emergency medical services - nhtsaas nhtsa embarks on 30 years of leadership in the field of...

E M E R G E N C Y

M E D I C A L

S E R V I C E S

A G E N D A

F O R

T H E

F U T U R E

As NHTSA embarks on 30 years of leadershipin the field of emergency medical services (EMS),our goal for the future is to focus community at-tention on the need to strengthen support for EMSsystems in an ever changing health care environ-ment. Our partnership with the Health Resourcesand Services Administration, Maternal and ChildHealth Bureau provided us with this opportunityto pursue that goal.

NHTSA realized the need foragencies, organizations, and indi-viduals involved in EMS to evalu-ate their roles and chart a course tothe future. The EMS Agenda for theFuture provides an opportunity forall health care providers to exam-ine what has been learned duringthe past 30 years. Its purpose is tooutline the most important directionsfor future EMS development. Dur-ing the process of creating this docu-ment, the EMS Agenda for the FutureSteering Committee sought and incorporated in-put from a broad, multi-disciplinary spectrum ofEMS stakeholders.

As the Steering Committee points out, this agendacomes at an important time, when the nation’s healthcare system is undergoing constant and rapidevolution. Resulting health care system changeswill affect EMS and its health care delivery roles.

MESSAGE FROM THE NATIONAL HIGHWAYTRAFFIC SAFETY ADMINISTRATOR

As we look to the future it is clear that EMS mustbe integrated with other services and systems thatare intended to maintain and improve communityhealth and ensure its safety. We must also focuson aspects of EMS that improve its science, strengthenits infrastructure, and broaden its involvement inenhancing the health of our communities. The Agendadescribes 14 EMS attributes and proposes contin-

ued development of them, enablingall of us to strive for a vision thatemphasizes a critical role for EMSin caring for our nation’s health.

Our EMS experiences over thepast 30 years provide us with a basison which to create the future. It isimportant, however, not to be heldhostage to the past, but to look freelyto the future. The EMS Agenda for theFuture is an important tool for do-ing that. It will be a valuable resourcefor government officials and all healthcare providers and administrators,

including EMS administrators, medical directors,managers, and all EMS providers. NHTSA is proudto have co-sponsored the project that led to comple-tion of this document, and is indebted to the Steer-ing Committee and all those who participated. Asboth NHTSA’s administrator and an emergencyphysician, I wholeheartedly endorse the vision andthe convictions to be found within the pages thatfollow.

EMS Agenda for the Future

Ricardo Martinez, M.D.

i

Emergency medical services (EMS) of the future will be community-based health man-agement that is fully integrated with the overall health care system. It will have the abilityto identify and modify illness and injury risks, provide acute illness and injury care andfollow-up, and contribute to treatment of chronic conditions and community health moni-toring. This new entity will be developed from redistribution of existing health care resourcesand will be integrated with other health care providers and public health and public safetyagencies. It will improve community health and result in more appropriate use of acute healthcare resources. EMS will remain the public’s emergency medical safety net.

THE VISION

EMS Agenda for the Future: The Vision

ii

During the past 30 years, emergency medi-cal services (EMS) in the United States haveexperienced explosive development and

growth. Yet initiatives to create a system to pro-vide emergency medical care for the nation’s popu-lation began with limited knowledge about whatconstituted the most efficient processes for deliv-ering ideal resources to the spectrum of situationsencountered by contemporary EMS.

The EMS Agenda for the Future provides an op-portunity to examine what has been learned duringthe past three decades and create a vision for thefuture. This opportunity comes at an importanttime, when those agencies, organizations, andindividuals that affect EMS are evaluating its rolein the context of a rapidly evolving health caresystem.

The EMS Agenda for the Future project wassupported by the National Highway Traffic SafetyAdministration and the Health Resources andServices Administration, Maternal and Child HealthBureau. This document focuses on aspects of EMSrelated to emergency care outside traditional healthcare facilities. It recognizes the changes occurringin the health care system of which EMS is a part.

EMS of the future will be community-based healthmanagement that is fully integrated with the over-all health care system. It will have the ability toidentify and modify illness and injury risks, pro-vide acute illness and injury care and follow-up,and contribute to treatment of chronic conditionsand community health monitoring. EMS will beintegrated with other health care providers and publichealth and public safety agencies. It will improvecommunity health and result in more appropriateuse of acute health care resources. EMS will remainthe public’s emergency medical safety net.

EXECUTIVE SUMMARY

To realize this vision, the EMS Agenda for theFuture proposes continued development of 14 EMSattributes. They are:

Integration of Health Services

EMS Research

Legislation and Regulation

System Finance

Human Resources

Medical Direction

Education Systems

Public Education

Prevention

Public Access

Communication Systems

Clinical Care

Information Systems

Evaluation

This document serves as guidance for EMSproviders, health care organizations and institu-tions, governmental agencies, and policy makers.They must be committed to improving the healthof their communities and to ensuring that EMSefficiently contributes to that goal. They must investthe resources necessary to provide the nation’spopulation with emergency health care that is re-liably accessible, effective, subject to continuousevaluation, and integrated with the remainder ofthe health system.

The EMS Agenda for the Future provides a visionfor out-of-facility EMS. Achieving such a visionwill require deliberate action and application ofthe knowledge gained during the past 30 year EMSexperience. If pursued conscientiously, it will bean achievement with great benefits for all of society.

EMS Agenda for the Future: Executive Summary

iii

Introduction.................................................................................................................................... 6

Emergency Medical Services Attributes.................................................................................... 11

Integration of Health Services ........................................................................................................... 12

EMS Research.................................................................................................................................... 16

Legislation and Regulation ................................................................................................................ 20

System Finance .................................................................................................................................. 23

Human Resources .............................................................................................................................. 26

Medical Direction .............................................................................................................................. 30

Education Systems ............................................................................................................................. 34

Public Education ................................................................................................................................ 37

Prevention .......................................................................................................................................... 39

Public Access ..................................................................................................................................... 42

Communication Systems ................................................................................................................... 46

Clinical Care ...................................................................................................................................... 49

Information Systems .......................................................................................................................... 52

Evaluation .......................................................................................................................................... 54

Appendix A EMS Historical Perspectives......................................................................................... 57

Appendix B Development of the Agenda........................................................................................... 61

Appendix C Summary of Recommendations...................................................................................... 62

Appendix D Glossary........................................................................................................................... 65

Appendix E List of Abbreviations....................................................................................................... 72

Appendix F References........................................................................................................................ 73

Appendix G Members of the Steering Committee............................................................................. 79

Appendix H Steering Committee Guest Speakers.............................................................................. 80

Appendix I Blue Ribbon Conference Participants........................................................................... 81

CONTENTS

EMS Agenda for the Future: Contents

iv

6

The year is 2009 and it’s a Thursday evening.Joe S. is a 60-year-old male who emigrated fromRussia in 1995 to work for a software company.

He does not speak English very well. He has severalcardiac risk factors including hypertension, elevatedcholesterol, a history of smoking (a pack a week), andhe is 20% overweight. For the past two days he hashad mild, intermittent chest discomfort unrelated toexercise. However, at 11:00 PM,the discomfort suddenlybecomes more severe. Joe’s wife, worried and anxious,instructs their computerized habitat monitor (CHM)to summon medical help. Through voice recognitiontechnology, the CHM analyzes the command, interpretsit as urgent, and establishes a linkage with the appro-priate public safety answering center (PSAC). At thePSAC, a “smart map” identifies and displays the lo-cation of the call. Richard Petrillo, the emergency medicalcommunicator (EMC) notes the type of linkage thathas been established (not a telephone, personal com-municator device, television, or personal computer).He also knows what sort of query can be conductedthrough this linkage. Petrillo commands the PSACcomputer to instruct the CHM to identify the poten-tial patient, report his chief complaint, and provide hismedical database identifiers. In the meantime, the “smartmap” has identified the closest acute care response vehicleand Petrillo instructs the computer to dispatch it. TheCHM provides the requested information and respondingpersonnel are automatically updated via their personaldigital assistants (PDAs). Petrillo accesses the patient’shealth care database, obtaining his current health problemlist, most recent electrocardiogram, current medications,allergies, and primary care physician data. This infor-mation automatically is copied to the respondingpersonnel’s PDAs and to the medical command center(MCC) computer. The PSAC computer also downloadspre-arrival instructions to the CHM which providesthem to Joe’s wife.

Staffing the acute care response vehicle are NancyQuam, Community Health Advanced Medical Practi-tioner (CHAMP) and Ed Perez, Community Health In-termediate Practitioner (CHIP). Nancy became a CHAMPbecause she recognized a declining need for physicians.She was credentialed following a four-year college degreeprogram. Many of her colleagues were previous para-medics and nurses who became credentialed throughcareer-bridging programs. Ed Perez was credentialedas a CHIP after a one-year academic program. He cur-

rently goes to school part-time, on a scholarship, workingtoward becoming a CHAMP. As Quam and Perez proceedtoward Joe’s home, a transponder in their vehicle changesall traffic signals in their favor. Also, digital displaysin all area vehicles are alerted that there is an emer-gency vehicle in their vicinity. The PSAC computerinforms Quam and Perez that neither a personal riskanalysis (PRA) nor a domicile risk analysis (DRA) hasbeen performed in the past five years.

As Quam and Perez arrive at the home, four minutesafter the initial linkage with CHM, they notice sub-standard lighting on the home’s outside walkways andfront-porch steps in need of repair. They also note thata maintenance light is illuminated on the CHM an-nunciator panel. As they greet the patient, they real-ize that he does not speak English well. Perez puts thetranslator module into his PDA, then he speaks to thePDA which translates his voice to Russian. The all-systems monitor is applied to the patient’s arm andacross his chest. Physiologic data is acquired by themonitor’s computer chip, then it is analyzed on the sceneand transmitted via burst technology to the medicalcommand center 100 miles away. By communicatingthrough their PDAs, Quam and Perez are able to ac-quire the patient’s history. Through Quam’s PDA videoscreen, she establishes a video connect with the MCC.The MCC EMS physician requests additional Level IIImonitoring which reveals the patient’s carbon monox-ide level to be 14%.

Analysis of all the data by the MCC computer andEMS physician suggests a 96% probability of acutemyocardial ischemia. Quam and the EMS physicianconfer and the patient subsequently is administered short-acting thrombolytics and IV antioxidants. The near-est cardiac care center that is part of Joe’s health networkis identified and alerted by computer. Joe is transportedthere, even though other hospitals may be closer. Heis examined very briefly in the emergency departmentand taken directly to the cardiac catheterization labo-ratory. There he undergoes complete laser debridementof his coronary arteries. Joe suffers no myocardial en-zyme leak, there is no permanent cardiac damage, andhe is discharged in two days.

Following Quam’s and Perez’s report, a PRA anda DRA are requested. Joe’s health care network con-tracts with their agency to return to the home where

INTRODUCTION

EMS Agenda for the Future: Introduction

7

initial EMS growth spurt began with a lack of knowl-edge about what constituted the most efficient pro-cesses for delivering the ideal resources to thespectrum of situations addressed by today’s EMSsystems.

We are now able to examine what has beenlearned during the past three decades, in order torefine contemporary EMS. This opportunity comesat a time when EMS systems and agencies and in-dividuals responsible for EMS structure, processes,and outcomes are evaluating their roles within arapidly evolving health care system and duringan era of fiscal restraint. Recognizing its need andpotential impact, the National Highway Traffic SafetyAdministration (NHTSA) and the Maternal andChild Health Bureau (MCHB) of the Health Re-sources and Services Administration (HRSA) pro-vided funding to support completion of the EMSAgenda for the Future .


they learn that the family did not completely under-stand the CHM’s operations. Thus, when its carbonmonoxide sensor had failed they were unaware. The healthcare network subsequently offers a matching grant torepair an aging furnace, the CHM, and the other en-vironmental hazards noted by Quam and Perez. In follow-up, it was determined that Joe had been noncompliantwith his previous medication instructions due to lackof understanding. A new caseworker is assigned whoensures that Joe understands his health care instruc-tions and begins to minimize all his risk factors.

Joe lives to 94 years old.

The roots of emergency medical services (EMS)are deep in history. The EMS chronology providesan overview of some important EMS developments(please refer to Appendix A for more detailed his-torical perspectives). During the past 30 years, EMSin the United States has experienced an explosiveevolution. The predisposing factors for such de-velopment have been multifactorial, including anappreciation that better response might improvepatient outcomes for some medical conditions. The

8

EMS Agenda for the Future: EMS Chronology

EMS CHRONOLOGY

1797 Napoleon’s chief physician implements a prehospital system designed to triage and transport theinjured from the field to aid stations

1860s Civilian ambulance services begin in Cincinnati and New York City

1915 First known air medical transport occurs during the retreat of the Serbian army from Albania

1920s First volunteer rescue squads organize in Roanoke, Virginia, and along the New Jersey coast

1958 Dr. Peter Safar demonstrates the efficacy of mouth-to-mouth ventilation

1960 Cardiopulmonary resuscitation (CPR) is shown to be efficacious

1966 The National Academy of Sciences, National Research Council publishes Accidental Death and Disability:The Neglected Disease of Modern Society

1966 Highway Safety Act of 1966 establishes the Emergency Medical Services Program in the Depart-ment of Transportation

1972 Department of Health, Education, and Welfare allocates 16 million dollars to EMS demonstrationprograms in five states

1973 The Robert Wood Johnson Foundation appropriates 15 million dollars to fund 44 EMS projectsin 32 states and Puerto Rico

1973 The Emergency Medical Services Systems (EMSS) Act provides additional federal guidelines andfunding for the development of regional EMS systems; the law establishes 15 components of EMSsystems

1981 The Omnibus Budget Reconciliation Act consolidates EMS funding into state preventive healthand health services block grants, and eliminates funding under the EMSS Act

1984 The EMS for Children program, under the Public Health Act, provides funds for enhancing theEMS system to better serve pediatric patients

1985 National Research Council publishes Injury in America: A Continuing Public Health Problem de-scribing deficiencies in the progress of addressing the problem of accidental death and disability

1988 The National Highway Traffic Safety Administration initiates the Statewide EMS Technical As-sessment program based on ten key components of EMS systems

1990 The Trauma Care Systems and Development Act encourages development of inclusive trauma sys-tems and provides funding to states for trauma system planning, implementation, and evaluation

1993 The Institute of Medicine publishes Emergency Medical Services for Children which points outdeficiencies in our health care system’s ability to address the emergency medical needs of pediatricpatients

1995 Congress does not reauthorize funding under the Trauma Care Systems and Development Act

9


PURPOSEThe purpose of the EMS Agenda for the Future

is to determine the most important directions forfuture EMS development, incorporating input froma broad, multidisciplinary spectrum of EMS stake-holders. This document provides guiding principlesfor the continued evolution of EMS, focusing onout-of-facility aspects of the system.

ASSUMPTIONSImplicit within this document are assumptions

about the nature of the future and the environmentin which EMS will exist. These assumptions are:

EMS represents the intersection of public safety,public health, and health care systems. A com-bination of the principles and resources of eachis employed by EMS systems.

The public expects that EMS will continue. EMSis viewed as a standard, valuable communityresource that must always be in place. The publichas come to expect an EMS response when itis faced with a perceived out-of-facility medi-cal emergency.

EMS will continue to exist in some form. Thecomplexion of EMS is subject to change dramati-cally in some aspects. Nevertheless, continuedexpectations for service by the public and itschosen leaders will ensure that, in some form,EMS will continue to exist and serve the emer-gency medical needs of communities.

EMS will continue to be diverse at the locallevel. Heterogeneity among EMS systems is oftena reflection of the diversity in the communitiesthey serve. Guiding principles are applicable toall EMS systems. However, the methods for ap-plying such principles and the ability to reachspecific process benchmarks will continue to beinfluenced by the nature of communities andthe resources they possess.

As a component of health care systems, EMSwill be influenced significantly by their con-tinuing evolution. The U.S. health care systemis undergoing constant evolution, which seemsmore rapid now than ever. Recent changes haveoccurred in terms of regional systems’ organi-zation and finance. An increasing proportion ofthe U.S. population is participating in health plans

(e.g., managed care) that compel patients to seekspecific medical care providers and place a greateremphasis on prevention and health maintenance.In many cases, both insurers and health care pro-viders have established regional networks (e.g.,managed care organizations) to enhance efficiencyand reduce costs. Such changes will continueto occur and affect EMS health care delivery rolesand logistical considerations.

There currently is a lack of information regard-ing EMS systems and outcomes. Despite manyyears of experience, we continue to lack adequateinformation regarding how EMS systems influ-ence patient outcomes for most medical condi-tions, and how they affect the overall health ofthe communities they serve. Emergency medi-cal services-related research usually has focusedon one disease or operations issue, and oftenis conducted in only one EMS system. The con-clusions drawn may not be valid or applicablein other EMS systems.

It will be necessary to continue to make someEMS system-related decisions on the basis oflimited information. The current relative lackof knowledge regarding system and outcomerelationships sometimes forces necessary de-cisions to be made with insufficient informa-tion. The time and resources required to com-plete the research necessary to produce suchknowledge may be extensive. Therefore, unlessprogress is to be held hostage, in many cases,the need to make decisions will continue toprecede the availability of all the informationthat might affect them.

The media will continue to influence thepublic’s perception of EMS. To date, the mediahas been the primary means for the publicto develop awareness of EMS. Except for thefew community members whom the EMSsystem contacts each year, the bulk of publicperception regarding EMS-related issues willcontinue to be derived from television pro-grams (fictional and documentary) and oc-casional news accounts.

Federal funding/financial resources will be de-creasing. The appropriation of federal fundinghad a significant impact on initial EMS devel-opment. In an era of governmental fiscal restraintit is likely that federal funding for EMS activi-ties will continue to decrease. Financial support

10


for EMS systems will be, to an increasing ex-tent, derived from unfound or undevelopedsources.

To make good decisions, public policy mak-ers must be well-informed about EMS issues.Attempts have been initiated to educate publicpolicy makers regarding important EMS-relatedissues. These efforts will continue, and will

include plans to educate members of the UnitedStates Congress and other federal, state and localofficials able to effect public policy that improvescommunity emergency health care.

11

The health system of today, with its empha-sis on advanced technology and costly acuteinterventions to promote societal health, is

transitioning to focus on the early identificationand modification of risk factors before illness orinjury strikes. This transition will lead to a morecost-effective medical management system andimproved patient outcomes. EMS will mirror and,in many cases, lead this transition.

EMS of the future will be community-basedhealth management that is fully integrated withthe overall health care system. It will have the abilityto identify and modify illness and injury risks,provide acute illness and injury care and follow-up, and contribute to treatment of chronic condi-tions and community health monitoring. This newentity will be developed from redistribution ofexisting health care resources and will be integratedwith other health care providers and public healthand public safety agencies. It will improve com-munity health and result in more appropriate useof acute health care resources. EMS will serve asthe public emergency medical safety net.

The focus of this document is the componentof the EMS system which provides emergency careremote from a health care facility. This health caremission is accomplished utilizing principles of publichealth and public safety systems.

EMS certainly does not exist in isolation, butis integrated with other services and systems in-tended to maintain and enhance community healthand ensure its safety. Therefore, EMS is affectedby changes that occur within those arenas. Oppor-tunities and challenges will be created by inter-acting with those responsible for overall maintenance

of community health, including providers of con-tinuous health care. Currently, the term “managedcare organization” (MCO) describes the combina-tion of insurer and health care provider. Althoughthe future of the term “MCO” is unclear, the conceptof large regional providers and underwriters ofhealth care is becoming more pervasive. Oppor-tunities exist for EMS systems to develop modelrelationships with other components of the healthcare system, while maintaining a commitment topublic safety services to improve community health.

Emergency medical services have and willcontinue to raise the standards for community healthcare by implementing innovative techniques andsystems to deliver the emergency care that is neededby the entire population. The following sectionsfocus on important EMS attributes, and providedirection and guiding principles for future EMSdevelopment that will facilitate EMS systems’abilities to fulfill their health care mission.

The EMS Agenda for the Future presents a per-spective from a single point in time. As the en-vironment in which EMS exists is dynamic, thisdocument is intended to serve as a guiding ref-erence only until the next periodic re-evaluationof EMS issues. Planning for such evaluation shouldcommence as implementation of the Agenda is con-templated.

Discussion of EMS attributes in any particularsequence, as in the text of this document, is nota statement regarding their relative importance.The vignettes of the future in each section are in-tended to be illustrative and thought-provoking.They are not meant to advocate specific actionsor terminology.

EMERGENCY MEDICAL SERVICES ATTRIBUTES

EMS Agenda for the Future: Attributes

12

Integration of health care services helps to en-sure that the care provided by EMS does notoccur in isolation, and that positive effects are

enhanced by linkage with other community healthresources and integration within the health caresystem.

