legislation, and its resultingregulations, are central to the provision of EMSin the public’s behalf. Legislation and regulationsaffect EMS funding, system designs, research,and EMS personnel credentialing andscope of practice.The future: In the town of Gaston, out-of-facilityemergency care is provided exclusively byMedstat EMS, a non-profit corporation. Medstatmerges with a larger company that, for numerousreasons, abruptly decides to cease operations inGaston. Fortunately, the state EMS agency usesits authority to compel the service to continue itsoperations, at least for emergency care, until adequatetemporary arrangements are made with neighboringlocal EMS systems to provideGaston with quality EMS. Theagency then works with Gastoncommunity leaders to develop along-term solution. During the interimperiod, when Medstat wouldhave otherwise ceased to operatein Gaston and temporary arrangementswere initiated, MedstatEMS personnel were able to resuscitatea three-year-old near-drowningvictim due, in part, totheir rapid response to the scene.WHERE WE AREAll states have legislation thatprovides a statutory basis for EMSactivities and programs. Stateshave found that it is within the public’s interestto assure that EMS is readily available, coordinated,and of acceptable quality. However, during 35 stateevaluations by NHTSA technical assessment teams,only 40% of states reported comprehensive enablingEMS legislation for development of a statewide EMSsystem.118 Only 20% of states had an identified leadagency, meeting the standard of the assessmentteams, that provided central coordination for EMSsystem activities.118 State laws vary greatly in theway they describe EMS system components. Somelaws permit greater flexibility on the part of thelead or regulatory agencies than others.In some cases, local governments also havepassed ordinances to delineate EMS standards fortheir communities. These may relate to system componentsor define process standards.Legislation leads to rules and regulations designedto carry out the intent of the law. State and regionalauthorities responsible for implementing regulations,are, in general, extensively involved in personnellicensing, training program certification, EMS vehiclelicensing, and record keeping.WHERE WE WANT TO BEThere is a federal lead EMS agency. The agencyis mandated by law, sufficiently funded and credible,and is recognized by thehealth care and public safetysystems. It directs nationwide EMSdevelopment, provides coordinationamong federal programs/agencies affecting EMS, serves asa central source for federal EMS-relatedresearch and infrastructurecreation funding, provides an informationclearinghouse function,and oversees development ofnational guidelines.All states have a single EMSlead agency, established in law,responsible for developing andoverseeing a statewide EMS system.Each state’s agency is adequatelyfunded to ensure itseffectiveness. Lead agency enabling legislation allowsflexibility; the ability to adapt and be responsiveto the health care and public safety environment.It is a facilitator, a clearinghouse for information,a developer of guidelines, and a promotor and educator.This helps ensure that statewide EMS systemdevelopment continues, that its developmentand oversight are efficient, and that EMS of acceptablequality is available to the entire population.State legislation provides a broad template thatallows local medical directors to determine thespecific parameters of practice for their EMS systemsand to conduct credible research and pilot projects. This ensures substantial uniformity withinstates, but provides the degree of flexibility necessaryto ensure that EMS systems, given their resources,are able to optimally meet the health careneeds of their communities. Justification for practiceparameters are required, as is maintaining minimumquality standards.In addition to regulating EMS, state lead agenciesprovide technical assistance to EMS systems. Theyprovide coordination and geographic integrationamong local EMS systems, and provide technicalexpertise that may not be available within individualsystems. They facilitate credible EMS researchand innovative pilot projects. Lead agenciesrely, to an increased extent, on national certifyingand accrediting bodies to ensure adequate qualityof some EMS system components, thus enablingenhancement of their roles as facilitators.State and local EMS lead agencies have the authorityand means to ensure the reliable availabilityof EMS to the entire population. Such authorityis exercised to act on the public’s behalf when eventualitiesoccur, such as potential changes in the healthcare system or EMS structural or financial circumstances,and threaten its quality or availability tothe entire population.HOW TO GET THERECollectively, those responsible for EMS mustconvince legislators in the U.S. Congress to authorizeand sufficiently fund a lead federal EMS agency.This agency should be health care based and credibleto public safety interests, responsible for coordinatingall federal initiatives for national EMSdevelopment, overseeing development of nationalguidelines, and serving as a national EMS clearinghouse.All states must pass, and periodically review,enabling legislation that supports innovation andintegration, and establishes and sufficiently fundsan EMS lead agency. This agency should be responsiblefor developing and maintaining a comprehensivestatewide EMS system.State EMS agencies must enhance their abilitiesto provide facilitation and technical assistanceto local EMS systems. Although states may retainresponsibility for licensing, they should increasereliance on available national resources for certificationand accreditation of EMS providers and someEMS system components.Each state must establish and fund the positionof State EMS Medical Director, delineate theauthority of all EMS medical directors within thestate, and establish qualifications for various medicaldirector positions in the state. Medical directors,within broad guidelines, should be responsible fordetermining the parameters of EMS practice withintheir systems.State and local EMS authorities must be authorizedto act on the public’s behalf in cases of threatsto the availability of quality EMS to the entire population.Actions should ensure that some segmentsof the population are not underserved, or deniedimmediate access to EMS due to socioeconomic orother factors.States should implement laws that provide protectionfrom liability for EMS field and medicaldirection personnel when dealing with unexpectedand/or unusual situations falling outside the realmof current protocols. These should include provisionsfor in-depth review of such cases, and notalter liability for grossly negligent conduct.LEGISLATION AND REGULATION:Authorize and sufficiently fund a lead federalEMS agencyPass and periodically review EMS enabling legislationin all states that supports innovation-and integration, and establishes and sufficientlyfunds an EMS lead agencyEnhance the abilities of state EMS lead agenciesto provide technical assistanceEstablish and fund the position of State EMSMedical Director in each stateAuthorize state and local EMS lead agencies toact on the public’s behalf in cases of threats tothe availability of quality EMS to the entirepopulationImplement laws that provide protection fromliability for EMS field and medical directionpersonnel when dealing with unusual situationsReturn to ContentsSYSTEM FINANCE“The future of EMS is indivisibly linked to how it is funded. In order to optimize the positiveinfluence of EMS on community health we must move to a system of finance that is proactive, accountingfor the costs of emergency safety net preparedness and aligning EMS financial incentives with theremainder of the health care system.”David R. MillerEmergency medical services systems, similarto all public and private organizations,must be financially viable. In an environmentof constant economic flux, it is critical to continuouslystrive for a solid financial foundation.The future: A consortium of regional hospitals formthe Optimal Health Network, a managed care provider/insurer organization. As its membership increases, thenetwork establishes collaborative relationshipswith EMS agencies in themembers’ communities. Based on aformula that accounts for patient carestandards, EMS system preparedness,and expectations of both the networkand the EMS systems, the network’ssupport for EMS is proactivelydetermined and EMS assumes a rolein the access of the network’s membersto efficient health care.WHERE WE AREProviding the nation with EMSis a multibillion dollar effort eachyear. While all the costs are notexactly known, Hawaii’s EMS systemprovides a basis for estimation.Out-of-facility EMS in Hawaiiis completely state-funded. The annual cost of EMSfor the state’s 1.2 million residents is $32,460,605. 