EMS provides out-of-facility medical care to thosewith perceived urgent needs. It is a component ofthe overall health care system. EMSdelivers treatment as part of, orin combination with, systematicapproaches intended to attenuatemorbidity and mortality for spe-cific patient subpopulations.

The future: Ella is 78 years old,and she trips and falls in her livingroom. Although initially she is unableto get herself up, she summons EMSvia a voice recognition habitat moni-tor. The EMS providers do not findserious injuries, but suspect an anklesprain. They schedule an appoint-ment for Ella later that day with herprimary care source, via a palm-sizecomputer. They also are able to re-quest transportation for her after con-sultation with the medical commandcenter. While at Ella’s, the EMS providers note thather home is oppressively hot due to a malfunctioningair conditioner, and that there are numerous risk factorsfor future falls. Using their computer, they arrangefor social services to follow-up, they notify her pri-mary care provider, notify her building maintenancesupervisor, and they schedule an EMS return visitto check on progress. Ella avoids an emergency de-partment visit, is treated for her ankle sprain, andshe receives attention that reduces her numerous riskfactors for future health problems.

WHERE WE AREAs a component of the health care delivery

system, EMS addresses all possible injuries andillnesses, and treats all ages. It is a component of,and is also comprised by, systems intended to pro-vide care for specific diseases and population seg-ments.

Contemporary EMS systems were created to meetthe immediate needs of the acutely ill and injured;to provide “stabilization” and transportation. EMS,in general, meets these objectives in relative iso-lation from other health care and communityresources. Reports have been published regardingpublic health surveillance by EMS personnel andreferral to social services agencies.50,51,69 However,

most EMS systems are discon-nected from other community re-sources, except perhaps otherpublic safety agencies, and are notinvolved in the business of ensur-ing follow-up by social serviceagencies or other communityagencies/resources potentiallyable to intervene when patientsneed support. Thus, the potentialpositive effects of EMS, in termsof improved health for individualpatients and the community, re-main unrealized.

EMS providers, in general, donot provide or ensure medical fol-low-up for patients who are nottransported. Failure to obtain suchcare in a timely fashion may bean issue responsible for subop-

timal patient outcomes and litigation involvingEMS systems and personnel. Lack of integrationwith other health care providers limits the abilityof EMS to coordinate aftercare for its patients.

Except for familiarity with medical directionfacilities and emergency departments, EMS per-sonnel in general, do not have substantial work-ing knowledge of the practices of other communityhealth care providers and the policies of regionalhealth care organizations. Thus, they are unableto integrate their care with sources for patients’continuing health care.

A model for incorporating EMS systems andhealth monitoring referral systems has been de-scribed.61 Some EMS systems are conducting pilotprojects to determine the benefits of collaborationand routine communication with patients’ healthcare providers, organizations and networks. Other

INTEGRATION OF HEALTH SERVICES

EMS Agenda for the Future: Integration of Health Services

“Out-of-facility care isan integral component ofthe health care system.EMS focuses on out-of-fa-cility care and also sup-ports efforts to implementcost-effective communityhealth care. By integrat-ing with other healthsystem components EMSimproves health care forthe entire community, in-cluding children, the eld-erly, and others withspecial needs.”

Alasdair K.T. Conn, MD

13

projects are exploring an expanded role for EMSregarding the clinical care it provides.115

WHERE WE WANT TO BEFor its patients and the community as a whole,

EMS provides care and service that is integratedwith other health care providers and communityhealth resources. Thus, EMS patients are assuredthat their care is considered part of a complete healthcare program, connected to sources for continu-ous and/or follow-up care, and linked to otherpotentially beneficial health resources.

Out-of-facility care is considered to be an integralcomponent of the health care system. The attributesor elements of out-of-facility care are shared bythe other health care components. Each EMS at-tribute applies to all groups of potential EMSpatients, addressing the needs of all communitymembers. Furthermore, the borders among patientgroups, system attributes, and health care compo-nents are not discrete and are shared (Figure 1).

EMS focuses on out-of-facility care and, at thesame time, it supports efforts to implement cost-effective community health care. Out-of-facility careis a component of the comprehensive health caresystem, and EMS shares structural and process el-ements common to all health care system compo-nents. 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 or-ganizations, health care provider networks, com-munity health educators, and others. This enablesEMS to be proactive in affecting people’s long-termhealth by relaying information regarding poten-tially unhealthy situations (e.g., potential for in-jury), 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; ad-ditional multiple dispositions are available followingpatient evaluation by EMS personnel. EMS is a com-munity health 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 pro-viders, including health care provider organiza-

tions and networks, and primary care physicians.As a health care provider, EMS, with medical di-rection, facilitates access for its patients to appro-priate sources 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 continu-ing health care.

EMS integrates with other health system com-ponents to improve its care for the entire commu-nity, 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 pa-tients are addressed adequately.

Efforts to improve EMS care for specific seg-ments of the population recognize the need for,and advocate implementation of, system enhance-ments that benefit the entire population. These effortsoften include attention to functional system de-sign, health care personnel education, and equip-ment and facility resources.

HOW TO GET THEREEMS must expand its public health role and

develop ongoing relationships with community pub-lic health and social services resources. Such re-lationships should 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. Re-ports of the effectiveness of these relationshipsshould be disseminated.

EMS must become involved in the business ofcommunity health monitoring, including partici-pation in data collection and transmittal to appro-priate community 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 or-ganizations and networks. Integration should benefitpatients by enhancing and maintaining the con-tinuum of care. Communications systems, includingconfidential transmittal of patient-related data,should be developed. These should explore the utilityof continuing communications technological ad-


14


15


INTEGRATION OF HEALTH SERVICES:

• Expand the role of EMS in public health

• Involve EMS in community health monitoringactivities

• Integrate EMS with other health care provid-ers and provider networks

• Incorporate EMS within health care networks’structure to deliver quality care

• Be cognizant of the special needs of the entirepopulation

• Incorporate health systems within EMS that ad-dress the special needs of all segments of thepopulation

vances. Mutually acceptable clinical guidelines re-garding patient 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 striv-ing to optimally meet these needs. An EMS phy-sician, 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 seg-ments served (e.g., pediatric, geriatric, medicaldevice-dependent; and other patients in urban, sub-urban, rural, and frontier areas). Such systems orplans should include education, system design, andresource components. They must be developed with

input 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 con-tinue to identify issues of interest to policy mak-ers to address specific aspects of EMS, and improvethe system as a whole. Attention paid to EMS com-ponents should 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 de-livered by 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-effec-tiveness. They must also include logistical evalu-ations such as the ongoing capabilities of EMS torespond to critical emergencies (e.g., cardiac ar-rests). These studies must precede widespread adop-tion of such practices and results should bedisseminated and subjected to scrutiny.

16

Research involves pursuit of the truth. In EMS,its purpose is to determine the efficacy, ef-fectiveness, and efficiency of emergency

medical care. Ultimately, it is an effort to improvecare and allocation of resources.

The future: A new pharmacologic agent becomesavailable and might potentially decrease the morbid-ity of 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 par-ticipating EMS systems about con-trol patients 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 accord-ingly.

WHERE WE AREEMS has evolved rapidly over the past 30 years

despite 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 com-plexities of EMS systems.119 With few exceptions,

there has been little emphasis on systems analy-sis. Development of the “chain of survival” con-cept for cardiac emergencies provides the bestevidence of completed systems research.22,94 Trauma-related research comprises the only other EMS re-search emphasis.119 However, study methods havenot been as extensively developed, and experimentaldesigns often limit abilities to compare studies and

reach meaningful conclusions.65

Other clinical conditions have notbeen scientifically studied with asystems approach. Component-based analyses often lead to con-clusions that are incorrect, or atleast cannot be supported, whenthey are considered in the contextof the entire EMS system.119,120

Thus, in many cases, our poorunderstanding of systems researchmodels has led to the developmentof wrong assumptions with regardto EMS care.

Currently there are five majorimpediments to the development of quality EMSresearch:

inadequate funding

lack of integrated information systems thatprovide for meaningful linkage with patient out-comes

paucity of academic research institutions withlong-term commitments to EMS systems research

overly restrictive informed consent interpreta-tions

lack of education and appreciation by EMS per-sonnel regarding 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 to

EMS Agenda for the Future: EMS Research

“The future of EMS isindelibly linked to thefuture of EMS research.This reality provides EMSwith its greatest opportu-nities, its greatest risks,and its greatest single needto depart from the waysof the past. EMS mustgrasp this quickly closingwindow of opportunity.”

Daniel W. Spaite, MD

EMS RESEARCH

17

determine EMS effectiveness, is difficult and in-frequently accomplished.

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-related investigations. Additional support oftenis sought from private and corporate interests.However, funding frequently is directed only towardcomponent-based studies. Overall, financial sup-port for EMS-related research is inadequate toaddress the many systems issues requiring study.

Overly restrictive informed consent interpre-tations create additional barriers to conducting EMSresearch. They do not consider the clinical and en-vironmental circumstances of field EMS investi-gations, 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 understand-ing and 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 interven-tions is based on in-hospital studies, and not onscientific investigation of their out-of-hospitaleffectiveness. The effectiveness of most EMS in-terventions and of EMS systems, in general, hasnot been well established with outcome criteria.35

Furthermore, the outcome criterion most studiedis death, which, although important, is not per-tinent to most EMS clinical situations.35,45

WHERE WE WANT TO BEThe essential nature of quality EMS research

is recognized. A sufficient volume of quality re-search is undertaken to determine the effective-ness of 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 sys-tem designs are determined. This includes the iden-tification of patients who are appropriate fortransport, and evaluation of the effects of alter-native dispositions 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 com-mitted to EMS-related research. NIH participatesin setting a national agenda and provides EMS-related research funding.

Integrated information systems provide link-ages between EMS and other public safety servicesand health care providers. They facilitate the datacollection necessary to determine EMS effective-ness.

Several academic centers have long-term com-mitments to EMS research. They serve as a nucleusof activity that involves many EMS systems withdifferent characteristics and all personnel levels,including field providers, managers, administra-tors, nurses, and physicians.

Informed consent rules account for the clini-cal and environmental circumstances of EMS re-search. 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 cre-ating a scientific basis for EMS patient care. Allindividuals with some responsibility for EMS struc-ture, process, and/or outcomes are involved, tosome extent, with EMS research.

EMS research examines multiple outcome cri-teria. Thus, it is pertinent to most EMS clinical situ-ations, which do not involve a likelihood of death.


18

HOW TO GET THEREPublic and private organizations responsible for

EMS structures, processes, and/or outcomes mustcollaborate to establish a national EMS researchagenda. They should determine general researchgoals and assist with development of research fund-ing sources.

The major impediments to EMS research mustbe 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 pro-viding research funding.

Integrated information systems must be devel-oped to 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-related research. They should support EMS-interested faculty members, collaborate with EMSsystems, and involve EMS personnel of all lev-els in conducting credible systems research.

The Department of Health and Human Servicesand the Food and Drug Administration must con-tinue to revise their interpretations of informedconsent rules so that they enable credible resus-citation and other out-of-facility research to beconducted. Informed consent interpretationsshould account for the clinical and environmentalcircumstances inherent in conducting EMS re-search.

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 de-velopment of well-trained EMS researchers mustbe an integral component of the EMS subspecialty,just as it is in other subspecialties. Those with sub-specialty credentials 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 assis-tance. They should be involved in promoting publichealth services research, and facilitating the de-velopment of relationships and resources neces-sary for such studies.

EMS Agenda for the Future: IEMS Research

19

EMS RESEARCH:

Allocate federal and state funds for a major EMSsystems research thrust

Develop information systems that provide linkagebetween various public safety services and otherhealth care providers

Develop academic institutional commitments toEMS-related research

Interpret informed consent rules to allow forthe clinical and environmental circumstancesinherent in conducting credible EMS research

Develop involvement and/or support of EMSresearch by all those responsible for EMS struc-ture, processes, and/or outcomes

Designate EMS as a physician subspecialty, anda subspecialty for other health professions

Include research related objectives in theeducation processes of EMS providers andmanagers

Enhance the quality of published EMS research

Develop collaborative relationships between EMSsystems, medical schools, other academic insti-tutions, and private foundations


20

Issues relating to legislation, and its resultingregulations, are central to the provision of EMSin the public’s behalf. Legislation and regula-

tions affect EMS funding, system designs, re-search, and EMS personnel credentialing andscope of practice.

The future: In the town of Gaston, out-of-fa-cil ity emergency 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 neighbor-ing local EMS systems to provideGaston with qual ity EMS. Theagency then works with Gastoncommunity leaders to develop along-term solution. During the in-terim period, when Medstat wouldhave otherwise ceased to operatein Gaston and temporary arrange-ments were in i t ia t ed , Medsta tEMS personnel were able to re-suscitate a three-year-old near-drowning victim due, in part, totheir rapid response to the scene.

WHERE WE AREAll states have legislation that

provides 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 com-ponents or 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 agency

is mandated by law, sufficiently funded and cred-ible, and is recognized by thehealth care and public safetysystems. It directs nationwide EMSdevelopment, provides coordina-tion among federal programs/agencies affecting EMS, serves asa central source for federal EMS-related research and infrastructurecreation funding, provides an in-formation clearinghouse function,and oversees development ofnational guidelines.

All states have a single EMSlead agency, established in law,responsible for developing andoverseeing a statewide EMS sys-tem. Each state’s agency is ad-equately funded to ensure its

effectiveness. Lead agency enabling legislation al-lows flexibility; 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 edu-cator. This helps ensure that statewide EMS sys-tem development continues, that its developmentand oversight are efficient, and that EMS of ac-ceptable quality is available to the entire popu-lation.

State legislation provides a broad template thatallows local medical directors to determine thespecific parameters of practice for their EMS sys-tems and to conduct credible research and pilot

LEGISLATION AND REGULATION

EMS Agenda for the Future: Legislation and Regulation

“Injuries and illnesses re-quiring an EMS response rep-resent a public healthproblem that can only beaddressed through the com-bined efforts of all levels ofgovernment and private or-ganizations. Governmentmust maintain its traditionalrole of assuring the existenceof an EMS safety net, andat the same time partner withothers to build new modelsfor improving EMS.”

Dan Manz

21

projects. This ensures substantial uniformity withinstates, but provides the degree of flexibility nec-essary to ensure that EMS systems, given their re-sources, are able to optimally meet the health careneeds of their communities. Justification for practiceparameters are required, as is maintaining mini-mum quality 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 indi-vidual systems. They facilitate credible EMS re-search and innovative pilot projects. Lead agenciesrely, to an increased extent, on national certifyingand accrediting bodies to ensure adequate qual-ity of some EMS system components, thus enablingenhancement of their roles as facilitators.

State and local EMS lead agencies have the au-thority and means to ensure the reliable availabilityof EMS to the entire population. Such authorityis exercised to act on the public’s behalf when even-tualities occur, such as potential changes in the healthcare system or EMS structural or financial circum-stances, and threaten its quality or availability tothe entire population.

HOW TO GET THERECollectively, those responsible for EMS must

convince legislators in the U.S. Congress to authorizeand sufficiently fund a lead federal EMS agency.This agency should be health care based and cred-ible to public safety interests, responsible for co-ordinating all federal initiatives for national EMSdevelopment, overseeing development of nationalguidelines, and serving as a national EMS clear-inghouse.

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 respon-sible for developing and maintaining a compre-hensive statewide EMS system.

State EMS agencies must enhance their abili-ties to provide facilitation and technical assistanceto local EMS systems. Although states may retainresponsibility for licensing, they should increasereliance on available national resources for certifi-cation and accreditation of EMS providers and someEMS system components.

Each state must establish and fund the posi-tion of 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 autho-rized to act on the public’s behalf in cases of threatsto the availability of quality EMS to the entire popu-lation. 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 pro-tection from liability for EMS field and medicaldirection personnel when dealing with unexpectedand/or unusual situations falling outside the realmof current protocols. These should include provi-sions for in-depth review of such cases, and notalter liability for grossly negligent conduct.


22

Authorize and sufficiently fund a lead federalEMS agency

Pass and periodically review EMS enabling leg-islation in all states that supports innovationand integration, and establishes and sufficientlyfunds an EMS lead agency

Enhance the abilities of state EMS lead agen-cies to provide technical assistance

Establish and fund the position of State EMSMedical Director in each state

Authorize state and local EMS lead agencies toact on the public’s behalf in cases of threats tothe availability of quality EMS to the entirepopulation

Implement laws that provide protection fromliability for EMS field and medical directionpersonnel when dealing with unusual situations

LEGISLATION AND REGULATION:


23

Emergency medical services systems, simi-lar to all public and private organizations,must be financially viable. In an environ-

ment of constant economic flux, it is critical to con-tinuously strive 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 re-lationships with 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 mem-bers to efficient health care.

WHERE WE AREProviding the nation with EMS

is a multibillion dollar effort eachyear. While all the costs are notexactly known, Hawaii’s EMS sys-tem provides a basis for estima-tion. Out-of-facility EMS in Hawaiiis completely state-funded. The annual cost of EMSfor the state’s 1.2 million residents is $32,460,605.76

This includes funding for training, communica-tions, 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. popu-lation (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 ac-quisition and maintenance, personnel training andcontinuing education, first response and ambulanceoperations, medical direction, and licensing and

regulation 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 compo-nents and 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 ar-eas. Additionally, many statesfund EMS development fromspecific revenue sources, such asvehicle or driver licensing, mo-tor vehicle violations, and othertaxes.128

Subscription programs allowthe public to pre-purchase EMSsystem services in one of twoforms. A subscription, depend-

ing on the program, is a contract to provide EMSwithout additional charges to the consumer, orfixes the price and pre-pays any potential insur-ance deductible. 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 com-panies, private paying patients, and special ser-vice contracts.125 Of these, Medicare, Medicaid,and private insurance company revenues are prob-ably the most important. Rates of payment, ingeneral, are based on customary charges and theprevailing charge in the area. However, rules varysignificantly among insurance carriers, and pay-ment can be affected by what neighboring sys-tems charge.

Those EMS systems relying on third party payorsfor significant revenue must, in general, provide

EMS Agenda for the Future: System Finance

SYSTEM FINANCE

“The future of EMS isindivisibly linked to howit is funded. In order tooptimize the positive in-fluence of EMS on commu-nity health we must moveto a system of finance thatis proactive, accounting forthe costs of emergencysafety net preparednessand aligning EMS finan-cial incentives with the re-mainder of the health caresystem.”

David R. Miller

24

transportation in order to charge for their services.In other words, if the EMS system provides treat-ment, but does not actually transport a person toa hospital, third party payors are not obliged topay for the service provided. Furthermore, pay-ment is 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 pay-ment policies, decreasing the percentage of trans-ports per patient assessed or treated results indecreased EMS system revenue, reduced operat-ing margin, and impaired ability to shift costs.

The primary determinants of EMS cost relateto system preparedness, or the cost of maintain-ing the 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 provid-ers stipulate to their subscriber patients that au-thorization must 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. Further-more, regional health care providers (e.g., man-aged care organizations) frequently require theirpatients to seek care at specific facilities. EMS sys-tems are then requested to provide transport tolocations that are not always geographically con-venient. 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 health

care delivery system, and provides health careservices, it is consistently funded by mechanismsthat fund other aspects of the system. These mecha-

nisms are proactive and recognize the value of treat-ment that is provided without transport. Trans-port is not a prerequisite for funding. Payment forEMS is preparedness-based (i.e., the cost of main-taining a suitable state of readiness), and dependson service area size and complexity, utilization,and pre-determined quality standards (i.e., staff-ing, level of care, response time, and others). Thisprovides EMS with financial incentives that en-courage, as appropriate, provision and/or direc-tion of 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 facili-tated by regional, state, and federal governments.Sufficient funds are allocated to ensure EMS pre-paredness, including its first response functions.

HOW TO GET THEREEMS systems must continually determine and

improve their cost-effectiveness and evaluate trendswithin the health care system as a whole. Evalu-ations should enable optimization of financial re-sources to provide improved care.

EMS systems must develop proactive relation-ships with health care insurers and other provid-ers. 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 pa-tients who believe that a medical emergency exists.They must recognize an emergency medical con-


25

based or 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 devel-opment, EMS evaluation and research, and pilotproject implementation.