76This includes funding for training, communications,ambulance services, quality improvement,data collection, and other aspects of the system,and amounts to approximately $27 per capita peryear. Extrapolating that cost to the entire U.S. population(249,632,692 in 1990) yields an estimate of$6.75 billion per year. Of course, such an estimatemight not account for some costs or fail to factorin cost-savings (e.g., volunteers). However, EMSclearly represents a large investment.The overall cost of EMS for a discreet geographicarea includes the costs of all the infrastructure andactivities required to provide service. For example,communications systems, vehicle/equipment acquisitionand maintenance, personnel training andcontinuing education, first response and ambulanceoperations, medical direction, and licensing andregulation activities all contribute to EMS costs.Also, process (e.g., response time) standards andstaffing requirements greatly influence these costs.In total, the combined costs of all EMS componentsand activities, the overall cost of EMS, isequivalent to the cost of preparedness, and it isgreatly affected by community requirements.EMS systems are funded by a combination ofpublic and/or private funds.Primary revenue streams includegovernmental subsidy via taxdollars, subscription revenue, andfees generated by providingservice. For those EMS systemssupported directly by tax dollars,subsidies vary greatly and mayexceed $20 per capita in some areas.Additionally, many statesfund EMS development fromspecific revenue sources, such asvehicle or driver licensing, motorvehicle violations, and othertaxes.128Subscription programs allowthe public to pre-purchase EMSsystem services in one of twoforms. A subscription, dependingon the program, is a contract to provide EMSwithout additional charges to the consumer, orfixes the price and pre-pays any potential insurancedeductible. With the latter, third party payorsmay be billed, but there are still no additionalcharges to the consumer.Fee for service revenue comes from five mainsources: Medicare, Medicaid, private insurance companies,private paying patients, and special servicecontracts.125 Of these, Medicare, Medicaid,and private insurance company revenues are probablythe most important. Rates of payment, ingeneral, are based on customary charges and theprevailing charge in the area. However, rules varysignificantly among insurance carriers, and paymentcan be affected by what neighboring systemscharge.Those EMS systems relying on third party payorsfor significant revenue must, in general, providetransportation in order to charge for their services.In other words, if the EMS system provides treatment,but does not actually transport a person toa hospital, third party payors are not obliged topay for the service provided. Furthermore, paymentis often based on the level of care requiredduring transport. It ignores that more advancedresources may have been initially required by thepatient, based on the first available information,but that less advanced resources were required fortransport.Treatment followed by transport (by the EMSsystem) to a hospital is not always necessary orthe most efficient means of delivering needed care.However, current EMS financial incentives may notbe aligned with efforts of the health care systemas a whole to optimize out-of-facility care andenhance health care efficiency. With current paymentpolicies, decreasing the percentage of transportsper patient assessed or treated results indecreased EMS system revenue, reduced operatingmargin, and impaired ability to shift costs.The primary determinants of EMS cost relateto system preparedness, or the cost of maintainingthe resources necessary to meet a benchmarkfor emergency response. On the other hand, theprimary determinant of payment (one source ofrevenue) is patient transport. Thus, the driving forcesfor cost and payment are not aligned.In some cases health care insurers or providersstipulate to their subscriber patients that authorizationmust precede utilization of EMS. Refusalto pay EMS for services provided may be basedon lack of preauthorization or claims that the patientcondition did not represent an emergency. Furthermore,regional health care providers (e.g., managedcare organizations) frequently require theirpatients to seek care at specific facilities. EMS systemsare then requested to provide transport tolocations that are not always geographically convenient.Accommodation of these requests mayrequire additional resources, with their associatedcosts, to be deployed by EMS systems.WHERE WE WANT TO BEIn as much as EMS is a component of the healthcare delivery system, and provides health careservices, it is consistently funded by mechanismsthat fund other aspects of the system. These mechanismsare proactive and recognize the value of treatmentthat is provided without transport. Transportis not a prerequisite for funding. Payment forEMS is preparedness-based (i.e., the cost of maintaininga suitable state of readiness), and dependson service area size and complexity, utilization,and pre-determined quality standards (i.e., staffing,level of care, response time, and others). Thisprovides EMS with financial incentives that encourage,as appropriate, provision and/or directionof EMS patients to efficient care or otherresources. It links finance to value, as determinedby community consumers, and aligns cost andpayment drivers.The continued development of EMS systems onregional, state-wide, and national bases is facilitatedby regional, state, and federal governments.Sufficient funds are allocated to ensure EMS preparedness,including its first response functions.HOW TO GET THEREEMS systems must continually determine andimprove their cost-effectiveness and evaluate trendswithin the health care system as a whole. Evaluationsshould enable optimization of financial resourcesto provide improved care.EMS systems must develop proactive relationshipswith health care insurers and other providers.Such relationships should include implementingpilot projects that determine ways for EMS andother health care organizations to collaborate toincrease the efficiency of patient care delivery. Thesecould address such issues as patient and systemoutcomes when patients are not transported to anemergency department. The results of such pilotprojects must be widely disseminated.Health care insurers and provider organizationsmust compensate EMS as a component of the healthcare system caring for their clients/subscribers/members/ patients/consumers. Model formulas foruse among these entities should be developed.Criteria for payment, that are preparedness-based,do not necessarily require patient transport, andare not volume driven, must be developed betweenEMS systems and insurers/provider organizations.Health care insurers/provider organizationsmust allow immediate access to EMS for their patientswho believe that a medical emergency exists.They must recognize an emergency medical condition as amedical condition, with a sudden onset,that manifests itself by symptoms of sufficient severity,such that a prudent layperson, possessingan average knowledge of health and medicine, couldreasonably expect the absence of immediate medicalattention to result in placing the person’s healthin serious jeopardy. Such a condition should serveas sufficient cause to access EMS.Governmental agencies responsible for healthcare finance policy must incorporate divisions thataddress issues relevant to EMS. Such issues shouldinclude reimbursement for services when transportdoes not occur, and development of preparedness-basedor other alternative, proactive criteria forEMS reimbursement/finance.Local, state, and federal governments mustcommit to funding agencies primarily responsiblefor facilitating coordinated EMS development andevolution. Such funding should be from stablesources that enable future planning to occur. Itshould provide resources for infrastructure development,EMS evaluation and research, and pilotproject implementation.SYSTEM FINANCE:Collaborate with other health care providers andinsurers to enhance patient care efficiencyDevelop proactive financial relationships betweenEMS, other health care providers, and healthcare insurers/provider organizationsCompensate EMS on the basis of a preparedness-based model, reducing volume-related incentivesand realizing the cost of an emergencysafety netProvide immediate access to EMS for emergencymedical conditionsAddress EMS relevant issues within governmentalhealth care finance policy-Commit local, state, and federal attention andfunds to continued EMS infrastructureReturn to ContentsHUMAN RESOURCES“Regardless of how integration with other health care services and increased use of advancedtechnology changes the picture of EMS, human resources remain our most precious commodity.Without effective “care” of our human resources, this exercise becomes academic.”John L. ChewThe task of providing quality EMS care requiresqualified, competent, and compassionatepeople. The human resource, comprisedof a dedicated team of individuals with complimentaryskills and expertise, is the most valuableasset to EMS patients.The future: Hannah is a paramedic in the north-eastU.S. She becomes interested in a new position ina Georgia city. The new position, paramedic-community health specialist,-involves all of her current duties, butalso requires some knowledge andskills Hannah does not currently use.She is accepted for the job, and throughroutine mechanisms involving credentialchecks, is authorized byGeorgia’s lead EMS agency to workthere. Her new employer verifies clinicalcompetency through medical directionand provides access to theeducational programs Hannah needsto be comfortable and proficient inher new role. Her credentials are partof a permanently accessible record inthe event she chooses to relocate inthe future.WHERE WE AREMany people with greatly diverse backgroundscontribute to the efficient operations of EMS systems.In addition to citizen bystanders, these includepublic safety communicators and emergency medicaldispatchers, first responders, emergency medicaltechnicians (EMTs) of various certification levels,nurses, physicians, firefighters, law enforcementofficers, other public safety officials, administrativepersonnel, and others. Among local EMS systems,specific contributions by different categoriesof personnel may vary significantly.The vast majority of out-of-hospital EMS careis provided by paramedics and other levels of EMTs.Estimates of the total number of EMS providersvary, but one indicated that there are more than70,000 paramedics and 500,000 other levels of EMTs.66Across the country, more than 40 different levelsof EMT certification exist. However, the NationalEMS Education and Practice Blueprint has establishedstandard knowledge and practice expectationsfor four levels of EMS providers: FirstResponder, EMT-Basic, EMT-Intermediate, and EMT-Paramedic.89 Much of the nation’s EMS is providedby volunteers with diverse occupational backgrounds.They serve more than 25% of the population.The economic value of their contributionis immeasurable.79 However, formany possible reasons, the numberof EMS volunteer organizationsis decreasing.40Nurses continue to be involvedin EMS systems in educational, administrative,and care deliverycapacities. The most frequentlyemployed crew configurations forair medical services include at leastone nurse.124 Nursing educationregarding out-of-facility emergencycare is variable. However,many nurses engaged in out-of-facilityEMS patient care activitiesalso are certified as EMTs atsome level.1 Several states havecreated curricula specifically for the purpose ofeducating, and thus credentialing, nurses who wishto be EMS field providers. Additionally, the EmergencyNurses Association has developed nationalstandard guidelines for prehospital nursing curricula.106Many other groups of health care workers alsocollaborate to effect the patient care provided byEMS. They include physicians (emergency physicians,family practitioners, pediatricians, surgeons,cardiologists, and others), nurses with various areasof special expertise, nurse practitioners, physician’sassistants, respiratory therapists, and others. Theirroles may involve EMS personnel education, systemplanning, evaluation, research and/or directprovision of care.Perennial EMS personnel-related issues includethe difficulties of recruitment and retention. Occupationalrisks, often limited mobility (e.g., credentialreciprocity), suboptimal recognition, andinadequate compensation contribute to these problems.Both volunteer and career (i.e, paid personnel)systems are affected.EMS personnel experience stressors and risksthat are unique to other health care workers and,no doubt, to other public safety workers. Amongthese stressors is exposure to highly traumaticevents or experiences. Emergency personnel areat least twice as likely as the general populationto suffer from post traumatic stress disorders.81,82 However, there is a paucity of literature describingsystematic approaches intended to furtherunderstand the spectrum of EMS workforcestressors.11,23,95,105 Instead, most descriptions of EMSpersonnel stress and subsequent “burnout” areanecdotal.Exposure to bloodborne pathogens is a significantrisk for EMS personnel. Exposure to HIV andhepatitis viruses are the greatest concerns.42 Reportsindicate that between 6 and 19 per 1,000 “ALS”EMS responses involve a contaminated needle stickinjury to EMS personnel.58,103 The average hepatitisB virus seroprevalance rate among EMSpersonnel is 14%, which is 3-5 times higher thanthe general population.80 Furthermore, the wide-spreadresurgence of tuberculosis poses an additionalthreat of serious occupation related infectionto EMS workers.42Other work related injuries also are common.EMS personnel, especially those in urban areas,are subject to assault.48 Back injury is the singlelargest category of occupational injuries, and frequentmechanisms of injury include lifting, falling,assaults, and motor vehicle crashes.49,60,111EMS workers often suffer from lack of fullrecognition as members of the health care deliverysystem. They frequently lack a satisfactorycareer ladder. Providers are also limited in termsof their mobility, as there is no uniform systemof credential reciprocity among all states. Barriersalso exist between regions in some states. Furthermore,the environment in which EMTs and,in particular, paramedics may practice is in manycases limited by state statutes and regulations.Among EMS systems, the numbers and typesof personnel who staff EMS vehicles vary greatly.Some literature addresses the value of a physicianin specific circumstances and as part of anair medical transport team.9,54,112 However, evaluationsof other desirable personnel attributes, interms of numbers and combined levels of educationand experience to provide specific services/interventions, have not been systematically performedand reported.WHERE WE WANT TO BEPeople attracted to EMS service are amongsociety’s best, and desire to contribute to theircommunity’s health. The composition of the EMSworkforce reflects the diversity of the populationit serves. The workforce receives compensation,financial or otherwise, that supports its needs andis comparable to other positions with similarresponsibilities and occupational risks.A career ladder exists for EMS personnel, andit includes established connections to parallel fields.EMS personnel may use accumulated knowledgeand skills in a variety of EMS-related positions,and neither advancing age or disability prevent EMSproviders from using their education and expertisein meaningful ways.Standard categories of EMS providers are recognizedon a national basis. Such levels providethe basis for augmentation of knowledge and patientcare skills that may be desirable for specific regionalcircumstances.Reciprocity agreements between states for standardcategories of EMS providers eliminates unreasonablebarriers to mobility. This enhances careeroptions for EMS workers and their ability to relocatewhether for personal or professional reasons.There is an understanding of the occupationalissues, including both physical and psychological,unique to EMS workers. All EMS personnel receiveavailable immunizations against worrisome communicablediseases, appropriate protective clothingand equipment, and pertinent education. Theyalso have ready access to counseling when needed.The value of supporting the well-being of theworkforce is recognized, and workforce diversityis considered during the design of strategies toaddress occupational issues.EMS personnel are prepared to provide the levelof service and care expected of them by the populationserved. Preparation includes physical resources,adequate personnel resources, and requisiteknowledge and skills. This helps ensure that thequality of care provided meets an acceptable communitystandard.EMS personnel are readily recognized as membersof the health care delivery team. This is congruentwith recognition of the role EMS plays inproviding out-of-facility care to the population,and its function as an initial treatment providerand facilitator of access to further care at timesof acute injury or illness.Health care workers with special competencyin EMS are readily identifiable. This includes physicians,nurses, administrators, and others whosepractices involve EMS. Recognition of special competencyhelps ensure quality of knowledge andexpertise for health care workers who are soughtto affect EMS and its ability to provide quality carefor its patients.Provider skills and patient care interventionsare evaluated continuously to determine which skillsand interventions positively impact EMS patientcoutcomes. This ensures that providers are appropriatelyeducated and distributed within EMSsystems so that they are able to deliver optimalcare to the population.HOW TO GET THEREAdequate preparation, in terms of both knowledgeand skills acquisition, must precede changesin the expectations of services to be provided byEMS personnel. EMS systems administrators,managers and medical directors are responsiblefor ensuring such preparation. Requisite knowledgeand skills should be estimated a priori andcontinuously evaluated.Those responsible for EMS structures, processesand outcomes, including EMS education, must adoptthe principles of the National Emergency MedicalServices Education and Practice Blueprint.89 Thiswill provide greater national uniformity amongEMS workers and enhance recognition of their expertiseand roles within health care.State EMS directors must work together todevelop a system of reciprocity for credentialingEMS professionals who relocate from one state toanother (e.g., the National Registry of EmergencyMedical Technicians). Although states may havespecific criteria for authorizing EMS providers topractice, it is not acceptable to require professionalsto repeat education that has already been acquired.This will ensure that EMS providers may take advantageof professional opportunities to which theyare otherwise entitled.EMS systems should develop relationships withacademic