SYSTEM FINANCE:

• Collaborate with other health care providers andinsurers to enhance patient care efficiency

• Develop proactive financial relationships betweenEMS, other health care providers, and healthcare insurers/provider organizations

• Compensate EMS on the basis of a prepared-ness-based model, reducing volume-related in-centives and realizing the cost of an emergencysafety net

• Provide immediate access to EMS for emergencymedical conditions

• Address EMS relevant issues within governmen-tal health care finance policy

• Commit local, state, and federal attention andfunds to continued EMS infrastructure

dition as a medical condition, with a sudden onset,that manifests itself by symptoms of sufficient se-verity, 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-

26

The task of providing quality EMS care re-quires qualified, competent, and compas-sionate people. The human resource, com-

prised of a dedicated team of individuals with com-plimentary skills and expertise, is the most valuableasset to EMS patients.

The future: Hannah is a paramedic in the north-east U.S. She becomes interested in a new position ina Georgia city. The new position, para-medic-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 cre-dential checks, is authorized byGeorgia’s lead EMS agency to workthere. Her new employer verifies clini-cal competency through medical di-rection and 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 backgrounds

contribute to the efficient operations of EMS sys-tems. 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, administra-tive personnel, and others. Among local EMS sys-tems, 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.66

Across the country, more than 40 different levelsof EMT certification exist. However, the National

EMS Education and Practice Blueprint has estab-lished standard knowledge and practice expecta-tions for 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 back-grounds. They serve more than 25% of the popu-lation. The economic value of their contribution

is immeasurable.79 However, formany possible reasons, the num-ber of EMS volunteer organizationsis decreasing.40

Nurses continue to be involvedin EMS systems in educational, ad-ministrative, and care deliverycapacities. The most frequentlyemployed crew configurations forair medical services include at leastone nurse.124 Nursing educationregarding out-of-facility emer-gency care is variable. However,many nurses engaged in out-of-facility EMS patient care activi-ties also are certified as EMTs atsome level.1 Several states have

created curricula specifically for the purpose ofeducating, and thus credentialing, nurses who wishto be EMS field providers. Additionally, the Emer-gency Nurses Association has developed nationalstandard guidelines for prehospital nursing cur-ricula.106

Many other groups of health care workers alsocollaborate to effect the patient care provided byEMS. They include physicians (emergency physi-cians, 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, sys-tem planning, evaluation, research and/or directprovision of care.

Perennial EMS personnel-related issues includethe difficulties of recruitment and retention. Oc-cupational risks, often limited mobility (e.g., cre-dential reciprocity), suboptimal recognition, andinadequate compensation contribute to these prob-

HUMAN RESOURCES

“Regardless of how in-tegration with otherhealth care services andincreased use of advancedtechnology changes thepicture of EMS, human re-sources remain our mostprecious commodity.Without effective “care”of our human resources,this exercise becomes aca-demic.”

John L. Chew

EMS Agenda for the Future: Human Resources

27

lems. 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 de-scribing systematic approaches intended to fur-ther understand 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 signifi-cant risk 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 hepa-titis B virus seroprevalance rate among EMSpersonnel is 14%, which is 3-5 times higher thanthe general population.80 Furthermore, the wide-spread resurgence of tuberculosis poses an addi-tional threat of serious occupation related infectionto EMS workers.42

Other 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 fre-quent mechanisms of injury include lifting, fall-ing, assaults, and motor vehicle crashes.49,60,111

EMS workers often suffer from lack of fullrecognition as members of the health care deliv-ery system. 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. Barri-ers also exist between regions in some states. Fur-thermore, 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 physi-cian in specific circumstances and as part of anair medical transport team.9,54,112 However, evalu-ations of other desirable personnel attributes, interms of numbers and combined levels of edu-

cation and experience to provide specific services/interventions, have not been systematically per-formed and reported.

WHERE WE WANT TO BEPeople attracted to EMS service are among

society’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 exper-tise in meaningful ways.

Standard categories of EMS providers are rec-ognized on 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 stan-dard categories of EMS providers eliminates un-reasonable barriers to mobility. This enhances careeroptions for EMS workers and their ability to re-locate whether 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 com-municable diseases, appropriate protective cloth-ing and 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 popu-lation served. Preparation includes physical re-sources, adequate personnel resources, and requisiteknowledge and skills. This helps ensure that thequality of care provided meets an acceptable com-munity standard.


28

EMS personnel are readily recognized as mem-bers of the health care delivery team. This is con-gruent with 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 phy-sicians, nurses, administrators, and others whosepractices involve EMS. Recognition of special com-petency helps 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 appro-priately educated and distributed within EMSsystems so that they are able to deliver optimalcare to the population.

HOW TO GET THEREAdequate preparation, in terms of both knowl-

edge and 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 knowl-edge and 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 ex-pertise and 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 ad-vantage of 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 stud-ies, national database, and others). Such studiesmust be designed to yield an improved understand-ing of occupational hazards for EMS workers andstrategies for minimizing them.

EMS systems must become affiliated with orimplement a system for critical incident stress man-agement. 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 profes-sionals with an EMS focus. This will facilitaterecognition of health care professionals with spe-cial competency in EMS.


29

HUMAN RESOURCES:

• Ensure that alterations in expectations of EMSpersonnel to provide health care services arepreceded by adequate preparation

• Adopt the principles of the National EMS Edu-cation and Practice Blueprint

• Develop a system for reciprocity of EMS pro-vider credentials

• Develop collaborative relationships between EMSsystems and academic institutions

• Conduct EMS occupational health research

• Provide a system for critical incident stressmanagement


30

Medical direction involves granting author-ity and accepting responsibility for thecare provided by EMS, and includes par-

ticipation in all aspects of EMS to ensure main-tenance of 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-based medical 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 pa-rameters. The medical direction staffand other physicians are formallyconsulted, and justif ication 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 com-munication between field person-nel 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 manage-

ment components, 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, pro-tocol development), contemporaneous, and retro-spective.

In most states, medical direction of EMS sys-tems that provide advanced levels of care is man-dated by law. Many basic level EMS systems (i.e.,

those without EMT-Intermediates or EMT-Para-medics) do not maintain continuous medical di-rection, 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.34

In many states, the majority of on-line medi-cal direction, referring to themoment-to-moment contempo-raneous medical supervision ofEMS personnel caring for pa-tients in 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 desig-nated hospitals or other healthcare facilities. Some areas uti-lize staff other than physicians,such as mobile intensive carenurses (MICN) to communicatewith field EMS personnel andaffect patient management.

Although on-line medicaldirection may be important for

selected patients, its systematic application for themajority of EMS patients remains controversial.Several investigators have examined the issue ofprolonged out-of-hospital times when radio con-tact with a physician was required.36,52,62,100 Theresults have been mixed. However, linkage to ob-jective, 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 communica-tion is nevertheless felt to be helpful by EMS per-sonnel.36,59,131,142

Medical direction activities that do not involvecontemporaneous direction of EMS personnel inthe field include development and timely revisionof protocols and medical standing orders, imple-mentation and maintenance of quality improve-ment systems, personnel education, development

EMS Agenda for the Future: Medical Direction

MEDICAL DIRECTION

“Medical direction bringsto EMS all the traditions ofpatient care, research and life-long learning inherent in Medi-cine. The ethical foundationof medical practice must bethe foundation for providingmedical care in the streets.Medical directors are made,not born. ‘Making’ them is notalways easy; programs forthem must reflect field prob-lems and field resources, andin a planned way should takeplace under conditions in thestreet.”

Ronald D. Stewart, OC, MD

31

and monitoring 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 authori-ties and other oversight agencies or boards ofteninclude other physicians (emergency physicians,pediatricians, surgeons, internists, family practi-tioners, and others), nurses and nurse practitio-ners, 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 medi-cal leadership for EMS. Those who serve as medi-cal directors 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 commu-nity physicians to ensure that their patients’ is-sues and 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 par-ticipate in 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 sub-specialty certification 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 medi-cal care providers change, hospitals’ incentives forengaging in EMS medical direction are diminish-ing. 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 ben-

efit of qualified medical direction. This is true re-gardless of the level of service provided, and helpsensure that EMS is delivering appropriate and qual-ity health 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 medi-cal direction, and the effects of various personnelproviding it. This helps ensure that on-line medi-cal direction 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 certifica-tion for physicians, nurses and administrators. Thishelps ensure that medical direction, which ultimatelyaffects the care provided to patients in the com-munity, is provided by knowledgeable and quali-fied individuals.

Every state has a state EMS Medical Directorwho is an EMS physician. This helps ensure ap-propriate medical direction for states’ EMS sys-tems. 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 size


32

of 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 re-sources is included with those of system prepared-ness.

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 direc-tor and other medical direction personnel ensurethat EMS providers are prepared, in terms of edu-cation and skills, to deliver the system’s patientcare.

Medical direction provides leadership for EMSsystems and personnel. The medical director en-sures collaboration 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 knowl-edge of the complexities of EMS, the spectrum ofissues related to population-based care, the occu-pational health concerns of EMS personnel, the op-timal care for the spectrum of EMS patients, andthe principles of clinical research.

HOW TO GET THEREEMS provider agencies, of all levels of sophis-

tication, 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 direc-tion is 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 di-rection and specific characteristics of local EMSsystems.

EMS physicians and researchers must conductinvestigations of adequate quality to elucidate theeffects of on-line medical direction. Effects stud-ied should address objective, relevant patient out-comes and systems costs.

Interested organizations must continue theirwork to develop the basis for EMS as a physiciansubspecialty. Such work should include encour-agement of institutions to develop resources nec-essary to implement EMS fellowships, so that thenumber of qualified EMS physicians will grow.

EMS authorities and systems should designatea physician(s) responsible for overall medical di-rection within the jurisdiction. Such an appoint-ment should be made with the intent of facilitatinguniformity of medical oversight policies and prac-tices throughout the jurisdiction. Additionally,medical director(s) should be charged with the re-sponsibility of, 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 sys-tem that is based on sound medical practice.


33

Formalize relationships between all EMS sys-tems and medical directors

Appropriate sufficient resources for EMS medicaldirection

Require appropriate credentials for all those whoprovide on-line medical direction

Develop collaborative relationships between EMSsystems and academic institutions

Develop EMS as a physician and nurse subspe-cialty certification

Appoint state EMS medical directors

MEDICAL DIRECTION:


34

As EMS care continues to evolve and becomemore sophisticated, the need for high qualityeducation for EMS personnel increases. Edu-

cation programs must meet the needs of new pro-viders and of seasoned professionals, who havea need to maintain skills and familiarity with ad-vancing technology 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 re-ceived academic credit for his one-year paramedic program, whichhe completed two years ago. Cur-rently, he has a partial scholar-ship and is pursuing a degree incommunity health, which willqual i fy him as a CommunityHealth Advanced Medical Prac-titioner, and result in his abilityto assume a new position (withhigher compensation) within theEMS system.

Many of his classmates havesimilar experiences. Some arenurses and other health profession-als transitioning to out-of-facility positions.

WHERE WE ARECurrently, EMS education programs primarily

prepare 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 varia-tion among states and local jurisdictions impedesefforts to develop agreements for credentialing reci-procity. The National Registry of Emergency MedicalTechnicians (NREMT) offers certification exami-nations for First Responder, EMT-Basic, EMT-In-

termediate, and Paramedic levels, which are ac-cepted by many states as evidence of competency.

Settings for EMS education include hospitals,community colleges, universities, technical centers,private institutions, and fire departments.130 Pro-gram quality and improvement efforts can beachieved in all settings. Ninety-four paramediceducation programs currently are accredited by the

Joint 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 Transpor-tation (DOT) provide the basesfor education of first respond-ers, EMT-Basics, EMT-Interme-diates, and EMT-Paramedics.Education of military EMS per-sonnel also follows these cur-ricula, and they often mayprovide a resource pool for ci-vilian EMS systems.

Standardized brief educational programs, withspecific objectives that address treatment of seg-ments of 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 edu-cation plans. Many reports discuss education ofEMS providers to perform specific skills.6, 16, 43, 70,

71, 102, 133, 140, 141 However, there have not been sys-tematic analyses of the suitability of EMS educa-tion with regard to expectations for EMS personnelto provide a spectrum of public safety and healthcare services. Additionally, issues related to knowl-edge and skill degradation have not been addressedextensively. While some EMS providers seek fur-ther educational opportunities, others, for variousreasons, do not wish to do so.130

“Education systems of thefuture will make maximum useof technology to reach studentsin outlying areas and those whootherwise have difficulty reach-ing traditional classrooms.Textbooks will seldom be madeof paper; videos, satellite tele-vision, and computer linkagesand programs will provide thebulk of study materials. Edu-cational bridge programs willmake it easier to advance one’sknowledge without repeatingprevious classroom and prac-tical experiences.”

E. Marie Wilson, RN, MPA

EDUCATION SYSTEMS

EMS Agenda for the Future: Education Systems

35

WHERE WE WANT TO BEEMS education employs sound educational

principles and sets up a program of lifelong learningfor EMS professionals. It provides the tools nec-essary for 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 cir-cumstances (e.g., wilderness rescue). They providenational direction and standardization of educa-tion curricula, which facilitates recognition bycredentialing agencies while allowing adequate op-portunity for customization as indicated by localnecessity.

Higher level EMS education programs areaffiliated with academic institutions. EMS educa-tion that is academically-based facilitates furtherdevelopment of EMS as a professional discipline.It increases the availability of educational oppor-tunities that acknowledge previous EMS educa-tional/academic achievements, provides moreacademic degree opportunities for EMS personnel,augments the management skills among EMS pro-fessionals, and protects the value of personal andsocietal resources invested in education.

Interdisciplinary and bridging programs pro-vide avenues 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 edu-cation programs, and assist them to strengthen theacademic basis of EMS education.

HOW TO GET THEREAny change in the vision of EMS should prompt

an 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 accord-ingly.

EMS education researchers must investigatecurricula adequacy and alternative education tech-niques. 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 dis-seminated.

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 incor-porate learning 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 manage-ment should be included.

All EMS education must be conducted with thebenefit of qualified medical direction. The physi-cian medical director(s) should be involved ineducation program planning, presentation, andevaluation, including evaluation of faculty, andparticipants.

The federal EMS lead agency should commis-sion the 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 accredi-tation by a nationally recognized accrediting agency.Accreditations should be sought to demonstratethat the educational programs provided meet a pre-defined national standard of quality.

Public funds for education should be directedpreferentially toward EMS education programs that


36

are 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 insti-tutions should develop innovative solutions thataddress cultural variation, rural circumstances, andtravel and time constraints. These should include

programs 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 per-sonnel the ability to transition to out-of-hospitalEMS roles.


EDUCATION SYSTEMS:

Ensure adequacy of EMS education programs

Update education core content objectives fre-quently enough so that they reflect patient EMShealth care needs

Incorporate research, quality improvement, andmanagement learning objectives in higher levelEMS education

Commission the development of national corecontents to replace EMS program curricula

Conduct EMS education with medical direction

Seek accreditation for EMS education programs

Establish innovative and collaborative relation-ships between EMS education programs and aca-demic institutions

Recognize EMS education as an academic achieve-ment

Develop bridging and transition programs

Include EMS-related objectives in all healthprofessions’ education

37

Public education, as a component of healthpromotion, is a responsibility of every healthcare provider and institution. It is an effort

to 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 respond-ing to an emergency call, but “on-scene” to brief kids about bicyclesafety. At the end of the program eachchild receives a family safety check-list . Once completed with theirparents, it is redeemable for food anddrinks at the pool snack bar. Chil-dren also 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 every

EMS system. Yet, as a tool for providing public edu-cation, EMS is woefully underdeveloped. A greatdeal of what the public knows about its EMS sys-tem and about dealing with medical emergenciesoriginates from the media, including television pro-grams intended for entertainment and not educa-tion. 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 devel-opment of knowledge, skills, and motivation thatlead to reduction of behavioral risks and more activeinvolvement of people in community affairs. This

includes greater participation in effecting healthand social policy and advocacy for improved healthsystems.53

Public education is often a focus of other publicsafety divisions. Examples include fire service cam-paigns regarding the importance of smoke detec-tors, and police educational efforts regardingimpaired driving, traffic and highway safety, and

personal safety. In general, EMShas not optimally engaged itselfin providing education that im-proves community health throughprevention, early identification,and treatment.

Certainly there are examplesof EMS public education initia-tives. In some areas EMS-C fundshave been utilized to develop pro-grams regarding childhood illnessand injury.39 The U.S. Fire Admin-istration (USFA)/National High-way Traffic Safety Administration(NHTSA)/Maternal and ChildHealth Bureau (MCHB) “Make theRight Call” campaign and othercommunity-wide efforts have fo-cused on timely access and appro-priate utilization of the EMSsystem.57, 84 Additionally, numer-ous EMS systems have assumeda leadership role in disseminat-ing CPR and “bystander care” edu-

cation to 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 de-spite the interest and role of EMS in improvingcommunity health, its stature and visibility withinthe community, and its potential ability to edu-cate individual patients and family members duringperiods of care and follow-up.

EMS Agenda for the Future: Public Education

“EMS has not yet be-gun to realize its poten-tial as an important publiceducator. It should acceptthe challenge to explore in-novative ways for educat-ing the broadest possiblespectrum of society withregard to prevention, EMSaccess and appropriate uti-lization, and bystandercare. EMS must also edu-cate the public and thosethat purchase services asconsumers, so they are en-abled to make informedEMS-related decisions fortheir communities.”

Patricia J. O’Malley, MD

PUBLIC EDUCATION

38

WHERE WE WANT TO BEPublic education is acknowledged as an essential

ongoing activity of EMS. Such programs supportthe role of EMS to improve community health andprovide valuable information regarding preven-tion of injuries and illnesses, appropriate accessand utilization of EMS and other health care ser-vices, and bystander care. It realizes the advan-tages of EMS as a community-based resource withbroad expertise and capacity for contributing tocommunity health monitoring and education dis-semination.

EMS and public education programs addressthe needs of all members of the community. Thisincludes school-age children, adults, senior citi-zens, and other members of the community withspecial needs.

EMS systems educate the public as consum-ers. 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, in-cluding evaluating and ensuring optimal EMS.

EMS systems explore innovative techniques toconduct their public education missions. These in-clude, among others, follow-up visits to patientsand their families, exploration of new technolo-gies (e.g., computers, worldwide web), and me-dia formats.

HOW TO GET THEREEMS should collaborate with other community

resources and agencies to determine public edu-cation needs. Such assessments will enable devel-opment of education programs with specificobjectives appropriate for the community.

EMS must engage in continuous public edu-cation. Such efforts should focus on areas of pre-vention, 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 tech-nologies to effect public education. Efforts shouldbe made to reach the broadest possible popula-tion in 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 EMS

• Collaborate with other community resources andagencies to determine public education needs

• Engage in continuous public education programs

• Educate the public as consumers

• Explore new techniques and technologies forimplementing public education

• Evaluate public education initiatives

EMS Agenda for the Future: Public Education

39

Prevention provides an opportunity to real-ize significant reductions in human morbidityand mortality—all with a manageable invest-

ment. Engaging in prevention activities is the re-sponsibility of 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 vic-tims originate from a particular roadintersection. Many of the crashesoccurred during the morning rushhours as motor is ts ex i ted the irneighborhood. 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 con-gestion there decreases.. Speed limitenforcement on the main highwayis increased. Also, new signs nearthe intersection and radio traffic re-porters remind drivers of the po-tential danger 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 evolving

from 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 infor-

EMS Agenda for the Future: Prevention

mation, a consensus panel has advocated additionof injury prevention modules to the National EMSEducation and Practice Blueprint.47

Other public safety services have demonstratedtheir effectiveness at public education and preven-tion activities. These include fire service efforts toeffect engineering, enforcement, and education thatdecrease the number of fires and fire-related burns

and deaths. Police departmentshave implemented deliberateefforts to decrease traffic-relatedinjuries and deaths through ag-gressive enforcement of impaireddriving laws.

EMS is not commonly linkedto the public’s prevention con-sciousness. However, the poten-tial role of EMS in prevention haspreviously been recognized.73 EMSproviders are widelydistributedthroughout the population, oftenreflect the composition of thecommunity, and generally enjoyhigh credibility.47 In some regions,EMS personnel currently aretaught principles of injury preven-tion.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 also

may benefit from linkage between the EMS sys-tem and other community services able to providespecific education and prevention initiatives.39,50,55,61

Such 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 inte-grate prevention, acute care and rehabilitation forall types of injuries among the many public and

PREVENTION

“In the future the suc-cess of EMS systems willbe measured not only bythe outcomes of their treat-ments, but also by theresults of their preventionefforts. Its expertise, re-sources, and positions incommunities and thehealth care system makeEMS an ideal candidate toserve linchpin roles dur-ing multi-disciplinary,community-wide preven-tion initiatives. EMS mustseize such responsibilityand profoundly enhance itspositive effects on commu-nity health.”

Theodore R. Delbridge MD, MPH

40

private 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 prac-titioners who provide acute care.

WHERE WE WANT TO BEEMS systems and providers are continuously

engaged 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-oriented environments for their providers, indi-vidually and collectively. An atmosphere of safetyand well- being, established through EMS systeminitiatives, provides the foundation for EMS pre-vention efforts within the community.

EMS providers receive education regardingprevention principles (e.g., engineering, enforce-ment, education, economics). They develop andmaintain an understanding of how prevention ac-tivities relate to themselves (e.g., while perform-ing EMS-related duties and at other times) and totheir outreach efforts.

EMS systems continuously enhance their abilitiesto document and analyze circumstances contrib-uting to 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/systems

must 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 col-laboration is to identify appropriate targets forprevention activities and share the tasks of imple-mentation.

EMS systems should support the Safe Commu-nities and 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 advo-cacy acknowledges the fiduciary responsibility thatEMS has for its communities’ health, in recogni-tion of the high costs of preventable injuries andillnesses. Such costs are not only monetary, but in-clude lost productivity and the human sufferingthat affects individual patients and the entire com-munity.

Prevention begins at home. Protecting the well-being of the workforce is a logical step toward thedevelopment and implementation of prevention ini-tiatives within 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 con-vey this information to others. These efforts capi-talize on the unique position of EMS providers toobserve illness and injury scenes, and to identifypotential contributing factors within the commu-nity.


41

PREVENTION:Collaborate with community agencies and healthcare providers with expertise and interest in ill-ness and injury prevention

Support the Safe Communities concept

Advocate for legislation that potentially resultsin injury and illness prevention

Develop and maintain a prevention-orientedatmosphere within EMS systems

Include the principles of prevention and its rolein improving community health as part of EMSeducation core contents

Improve the ability of EMS to document injuryand illness circumstances


42

The focus of public access is the ability to secureprompt and appropriate EMS care regard-less of socioeconomic status, age, or special

need. For all those who contact EMS with a per-ceived requirement for care, the subsequent responseand level of care provided must be commensuratewith the situation.

The future: During a severe winter storm 24-year-old Mary 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 occu-pant injury. The appropriate PSAPfor the location is automaticallynotified by the vehicle’s communi-cations computer. 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 as-sistance was summoned immediately instead of requiringeventual discovery by another motorist.

WHERE WE AREIn the United States, most people access EMS

by 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, approxi-mately 25% of the U.S. geography is covered by9-1-1, making it available to 78% of the U.S. popu-lation.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 enhanced

9-1-1 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 popula-tion may not have access to 9-1-1. In some statesas many as 12% of housing units are without tele-phones. 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 tele-phone number is seven digits.28

Additionally, 74% of people suc-cessfully access EMS on their firstattempt when 9-1-1 is the emer-gency telephone number, com-pared to 40% when the numberis seven digits.78 People living incommunities where 9-1-1 serviceis not available, but adjacent tocommunities where it is, may ex-perience delays in getting emer-gency help by inadvertently calling9-1-1 instead of a designated sevendigit telephone number.

The single most importantpiece of information provided

during an emergency call is the location of theperson(s) requiring help. Yet, addresses are lack-ing for housing units and work sites in many areas.

Highway call boxes, citizens band (CB) radio,amateur radio, and cellular telephones provide al-ternative means 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 cen-ter.85 However, in many areas cellular telephoneusers cannot be assured of reaching the appropri-ate PSAP for their location. Callers may be advisedthat they are unable to use 9-1-1, or they may ex-perience significant delays while call recipients de-termine where to route their calls.

EMS Agenda for the Future: Public Access

“Public access to EMSis closer to being univer-sal than any other healthservice. Yet, barriers to se-curing prompt and appro-priate care may still existfor many. It is incumbentupon all of us who shareresponsibility for leadingour communities, planningtheir emergency healthcare, and appropriating re-sources to strive to achievetrue universal public ac-cess to EMS.”

Jack J. Krakeel, MBA

PUBLIC ACCESS

43

In some instances financial barriers limit ac-cess to 9-1-1 for appropriate emergency care. Eco-nomic conditions 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 even-tual response 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 any

land-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 us-ers, “9-1-1” is available wherever the cellulartelephone might be in service. Cellular telephonetechnology (e.g., link to a global positioning sys-

tem) ensures that all emergency calls are routedto the appropriate communications center.

Every call for emergency services is automati-cally accompanied by location identifying infor-mation. Within metropolitan areas, unique locationaddress codes suffice. For all calls originating fromroadways, rural, frontier, backcountry, and wilder-ness areas, exact locations derived from a geographicinformation system are provided. This acknowl-edges location identifiers as the most importantinformation obtained by emergency call recipientsand that techniques for accurately enhancing in-formation transfer facilitates timely access toemergency services. Such mechanisms also attenuatebarriers to access that might otherwise be expe-rienced by 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 mem-bers of society.

Systems for accessing EMS and other emergencyservices employ communications technology ad-vances that 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 moni-tors and communications devices, instantaneouslytranslate languages, provide the ability to electroni-cally visualize callers (e.g., interactive video com-munications processes), 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 re-ceived at access points are triaged (e.g., to anemergency communicator, medical advice program,social worker, primary health care provider, otherpublic safety services, and other community re-sources) so that the resulting output, given avail-able options, provides the most appropriate response(Figure 2).


44

Pri

ma

ry H

ea

lth

Ca

reP

rovi

de

r/N

etw

ork

So

cia

l S

erv

ice

Ag

en

cy

EM

S “

Em

erg

en

cy”

Re

spo

nse

EM

S “

No

n-E

me

rge

nc

y”R

esp

on

seM

ed

ica

l Tr

an

spo

rta

tio

nM

ed

ica

l A

dvi

ce

/In

form

ati

on

Re

sou

rce

sF

ire

, L

aw

En

forc

em

en

t,a

nd

oth

er

Pu

blic

Sa

fety

Se

rvic

es

Exa

mp

le O

pti

on

s A

vail

ab

le t

o

Em

erg

en

cy

Me

dic

al

Dis

pa

tch

er

Cal

l to

Pu

blic

Saf

ety

An

swer

ing

Po

int

Ap

pro

pri

ate

Sys

tem

Ou

tpu

t/R

esp

on

se


Fig

ure

2.

Pu

blic

Acc

ess

to a

n A

pp

rop

riat

e E

MS

Res

po

nse

45

HOW TO GET THEREOrganizations with an interest in EMS and all

with responsibility for EMS structures, processes,and outcomes must continue to encourage imple-mentation of 9-1-1 in all areas. When necessary,resolution of political disputes delaying 9-1-1 imple-mentation must be facilitated. Legislation shouldbe adopted that requires implementation of 9-1-1 and/or implementation should be mandated bypublic utility commissions.

Local governments and public utility commis-sions must ensure that those who cannot affordtelephone service, that would routinely be avail-able in their housing units, are nevertheless ableto immediately access emergency services. For ex-ample, they might compel provision of minimumtelephone service that only enables 9-1-1 calls, fa-cilitate strategic placement of public telephones,provide cable calling systems, or develop otherservices that facilitate access to emergency care.

Utility companies (e.g., telephone, cable) andgovernmental authorities must continue initiativesto assign unique geographic location codes oraddresses to all telephone numbers and housingunits, and implement systems to continuously andreliably update such information.

Technology should be employed so that dataderived from geographic information systems isautomatically supplied to the PSAP regardless ofwhere a call originates. Communication centersmust prepare themselves to receive and utilize suchinformation.

Cellular telephone service companies and 9-1-1 PSAPs must engage in cooperative ventures todevelop the necessary funding and technology toachieve implementation of cellular 9-1-1 service.Within “cells,” 9-1-1 calls should receive priorityso that delays are not experienced due to other cel-lular activity. Calls from cellular telephones shouldbe locatable with a geographic information systemto facilitate linkage with the appropriate PSAP andprovide timely response of emergency services tothe correct location. Such efforts should be facili-tated by the Federal Communications Commission(FCC) and appropriate public utility commissions.

Communications centers, EMS providers, andother public safety agencies must continue to evalu-ate the appropriateness of communications tech-nology advances which may enhance system accessand benefit the efficiency of emergency medicalcare. Pilot projects that exploit technological ad-vances must be conducted, and the results of suchprojects must be made public.

EMS access points must improve their abilitiesto triage calls, providing linkage with other com-munity health resources, so that the system’s re-sponse is tailored to patients’ needs. Such effortsshould incorporate the input of community mem-bers and community health care providers andresources.

Implement 9-1-1 nationwide

Provide emergency telephone service for thosewho cannot otherwise afford routine telephoneservices

Ensure that all calls to a PSAP, regardless of theirorigins, are automatically accompanied by uniquelocation-identifying information

Develop uniform cellular 9-1-1 service that re-liably routes calls to the appropriate PSAP

Evaluate and employ technologies that attenu-ate potential barriers to EMS access

Enhance the ability of EMS systems to triagecalls, and provide resource allocation that is tai-lored to patients’ needs.

PUBLIC ACCESS:


46

Communication steers all organizations, including EMS systems. It provides the trans-fer of information that enables decisions

to be made.

The future: A neighbor finds John, a 65-year-oldrural farmer, unconscious in his house and summonsEMS. At the communications center John’s health pro-vider information is available automatically. The patient’shealth database is accessed and hiscurrent problem list, medications, andallergies are downloaded to the re-sponding personnel’s personal digi-tal assistants. EMS personnel findJohn in severe shock and in criticalcondition. They learn from his healthdatabase that he suffers from severeadrenal insufficiency, and suspect thatan intercedent illness or inability totake his medication has led to John’scurrent condition. By computer thisinformation is relayed to the medi-cal command center 50 miles away,and the decision is made to admin-ister a stress dose of hydrocortisonein addition to other resuscitative treat-ment. The patient’s primary care pro-vider is also identified from the database, is updateddirectly from the EMS unit, and is able to provideadditional helpful information to emergency depart-ment staff prior to John’s arrival there. John is muchimproved by then, and he recovers fully.

WHERE WE AREContemporary EMS systems and their personnel

rely as heavily on their communications systemsas they do on any other resource available to them.Effective communications networks provide: ac-cess to the EMS system, dispatch of EMS and otherpublic safety agencies, coordination among EMSand other public safety agencies, access to medi-cal direction, communications to and betweenemergency health care facilities, communicationsbetween EMS and other health care providers, andoutlets for disseminating information to the public.24

Within public safety answering points (PSAP),calls for EMS are answered by personnel with

greatly varying levels of education, experience,ability to provide potentially life-saving instruc-tions via telephone, and medical direction. Emer-gency medical dispatchers (EMD) have beenadvocated as essential personnel at all EMS dis-patching centers, and a national standard curriculumis available.7,18,19,32,88 They are able to query callersand determine the appropriate resources to be dis-

patched.126 Furthermore, EMDs areable to provide dispatch life sup-port via pre-arrival instructionsfor appropriate patients.17 Pre-ar-rival instructions are thought tobe a cost-effective mechanism forimproving survival from out-of-hospital cardiac arrest.138 How-ever, there is a paucity of publishedwell-constructed, objective studiesaddressing the effectiveness ofEMS dispatching components.

Once EMS units are dispatched,they frequently are isolated fromother emergency services, imped-ing abilities to coordinate appro-priate actions. The spectrum ofcommunications equipment cur-

rently in use is broad, ranging from antiquated radiosto mobile data terminals mounted inside the emer-gency vehicles. Specific radio frequency utiliza-tion by EMS systems varies significantly, includingCB, very high frequency (VHF) low and high bands,ultra high frequency (UHF), and 800 and 900 MHZtrunking systems. The latter provide some degreeof management for congested radio frequencies,but are also becoming overburdened in some met-ropolitan areas. Additionally, trunking system costsare greater than other systems, so they are mosteffective for large metropolitan jurisdictions or mul-tiple cooperating systems. Cellular telephones alsoare commonly used. They provide an alternativeto busy radio frequencies, enhance communicationsystem coverage with cellular-satellite technology,enable data transfer (e.g., 12 lead ECG), and providefor more privacy than routine radio communica-tions.

EMS Agenda for the Future: Communication Systems

“As EMS becomes bet-ter integrated with otherhealth services, the needsfor efficient informationtransfer among systempartners will increase.Communication systemsprovide the links thatmake information trans-fer possible, and theyshould exploit technologythat enhances their effi-ciency.”

Bob Bailey

COMMUNICATION SYSTEMS

47

At the hub is a communications center, withvariable control over EMS system status, depend-ing on the operations theory being employed.127

Automatic vehicle location (AVL) technologies areutilized by many emergency services to facilitatecontinuous vehicle (and system) status updates andto increase efficiency. However, in general, EMSsystems are not the sole proprietors of the com-munications networks they utilize. Currently, only14 states have a comprehensive EMS communica-tions plan in place.118

From a communications perspective, EMS per-sonnel are, for the most part, isolated from the restof the health care delivery system. They rarely haveaccess to meaningful medical history data (e.g.,medications, previous illnesses, results of previ-ous evaluations/diagnostic tests, and others) abouttheir patients that might enable implementationof efficient decisions. Many EMS systems employon-line medical direction (direct medical control)as part of their overall medical direction. How-ever, communications often are via crowded VHFfrequencies, and are easily monitored. Therefore,potentially confidential information cannot be se-curely transmitted. Additionally, terrain and limi-tations of the communications system, includingcellular telephone systems, may limit the abilityto obtain on-line medical direction at all. Althoughelectrocardiogram (ECG) data may be transmittedvia telemetry (marginal quality) or cellular tele-phone (not yet widely available), other patient datais not transmitted real-time. Also, communicationswith other health care services, beyond the medi-cal direction facility, is often cumbersome.

WHERE WE WANT TO BECalls for emergency medical care are received

by personnel with the requisite combination of edu-cation, experience, and resources necessary to enableoptimal query of the caller, make determinationof the most appropriate resources to be mobilized,and implement an effective course of action. TheEMS response is appropriate, optimal care is de-livered, and utilization of resources is efficient. Allcallers to EMS are provided dispatch life supportby qualified and credentialed personnel. This en-tails pre-arrival life saving instructions via pro-tocol and with medical direction.

EMS communications networks incorporate otherproviders of medical care. Such networks enable

the EMS system to receive and transmit patient-related information from and to other providersresponsible for patients’ continuous care. Thesenetworks employ useful technological advances,such as transmission of computerized records tomaintain confidentiality, so that EMS personnel maymake improved decisions with regard to patientcare, follow-up care, and transport destination (ifnecessary). Such communication networks facili-tate integration of EMS with other health care ser-vices.

EMS communications systems incorporate otherpublic service agencies. Such agencies includedepartments of public health, social services, andothers able to address unhealthy or undesirablecircumstances identified by EMS personnel whilecaring for their patients.

EMS communications systems ensure reliableavailability of on-line medical direction and en-able transmission of relevant real-time patient datato a receiving medical facility. Such capabilitiespotentially may allow medical decisions of greatercomplexity to be made in the field, permit a greaterdegree of preparation at the receiving facility, en-hance EMS system data collection, and facilitatecommencement of patients’ medical records ear-lier in the course of their injuries/illnesses.

Communications networks are geographicallyintegrated and based on functional need to enableroutine and reliable communications among EMS,fire, law enforcement, and other public safetyagencies. This facilitates coordinated responses dur-ing both routine and large scale operations, andeffects optimal utilization of resources on a largegeographic basis. Issues related to disaster prepared-ness are addressed.

Communications networks for EMS do not standalone, but EMS is a full partner in the communi-cations system. EMS has the ability to impact net-work design and function in order to better serveits patients’ needs. In some areas, this includes uti-lization of AVL technology and development of in-teractive video communications between the public,EMS, fire, law enforcement, other public safetyagencies, and other health care providers.

HOW TO GET THEREResearch and pilot projects must be conducted

to assess the effectiveness, including patient out-


48

comes, of various personnel and resource attributesfor EMS dispatching. Results of these projects shouldbe made available so that the roles of such per-sonnel within an evolving health care and EMSsystem can be optimized.

Standards for emergency medical dispatchingmust be promulgated and updated by public safetycommunications and other EMS interested orga-nizations, and be commensurate with system needs.In some cases, state legislation will be appropri-ate in order to ensure that EMDs obtain the edu-cation, experience, and resources necessary toperform their intended tasks safely and effectively.

States should legislate immunity from liabilityfor EMDs providing service and following standardsat a pre-designated level. Relevant organizationsshould develop model legislation.

Communications centers and health care pro-viders must commit to cooperative ventures aimedat improving the exchange of confidential patient-related data, in a timely manner. Such efforts mustbe accompanied by integration of practices andpolicies so that optimal patient care is achieved.

Research and pilot projects should be conductedto determine the benefits of real-time patient datatransfer (e.g., via cellular communications, satel-lite, interactive video, and others) relative to itscosts. As advancing technology is explored, theresults of such projects must be made public.

Funds must be appropriated on federal, state,and regional levels to further develop and updatecommunications systems that are geographicallyintegrated and functionally based. States mustcontinue to develop statewide EMS communica-tions plans.

The FCC must reform policies regarding EMScommunications. The radio frequency spectrum re-served for EMS utilization must be expanded. TheFCC must facilitate exploration of advancing com-munications technology for potential use by EMS(e.g., personal communication devices, satellite andcellular communications, interactive video, andothers). The interest of EMS patients must be con-sidered a priority as changes in federal commu-nications structures are implemented.

EMS systems should collaborate with privateinterests to effect shared purchasing of commu-nications technology, developing economies of scale.Such pooling of resources will provide an increasedability to explore potential uses of technologic com-munications advances.

Assess the effectiveness of various personneland resource attributes for EMS dispatching

Receive all calls for EMS using personnel withthe requisite combination of education, expe-rience, and resources to optimally query the caller,make determination of the most appropriate re-sources to be mobilized, and implement aneffective course of action

Promulgate and update standards for EMSdispatching

Develop cooperative ventures between commu-nications centers and health providers to inte-grate communications processes and enable rapidpatient-related information exchange

Determine the benefits of real-time patient datatransfer

Appropriate federal, state, and regional fundsto further develop and update geographicallyintegrated and functionally-based EMS commu-nications networks

Facilitate exploration of potential uses ofadvancing communications technology by EMS

Collaboration with private interests to effectshared purchasing of communication technology

COMMUNICATION SYSTEMS:


49

EMS provides care to those with perceivedemergency needs and, when indicated,provides transportation to, from, and between

health care facilities. Mobility and immediate avail-ability to the entire population distinguish EMSfrom other components of the health care system.

The future: In rural America, EMS personnel areevaluating a 65-year-old woman with chest pain. Afterconsultation with the medical com-mand center (80 miles away), short-acting thrombolytics are administeredfor a suspected acute myocardial in-farction. Because of the anticipatedduration of transport, anti-oxidantsalso are administered. The patient’spain begins to subside. Although airmedical transport would get thepatient to her hospital destinationsooner, previous studies have dem-onstrated deleterious effects for acutecardiac patients. Thus, the patientis taken by ground to the cardiaccenter (100 miles away), where sheis immediately met by the cardiolo-gist who performs definitive intra-coronary debridement. She fully recovers.

WHERE WE AREThe clinical care delivered by EMS has evolved

significantly over the past 30 years. To some ex-tent it has capitalized on the availability of newpharmacologic agents and technology, developedmeans to deliver life-saving care faster (e.g., lay-person CPR, use of automatic external defibrillatorsby lesser trained personnel, dispatch life support,and others), and begun to systematically addressthe particular needs of specific groups of patients.EMS systems vary remarkably with regard to thesophistication of out-of-facility care they provideand the tools they utilize. Variation exists due tostate legislation and regulations, availability of localresources, and the functional needs and expecta-tions of communities.

Currently, there is no standard baseline of carethat is provided by all EMS systems. Historically,“basic life support” (BLS) EMS systems have pro-

vided only non-invasive care (e.g., oxygen therapy,splinting, dressing, CPR, etc.). However, due tovariations in requirements for EMS providercredentialing and for EMS system component (e.g.,ambulance service) licensing, potential EMS pa-tients cannot expect the same standard of “BLS”care in all communities. Furthermore, the terms“BLS” and “advanced life support” (ALS) have

become antiquated, as providers,once assigned the designations“basic” are in some areas now pro-viding interventions once thoughtto be “advanced” (e.g., defibril-lation, intubation, and others).

Just as the floor of EMS careis not even, neither is the ceiling.The scope of EMS care differsamong states and often betweenlocalities. The interventions para-medics may perform, the equip-ment available to them, and themedications they carry variesgreatly.25, 44 The care delivered byEMS makes intuitive sense, in thatit is similar to emergency depart-

ment care —sooner. However, with the exceptionof a few clinical situations (e.g., cardiac arrest,certain trauma), the effects of EMS care are notadequately known. In some areas, EMS clinicalcare variations may be the result of adapting tomeet the health care needs of communities.