institutions. This will facilitate access toresources necessary to conduct occupational healthstudies and provide education opportunities forpersonnel. Education opportunities sought shouldinclude recognized management course work forEMS system managers/administrators.Researchers in EMS systems should collaborateto conduct occupational health studies regardingEMS personnel (e.g., long-term surveillance studies,national database, and others). Such studiesmust be designed to yield an improved understandingof occupational hazards for EMS workers andstrategies for minimizing them.EMS systems must become affiliated with orimplement a system for critical incident stress management.The potential effects of overwhelminglytragic events on EMS workers cannot be ignored,and must be addressed to the greatest extent possible.EMS must be developed as a subspecialty forphysicians, nurses, and other health care professionalswith an EMS focus. This will facilitaterecognition of health care professionals with spe-cialcompetency in EMS.HUMAN RESOURCES:Ensure that alterations in expectations of EMSpersonnel to provide health care services arepreceded by adequate preparationAdopt the principles of the National EMS Educationand Practice Blueprint-Develop a system for reciprocity of EMS providercredentials-Develop collaborative relationships between EMSsystems and academic institutionsConduct EMS occupational health researchProvide a system for critical incident stressmanagementReturn to ContentsMEDICAL DIRECTION“Medical direction brings to EMS all the traditions of patient care, research and life-longlearning inherent in Medicine. The ethical foundation of medical practice must be the foundation forproviding medical care in the streets. Medical directors are made, not born. ‘Making’ them is notalways easy; programs for them must reflect field problems and field resources, and in a planned wayshould take place under conditions in the street.”Ronald D. Stewart, OC, MDMedical direction involves granting authorityand accepting responsibility for thecare provided by EMS, and includes paricipationin all aspects of EMS to ensure maintenanceof accepted standards of medical practice.Quality medical direction is an essential processto provide optimal care for EMS patients. It helpsto ensure the appropriate delivery of population-basedmedical care to those with perceived urgentneeds.The future: In Quinton, the EMSmedical director, after input fromother community physicians, wishesto add follow-up visits for certaindischarged emergency departmentpatients to her system’s practice parameters.The medical direction staff-and other physicians are formallyconsulted, and justification isprovided to the state EMS leadagency. After extensive educationand granting of clinical privilegesto a number of system personnel,the plan goes into effect. The medicalcommand center coordinates communicationbetween field personnel-and patients’ primary careproviders. The medical direction staffconducts a continuous evaluationof the new activity and its effectson the system’s emergency responsecapabilities.WHERE WE AREAdministrative and medical direction managementcomponents, working in concert, are requiredto ensure quality state-of-the-art EMS. Physiciansaffiliated with EMS systems serve at varying extents,from informal system medical advisors to full-timemedical directors and system administrators. Withrespect to EMS events, medical direction includesactivities that are prospective (e.g., planning, protocoldevelopment), contemporaneous, and retrospective.In most states, medical direction of EMS systemsthat provide advanced levels of care is mandatedby law. Many basic level EMS systems (i.e.,those without EMT-Intermediates or EMT-Paramedics)do not maintain continuous medical direction,but a growing number are now beingrequired to establish formal relationships withresponsible physician medical directors.118 TheEmergency Medical Technician: Basic, National StandardCurriculum emphasizes the role of medical directionduring EMT-B education and practice.34In many states, the majority of on-line medicaldirection, referring to themoment-to-moment contemporaneousmedical supervision ofEMS personnel caring for patientsin the field, is providedby emergency physicians.118 Itoccurs via radio, telephone, oron-scene physicians. Within anygiven EMS system, on-linemedical direction may emanatefrom a central communicationsfacility or one or more designatedhospitals or other healthcare facilities. Some areas utilizestaff other than physicians,such as mobile intensive carenurses (MICN) to communicatewith field EMS personnel andaffect patient management.Although on-line medicaldirection may be important forselected patients, its systematic application for themajority of EMS patients remains controversial.Several investigators have examined the issue ofprolonged out-of-hospital times when radio contactwith a physician was required.36,52,62,100 Theresults have been mixed. However, linkage to objective,relevant outcomes has been incomplete.In the majority of cases on-line medical directiondoes not result in orders for care beyond what hasbeen directed via protocol, but such communicationis nevertheless felt to be helpful by EMS personnel.36,59,131,142Medical direction activities that do not involvecontemporaneous direction of EMS personnel inthe field include development and timely revisionof protocols and medical standing orders, implementationand maintenance of quality improvementsystems, personnel education, development andmonitoring of communications protocols,attention to the health and wellness of personnel,and addressing equipment and legislative issues.Such activities are critical for ensuring optimal EMS.The task of medical direction involves manypeople in addition to the EMS medical director.Medical direction staffs, medical control authoritiesand other oversight agencies or boards ofteninclude other physicians (emergency physicians,pediatricians, surgeons, internists, family practitioners,and others), nurses and nurse practitioners,physician’s assistants, paramedics and otherEMTs, administrative staff, and others. Medicaldirection results from a collaborative effort of allto positively affect the patient care delivered byEMS systems.The medical director ’s role is to provide medicalleadership for EMS. Those who serve as medicaldirectors are charged with ultimate responsibilityfor the quality of care delivered by EMS, must havethe authority to effect changes that positively affectquality, and champion the value of EMS within theremainder of the health care system. The medicaldirector has authority over EMS medical careregardless of providers’ credentials. He or she isresponsible for coordinating with other communityphysicians to ensure that their patients’ issuesand needs are understood and adequatelyaddressed by the system.Medical directors evolve from several medicaldisciplines. In some areas, emergency physiciansprovide the majority of medical direction. Duringtheir residency training, emergency physicians areexposed to the principles of providing medicaldirection. A model curriculum for EMS educationwithin emergency medicine residency programshas been published.129 However, not all emergencyphysicians are EMS physicians, nor are all EMSphysicians emergency physicians. Furthermore,not all EMS physicians are EMS medical directors.Nevertheless, no matter what other clinical expertisethey possess, these physicians are knowledgeableregarding EMS systems and clinical issues. Theyprovide input to their communities’ EMS systems,affect the care that is delivered by EMS, and participatein local, state, and/or national EMS issuesresolutions. A growing number of EMS fellowshipsare being created to facilitate development of specialcompetency in EMS among physicians, but no subspecialtycertification by the American Board ofMedical Specialties yet exists.Currently, medical direction is often providedby physicians and staffs on behalf of hospitals whodonate, to some extent, their resources. As thestructure of the health care delivery system as awhole evolves, and financial incentives for medicalcare providers change, hospitals’ incentives forengaging in EMS medical direction are diminishing.The potential of a crisis may exist for medicaldirection in its current form, involving physicianexpertise that is often volunteered or compensatedby hospitals.WHERE WE WANT TO BEAll EMS providers and activity have the benefitof qualified medical direction. This is true regardlessof the level of service provided, and helpsensure that EMS is delivering appropriate and qualityhealth services that meet the needs of individualpatients and the entire population.The effects of on-line medical direction areunderstood, including identification of situationsthat are significantly influenced by on-line medicaldirection, and the effects of various personnelproviding it. This helps ensure that on-line medicaldirection is available and obtained for thosesituations when it is likely to have a positive effectfor EMS patients.Medical direction is provided by qualifiedphysicians and staffs with special competency inEMS. Recognition of competency, by virtue ofacquisition of knowledge and skills relevant to thedelivery of EMS care and administration of EMSsystems as population-based health care systems,is available in the form of subspecialty certificationfor physicians, nurses and administrators. Thishelps ensure that medical direction, which ultimatelyaffects the care provided to patients in the community,is provided by knowledgeable and qualifiedindividuals.Every state has a state EMS Medical Directorwho is an EMS physician. This helps ensure appropriatemedical direction for states’ EMS systems.It acknowledges EMS as a component of thehealth care system serving patients’ needs andrequiring physician leadership. States recognizethat out-of-facility medical care must be supervisedby a qualified physician.Resources available to the medical director(s)are commensurate with the responsibilities and sizeof the population served. This ensures that resources(e.g., personnel, equipment, funding, and others)are sufficient to carry out the responsibilities andauthorities incumbent upon the medical directorand medical direction staff. The cost of such resourcesis included with those of system preparedness.EMS medical directors, in consultation with othermedical direction participants, are responsible fordetermining EMS systems’ practice parameters. Theymaintain authority for all care provided by EMS,and they have responsibility for granting clinicalprivileges to EMS providers. The medical directorand other medical direction personnel ensurethat EMS providers are prepared, in terms of educationand skills, to deliver the system’s patientcare.Medical direction provides leadership for EMSsystems and personnel. The medical director ensurescollaboration between EMS and other healthcare partners, and actively seeks contributions fromother community physicians so that the interestsand needs of the entire population served (e.g.,children, senior citizens, and others with specialhealth care needs) are addressed. EMS medicaldirectors are in a position to positively influencesystems and the care delivered through their knowledgeof the complexities of EMS, the spectrum ofissues related to population-based care, the occupationalhealth concerns of EMS personnel, the optimalcare for the spectrum of EMS patients, andthe principles of clinical research.HOW TO GET THEREEMS provider agencies, of all levels of sophistication,must formalize a relationship with a medicaldirector(s) for the purpose of obtaining medicaldirection. Medical direction must be available andprovided to all EMS processes, including emergencymedical dispatching and education. In some cases,local or state legislation may be appropriate tocompel such relationships.EMS systems must ensure that medical directionis appropriated sufficient resources to justifyits accountability to the systems, communities, andpatients served. The cost of such resources shouldbe included with those of system preparedness.All individuals who provide on-line medicaldirection must be appropriately credentialed. Thisshould be accomplished, in part, through formalorientation to the principles of on-line medical directionand specific characteristics of local EMSsystems.EMS physicians and researchers must conductinvestigations of adequate quality to elucidate theeffects of on-line medical direction. Effects studiedshould address objective, relevant patient outcomesand systems costs.Interested organizations must continue theirwork to develop the basis for EMS as a physiciansubspecialty. Such work should include encouragementof institutions to develop resources necessaryto implement EMS fellowships, so that thenumber of qualified EMS physicians will grow.EMS authorities and systems should designatea physician(s) responsible for overall medical directionwithin the jurisdiction. Such an appointmentshould be made with the intent of facilitatinguniformity of medical oversight policies and practicesthroughout the jurisdiction. Additionally,medical director(s) should be charged with the responsibilityof, and accountable for, collaboratingwith other community physicians to ensure the bestpossible care for the population.All states must appoint a statewide EMS medicaldirector. This physician ultimately will be responsiblefor statewide EMS medical direction, providingleadership and guidance for the state’s EMS systemthat is based on sound medical practice.MEDICAL DIRECTION:Formalize relationships between all EMS systemsand medical directorsAppropriate sufficient resources for EMS medicaldirectionRequire appropriate credentials for all those whoprovide on-line medical directionDevelop collaborative relationships between EMSsystems and academic institutionsDevelop EMS as a physician and nurse subspecialtycertification-Appoint state EMS medical directorsReturn to ContentsEDUCATION SYSTEMS“Education systems of the future will make maximum use of technology to reach students in outlyingareas and those who otherwise have difficulty reaching traditional classrooms. Textbooks will seldom bemade of paper; videos, satellite television, and computer linkages and programs will provide thebulk of study materials. Educational bridge programs will make it easier to advance one’s knowledgewithout repeating previous classroom and practical experiences.”E. Marie Wilson, RN, MPAAs EMS care continues to evolve and becomemore sophisticated, the need for high qualityeducation for EMS personnel increases. Educationprograms must meet the needs of new providersand of seasoned professionals, who havea need to maintain skills and familiarity with advancingtechnology and the scientific basis of theirpractice.The future: Tom Klowska is aparamedic in a municipal EMSsystem. He started his career asan EMT-Basic after completinga standard accredited course atthe community college. He receivedacademic credit for his one-yearparamedic program, whichhe completed two years ago. Currently,he has a partial scholarship-and is pursuing a degree incommunity health, which willqualify him as a CommunityHealth Advanced Medical Practitioner,and result in his ability-to assume a new position (withhigher compensation) within theEMS system.Many of his classmates havesimilar experiences. Some arenurses and other health professionalstransitioning to out-of-facility positions.WHERE WE ARECurrently, EMS education programs primarilyprepare those who are interested for certificationas an EMT at various levels. The National EMSEducation and Practice Blueprint describes thestandard knowledge and practice expectations forfour levels of EMS providers.89 However, there arecurrently more than 40 different types of EMTcertification, in terms of requisite knowledge andskills, available across the United States. Such variationamong states and local jurisdictions impedesefforts to develop agreements for credentialing reciprocity.The National Registry of Emergency MedicalTechnicians (NREMT) offers certification examinationsfor First Responder, EMT-Basic, EMT-Intermediate,and Paramedic levels, which are acceptedby many states as evidence of competency.Settings for EMS education include hospitals,community colleges, universities, technical centers,private institutions, and fire departments.130 Programquality and improvement efforts can beachieved in all settings. Ninety-four paramediceducation programs currently are accredited by theJoint Review Committee onEducational Programs for theEMT-Paramedic. Additionally,increasing numbers of collegesoffer bachelor ’s degrees inEMS.101 However, overall thereis inadequate availability ofEMS education opportunitiesin management, public health,and research principles.Curricula developed by theU.S. Department of Transportation(DOT) provide the basesfor education of first responders,EMT-Basics, EMT-Intermediates,and EMT-Paramedics.Education of military EMS personnelalso follows these curricula,and they often mayprovide a resource pool for civilianEMS systems.Standardized brief educational programs, withspecific objectives that address treatment of segmentsof the population, also have been developed.They include courses in cardiac, trauma, andpediatric life support. Such programs are frequentlyincorporated into, or used to supplement, EMS educationplans. Many reports discuss education ofEMS providers to perform specific skills.6, 16, 43, 70,71, 102, 133, 140, 141 However, there have not been systematicanalyses of the suitability of EMS educationwith regard to expectations for EMS personnelto provide a spectrum of public safety and healthcare services. Additionally, issues related to knowledgeand skill degradation have not been addressedextensively. While some EMS providers seek furthereducational opportunities, others, for variousreasons, do not wish to do so.130WHERE WE WANT TO BEEMS education employs sound educationalprinciples and sets up a program of lifelong learningfor EMS professionals. It provides the tools necessaryfor EMS providers to serve identified healthcare needs of the population. Education is basedon research and employs adult learning techniques.It is conducted by qualified instructors.Educational objectives for EMS providers arecongruent with the expectations of health and publicsafety services to be provided by them. This ensuresthat acquired knowledge and skills are those thatadequately prepare providers to meet expectationsfor personnel of their stature.Education programs are based on the nationalcore contents for providers at various levels. Corecontents provide infrastructure