The Red River, New Mexico project, as it isknown, is an example of adapting EMS clinicalcare to meet the health care needs of a rural com-munity.115 In one community the EMS system wasable to augment its services, thus improving thehealth care available within the town. Other similarprojects also have been launched.

For the most part, regardless of its sophisti-cation, EMS clinical care is intended to get pa-tients to a hospital. For most EMS patients, theircare entails transportation to a medical facility (e.g.,hospital emergency department). For those EMSproviders who seek payment for their services,payment usually is based on the patient transport

EMS Agenda for the Future: Clinical Care

CLINICAL CARE

“Advances in technol-ogy and provider educa-tion will enable EMSsystems of the future toprovide increasingly so-phisticated clinical care.The menu of state-of-the-art interventions availableto patients will be limitedprimarily by relevantoutcomes data and com-munity needs.”

Robert E. Suter DO, MHA

50

and retrospective determination of medical neces-sity.

Patient transport is mostly effected by groundambulances. Design specifications for such vehicleshave been developed and revised by the GeneralServices Administration. 38 Ambulances areequipped and staffed to provide care ranging fromnon-invasive monitoring and support to sophis-ticated interventions and pharmacotherapy dur-ing transport. Essential equipment for ambulances,including minimum guidelines for “ALS” and pe-diatric equipment and medications, has beendefined.3, 4, 37, 113 Other modes of transportation (e.g.,helicopter, fixed wing aircraft, boat, and others)also are often used.

Transportation of patients to non-emergencymedical care facilities, or between facilities maybe accomplished by EMS providers or ambulanceservices operating outside the EMS system. Out-of-facility EMS providers must assume differentroles with respect to primary and secondary trans-port.20 Currently, these differences are not alwaysclearly delineated in EMS regulations. Specialtyground transport vehicles, often staffed and main-tained by hospitals, sometimes are utilized forinterfacility transport of patients with special needs,such as critical care, high risk obstetrical, neona-tal, and cardiac.124 These vehicles frequently arestaffed by personnel with specific expertise, andmay include paramedics, nurses, respiratory thera-pists, cardiopulmonary technologists, and physi-cians. Medical direction for the transporting teammay emanate from different sources that are notalways linked to the rest of the EMS system.20

WHERE WE WANT TO BEEMS provides a defined baseline of clinical care

and services in all communities. Expansion of careand services occurs in response to community healthcare needs and availability of resources.

Out-of-facility EMS clinical care is optimal forpatients’ circumstances, so that it positively im-pacts patient outcomes. In some cases, the carethat is provided is intended to avoid the patient’sneed for immediate transport to a hospital. Theeffects of EMS care, in terms of outcomes, for specificconditions are continuously evaluated. This helpsfacilitate appropriate distribution of health care

resources, including equipment, personnel, and edu-cation.

Therapeutic technology and pharmaceutical ad-vances are evaluated in terms of their impact onpatient outcomes and appropriateness for EMS use(e.g., portable, effective, information-adding, andothers) prior to their deployment. EMS clinical careevolves as new diagnostic and therapeutic toolsbecome available, but those that do not providedemonstrable benefit are not used.

As much as possible, transportation modalitiesare allocated according to patients’ conditions sothat resources are not overutilized. The composi-tion and expertise of transport teams matches theneeds of complex patients undergoing secondarytransport. Transport of individuals not requiringsophisticated equipment or supervision does notconsume those resources which could be madeavailable elsewhere.

Patient transport activities are integrated withthe total health care system. EMS is capable offacilitating access to hospital emergency depart-ments and other health care sources designated bymedical direction in consideration of patients’providers of continuous care. Requisite for suchfacilitation is working knowledge of and agree-ments with other health care partners.

Staffing patterns, in terms of available skills andexpertise, for interfacility or secondary transportsresult from an understanding of potential carerequired for specific types of patients. The authorityand responsibility for medical direction during suchtransports is clear.

EMS clinical care and transportation systemsare networked. Providers of non-acute, acute, spe-cialty, and air medical transport are closely linkedso that communications are smooth and patienttransfers, including accompanying data, appearseamless. Communications within networks allowinstantaneous assessment of the availability andlocations of out-of-facility clinical care and trans-portation resources.

HOW TO GET THEREEMS organizations and those responsible for

EMS structures, processes, and outcomes must com-mit to a common definition of what constitutesbaseline out-of-facility community EMS care. Such


51

a definition should address, for example, minimumpersonnel qualifications and resources/equipmentavailable to them.

EMS should work with national organizationsand associations to help determine its role in en-hancing identification and treatment of variousclinical conditions (e.g., myocardial infarction). EMSclinical care must be subjected to ongoing evalu-ation to determine its impact on patient outcomes.New services and treatments should be implementedonly after their effects have been demonstrated.Furthermore, changes in clinical care should be jus-tifiable based on community health care needs.

Research and pilot projects must be conductedto determine the effects of patient outcomes afterspecific care and transport via various modalities.This should include investigations regarding therelative effects of ground and air transport onpatients with a variety of conditions. The cost ef-fectiveness and relative safety of transport shouldbe addressed.

Research must be conducted and published re-garding treatments that can be administered safelyduring transport by various personnel configura-tions. Such projects should include interfacility/secondary transfers, when patients are being movedto a different level of care or to access providersresponsible for ongoing care.

Task analyses must be conducted to determinethe needs for availability of specific skills andexpertise during transport of various types of pa-tients. Such analyses should determine optimal per-sonnel configurations for interfacility/ secondarypatient transfers.

Local and state EMS lead agencies shouldfacilitate development of arrangements that ren-der delineation of medical direction authority andresponsibility unambiguous during interfacility/secondary patient transfers. EMS medical direc-tors should strive to reach consensus among phy-sicians (e.g., on-line medical direction providers,intensivists, trauma surgeons, cardiologists, pedia-tricians, and others including referring and receivingphysicians) and others regarding their roles dur-ing interfacility transfers.

The Health Care Finance Administration (HCFA),and others responsible for establishing policy withregard to EMS payment, must eliminate patienttransport as a requirement for compensating EMSsystems. Patient assessment and care delivered,regardless of whether or not transport occurred,must be recognized and compensated appropri-ately. Additionally, the cost of system prepared-ness (e.g., readiness costs) should be recognized.Alternative models for determining rates of reim-bursement must be developed.

EMS systems should seek to establish proac-tive relationships with other providers (e.g., pri-mary care providers, managed care organizations,health clinics) within the health care delivery system.Such relationships should seek to establish under-standings of the perspectives of all providers, andto develop mutual policies that enhance the de-livery of efficient care to patients. Reports of theeffects of these relationships must be disseminated.

EMS systems must establish regional collabo-rative networks with all potential transportationresources. Networks should include clarificationof medical direction roles during primary and sec-ondary patient transport. State and local EMS au-thorities should facilitate establishment of suchnetworks.


Commit to a common definition of what con-stitutes baseline community EMS care

Subject EMS clinical care to ongoing evaluationto determine its impact on patient outcomes

Employ new care techniques and technology onlyafter shown to be effective

Conduct task analyses to determine appropri-ate staff configurations during secondary pa-tient transfers

Eliminate patient transport as a criterion for com-pensating EMS systems

Establish proactive relationships between EMSand other health care providers

CLINICAL CARE:

52

The raw material for information is data. In-formation systems collect and arrange datato service particular purposes.

The future: Erin, a nineteen-year-old woman, callsEMS because she is experiencing abdominal pain. WhenEMS personnel evaluate her, she complains of some leftlower abdominal tenderness. However, she states thather pain has somewhat subsided, and for that and otherreasons she refuses to be transported.The personnel update her medical“smart card” , and their computeralso advises Erin’s primary care net-work of the call and their findingsand request that she receive follow-up. During the primary care follow-up telephone call, four hours later,Erin is not well. She explains thather pain has mostly gone, but thatshe is too lightheaded to stand. Again,EMS is called, although different per-sonnel respond. Enroute, they are up-dated via their personal digitalassistants. Erin is no longer able toconverse, and her blood pressure is low. Because of theprevious call, which was recorded in the EMS infor-mation system and on Erin’s “smart card”, personnelsuspect a ruptured ectopic pregnancy. She is resusci-tated and transported to the nearest hospital with gy-necologic services. There, she is met by a physician alreadyfamiliar with her care to this point. Following emer-gency surgery, Erin does well. She credits EMS andthe follow-up call from her primary care health net-work for saving her life.

WHERE WE ARESystems for data collection and information

management have developed slowly within EMS.Several recent initiatives have focused on thedevelopment of improved techniques for collect-ing EMS-related data. The Trauma Care SystemsPlanning and Development Act of 1990 emphasizedthe need for collection of data for the evaluationof emergency care for serious injuries.132 The 1993Institute of Medicine report, Emergency Medical Ser-vices for Children, recommended that states col-lect and analyze uniform EMS data needed for

planning, evaluation, and research of EMS for chil-dren.27 During the 1993 Uniform Pre-hospitalEmergency Medical Services Data Conference,potential data elements were discussed and deter-mined to be essential or desirable.135 Perhaps evenmore important, the conference resulted in stan-dard definitions for data elements.

There is no central database, at a national levelfor example, that relates to thecurrent practice of EMS. The datarequired to completely describean EMS event exists in separatedisparate locations. These includeEMS agencies, emergency depart-ments, hospital medical records,other public safety agencies, andvital statistics offices.104 In mostcases, meaningful linkages be-tween such sites are nonexistent.

The purpose of collecting EMSdata is to evaluate the emergencymedical care of individuals withillnesses and injuries in an effort

to improve access and reduce morbidity and mor-tality. The lack of organized information systemsthat produce data which are valid, reliable, andaccurate is a significant barrier to coordinating EMSsystem evaluation, including outcomes analyses.35,120

Lack of information systems that are integratedwith EMS and other health care providers and com-munity resources severely limits the ability to shareuseful data. Patient-related data are not shared toallow EMS care to be part of a continuum, accountingfor past care and considered during future care.Furthermore, within EMS agencies themselves, datasystems generally do not provide readily acces-sible information about previous EMS patient contactand care.

Research efforts are hindered by underdevel-oped information systems. In general, the data de-rived from an information system may be inadequatefor research purposes. However, it is extremelyuseful for hypothesis generation and may requireonly minimal supplementation. Integrated infor-mation systems serve as multisource databases which

EMS Agenda for the Future: Information Systems

“Finding desperatelyneeded answers to manyimportant questions inEMS is hopeless withoutthe development of newways to collect, link, andanalyze valid, meaningfulinformation. This is thevery foundation of the fu-ture of EMS!”

Daniel W. Spaite, MD

INFORMATION SYSTEMS

53

have been advocated as useful tools for conduct-ing EMS cardiac arrest research.56

WHERE WE WANT TO BEEMS systems share integrated information

systems with other health care providers, includ-ing provider networks, and other public safety agen-cies. These systems enable EMS to accesspatient-related data necessary to optimize care (e.g.,clinical care, transport disposition and destinations,arrangements for follow-up, and others). They pro-vide mechanisms for EMS to use data, and the abilityto transmit useful information to other health careproviders and community resources that are partof patients’ continuums of care.

EMS information systems incorporate uniformdata elements. These are derived from the uniformprehospital data set and use standard definitions.135

This enables evaluation across multiple EMS sys-tems.

Information systems support data collection forcontinuous EMS evaluation and for EMS-relatedresearch. Generated data are of sufficient valid-ity, reliability, and accuracy. The data necessaryto describe entire EMS events are available withininformation systems that link multiple source da-tabases.

HOW TO GET THEREEMS must adopt uniform data elements and

definitions, and incorporate these into informationsystems. Such efforts should be directed towardrealizing a degree of commonality that facilitatesmultisystem evaluations and collaborative research.

EMS must develop mechanisms to generate andtransmit data that are valid, reliable, and accurate.These factors should be considered during the designand enhancement of information systems. Periodicevaluation should focus on these aspects of dataintegrity.

EMS must develop and refine information sys-tems that describe entire EMS events. They shouldlink multiscore databases so that patient outcomescan be determined following EMS treatment. Theyshould readily support ongoing systems evalua-tion and EMS-related research. This is necessaryif the cost-effectiveness of EMS is to be determined.

EMS should collaborate with other health careproviders and community resources to develop in-tegrated information systems. Such efforts shouldprovide each participant with patient-related datathat potentially affects the continuum of care,facilitates access for patients to appropriate careand attention, enhances clinical care decision making,and facilitates follow-up care.

Information system users must provide feed-back to those who generate data. Feedback shouldinclude, but be not limited to, results of evalua-tions and research.

EMS Agenda for the Future: Information Systems

Adopt uniform data elements and definitionsand incorporate them into information systems

Develop mechanisms to generate and transmitdata that are valid, reliable, and accurate

Develop information systems that are able todescribe an entire EMS event

INFORMATION SYSTEMS:

Develop integrated information systems withother health care providers, public safety agen-cies, and community resources

Provide feedback to those who generate data

54

Evaluation is the essential process of assess-ing the quality and effects of EMS, so thatstrategies for continuous improvement can

be designed and implemented.

The future: In collaboration with the area’s majorhealth care provider/insurer groups, one year ago theEMS system began an injury prevention initiative. Lightduty personnel perform domicile risk analyses duringpatient follow-up visits, upon requestof home dwellers, and at randomlyselected senior citizens’ homes.Continuous evaluation has revealeda decrease in the incidence of fallsin the home resulting in hospitaliza-tion. The cost savings to the healthcare system (not including humansuffering costs) are much greater thanthe activity’s costs. Furthermore, com-munity satisfaction regarding the pro-gram has been high, especially amongthose whose elderly parents live alone.Evaluation results are being analyzedto explore ways to further enhancethe program.

WHERE WE AREEMS systems are evaluated using structural

(input), process, and outcome measures. Structuralevaluation is the least complex and easily repli-cated, however, its relationship to outcome is un-certain. Process evaluation assesses aspects of caredelivered, including its presumed appropriateness,patterns of delivery, technical intervention success/failure rates, and others. Fractile response timesare process measures often utilized to evaluate EMSsystems. Although these factors might influenceultimate patient outcomes, their relationships arealso ambiguous. Furthermore, the reliability ofsources for data required for these analyses is of-ten questioned. The relative lack of consistentlyreliable and accurate data, and its importance forEMS systems analyses, has only recently becomeappreciated.21,121,139

Assessment of patient outcomes is part ofcomprehensive EMS evaluation. Ultimate patientoutcomes may be insensitive to variations in EMS

care. Therefore, intermediate outcome measures,which have a closer temporal relationship to EMScare, often are utilized.15 Intermediate patientoutcomes can be used to determine the effects ofdifferent phases of EMS care. Utilization of tracerconditions has been advocated for evaluating EMSsystems and other aspects of health care.15,67,75 Car-diac arrest has been the most widely used EMS

tracer condition to determine theoverall effects of EMS systems.29

Trauma also has served as a tracercondition, comparing actual sur-vival to survival probability basedon injury severity scores (ISS).5,116

Other than cardiac arrest andtrauma conditions, there is apaucity of literature evaluating theeffects of EMS systems.

Similarly, there has been littleattempt to determine the cost-ef-fectiveness of EMS. Estimates ofEMS costs for saving the life ofa cardiac arrest victim are simi-lar to those for other life-saving

medical treatments.136,137 However, such estimatesare locality specific and do not necessarily applyto all EMS systems. The cost-effectiveness of veryfew interventions delivered by EMS is known.46,64,138

Models for determining EMS system effectivenessand cost-effectiveness are lacking.

EMS systems evaluation and EMS research bothrely on information systems as sources of data(Figure 3). However, research although very im-portant, is an optional activity for every system.Furthermore, research seeks to enhance the knowl-edge base by answering new questions. On the otherhand, continuous evaluation is essential for everyEMS system, and it should be a pervasive part ofthe environment. It seeks to determine the outcomechanges that occur with application of new knowl-edge and system alterations.

WHERE WE WANT TO BEContinuous comprehensive evaluation of EMS

assesses all aspects of the system. Such evaluationsinclude structural, process (i.e., key points in EMS

EMS Agenda for the Future: Evaluation

EVALUATION

“The ability of EMS tooptimally meet communi-ties’ and individual pa-tients’ needs in the futureis dependent on evaluationprocesses that assess andimprove the quality ofEMS. Continuous evalu-ation is essential andshould pervade all aspectsof every EMS system.”

Theodore R. Delbridge MD, MPH

55


56

processes), and outcome measures, and are under-taken with consideration of confidentiality issues.Evaluation is integral to quality improvementsystems that continuously measure, maintain, andimprove the efficiency of EMS. These system analyseshelp determine optimal design and effect enhance-ments to meet individual patient and communityhealth care needs.

Evaluation involves many clinical conditions.Thus, the value of EMS is determined relative tothe medical needs of an expanded portion of thepopulation served.

Other outcomes, in addition to death, are uti-lized to determine the effects of EMS. These in-clude disease, disability, discomfort, dissatisfaction,and destitution.41 This enables appreciation of thecomplete spectrum of EMS effects for the commu-nity.

The cost-effectiveness of EMS is evaluated. Thisincludes the cost- effectiveness of system prepared-ness (e.g., maintaining a state of readiness that issuitable to the mission) and the cost-effectivenessrelative to various illness/injury conditions andto specific treatments. This helps determine the valuerelated to EMS as a continued health care expen-diture.

Public satisfaction and consumer input is a focusof EMS evaluation. The interests of consumers areacknowledged as paramount. This helps to ensurethat EMS is adequately meeting the expectationsof the population it serves.

HOW TO GET THEREEMS system administrators and researchers must

develop valid models for EMS evaluations. Suchmodels should include structural, process, andoutcome features. Furthermore, outcomes shouldbe objective and relevant to EMS care.

EMS system administrators and researchers mustdevelop tracer conditions, in addition to cardiacarrest and trauma, for the purposes of evaluation.Evaluation for several conditions, including car-diac arrest, should be continuous in all EMS sys-tems. Such evaluation should be facilitated, viatechnical assistance, by EMS lead agencies. Theseagencies should also facilitate development of “reportcards” for EMS systems.

Models must be standardized and EMS systemevaluations should incorporate multiple outcomecategories. Evaluations must seek to determine sys-tem effects for several outcome determinants if thefull impact of EMS is to be appreciated.

EMS system administrators and researchers mustdetermine the cost- effectiveness of EMS. This shouldinclude analyses relative to specific illnesses andinjuries, specific interventions, and system prepared-ness.

EMS evaluation processes must incorporate con-sumer input. Such input may be sought in variousforms (e.g., follow-up, surveys, focus groups, lay-person representation in evaluation councils, andothers) and should determine if patient and com-munity needs and expectations are being met bythe EMS system.

Develop valid models for EMS evaluations

Evaluate EMS effects for multiple medical con-ditions

Determine EMS effects for multiple outcomecategories

EVALUATION:

Determine EMS cost-effectiveness

Incorporate consumer input in evaluation pro-cesses


57

EARLY EMSThe development of EMS has been based on tra-

dition and, to some extent, on scientific knowledge.Its roots are deep in history. For example, the GoodSamaritan bound the injured traveler’s wounds withoil and wine at the side of the road, and evidenceof treatment protocols exists as early as 1500 B.C.12

Although the Romans and Greeks used chari-ots to remove injured soldiers from the battlefield,most credit Baron Dominique-Jean Larrey, chief phy-sician in Napoleon’s army, with institution of thefirst prehospital system (1797) designed to triageand transport the injured from the field to aid sta-tions. Flying ambulances (dressing stations) weremade to effect transport, and protocols dictatedmuch of the treatment.13 In the United States, or-ganized field care and transport of the injured beganafter the first year of the Civil War, when neglectof the wounded had been abysmal.123

Military conflicts have provided the impetusfor many of the innovations for treating and trans-porting injured people. Among the most obviousof these is the use of aircraft for medical trans-port. The first known air medical transport occurredduring the retreat of the Serbian army from Al-bania in 1915. An unmodified French fighter air-craft was used. 74 During World War I mortalitywas linked to the time required to get to a dress-ing station. Additionally, application of a splintdevised by Sir Hugh Owen-Thomas resulted in areduction of mortality due to femur fractures from80% to 20%.123 The use of rotary wing aircraft forrapid evacuation of casualties from the field to treat-ment areas was demonstrated during later conflicts,especially in Korea and Vietnam.