for programs, whichmight be augmented as appropriate for local circumstances(e.g., wilderness rescue). They providenational direction and standardization of educationcurricula, which facilitates recognition bycredentialing agencies while allowing adequate opportunityfor customization as indicated by localnecessity.Higher level EMS education programs areaffiliated with academic institutions. EMS educationthat is academically-based facilitates furtherdevelopment of EMS as a professional discipline.It increases the availability of educational opportunitiesthat acknowledge previous EMS educational/academic achievements, provides moreacademic degree opportunities for EMS personnel,augments the management skills among EMS professionals,and protects the value of personal andsocietal resources invested in education.Interdisciplinary and bridging programs provideavenues for EMS providers to enhance theircredentials or transition to other health care roles,and for other health care professionals to acquireEMS field provider credentials. They facilitateadaptation of the work force as community healthcare needs, and the role of EMS, evolve.Institutions of higher learning recognize EMSeducation as an achievement worthy of academiccredit. They welcome affiliations with EMS educationprograms, and assist them to strengthen theacademic basis of EMS education.HOW TO GET THEREAny change in the vision of EMS should promptan analysis of new tasks required by that vision,providing the basis for determining the educationneeds of the EMS workforce. Alterations of EMSeducation core contents should then follow accordingly.EMS education researchers must investigatecurricula adequacy and alternative education techniques.Such investigations should be designed toprovide improved understanding of the educationthat is optimal for serving various EMS roles. Theresults of such investigations should be widely disseminated.Objectives of education programs must beupdated sufficiently and frequently so that the needsof EMS patients are met. Modifications should ensurethat objectives serve the current needs of EMSpatients and the personnel who care for them, socommunity standards of practice can be achieved.Higher level EMS education programs must incorporatelearning objectives regarding research, qualityimprovement, and management. The scientific basisof EMS practice, basic principles of clinical research,the importance of ongoing EMS research, and theprinciples of quality improvement and managementshould be included.All EMS education must be conducted with thebenefit of qualified medical direction. The physicianmedical director(s) should be involved ineducation program planning, presentation, andevaluation, including evaluation of faculty, andparticipants.The federal EMS lead agency should commissionthe development of national core contents forvarious levels of EMS providers. Core contentsshould replace current curricula. These should beupdated on a predetermined schedule to ensuretheir ongoing utility.EMS education programs should seek accreditationby a nationally recognized accrediting agency.Accreditations should be sought to demonstratethat the educational programs provided meet a predefinednational standard of quality.Public funds for education should be directedpreferentially toward EMS education programs thatare accredited. This includes student financial aid(e.g., state and federal).Providers of EMS education should seek toestablish relationships with academic institutions(e.g., colleges, universities, academic medicalcenters). Such relationships should enhance theacademic basis of EMS education and facilitaterecognition of advanced level EMS education asan accomplishment worthy of academic credit.EMS education providers and academic institutionsshould develop innovative solutions thataddress cultural variation, rural circumstances, andtravel and time constraints. These should includeprograms that incorporate, for example, distancelearning and advancing technology. Reports of suchprograms should be made widely available. In somecases, these institutions should develop their ownEMS education programs that offer academic credit.EMS educators must develop bridging andtransitioning programs. These programs should offermechanisms for EMS providers to enhance theircredentials or transition to new health care roles.They should also provide other health care personnelthe ability to transition to out-of-hospitalEMS roles.EDUCATION SYSTEMS:Ensure adequacy of EMS education programsUpdate education core content objectives frequentlyenough so that they reflect patient EMS-health care needsIncorporate research, quality improvement, andmanagement learning objectives in higher levelEMS educationCommission the development of national corecontents to replace EMS program curriculaConduct EMS education with medical directionSeek accreditation for EMS education programsEstablish innovative and collaborative relationshipsbetween EMS education programs and academic-institutionsRecognize EMS education as an academic achievementDevelop bridging and transition programs-Include EMS-related objectives in all healthprofessions’ educationReturn to ContentsPUBLIC EDUCATION“EMS has not yet begun to realize its potential as an important public educator. It should acceptthe challenge to explore innovative ways for educating the broadest possible spectrum of society withregard to prevention, EMS access and appropriate utilization, and bystander care. EMS must also educatethe public and those that purchase services as consumers, so they are enabled to make informed EMS-related decisions fortheir communities.”Patricia J. O’Malley, MDPublic education, as a component of healthpromotion, is a responsibility of every healthcare provider and institution. It is an effortto provide a combination of learning experiencesdesigned to facilitate voluntary actions leading tohealth.The future: Nine-year-old Sara and her friends areswimming at the neighborhood pool when they hear asiren. They run to the parking lot todiscover an ambulance, not respondingto an emergency call, but “on-scene”to brief kids about bicyclesafety. At the end of the program eachchild receives a family safety checklist.Once completed with theirparents, it is redeemable for food anddrinks at the pool snack bar. Childrenalso receive information abouthow they and their parents can usetheir home computers to learn moreabout safety, first aid, and EMS intheir town, and at the same time wincoupons redeemable for ice cream conesand other treats. Later that week Saracrashes her bicycle as she tries to avoida squirrel in her path. Although shestrikes her head, she is fortunatelywearing her new helmet and suffersno injuries.WHERE WE AREPublic education is an essential activity for everyEMS system. Yet, as a tool for providing public education,EMS is woefully underdeveloped. A greatdeal of what the public knows about its EMS systemand about dealing with medical emergenciesoriginates from the media, including television programsintended for entertainment and not education.The media does not prepare the public toevaluate or ensure the quality of EMS.Education, with all its various dimensions, isthe linchpin for health promotion. As a componentof health promotion, education facilitates developmentof knowledge, skills, and motivation thatlead to reduction of behavioral risks and more activeinvolvement of people in community affairs. Thisincludes greater participation in effecting healthand social policy and advocacy for improved healthsystems.53Public education is often a focus of other publicsafety divisions. Examples include fire service campaignsregarding the importance of smoke detectors,and police educational efforts regardingimpaired driving, traffic and highway safety, andpersonal safety. In general, EMShas not optimally engaged itselfin providing education that improvescommunity health throughprevention, early identification,and treatment.Certainly there are examplesof EMS public education initiatives.In some areas EMS-C fundshave been utilized to develop programsregarding childhood illnessand injury. 