Civilian ambulance services in the United Statesbegan in Cincinnati and New York City in 1865and 1869, respectively.122 Hospital interns rode inhorse drawn carriages designed specifically for trans-porting the sick and injured. The first volunteerrescue squads organized around 1920 in Roanoke,Virginia, and along the New Jersey coast. Gradu-ally, especially during and after World War II, hos-pitals and physicians faded from prehospitalpractice, yielding in urban areas to centrally co-

ordinated programs. These were often controlledby the municipal hospital or fire department, whoseuse of “inhalators” was met with widespread publicacceptance.122 Sporadically, funeral home hearses,which had been the common mode of transport,were being replaced by fire department, rescue squadand private ambulances.

By 1960, new advances to care for the sickestpatients were being made. The first recorded useof mouth-to-mouth ventilation had been in 1732,involving a coal miner in Dublin, and the first majorpublication describing the resuscitation of neardrowning victims was in 1896. However, it wasnot until 1958 that Dr. Peter Safar demonstratedmouth-to-mouth ventilation to be superior to othermethods of manual ventilation.109 Of note, Dr. Safarused Baltimore firefighters in his studies to per-form ventilation of anesthetized surgical residents.In 1960, cardiopulmonary resuscitation (CPR) wasshown to be efficacious.68 Shortly thereafter, modelEMS programs were developed based on successesin Belfast, where hospital-based mobile coronarycare unit ambulances were being used to treatprehospital cardiac patients.97 American systemsrelied on fire department personnel trained in thetechniques of cardiac resuscitation. These new mod-ernized EMS systems spurred success stories fromcities such as Columbus, Los Angeles, Seattle, andMiami.

MODERN EMS IN THE U.S.Demonstration of the effectiveness of mouth-

to-mouth ventilation in 1958 and closed cardiacmassage in 1960 led to the realization that rapidresponse of trained community members to car-diac emergencies could help improve outcomes.68,109

The introduction of CPR provided the� founda-tion on which the concepts of advanced cardiaclife support (ACLS), and subsequently EMS sys-tems, could be built. The result has been EMS systemsdesigned to enhance the “chain of survival” .22,94

The 1966 white paper, Accidental Death andDisability: The Neglected Disease of Modern Societyprepared by the Committee on Trauma and Com-mittee on Shock of the National Academy of Sci-ences—National Research Council, provided great

Appendix A EMS Agenda for the Future: EMS Historical Perspectives

EMS HISTORICAL PERSPECTIVES

58

impetus for attention to be turned to the devel-opment of EMS.87 This document pointed out thatthe American health care system was prepared toaddress an injury epidemic that was the leadingcause of death among persons between the agesof 1 and 37. It noted that, in most cases, ambu-lances were inappropriately designed, ill-equipped,and staffed with inadequately trained personnel;and that at least 50% of the nation’s ambulanceservices were being provided by 12,000 morticians.87

The paper made 29 recommendations for ul-timately improving care for injured victims; 11related directly to out-of-facility EMS. They were:87

Extension of basic and advanced first aid trainingto greater numbers of the lay public;

Preparation of nationally acceptable texts, trainingaids, and courses of instruction for rescue squadpersonnel, policemen, firemen, and ambulanceattendants;

Implementation of recent traffic safety legisla-tion to ensure completely adequate standardsfor ambulance design and construction, forambulance equipment and supplies, and for thequalifications and supervision of ambulance per-sonnel;

Adoption at the state level of general policiesand regulations pertaining to ambulance services;

Adoption at district, county, and municipal levelsof ways and means of providing ambulanceservices applicable to the conditions of the locality,control and surveillance of ambulance services,and coordination of ambulance services withhealth departments, hospitals, traffic authori-ties, and communication services;

Pilot programs to determine the efficacy of pro-viding physician-staffed ambulances for care atthe site of injury and during transportation;

Initiation of pilot programs to evaluate auto-motive and helicopter ambulance services insparsely populated areas and in regions wheremany communities lack hospital facilities ad-equate to care for seriously injured persons;

Delineation of radio frequency channels and ofequipment suitable to provide voice communi-cation between ambulances, emergency depart-ment, and other health-related agencies at thecommunity, regional, and national levels;

Pilot studies across the nation for evaluation ofmodels of radio and telephone installations toensure effectiveness of communication facilities;

Day to day use of voice communication facili-ties by the agencies serving emergency medi-cal needs; and

Active exploration of the feasibility of designatinga single nationwide telephone number to sum-mon an ambulance.

In the same year, the Highway Safety Act of1966 which established the Department of Trans-portation (DOT) was passed.91 The DOT was givenauthority to improve EMS, including program imple-mentation and development of standards for pro-vider training. States were required to developregional EMS systems, and costs of these systemswere funded by the Highway Safety Program. Overthe next 12 years the DOT contributed more than$142 million for EMS system development.86

The Highway Safety Act of 1966 included fundsto create an appropriate training course for emer-gency care providers, as recommended in AccidentalDeath and Disability: The Neglected Disease , and thefirst nationally recognized EMT-A curriculum waspublished in 1969. Shortly thereafter paramedic edu-cation began, but training focused heavily on cardiaccare and cardiac arrest resuscitation, almost to theexclusion of other problems. Although national cur-ricula have been developed and revised, trainingstandards and certification requirements have con-tinued to vary significantly in communities through-out the nation.

In 1972 the Department of Health, Education,and Welfare allocated $16 million to EMS dem-onstration programs in five states. Funds were usedto develop regional EMS systems. In 1973, The RobertWood Johnson Foundation appropriated $15 mil-lion to fund 44 EMS projects in 32 states and PuertoRico.

Title XII to the Public Health Service Act, TheEmergency Medical Services Systems Act of 1973 , pro-vided additional federal guidelines and fundingfor the development of regional EMS systems.33 Intotal, more than $300 million were appropriatedfor EMS feasibility studies and planning, opera-tions, expansion and improvement, and research.86By1978, states had identified 304 EMS regions. Thelaw established that there should be 15 components


59

of the EMS systems. They are commonly referredto as:

Manpower

Training

Communications

Transportation

Facilities

Critical care units

Public safety agencies

Consumer participation

Access to care

Patient transfer

Coordinated patient record keeping

Public information and education

Review and evaluation

Disaster plan

Mutual aid

Funding under the EMS Systems Act essentiallyended with the Omnibus Budget Reconciliation Actof 1981 , which consolidated EMS funding into statepreventive health and health services block grants.Thus, states gained greater discretion in fundingstatewide EMS activities and regional EMS systems,and many of the regional EMS management en-tities established by federal funding quickly dis-solved. Others continued, becoming more the partof technical assistants and enablers while seekingimproved EMS quality.

The development of emergency medicine as amedical specialty has paralleled that of EMS. Thefirst residency program to train new physiciansexclusively for the practice of emergency medicinewas established in 1972 at the University of Cin-cinnati. By 1975 there were 32 such programs, andthere are currently 112 accredited emergency medi-cine residency programs graduating in excess of800 emergency medicine physicians each year. Sincethe late 1970s, pediatric emergency medicine fel-lowships have provided physicians with special-ized training in the management of childhoodemergencies. Pediatric emergency medicine becameofficially recognized as a subspecialty of pediat-rics and emergency medicine in 1992. To varying

degrees, emergency physicians in training areexposed to the principles and practices of provid-ing medical direction for EMS systems, and theSociety of Academic Emergency Medicine has pub-lished a model EMS education curriculum forphysicians.98,129 Although emergency physiciansoften fulfill the medical direction needs of EMSsystems, other groups of physicians continue tosignificantly and positively influence EMS. Theyinclude pediatricians, cardiologists, surgeons,intensivists, family practitioners, and others.

Efforts to improve EMS care for specific groupsof patients have included development and suc-cessful implementation of standardized courses ascomponents of EMS curricula or to supplement per-sonnel education in focused areas. These includecardiac, pediatric, and trauma life support courses.

The American Heart Association, throughadoption and promotion of the “Chain of Survival”concept, has provided leadership to improve emer-gency cardiac care.31 It continues to explore waysto increase survival from cardiac emergencies.30

Federal legislation established the EmergencyMedical Services for Children (EMS-C) programin 1984, as issues relating to children’s emergencycare required attention.113,114 Emergency Medical Ser-vices for Children projects have represented thelargest federal funding outlay for EMS develop-ment since consolidation of funds in block grants.During the first 10 years of the EMS-C program,the Maternal and Child Health Bureau (MCHB) ofthe Health Resources and Services Administration(HRSA) funded projects in 40 states, Puerto Rico,and the District of Columbia.39 Project efforts haveinvolved systems development, injury prevention,research and evaluation, improved training andeducation, and other aspects of EMS. The resultshave been EMS improvements benefitting not onlychildren, but the entire population. The programcommissioned the 1993 Institute of Medicine Re-port, Emergency Medical Services for Children whichpointed out continuing deficiencies in our healthcare system’s abilities to address the emergencymedical needs of pediatric patients.27 It noted thatin 1988, 21,000 people under the age of 20 diedfrom injuries; thousands more were hospitalizedand millions more were treated in emergencydepartments.27 The report indicated that althoughEMS systems and emergency departments are widelyassumed to be equally capable of caring for chil-


60

dren and adults, this is not always the case. Fortoo many children important resources were notavailable when needed. The EMS-C program con-tinues to work to ensure that pediatric issues arebetter integrated into the EMS system.26,27,134

In 1985, the National Research Council’s In-jury in America: A Continuing Public Health Prob-lem described deficiencies in the progress ofaddressing the problem of accidental death anddisability.93 Development of trauma care systemsbecame a renewed focus of attention with passageof the Trauma Care Systems Planning and Devel-opment Act of 1990.132 HRSA Division ofTraumaand EMS (DTEMS) was created to administer thislegislation, which supported the concept of a traumasystem that addresses the needs of all injured patientsand matches them to available resources. The actencouraged the establishment of inclusive traumasystems and called for the development of a modeltrauma care system plan, which was completed in1992.83 More inclusive trauma care better servesthe population’s needs.63,108 Local EMS authori-ties assumed responsibility for establishing traumasystems and designating trauma centers in an effortto improve care for trauma victims.2 However, onesurvey concluded that by 1993 only five states metcriteria for having a complete trauma system.10 Al-though interest in developing inclusive trauma caresystems remains, DTEMS was disbanded in 1995.

The National Highway Traffic Safety Admin-istration implemented a statewide EMS technicalassessment program in 1988. During assessments,statewide EMS systems are evaluated based on 10essential components.92 They are:

Regulation and policy

Resource management

Human resources and training

Transportation

Facilities

Communications

Public information and education

Medical direction

Trauma systems

Evaluation

It is impossible to overestimate the influenceof the media on the evolution of EMS. In 1971,the television program “Emergency” caught theattention of the country — it was visionary in itself.The program suggested to the public that para-medics existed everywhere. In reality, they did not.Additionally, it portrayed paramedics as frequentlifesavers when they were part of an integratedEMS system. In reality, they did save lives, thoughnot as readily. The vision continues in current pro-grams such as “Rescue 911”, where all callers dial“911” for help and all calls are answered by per-sonnel able to provide lifesaving instructions overthe telephone. In fact, much of the country can-not access EMS help by calling “911” and pre-ar-rival instructions are not uniformly provided. Asin the 1970s, the media continues to create publicinterest and effect perception and expectations re-garding EMS. Responses to the public’s expecta-tions may secondarily prompt EMS system changes.However, the value of the media’s effect is un-certain. While the media might hasten change, wecannot be certain that the changes created are thosethat would have been chosen had the impetus beendifferent.


61

The need for the EMS Agenda for the Futurewas initially recognized in 1992 by the Na-tional Association of EMS Physicians

(NAEMSP) and the National Association of StateEMS Directors (NASEMSD). A project task forcewith members from several organizations first metin 1993. In January 1994, the National EMS Alli-ance also expressed support for the project. Ac-tual work on the document began in June 1995,after the National Highway Traffic Safety Admin-istration (NHTSA) and the Maternal and ChildHealth Bureau (MCHB) of the Health Resourcesand Services Administration (HRSA) authorizedfunding for the project.

The process used to develop the EMS Agendafor the Future was a modification of the NationalInstitutes of Health (NIH) Technology Assessmentand Practice Guidelines Forum.99 Initial drafts ofthe EMS Agenda for the Future were prepared bya steering committee, whose expertise was derivedfrom diverse backgrounds and EMS-related expe-riences (Appendix G). The steering committee firstmet in July 1995 in Big Sky, Montana. The first draftof the document was completed, and the commit-tee met again in August 1995 in Pittsburgh, Penn-sylvania to make revisions and begin a second draft.Additional steering committee meetings were heldin October and December 1995 and March 1996 torevise the Agenda in accordance with commentsreceived during peer review processes.

As part of its mission, the steering committeesought the broadest possible input from EMS stake-holders. The second draft was sent to 500 EMS-interested organizations and individuals for peer

review. Of these, 178 reviewers supplied commentsvia peer review forms or telephone calls. Thesecomments were analyzed by the steering commit-tee and subsequent revisions to the Agenda werediscussed at a Blue Ribbon Conference.

The EMS Agenda for the Future Blue RibbonConference was held on December 1-3, 1995, inMcLean, Virginia. One hundred and thirty-threeindividuals participated (Appendix I). Followingopening remarks by Dr. Ricardo Martinez and Dr.Jean Athey, steering committee members presentedbackground information and individual sectionsof the draft document. After listening to three tofive section presentations, conference participantsattended breakout sessions to further review theindividual document sections and provide feed-back. A facilitator was assigned to each breakoutsession, and one to three steering committeemembers also attended each session. Thirty-twobreakout sessions were held, each addressing aspecific section of the draft document. In a gen-eral session at the end of the conference, facilita-tors provided an overview of feedback receivedduring their breakout sessions.

The steering committee met after the Blue RibbonConference to incorporate participants’ feedback.The revised draft was sent to the Blue RibbonConference participants in mid-February for theirfinal comments. These were reviewed and finalchanges were made during the last steering com-mittee meeting on March 5-7, 1996. The EMS Agendafor the Future was submitted NHTSA and MCHBon April 16, 1996.

Appendix B EMS Agenda for the Future: Development of the Agenda

DEVELOPMENT OF THE AGENDA

62

HOW TO GET “WHERE WE WANT TO BE”Integration of Health Services

Expand the role of EMS in public health �

Involve EMS in community health monitoringactivities

Integrate EMS with other health care providersand provider networks

Incorporate EMS within health care networks’structure to deliver quality care

Be cognizant of the special needs of the entirepopulation

Incorporate health systems within EMS thataddress the special needs of all segments ofthe population

EMS ResearchAllocate federal and state funds for a major EMSsystems research thrust

Develop information systems that provide linkagebetween various public safety services and otherhealth care providers

Develop academic institutional commitments toEMS-related research

Interpret informed consent rules to allow forclinical and environmental circumstances inherentin conducting credible EMS research

Develop involvement and/or support of EMSresearch by all those responsible for EMS struc-ture, processes, and/or outcomes

Designate EMS as a physician subspecialty, anda subspecialty for other health professions

Include research related objectives in the educa-tion processes of EMS providers and managers

Enhance the quality of published EMS research

Develop collaborative relationships betweenEMS systems, medical schools, other aca-demic institutions, and private foundations

Legislation and RegulationAuthorize and sufficiently fund a lead federalEMS agency

Pass and periodically review EMS enabling leg-islation in all states that supports innovationand integration, and establishes and sufficientlyfunds a EMS lead agency

Enhance the abilities of state EMS lead agen-cies to provide technical assistance

Establish and fund the position of State EMSMedical Director in each state

Authorize state and local EMS lead agencies toact on the public’s behalf in cases of threats tothe availability of quality EMS to the entire popu-lation

Implement laws that provide protection fromliability for EMS field and medical direction per-sonnel when dealing with unusual situations

System FinanceCollaborate with other health care providers andinsurers to enhance patient care efficiency

Develop proactive financial relationships betweenEMS, other health care providers, and health careinsurers/provider organizations

Compensate EMS on the basis of a prepared-ness-based model, reducing volume-related in-centives and realizing the cost of an emergencysafety net

Provide immediate access to EMS for emergencymedical conditions

Address EMS relevant issues within governmentalhealth care finance policy

Commit local, state, and federal attentionand funds to continued EMS infrastructuredevelopment

Appendix C EMS Agenda for the Future: Summary of Recommendations

SUMMARY OF RECOMMENDATIONS

63

Human ResourcesEnsure that alterations in expectations of EMSpersonnel to provide health care services are pre-ceded by adequate preparation

Adopt the principles of the national EMS Edu-cation and Practice Blueprint

Develop a system for reciprocity of EMS pro-vider credentials

Develop collaborative relationships between EMSsystems and academic institutions

Conduct EMS occupational health research

Provide a system for critical incident stressmanagement

Medical DirectionFormalize relationships between all EMS sys-tems and medical directors

Appropriate sufficient resources for EMS medicaldirection

Require appropriate credentials for all those whoprovide on-line medical direction

Develop EMS as a physician and nurse subspe-cialty certification

Appoint state EMS medical directors

Education SystemsEnsure adequacy of EMS education programs

Update education core content objectives fre-quently enough so that they reflect patient EMShealth care needs

Incorporate research, quality improvement, andmanagement learning objectives in higher levelEMS education

Commission the development of national corecontents to replace EMS program curricula

Conduct EMS education with medical direction

Seek accreditation for EMS education programs

Establish innovative and collaborative relation-ships between EMS education programs and aca-demic institutions

Recognize EMS education as an academic achieve-ment

Develop bridging and transition programs

Include EMS-related objectives in all health pro-fessions’ education

Public EducationAcknowledge public education as a criticalactivity for EMS

Collaborate with other community resourcesand agencies to determine public education needs

Engage in continuous public education programs

Educate the public as consumers

Explore new techniques and technologies forimplementing public education

Evaluate public education initiatives

PreventionCollaborate with community agencies andhealth care providers with expertise andinterest in illness and injury prevention

Support the Safe Communities concept

Advocate for legislation that potentially resultsin injury and illness prevention

Develop and maintain a prevention-oriented at-mosphere within EMS systems

Include the principles of prevention and its rolein improving community health as part of EMSeducation core contents

Improve the ability of EMS to documentinjury and illness circumstances

Public AccessImplement 9-1-1 nationwide

Provide emergency telephone service for thosewho cannot otherwise afford routine telephoneservices

Ensure that all calls to a PSAP, regardless of theirorigins, are automatically accompanied by uniquelocation-identifying information

Develop uniform cellular 9-1-1 service thatreliably routes calls to the appropriate PSAP

Evaluate and employ technologies that attenu-ate potential barriers to EMS access

EMS Agenda for the Future: Summary of Recommendations Appendix C

64

Enhance the ability of EMS systems to triage calls,and provide resource allocation that is tailoredto patients’ needs

Communications SystemsAssess the effectiveness of various personnel andresource attributes for EMS dispatching

Receive all calls for EMS using personnel withthe requisite combination of education, experi-ence, and resources to optimally query the caller,make determination of the most appropriateresources to be mobilized, and implement aneffective course of action

Promulgate and update standards for EMS dis-patching

Develop cooperative ventures between commu-nications centers and health providers to inte-grate communications processes and enable rapidpatient-related information exchange

Determine the benefits of real-time patient datatransfer

Appropriate federal, state, and regional fundsto further develop and update geographicallyintegrated and functionally-based EMS commu-nications networks

Facilitate exploration of potential uses of advanc-ing communications technology by EMS

Collaborate with private interests to effectshared purchasing of communication tech-nology

Clinical CareCommit to a common definition of what con-stitutes baseline community EMS care

Subject EMS clinical care to ongoing evaluationto determine its impact on patient outcomes

Employ new care techniques and technology onlyafter shown to be effective

Conduct task analyses to determine appropri-ate staff configurations during secondary pa-tient transfers

Eliminate patient transport as a criterion for com-pensating EMS systems

Establish proactive relationships between EMSand other health care providers

Information SystemsAdopt uniform data elements and definitionsand incorporate them into information systems

Develop mechanisms to generate and transmitdata that are valid, reliable, and accurate

Develop information systems that are able todescribe an entire EMS event

Develop integrated information systems withother health care providers, public safety agencies,and community resources

Provide feedback to those who generatedata

EvaluationDevelop valid models for EMS evaluations

Evaluate EMS effects for multiple medical con-ditions

Determine EMS effects for multiple outcomecategories

Determine EMS cost-effectiveness

Incorporate consumer input in evaluation pro-cesses

Appendix C EMS Agenda for the Future: Summary of Recommendations

65

Academic Based upon formal education; scholarly; conventional.

Academic Institution A body or establishment instituted for an educational purpose andproviding college credit or awarding degrees.

Accreditation The granting of approval by an official review board after specificrequirements have been met.

Advanced Directive Written instructions by an individual providing directions to medi-cal personnel in the event of critical illness with regard to the ex-tent of resuscitative measures to be pursued.

Air Medical Transport Emergency transport via rotor or fixed wing aircraft; may be fromthe scene (primary transport) or interfacility (secondary transport).