39 The U.S. Fire Administration(USFA)/National HighwayTraffic Safety Administration(NHTSA)/Maternal and ChildHealth Bureau (MCHB) “Make theRight Call” campaign and othercommunity-wide efforts have focusedon timely access and appropriateutilization of the EMSsystem.57, 84 Additionally, numerousEMS systems have assumeda leadership role in disseminatingCPR and “bystander care” educationto the public. The NHTSA Public Informationand Education Relations (PIER) program seeks, inpart, to augment EMS provider public educationskills.However, planned and evaluated EMS publiceducation initiatives remain sporadic. This is despitethe interest and role of EMS in improvingcommunity health, its stature and visibility withinthe community, and its potential ability to educateindividual patients and family members duringperiods of care and follow-up.WHERE WE WANT TO BEPublic education is acknowledged as an essentialongoing activity of EMS. Such programs supportthe role of EMS to improve community health andprovide valuable information regarding preventionof injuries and illnesses, appropriate accessand utilization of EMS and other health care services,and bystander care. It realizes the advantagesof EMS as a community-based resource withbroad expertise and capacity for contributing tocommunity health monitoring and education dissemination.EMS and public education programs addressthe needs of all members of the community. Thisincludes school-age children, adults, senior citizens,and other members of the community withspecial needs.EMS systems educate the public as consumers.The importance of the public’s knowledge ofEMS-related issues, including funding, level of careprovided, equipment, and system expectations andstandards is acknowledged. Purchasers of healthcare services, whether individual, corporate, orpublic, are well-informed about EMS issues, includingevaluating and ensuring optimal EMS.EMS systems explore innovative techniques toconduct their public education missions. These include,among others, follow-up visits to patientsand their families, exploration of new technologies(e.g., computers, worldwide web), and mediaformats.HOW TO GET THEREEMS should collaborate with other communityresources and agencies to determine public educationneeds. Such assessments will enable developmentof education programs with specificobjectives appropriate for the community.EMS must engage in continuous public education.Such efforts should focus on areas of prevention,early identification and health care serviceaccess, and initial treatment.EMS must educate the public as consumers.Targets for such efforts should include at-largecommunity members, other members of the healthcare system, policy makers, lawmakers, and healthcare service purchasers.EMS must explore new techniques and technologiesto effect public education. Efforts shouldbe made to reach the broadest possible populationin the community.Public education efforts must be scrutinizedby an evaluation process. Such evaluation helpsensure that program objectives are being met andprovides guidance for program modification.PUBLIC EDUCATION:Acknowledge public education as a criticalactivity for EMSCollaborate with other community resources andagencies to determine public education needsEngage in continuous public education programsEducate the public as consumersExplore new techniques and technologies forimplementing public educationEvaluate public education initiativesReturn to ContentsPREVENTION“In the future the success of EMS systems will be measured not only by the outcomes of theirtreatments, but also by the results of their prevention efforts. Its expertise, resources, and positionsin communities and the health care system make EMS an ideal candidate to serve linchpin roles duringmulti-disciplinary, community-wide prevention initiatives. EMS must seize such responsibility andprofoundly enhance its positive effects on community health.”Theodore R. Delbridge MD, MPHPrevention provides an opportunity to realizesignificant reductions in human morbidityand mortality—all with a manageable investment.Engaging in prevention activities is the responsibilityof every health care practitioner, including those involved with the provision of EMS.The future: EMS personnel analyzing uniformpatient care records realize that a disproportionatenumber of motor vehicle crash victimsoriginate from a particular roadintersection. Many of the crashesoccurred during the morning rushhours as motorists exited theirneighborhood. The information isrelayed to the local law enforcementagency and community groups,which form a coalition to evaluatethe problem. At civic associationmeetings, neighborhood residents areadvised of a safer route that avoidsthe dangerous intersection, and congestionthere decreases.. Speed limitenforcement on the main highwayis increased. Also, new signs nearthe intersection and radio traffic reportersremind drivers of the potentialdanger spot so that theyexercise caution and stay attentive.Soon thereafter, crash incidence andresulting injuries decrease at thatintersection.WHERE WE AREAs a whole, the health care system is evolvingfrom an emphasis on providing highly technologic,curative care to improving health through preventionand wellness. The objective is to prevent peoplefrom ever requiring costly medical care.In this era, injury prevention has taken on anew dimension for both improving the nation’shealth and truly controlling health care costs.77 Injuryis the third leading cause of death and disabilityin all age groups and accounts for more years ofpotential life lost (YPLL) than any other healthproblem.8 Following consideration of such information,a consensus panel has advocated additionof injury prevention modules to the National EMSEducation and Practice Blueprint. 47Other public safety services have demonstratedtheir effectiveness at public education and preventionactivities. These include fire service efforts toeffect engineering, enforcement, and education thatdecrease the number of fires and fire-related burnsand deaths. Police departmentshave implemented deliberateefforts to decrease traffic-relatedinjuries and deaths through aggressiveenforcement of impaireddriving laws.EMS is not commonly linkedto the public’s prevention consciousness.However, the potentialrole of EMS in prevention haspreviously been recognized.73 EMSproviders are widely distributedthroughout the population, oftenreflect the composition of thecommunity, and generally enjoyhigh credibility. 47 In some regions,EMS personnel currently aretaught principles of injury prevention.117 EMS-initiated preventionprograms have been successful inreducing drownings in PinellasCounty, Florida, and Tucson,Arizona, and falls from height inNew York.39,55,96 EMS patients alsomay benefit from linkage between the EMS systemand other community services able to providespecific education and prevention initiatives.39,50,55,61Such linkages remain rare, however.Early efforts are underway to implement SafeCommunities projects.110 The Safe Communitiesconcept involves undertaking a systematic approachto address all injuries, and emphasizes the needfor coordination among prevention, acute care, andrehabilitation efforts. The Centers for Disease Controland Prevention is developing the concept of “SafeAmerica” and is working with NHTSA to integrateprevention, acute care and rehabilitation forall types of injuries among the many public andprivate partners involved in injury control.107 EMSsystems are crucial to these efforts as collectorsof important injury-related data, as communitypartners that help study the injury problem anddesign risk reduction strategies, and as health practitionerswho provide acute care.WHERE WE WANT TO BEEMS systems and providers are continuouslyengaged in injury and illness prevention programs.Prevention efforts are based on regional need; theyaddress identified community injury and illnessproblems.EMS systems develop and maintain prevention-orientedenvironments for their providers, individuallyand collectively. An atmosphere of safetyand well- being, established through EMS systeminitiatives, provides the foundation for EMS preventionefforts within the community.EMS providers receive education regardingprevention principles (e.g., engineering, enforcement,education, economics). They develop andmaintain an understanding of how prevention activitiesrelate to themselves (e.g., while performingEMS-related duties and at other times) and totheir outreach efforts.EMS systems continuously enhance their abilitiesto document and analyze circumstances contributingto injuries and illnesses. This informationis provided to other health care and communityresources able to help evaluate and attenuate injuryand illness risk factors for individual patients andthe community as a whole.HOW TO GET THEREEmergency medical services providers/systemsmust collaborate with other community agenciesand health care providers which possess expertiseand interest in injury and illness prevention (e.g.,other public safety agencies, safety councils, publichealth departments, health care provider groups,colleges and universities). The intent of such collaborationis to identify appropriate targets forprevention activities and share the tasks of implementation.EMS systems should support the Safe Communitiesand Safe America concepts. For the sake ofthe health of the communities they serve, EMSsystems must identify their potential roles withinpartnerships to reduce preventable injuries andillnesses.EMS providers and systems must advocate forlegislation that potentially results in injury andillness prevention (e.g., through engineeringimprovements, enhanced enforcement, bettereducation, and economic incentives). This advocacyacknowledges the fiduciary responsibility thatEMS has for its communities’ health, in recognitionof the high costs of preventable injuries andillnesses. Such costs are not only monetary, but includelost productivity and the human sufferingthat affects individual patients and the entire community.Prevention begins at home. Protecting the well-beingof the workforce is a logical step toward thedevelopment and implementation of prevention initiativeswithin the community.EMS education core contents must include theprinciples of prevention and its role in improvingindividual and community health. Such educationwill better enable EMS to fulfill its prevention roleas a health care and public safety provider.EMS must continue to improve its ability todocument illness and injury circumstances and conveythis information to others. These efforts capitalizeon the unique position of EMS providers toobserve illness and injury scenes, and to identifypotential contributing factors within the community.PREVENTION:Collaborate with community agencies and healthcare providers with expertise and interest in illnessand injury prevention-Support the Safe Communities conceptAdvocate for legislation that potentially resultsin injury and illness preventionDevelop and maintain a prevention-orientedatmosphere within EMS systemsInclude the principles of prevention and its rolein improving community health as part of EMSeducation core contentsImprove the ability of EMS to document injuryand illness circumstancesReturn to ContentsPUBLIC ACCESS“Public access to EMS is closer to being universal than any other health service. Yet, barriers tosecuring prompt and appropriate care may still exist for many. It is incumbent upon all of us who shareresponsibility for leading our communities, planning their emergency health care, and appropriatingresources to strive to achieve true universal public access to EMS.”Jack J. Krakeel, MBAThe focus of public access is the ability to secureprompt and appropriate EMS care regardlessof socioeconomic status, age, or specialneed. For all those who contact EMS with a perceivedrequirement for care, the subsequent responseand level of care provided must be commensuratewith the situation.The future: During a severe winter storm 24-year-oldMary is driving home from worklate in the evening. On a rural roadher car skids and crashes into a tree.Mary’s legs are entrapped beneaththe dash, but her torso and head areuninjured due to her car’s airbag. Thecar’s engine is smoldering, makingthe passenger compartment smoky.A sensor in the vehicle’s intelligencesystem detects the crash and estimatesits force and the likelihood of occupantinjury. The appropriate PSAPfor the location is automaticallynotified by the vehicle’s communicationscomputer. Help is promptlydispatched to Mary, who is extricatedfrom the car and transported to theregional mid-level trauma center.Although she suffered a fractured legas a result of the crash, additionalmorbidity due to environmental factors, including smokeand extreme cold, was avoided because emergency assistancewas summoned immediately instead of requiringeventual discovery by another motorist.WHERE WE AREIn the United States, most people access EMSby telephone. For nearly 30 years, 9-1-1 has beendesignated as the national emergency telephonenumber. The first 9-1-1 telephone call was madein Halleyville, Alabama, in 1968. Currently, approximately25% of the U.S. geography is covered by9-1-1, making it available to 78% of the U.S. population.72,90 At many 9-1-1 communication centers,call-takers are automatically provided with thecaller ’s telephone number and location; automaticnumber identity (ANI); and automatic locationidentity (ALI). Such systems are known as enhanced9-1-1 or 9-1-1E. Seventy-nine percent of the mostpopulous U.S. cities utilize 9-1-1E.14 However, withinindividual states, as much as 85% of the populationmay not have access to 9-1-1. In some statesas many as 12% of housing units are without telephones.Obviously, occupants of those homes donot have immediate access to emergency servicesvia 9-1-1.When 9-1-1 is the emergencytelephone number, 85% of thepublic knows it, compared to 36-47% when the emergency telephonenumber is seven digits.28Additionally, 74% of people successfullyaccess EMS on their firstattempt when 9-1-1 is the emergencytelephone number, comparedto 40% when the numberis seven digits.78 People living incommunities where 9-1-1 serviceis not available, but adjacent tocommunities where it is, may experiencedelays in getting emergencyhelp by inadvertently calling9-1-1 instead of a designated sevendigit telephone number.The single most importantpiece of information providedduring an emergency call is the location of theperson(s) requiring help. Yet, addresses are lackingfor housing units and work sites in many areas.Highway call boxes, citizens band (CB) radio,amateur radio, and cellular telephones provide alternativemeans of accessing emergency help insome regions. Accuracy of 9-1-1 cellular telephonecalls, in terms of reaching the appropriate publicsafety answering point (PSAP), has been reportedto be 80% in one region. In the remaining 20%, thePSAP that was contacted forwarded the necessaryinformation to the appropriate dispatching center.85 However, in many areas cellular telephoneusers cannot be assured of reaching the appropriatePSAP for their location. Callers may be advisedthat they are unable to use 9-1-1, or they may experiencesignificant delays while call recipients determinewhere to route their calls.In some instances financial barriers limit accessto 9-1-1 for appropriate emergency care. Economicconditions may result in lack of a telephone.In other cases, health care provider organizationsmay impose penalties for their patients who donot obtain prior authorization or access emergencycare through an alternative designated telephonenumber, even when 9-1-1 is available.Presently, EMS is unsophisticated in terms ofits ability to allocate appropriate resources to matchthe nature of calls. Numerous EMS systems triagecalls depending on how long a situation can waitbefore a response is initiated. However, the eventualresponse is not necessarily commensurate withcircumstances (e.g., an over-response is generated)because calling a PSAP does not facilitate accessto actually needed services.WHERE WE WANT TO BEImplementation of 9-1-1 is nationwide. From anyland-line telephone in the U.S., a caller can dial 9-1-1, or push an emergency icon, in order to contactthe appropriate PSAP for his/her location. In a mobilesociety, this facilitates timely access to emergencyservices regardless of location and familiarity withlocal telephone number requirements. Furthermore,potential barriers to emergency services access aredecreased for children, elderly, mentally disabled,foreign visitors, and others with special needs.Alternative access to 9-1-1 is made available toindividuals unable to pay for telephone serviceswhere they routinely exist. In cases where the routinespectrum of telephone services is not providedbecause of an inability to pay, limited service thatmerely enables emergency services access via 9-1-1 is nevertheless made available. This helpsfacilitate access to emergency medical care for thefinancially disadvantaged, members of society whoalso are often medically disadvantaged.Cellular telephones uniformly provide a meansof accessing EMS via 9-1-1. Cellular telephones arein widespread use, and may provide a convenientmeans of accessing emergency services, especiallyfrom vehicles, in areas within a “cell” but wherea land-line telephone is not readily available. Tofacilitate timely access by cellular telephone users,“9-1-1” is available wherever the cellulartelephone might be in service. Cellular telephonetechnology (e.g., link to a global positioning system)ensures that all emergency calls are routedto the appropriate communications center.Every call for emergency services is automaticallyaccompanied by location identifying information.Within metropolitan areas, unique locationaddress codes suffice. For all calls originating fromroadways, rural, frontier, backcountry, and wildernessareas, exact locations derived from a geographicinformation system are provided. This acknowledgeslocation identifiers as the most importantinformation obtained by emergency call recipientsand that techniques for accurately enhancing informationtransfer facilitates timely access toemergency services. Such mechanisms also attenuatebarriers to access that might otherwise be experiencedby children and others who have difficultydefining their locations.No financial, legal, social, and age-related barriersto accessing appropriate care via 9-1-1 exist for thosewho perceive an emergency. The subsequent EMSresponse and level of care provided match the needregardless of other factors. Equal access to 9-1-1and timely emergency care is provided to all membersof society.Systems for accessing EMS and other emergencyservices employ communications technology advancesthat reduce barriers to access imposed bygeography, age of the caller, specific disabilities,language, and other phenomena. Such systemsinclude mechanisms for computerized automaticPSAP notification in cases of motor vehicle andother types of crashes, utilize personal status monitorsand communications devices, instantaneouslytranslate languages, provide the ability to electronicallyvisualize callers (e.g., interactive video communicationsprocesses), and incorporate computersto receive and transmit data between the caller,call recipient, EMS provider, other public safetyagencies, and other health care services.EMS access includes allocation of appropriatesystem resources for the circumstances. Calls receivedat access points are triaged (e.g., to anemergency communicator, medical advice program,social worker, primary health care provider, otherpublic safety services, and other community resources)so that the resulting output, given availableoptions, provides the most appropriate response(Figure 2).FIGURE 2. Public Access to an Appropriate EMS Response
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