Automatic Vehicle Location Technology or method used to track or determine a vehicle’s loca-tion or position and report the position, usually by radio, to a com-munications or command center. Methods include geo- positioningsatellite (GPS), electronic sensed sign-posts, loran navigation, andinertial guidance computer mapped systems.

Bridging Program An abbreviated educational program resulting in credentials thatbuild on prior credentials in a related field; EMT certification forregistered nurses.

Bystander A citizen responder, not part of the EMS response team, on thescene of an illness or injury incident irrespective of training.

Chain of Survival The four components of EMS response to out-of-facility cardiacarrest that are thought to effect the most optimal patient outcome.The four components include early recognition and EMS access,early CPR, rapid defibrillation, and advanced life support.

Command and Control Center (Central Communications Center) - A place where responsibilityrests for establishing communications channels and identifying thenecessary equipment and facilities to permit immediate manage-ment and control of an EMS patient. This operation provides accessand availability to public safety resources essential for efficientmanagement of the immediate EMS problem.

Communication The act of communicating. The exchange of thoughts, messages orinformation, as by speech, signals, writing or behavior. The art andtechnique of using words effectively and with grace in impartingone’s ideas. Something communicated; a message.

Communications A means of communicating, especially: a system, such as mail, tele-phone, television or radio, for sending and receiving messages. Anetwork of routes or systems for sending messages. The technologyemployed in transmitting messages.

Community Health Resource Capability that may be offered within a neighborhood or commu-nity to aid in the detection, surveillance, and support of commu-nity health. This may include a municipal organization such as thefire service or EMS, department of public health, social service or-ganization, volunteer organization, and others.

Appendix D EMS Agenda for the Future: Glossary

GLOSSARY

66

Component An individual element, aspect, subgroup, or activity within a sys-tem. Complex systems (such as EMS) are composed of many com-ponents.

Computerized Record Data maintained on computer for easy access, manipulation, refine-ment and review.

Core Content The central elements of a professional field of study and relationsinvolved; does not specify the course of study.

Cost-effective Providing the maximal improved health care outcome improvementat the least cost.

Cost-effective Analysis that determines the costs and effectiveness of an interven-tion or system. This includes comparing similar alternative activi-ties to determine the relative degree to which they obtain thedesired objective or outcome. The preferred alternative is the onethat requires the least cost to produce a given level of effectivenessor provides the greatest effectiveness for a given level of cost.

Credentialing Agency Organization which certifies an institution’s or individual’s author-ity or claim to confidence for a course of study or completion ofobjectives.

Curriculum A particular course of study, often in a special field. For EMS edu-cation it has traditionally included detailed lesson plans.

Customary Charge The amount that an individual company charges in the majority ofclaims for a specific item or service.

Data Crude, isolated, nonanalyzed measures that reflect the status ordegree of a measured attribute of a component or system.

Educational Affiliation An association with a learning institution(s) (academic), the extentof which can vary greatly from recognition to integration.

Educational Objective The outcome/goal of the teaching/training conducted; the desiredknowledge to be imparted.

Effective Capable of producing or designed to produce a particular desired�effect in “real world” circumstances.

Efficacy The effect of an intervention or series of interventions on patientoutcome in a setting that is most likely to be positive (e.g., thelaboratory or other “perfect” settings).

Efficiency The effect or results achieved in relation to the effort expended(resources, money, time). It is the extent to which the resourcesused to provide an effective intervention or service are minimized.Thus, if two services are provided that are equally effective, butone requires the expense of fewer resources, that service is said tobe more efficient.

Emergency Medical The function of providing prompt and accurate processing of calls,for emergency medical assistance by trained individuals, using amedically approved dispatch protocol system and functioning un-der medical supervision.

Analysis

Dispatch

EMS Agenda for the Future: Glossary Appendix D

67

Emergency Medical A trained public safety telecommunicator with additional trainingand specific emergency medical knowledge essential for the effi-cient management of emergency medical communications.

Emergency Medical A member of the emergency medical services team who providesout-of-facility emergency care; includes certifications of EMT-Basic,EMT-Intermediate, and EMT-Paramedic progressively advancinglevels of care.

Emergency Physician A physician specialized in the emergency care of acutely ill or in-jured patients.

EMS Personnel Paid or volunteer individuals who are qualified, by satisfying for-malized existing requirements, to provide some aspect of care orservice within the EMS system.

EMS Physician A physician with specialized knowledge and skills in the area ofemergency medical services, including clinical care and systemsmanagement; a physician who specializes in emergency medicalservices system management, in which the provision of direct pa-tient care is only one component.

EMS Protocol Written medical instructions or algorithms authorized by an EMSmedical director to be used by personnel in the field without thenecessity of on-line or real-time consultation with the physician ornurse providing medical direction.

EMS System Any specific arrangement of emergency medical personnel, equip-ment, and supplies designed to function in a coordinated fashion.May be local, regional, state, or national.

Enabling EMS Legislation Law that grants authority to specific entities to undertake activityrelated to the provision or establishment of an EMS system. Gener-ally, enabling legislation represents a legislature’s delegation ofauthority to a state agency to regulate some or all aspects of anEMS delivery system. This may include technical support, funding,or regulation.

Episodic care An acute, relatively brief, intervention representing a segment ofcontinuous health care experience.

Expanded Role/Expanded Scope Increased dimensions of the services, activities, or care provided byEMS.

Federal Communications A board of five commissioners appointed by the president underCommission (FCC) the Communications Act of 1934 to formulate rules and regulations

and to authorize use of radio communications. The FCC regulatesall communications in the United States by radio or wireline, in-cluding television, telephone, radio, facsimile, and cable systems,and maintains communications in accordance with applicable trea-ties and agreements to which the United States is a party.

First Responder The initial level of care within an EMS system as defined by theEMS Education and Practice Blueprint, as opposed to a bystander.

Dispatcher (EMD)

Technician (EMT)


68

Health Care Delivery System A specific arrangement for providing preventive, remedial, andtherapeutic services; may be local, regional, or national.

Health Care Facility A site at which dedicated space is available for the delivery ofhealth care. This may include physicians’ offices and urgent carecenters, as well as hospitals and other medical facilities.

Health Care Provider Network Conglomerate of both community and hospital resources participat-ing in a common contractual agreement to provide all health careneeds to individual members of society.

Information A combination of data, usually from multiple sources, used to de-rive meaningful conclusions about a system (health resources, costs,utilization of health services, outcomes of populations, etc.). Infor-mation cannot be developed without crude data. However, datamust be transformed into information to allow decision makingthat improves a given system.

Informed Consent Voluntary consent by a given subject, or by a person responsiblefor a subject, for participation in an investigation, treatment pro-gram, medical procedure, etc., after being informed of the purpose,methods, procedures, benefits, and potential risks. Awareness ofrisk is necessary for any subject to make an informed choice.

Infrastructure The basic facilities, equipment, services, and installations neededfor functioning; the substructure, components, or underlying foun-dation of a community or system.

Injury Control A systematic approach to preventing and mitigating the effects ofall injuries.

Injury Prevention Activities to keep injuries from ever occurring (primary), or reduc-ing further injury once it has occurred through acute care (second-ary) and rehabilitation (tertiary).

Legislation Lawmaking; the procedure of legislating; law or laws made by sucha procedure.

Licensing The act of granting an entity permission to do something which theentity could not legally do absent such permission. Licensing isgenerally viewed by legislative bodies as a regulatory effort to pro-tect the public from potential harm. In the health care deliverysystem, an individual who is licensed tends to enjoy a certainamount of autonomy in delivering health care services. Conversely,the licensed individual must satisfy certain initial proficiency crite-ria and may be required to satisfy ongoing requirements whichassure certain minimum levels of expertise. A license is generallyconsidered a privilege and not a right.

Linkage Connected; combining crude data from various sources to provideinformation that can be analyzed. This analyzed information allowsmeaningful inferences to be made about various aspects of a sys-tem. (An example would be linking EMS dispatch records, out-of-hospital patient care records, and hospital discharge data.)


69

Medicaid A federal program, administered by the states, designed to providehealth care coverage to the indigent. Established by Title XIX of theSocial Security Act.

Medical Direction The provision of management, supervision, and guidance for allaspects of EMS to assure its quality of care.

Medical Director The physician who has the ultimate responsibility and authority toprovide management, supervision, and guidance for all aspects ofEMS in an effort to assure its quality of care (may be on a local,regional, state, and national level).

Medical Facility A stationary structure with the purpose of providing health careservices (e.g., hospital, emergency department, physician office, andothers).

Medical Oversight The ultimate responsibility and authority for the medical actions ofan EMS system.

Medicare A federal program designed to provide health care coverage to in-dividuals 65 and over. Established on July 30, 1965, by Title XVIIIof the Social Security Act.

Network A formal system linking multiple sites or units.

Noninvasive Monitoring Measurement/scanning accomplished without penetrating the vis-cera or superficial tissues.

On-line Medical Direction The moment-to-moment contemporaneous medical supervision/guidance of EMS personnel in the field, provided by a physician orother specialty qualified health professional (e.g., mobile intensivecare nurse), via radio transmission, telephone, or on the scene.

Out-of-facility EMS Remote from a medical facility. In the case of EMS it pertains tothose components of the emergency health care delivery systemthat occur outside of the traditional medical settings (e.g.,prehospital care, transportation, and others).

Outcome The short, intermediate, or long-term consequence or visible resultof treatment, particularly as it pertains to a patient’s return to soci-etal function.

Perceived Emergent Need A medical condition for which a prudent layperson possessing anaverage knowledge of health care believes there is a necessity ofrapid medical treatment.

Personnel Configuration Specific way of staffing or organizing members of the work force.

Pilot Project A systematic planned undertaking which serves as an experimentalmodel for others to follow.

Preparedness Based Payment Reimbursing EMS agencies for the cost of being prepared to re-spond to an emergency.

Prevailing Charge The amount that falls within the range of charges most frequentlybilled in the locality for a particular service.

Protocol The plan for a course of medical treatment; the current standard ofmedical practice.


70

Provider An individual within an EMS system with a specific credential(s)that defines a specific level of competency (i.e., first responder,EMT- Basic, EMT-Intermediate, EMT-Paramedic, or other).

Public Education Activities aimed at educating the general public concerning EMSand health related issues.

Public Health The science of providing protection and promotion of communityhealth through organized community effort.

Public Safety Answering A facility equipped and staffed to receive and control 9-1-1 emer-gency telephone calls.

Public Safety An individual trained to communicate remotely with persons seek-ing emergency assistance, and with agencies and individuals pro-viding such assistance.

Real-time Patient Data Current patient information provided by a field technician at thepatient location to a physician or health care facility at a remotesite, potentially for the purpose of assisting the physician to makea better informed decision on patient treatment and/or transport.–

Reciprocity The ability for a license or certificate to be mutually interchange-able between jurisdictions.

Regional EMS System A systematic approach to the delivery of Emergency Medical Ser-vices defined by distinct geographic boundaries that may or maynot cross state boundaries.

Regulation Either a rule or a statute which prescribes the management, gover-nance, or operating parameters for a given group; tends to be afunction of administrative agencies to which a legislative body hasdelegated authority to promulgate rules/regulations to “regulate agiven industry or profession. Most regulations are intended to pro-tect the public health, safety and welfare.

Reimbursement To compensate; to repay.

Research The study of questions and hypotheses using the scientific method.

Safe Communities An integrated injury control system—incorporating prevention,acute care, and rehabilitation—to understand and solve injury prob-lems, and identify new partners to help develop and implementsolutions.

Scope of Practice Defined parameters of various duties or services which may beprovided by an individual with specific credentials. Whether regu-lated by a rule, statute, or court decision, it tends to represent thelimits of what services an individual may perform.

Stabilizing Care The medical attention needed to achieve physical equilibrium in aperson.

Standardized Nomenclature An authoritative system of designated names for a specific item orconfiguration.

State-of-the-art The highest use of technology or technique known at the time.

Point (PSAP)

Telecommunicator


71

Statute An act of a legislative body which has been adopted pursuant toconstitutional authority, by certain means and in such form that itbecomes a law governing conduct or actions.

Subscription Program A prepayment program; a prepayment made to secure futureevents; a prepayment made to secure a reduced ambulance billeither through assignment or discount. Must be actuarially sound.

System Preparedness Efforts necessary to ensure the readiness to provide a specific stan-dard of care.

Systems Analysis The research discipline that evaluates efficacy, effectiveness, andefficiency based upon all relevant components that contribute to asystem. This entails the examination of various elements of a sys-tem to ascertain whether the proposed solution to a problem willfit into the system and, in turn, effect an overall improvement inthe system.

Telephone Aid Ad-libbed telephone instructions provided by either trained or un-trained dispatchers, differing from “dispatch life support pre-ar-rival instructions in that the instructions provided to the caller arebased on the dispatcher ’s knowledge or previous training in a pro-cedure or treatment without following a scripted pre-arrival in-struction protocol. They are not medically pre-approved since theydo not exist in written form.

Telephone Treatment Protocol Specific treatment strategy designed in a conversational script for-mat that direct the EMD step-by-step in giving critical pre-arrivalinstructions such as CPR, Heimlich maneuver, mouth-to-mouthbreathing, and childbirth instruction.

Third Party Payor Insurance; an entity which is responsible to pay for services eventhough it is not directly involved in the transaction.


72

ACLS Advanced Cardiac Life Support

ACS American College of Surgeons

ALI Automatic Location Identity

ANI Automatic Number Identity

AVL Automatic Vehicle Location

CB Citizens Band

CPR Cardiopulmonary resuscitation

DOT Department of Transportation

DTEMS Division of Trauma and EMS

ECG Electrocardiogram

EMD Emergency Medical Dispatcher

EMS Emergency Medical Services

EMS-C Emergency Medical Services for Children

EMSS Act Emergency Medical Services Systems Act

EMT Emergency Medical Technician

FCC Federal Communications Commission

GPS Geopositioning satellite

HCFA Health Care Finance Administration

HRSA Health Resources & Services Administration

HSA Highway Safety Act

ISS Injury Severity Score

MCHB Maternal & Child Health Bureau

MCO Managed Care Organization

MICN Mobile Intensive Care Nurse

NAEMSP National Association of EMS Physicians

NAS National Academy of Sciences

NHAAP National Heart Attack Alert Program

NHTSA National Highway Traffic Safety Administration

NRC National Research Council

NREMT National Registry of Emergency Medical Technicians

PSAP Public Safety Answering Point

UHF Ultra High Frequency

USFA U.S. Fire Administration

VHF Very High Frequency

YPLL Years of Potential Life Lost

Appendix E EMS Agenda for the Future: List of Abbreviations

LIST OF ABBREVIATIONS

73

1. Adams EL, Trumble P: Nurses. In Kuehl AE (ed): Prehospital Systems and Medical Oversight. 2d ed., St. Louis: Mosby-Year Book, Inc., 1994, 307-315.

2. American College of Emergency Physicians: Guidelines for trauma care systems. Ann Emerg Med 1993;22:1079-1100.

3. American College of Emergency Physicians: Minimum pediatric prehospital equipment guidelines. ACEP PolicyStatement, approved October 1991.

4. American College of Emergency Physicians: Prehospital advanced life support skills, medications, and equip-ment. Ann Emerg Med 1988;17:1109-1111.

5. American College of Surgeons Committee on Trauma: Quality assessment and assurance in trauma care. Bull AmColl Surgeons 1986;71:4-23.

6. Anderson TE, Arthur K, Kleinman M, et al: Intraosseous infusion: Success of a standardized regional trainingprogram for prehospital advanced life support providers. � � Ann Emerg Med 1994;23:52-55.

7. ASTM Committee F-30 on Emergency Medical Services: ASTM Standards on Emergency Medical Services. Philadel-phia: ASTM, 1994.

8. Baker SP, O’Neill B, Ginsburg MJ, Guohua L: The Injury Fact Book, 2d ed. New York: Oxford University Press,1992.

9. Baxt WG, Moody P: The impact of the physician as part of the aeromedical prehospital team in patients withblunt trauma. JAMA 1987;257:3246-3250.

10. Bazzoli GJ, Madura KJ, Cooper GF, MacKenzie EJ, Maier RV: Progress in the development of trauma systemsin the United States: Results of a national survey. JAMA 1995;273:395-401.

11. Beaton RD, Murphy SA: Sources of occupational stress among firefighters/EMTs and firefighters/paramedics andcorrelations with job related outcomes. Prehosp Disaster Med 1993;8:140-149.

12. The Bible, Luke 10:34.

13. Brewer LA: Baron Larrey 1766-1862. J Thorac Cardio Vasc Surg 1986;92:1096-1098.

14. Cady G, Scott T: EMS in the United States 1995 Survey of providers in the 200 most populous cities. JEMS 1995;20(1):78.

15. Cayten CG: Evaluation. In Kuehl AE (ed): Prehospital Systems and Medical Oversight. 2d ed., St. Louis: Mosby-Year Book, Inc., 1994, 158-167.‘

16. Cayten CG, Staroccik R, Walker K, et al: Impact of prehospital cardiac algorithms on ventricular fibrillation survivalrates. Ann Emerg Med 1981;10:432-436.

17. Clark JJ, Culley L, Eisenberg M, Henwood DK: Accuracy of determining cardiac arrest by emergency medicaldispatchers. Ann Emerg Med 1994;23:1022-1026

18. Clawson JJ: Emergency medical dispatch. In Kuehl AE (ed): Prehospital Systems and Medical Oversight. 2d ed.,St. Louis: Mosby-Year Book, Inc., 1994, 125-152.

19. Clawson JJ: Emergency medical dispatch. In Roush WR (ed): Principles of EMS Systems. Dallas: ACEP, 1994, 263-289.

20. Cooper A, Foltin G: Transport protocols. In McCloskey KAL, Orr RA (eds): Pediatric Transport Medicine. St. Louis:Mosby-Year Book, 1995, 463-473.

21. Cummins RO, Chamberlain DA, Abramson NS, et al: Recommended guidelines for uniform reporting of datafrom out-of-hospital cardiac arrest, the Utstein style. � � Ann Emerg Med 1991;20:861-874.

22. Cummins RO, Ornato JP, Thies WH, Pepe PE: Improving survival from sudden cardiac arrest: The chain of survivalconcept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and theEmergency Cardiac Care Committee, American Heart Association. Circulation 1991;83:1832-1847.

23. Cydulka RK, Emerman CL, Shade B, et al: Stress levels in EMS personnel: A longitudinal study with work schedulemodification. AEM 1994;1:240-246.

REFERENCES

Appendix F EMS Agenda for the Future: References

74

24. Delbridge TR, Paris PM: EMS Communications. In Roush WR (ed): Principles of EMS Systems. Dallas: ACEP,1994, 245-261.

25. Delbridge TR, Verdile VP, Platt TE: Variability of state-approved emergency medical services drug formularies.Prehosp Disaster Med 1994;9:S55.

26. Dieckmann RA, Schafermeyer RW: EMS for Children. In Roush WR (ed): Principles of EMS Systems. Dallas:ACEP, 1994, 51-82.

27. Durch JS, Lohr KN (eds): Emergency Medical Services for Children. Washington, D.C.: National Academy Press,1993.

28. Eisenberg M, Hallstrom A, Becker L: Community awareness of emergency phone numbers. Am J Publ Health1981;71:1058-1060.

29. Eisenberg MS, Horwood BT, Cummins RO: Cardiac arrest and resuscitation: A tale of 29 cities. Ann Emerg Med1990;19:179-186.

30. Emergency Cardiac Care Committee and Subcommittees, American Heart Association: Guidelines for Cardio-pulmonary Resuscitation in Emergency Cardiac Care, III: Adult Advanced Cardiac Life Support. JAMA 1992;268:2199-2241.

31. Emergency Cardiac Care Committee and Subcommittees, American Heart Association: Guidelines for Cardio-pulmonary Resuscitation in Emergency Cardiac Care, IX: Insuring effectiveness of community-wide emergencycardiac care. JAMA 1992;268:2289-2295.

32. Emergency Medical Dispatch National Standard Curriculum, Instructor’s Guide . Washington, D.C.: National High-way Traffic Safety Administration, 1996.

33. Emergency Medical Services Systems Act of 1973: Public Law 93-154, Title XII of the Public Health Service Act. Washington,D.C.: 1973.

34. Emergency Medical Technician: Basic, National Standard Curriculum. Washington, D.C., U.S. Department of Trans-portation, National Highway Traffic Safety Administration, 1994.

35. EMS Outcomes Evaluation: Key Issues and Future Directions, Proceedings from the NHTSA Workshop on Methodologiesfor Measuring Morbidity Outcomes in EMS. Washington, D.C.: National Highway Traffic Safety Administration,April 11-12, 1994.

36. Erder MH, Davidson SJ, Chaney RA: Online medical command in theory and practice. Ann Emerg Med 1989;18:261-288.

37. Essential equipment for ambulances. Am Coll Surg Bull 1983;68:36-38.

38. Federal Specifications for Ambulances: KKK-A-1822D. Washington, D.C.: Department of Transportation and GeneralServices Administration, 1994.

39. Feely HB, Athey JL: Emergency Medical Services for Children: Ten Year Report . Arlington, VA: National Center forEducation in Maternal and Child Health, 1995.

40. Fitch JJ: Volunteers. In Kuehl AE (ed): Prehospital Systems and Medical Oversight . 2d ed., St. Louis: Mosby-YearBook, Inc., 1994, 316-320.

41. Fletcher RH, Fletcher SW, Wagner EH: Clinical Epidemiology — The Essentials. Baltimore: Williams & Wilkins,1988.

42. Fontanarosa PB: Occupational issues for EMS personnel. In Roush WR (ed): Principles of EMS Systems . Dallas:ACEP, 1994, 411-431.

43. Fuchs S, LaCovey D, Paris P: A prehospital model of intraosseous infusion. Ann Emerg Med 1991;20:371-374.

44. Garrison HG, Benson NH, Whitley TW, Bailey BW: Paramedic skills and medications: Practice options utilizedby local advanced life support medical directors. Prehosp Disaster Med 1991;6:29-33.

45. Garrison HG, Brice JH, Evans AT: Prehospital interventions: An analysis of research design and patient outcomes.Prehosp Disaster Med 1992;7:165.

46. Garrison HG, Downs SM, McNutt RA, Griggs TR: A cost effectiveness analysis of pediatric intraosseous infusionas a prehospital skill. Prehosp Disaster Med 1992;7:221-226.

EMS Agenda for the Future: References Appendix F

75

47. Garrison HG, Foltin G, Becker L, et al: Consensus statement: The Role of Out-of-Hospital Emergency Medical Servicesin Primary Injury Prevention. Consensus Workshop on the Role of EMS in Injury Prevention, Arlington, VA, August25-26, 1995, Final Report.

48. Garza M (ed): Paramedics report many on-duty assaults. EMS Insider 1993;20(9):7.

49. Gershon RRM, Vlahov D, Kelen G, Conrad B, Murphy C: Review of accidents/injuries among emergency medicalservices workers in Baltimore, Maryland. Prehosp Disaster Med 1995;10:14-18.

50. Gerson LW, Hoover R, McCoy S, Palmisano B: Linking the elderly to community services. JEMS 1991; 16(6):45-48.

51. Gerson LW, Schelble DT, Wilson JE: Using paramedics to identify at-risk elderly. Ann Emerg Med 1992;21:688-691.

52. Gratton MC, Bethkey RA, Watson WA, et al: Effect of standing orders on paramedic scene time for trauma patients.Ann Emerg Med 1991;20:52-55.

53. Green LW, Kreuter M: Health Promotion Planning: An Educational and Environmental Approach. 2d ed. Mountainview,CA: Mayfield Publishing Co., 1991.

54. Hamman BL, Qcue JI, Miller FD, et al: Helicopter transport of trauma victims: Does a physician make a dif-ference? J Trauma 1991;31:490-494.

55. Harrawood D, Gunderson MR, Fravel S, Cartwright K, Ryan JL: Drowning prevention, a case study in EMS epi-demiology. � � JEMS 1994;19(6):34-41.

56. Hedges JR: Beyond Utstein: Implementation of a multi-source uniform database for prehospital cardiac arrestresearch. Ann Emerg Med 1993;22:41-46.

57. Ho MT, Eisenberg MS, Litwin PE, et al: Delay between onset of chest pain and seeking medical care: The effectof public education. Ann Emerg Med 1989;18:727-731.

58. Hockreiter MC, Barton LL: Epidemiology of needlestick injury in emergency medical service personnel. J EmergMed 1988;6:9-12.

59. Hoffman JR, Luo J, Schriger DL, et al: Does paramedic base hospital contact result in beneficial deviations fromstandard prehospital protocols? Western J Med 1989;153:283-287.

60. Hogya PT, Ellis L: Evaluation of the injury profile of personnel in a busy urban EMS system. Am J Emerg Med1990;8:308-311.

61. Hsiao AK, Hedges JR: Role of the emergency medical services system in region wide health monitoring and re-ferral. Ann Emerg Med 1993;22:1696-1702.

62. Hunt RC, Bass RR, Graham RG, et al: Standing orders vs. voice control. JEMS 1982;7:26-31.

63. Injury Control in the 1990s: A National Plan for Action—Trauma Care Systems. Atlanta: Centers for Disease Controland Prevention, 1993, 377-432.

64. Jolley S, Delbridge T: A description of the system wide application of transcutaneous cardiac pacing in an urbanEMS system. Prehosp Disaster Med 1995;10:S71.

65. Jones SE, Brenneis AT: Study design in prehospital trauma advanced life support — basic life support research:A critical review. Ann Emerg Med 1991;20:857-860.

66. Keller RA: 1992 EMS Salary Survey. JEMS 1992;17(11):62-73.

67. Kessner DM, Kalk CE, James S: Assessing health quality — the case for tracers. New Eng J Med 1973;288:189-194.

68. Kouwenhoven WB, Jude JR, Nickerbocker GG: Closed-chest cardiac message. JAMA 1960;173:1064-1067.

69. Krumperman KM: Filling the gap: EMS social service referrals. JEMS 1993;18(2):25-29.

70. Landis SS, Benson NH, Whitley TW: A comparison of four methods of testing emergency medical technician triageskills. Am J Emerg Med 1989;7:1-4.

71. Losek JD, Szewczuga D, Glaeser PW: Improved prehospital pediatric ALS care after an EMT-Paramedic clinicaltraining course. Am J Emerg Med 1994;12:429-432.

72. Lumpe D: Calling 911: Who will answer? Emerg Med News, April 1993.


76

73. MacLean CB: The future role of emergency medical services systems in prevention. Ann Emerg Med 1993;22:1743-1746.

74. Macnab AJ: Air medical transport: “Hot Air” and a French lesson. J Air Med Transport 1992;11(8):15-18.

75. Maio RF: Using cardiac arrest data to evaluate the EMS system. In Swor RA, Rottman SJ, Pirrallo RG, Davis E(eds): Quality Management in Prehospital Care. St. Louis: Mosby-Year–�Book, Inc., 1993, 233-239.

76. Maiava D: Personal Communication, February 1996.

77. Martinez R: Injury Prevention: A new perspective. JAMA 1994;19:1541-1542.

78. Mayron R, Long RS, Ruiz E: The 911 emergency telephone number: Impact on emergency medical systems accessin a metropolitan area. Am J Emerg Med 1984;2:491-493.

79. McNally VP: A history of the volunteers. Fire House 1986;11:49.

80. Menegazzi JJ: A meta-analysis of hepatitis B serologic marking prevalence in EMS personnel. Prehosp DisasterMed 1991;6:299-302.

81. Mitchell JT: Critical incident stress management. In Kuehl AE (ed): Prehospital Systems and Medical Oversight.2d ed., St. Louis: Mosby-Year Book, Inc., 1994, 239-344.

82. Mitchell J, Bray G: Emergency Services Stress: Guidelines for Preserving the Health and Careers of Emergency Per-sonnel � � . Englewood Cliffs, NJ: Brady Publishing-Prentice Hall, 1990.

83. Model Trauma Care System Plan. Rockville, MD: U.S. Department of Health and Human Services, Public HealthService, Health Resources and Services Administration, 1992.

84. Moses HW, Engelking N, Taylor GJ, et al: Effect of a two year public education campaign on reducing responsetime of patients with symptoms of acute myocardial infarction. Am J Cardiol 1991;68:249-251.

85. Munn B: Cellular phones and 911. Emerg Med Svcs 1987;16(8):12-14.

86. Mustalish AC, Post C: History. In Kuehl AE (ed): Prehospital Systems and Medical Oversight. 2d ed., St. Louis:Mosby-Year Book, Inc., 1994, 1-27.

87. National Academy of Sciences, National Research Council: Accidental Death and Disability: The Neglected Diseaseof Modern Society. Washington D.C.: National Academy Press, 1966.

88. National Association of EMS Physicians: Emergency medical dispatching. Prehosp Disaster Med 1989;4:163-166.

89. National Emergency Medical Services Education and Practice Blueprint . Columbus, OH: National Registry of Emer-gency Medical Technicians, 1993.

90. National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee: 9-1-1: Rapid iden-tification and treatment of acute myocardial infarction. Am J Emerg Med 1995;13:188-195.

91. National Highway Safety Act of 1966: Public Law 89-564. Washington, D.C.: 1966.

92. National Highway Traffic Safety Administration: EMS System Development: Results of the Statewide EMS Assess-ment Program. Washington, D.C.: U.S. Department of Transportation (DOT HS 808084), 1994.

93. National Research Council, Committee on Trauma Research: Injury in America: A Continuing Public Health Prob-lem. Washington, D.C.: National Academy Press, 1985.

94. Newman MM: Chain of survival takes hold. JEMS 1989;14(8):11-13.

95. Norton RL, Bartkus EA, Schmidt TA, et al: Survey of emergency medical technicians’ ability to cope with thedeaths of patients during prehospital care. Prehosp Disaster Med 1992;7:235-241.

96. Ogden JR, Criss EA, Spaite DW, Valenzuela TD: The impact of an EMS-initiated, community-based drowningprevention coalition on submersion deaths in a southwestern metropolitan area. Acad Emerg Med 1994;1(2):304.

97. Pantridge JF, Geddes JS: Cardiac arrest after myocardial infarctions. Lancet 1966;1:807-808.

98. Paris PM, Benson NH: Education about prehospital care during emergency education residency training: The resultsof a survey. Prehosp Disaster Med 1990;5:209-215.

99. Perry S, Wilkinson SL: The technology assessment practice guidelines forum: A modified group judgement method.Intl J Tech Assess in Health Care 1992;8:289-300.


77

100. Pointer JE, Osur MA: Effective standing orders on field times. Ann Emerg Med 1989;18:1119-1121.

101. Polk DA, Langford SJ: EMS degree programs. JEMS 1992;17(8):69-75.

102. Powell JP: Training for EMT/Paramedics in perinatal care and transport. J Tennessee Med Assoc 1982;75:133-134.

103. Reed E, Daya MR, Jui J, et al: Occupational infectious disease exposures in EMS personnel. J Emerg Med 1993;11:916.

104. Report to Congress on the Benefits of Safety Belts and Motorcycle Helmets. Washington, D.C.: National Highway TrafficSafety Administration, 1996.

105. Revicki DA, Whitley TW, Landis SS, Allison EJ: Organizational characteristics, occupational stress, and depres-sion in rural emergency medical technicians. J Rural Health 1988;4:73-83.

106. Robinson K: Development of ENA national standard guidelines for prehospital nursing curriculum. J Emerg Nursing1992;18:48-53.

107. Rosenberg M: Program Briefing to Dr. David Satcher, Director, Centers for Disease Control and Prevention. Atlanta,GA: CDC, March 13, 1996.

108. Sacra JC, Martinez R: Trauma Systems. In Roush WR (ed): � �Principles of EMS Systems . Dallas: ACEP, 1994, 25-50.

109. Safar P, Escarraga LA, Elam JO: A comparison of mouth-to-mouth and mouth-to-airway methods of artificialrespiration with the chest-pressure arm-lift methods. N Engl J Med 1958;258;671-677.

110. Safe Communities: An approach to reduce traffic injuries, discussion paper. Washington, D.C.: National Highway TrafficSafety Administration, September 24, 1995.

111. Schwartz RJ, Benson L, Jacobs LM: The prevalence of occupational injuries in EMTs in New England. PrehospDisaster Med 1993;8:45-50.

112. Schwartz RJ, Jacobs LM, Lee M: The role of the physician in a helicopter EMS system. Prehosp Disaster Med 1990;5:31-37.

113. Seidel JS: Emergency medical services and the pediatric patient: Are the needs being met? Training and Equip-ping Emergency Medical Services Providers for Pediatric Emergencies. Pediatrics 1986;78:808-812.

114. Seidel JS, Hornbein M, Youshiyama K, et al: Emergency medical services and the pediatric patient: Are the needsbeing met? Pediatrics 1984;73:769-772.

115. Senate Joint Memorial #44: Expanded-EMS Study. Albuquerque NM Department of Health, Emergency Medical Ser-vices Bureau, 1995.

116. Shackford SR, Mackersie RC, Hoyt DB, et al: Impact of a trauma system on outcome of severely injured patients.Arch Surg 1987;122:523-527.

117. Sklar D, Sapien R, Olson L, Monahan C: EMTs and Injury Prevention, Advocates for Children. Albuquerque NM:New Mexico EMS-C Project, 1995.

118. Snyder JA, Baren JM, Ryan SD, Chew JL, et al: Emergency medical service system development: Results of thestate-wide emergency medical service technical assessment program. Ann Emerg Med 1995;25:768-775.

119. Spaite DW, Criss EA, Valenzuela TD, Guisto J: Emergency medical service systems research: problems of thepast, challenges of the future. Ann Emerg Med 1995;26:146-152.

120. Spaite DW, Valenzuela TD, Meislin HW: Barriers to EMS system evaluation — problems associated with fielddata collection. Prehosp Disaster Med 1993;8:S35-S40.

121. Spaite DW, Valenzuela TD, Meislin HW, et al: Prospective validation of a new model for evaluating emergencymedical services systems by in-field observation of specific time intervals in prehospital care. Ann Emerg Med1993;22:638-645.

122. Stewart RD: The history of emergency medical services. In Roush WR (ed): Principles of EMS Systems. Dallas:ACEP, 1989.

123. Stewart RD: The history of emergency medical services. In Kuehl AE (ed): National Association of EMS PhysiciansEMS Medical Directors’ Handbook. St. Louis: CV Mosby, 1989, 3-6.

124. Stone KC, Benson NH: Specialty transport. In Roush WR (ed): Principles of EMS Systems . Dallas: ACEP, 1994,183-201.


78

125. Stout JL: System financing. In Roush WR (ed): Principles of EMS Systems. Dallas: ACEP, 1994, 451-473.

126. Stratton SJ: Triage by emergency medical dispatchers. Prehosp Disaster Med 1992;7:263-268.

127. Suter RE: Who calls the shots? EMS operations control and the role of the communication center. Prehosp DisasterMed 1992;7:396-399.

128. Swor R: Funding strategies. In Kuehl AE (ed): Prehospital Systems and Medical Oversight. 2d ed., St. Louis: Mosby-Year Book, Inc., 1994, 76-80.

129. Swor RA, Chisolm C, Krohmer J: Model curriculum in emergency medical services for emergency medicine residencies.Ann Emerg Med 1989;18:418-421.

130. The Future of EMS Education: A National Perspective . Washington, D.C.: Joint Review– Committee on EducationalPrograms for the EMT Paramedic, 1994.

131. Thompson SJ, Schriber JA: A survey of prehospital care paramedic/physician communication from MultnomahCounty (Portland), OR. J Emerg Med 1984;1:421-428.

132. Trauma Care Systems Training and Development Act of 1990: Public Law 101-590 . Washington, D.C.: 1990.

133. Trooskin SZ, Rubinowicz S, Eldridge C, et al: Teaching endotracheal intubation with animals and cadavers. PrehospDisaster Med 1992;7:179-184.

134. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal andChild Health Bureau: Five Year Plan: Emergency Medical Services for Children, 1995-2000 . Washington, D.C.: Emer-gency Medical Services for Children National Resource Center, 1995.

135. Uniform Pre-hospital Emergency Medical Services (EMS) Data Conference: Final Report . Washington, D.C.: NationalHighway Traffic Safety Administration, 1994.

136. Urban N, Bergner L, Eisenberg MS: The costs of the suburban paramedic program in reducing deaths due to cardiacarrest. Med Care 1981;19:279-392.

137. Valenzuela TD, Criss EA, Spaite D, et al: Cost effectiveness analysis of paramedic emergency medical servicesin the treatment of prehospital cardiopulmonary arrest. Ann Emerg Med 1990;19:1407-1411.

138. Valenzuela T, Spaite D, Clark D, et al: Estimated cost-effectiveness of dispatcher CPR instruction via telephoneto bystanders during out-of-hospital ventricular fibrillation. Prehosp Disaster Med 1992;7:229-234.

139. Valenzuela TD, Spaite DW, Meislin HW, et al: Emergency vehicle intervals vs. collapse to CPR and collapse todefibrillation intervals: Monitoring emergency medical services system performance in sudden cardiac arrest.Ann Emerg Med 1993;22:1678-1683.

140. Walters G, D’Auria D, Glucksman E: Automatic external defibrillators: Implications for training qualified am-bulance staff. Ann Emerg Med 1992;21:692-697.

141. Werman HA, Keseg DR, Glimcher M: Retention of basic life support skills. Prehosp Disaster Med 1990;5:137-144.

142. Wuerz RC, Swope GE, Holliman CJ, Vazquez-de Miguell G: Online medical direction: Aprospective study. PrehospDisaster Med 1995;10:174-177.


79

Bob BaileyChiefNorth Carolina Emergency Medical ServicesRaleigh, NC

Alasdair K.T. Conn, MD, FACSChief of Emergency ServicesMassachusetts General HospitalBoston, MA

Theodore R. Delbridge, MD, MPH(Principal Investigator)Assistant Professor of Emergency MedicineUniversity of PittsburghPittsburgh, PA

Jack J. Krakeel, MBADirector of Fire & Emergency ServicesFayette County, GAFayetteville, GA

Dan Manz(Co-Chair)DirectorVermont Emergency Medical ServicesBurlington, VT

David R. MillerVice President, Allina Health SystemPresident, HealthSpan Transportation ServicesSt. Paul, MN

Patricia J. O’Malley, MDChief, Pediatric Emergency ServicesMassachusetts General HospitalBoston, MA

Daniel W. Spaite, MD, FACEPProfessor of Emergency MedicineArizona Emergency Medicine Research CenterUniversity of ArizonaTucson, AZ

Ronald D. Stewart, OC, MD, FACEP, DSCMinister of Health, Province of Nova ScotiaProfessor of Anaesthesia & Emergency MedicineDalhousie UniversityHalifax, Nova Scotia

Robert E. Suter, DO, MHA(Co-Chair)Medical Director, Emergency ServicesProvidence Hospital and Medical CentersSouthfield, MI

E. Marie Wilson, RN, MPAChief, Field ServicesConnecticut Office of EmergencyMedical ServicesHartford, CT

PROJECT DIRECTOR:Kathleen Stage-KernNational Association of EMS PhysiciansPittsburgh, PA

ADMINISTRATIVE STAFF:Thomas E. Auble, PhDResearch Assistant Professor ofEmergency MedicineUniversity of PittsburghPittsburgh, PA

Gina A. BakerAdministrative Assistant, Department ofEmergency MedicineUniversity of PittsburghPittsburgh, PA

Bonnie DarrNational Association of EMS PhysiciansPittsburgh, PA

Mary NewmanCatalyst Research and Communications, Inc.Carmel, IN

CONTRACTING OFFICER’STECHNICAL REPRESENTATIVES:John L. Chew, Jr.National Highway Traffic Safety Administration(Retired)Annapolis, MD

Susan D. RyanNational Highway Traffic Safety AdministrationWashington, DC

Appendix G EMS Agenda for the Future: Members of the Steering Committee

MEMBERS OF THE STEERING COMMITTEE

80

First Steering Committee Meeting

Drew DawsonChief, Emergency Medical Services BureauState of MontanaHelena, MT

Second Steering Committee Meeting

Susan Fuchs, MDAssociate Professor, Pediatric Emergency MedicineChildren’s Hospital of PittsburghPittsburgh, PA

Jack StoutAdvisor to the Business Council - MedTransWest River, MD

Michael Yee, EMT-PParamedicCity of Pittsburgh Emergency Medical ServicesPittsburgh, PA

Blue Ribbon Conference

Ricardo Martinez, MDAdministratorNational Highway Traffic Safety AdministrationWashington, DC

Jean Athey, PhDDirector, EMS-C ProgramMaternal & Child Health BureauHealth Resources and Services AdministrationRockville, MD

Acknowledgement:

Hewlett Packard CompanyBlue Ribbon Conference Synergies Video Program

Appendix H EMS Agenda for the Future: Steering Committee Guest Speakers

STEERING COMMITTEE GUEST SPEAKERS

81

Kevin M. Agard, BS EMT-PNational Paramedic Society507 Hoboken RoadCarlstadt, NJ 07072-1119(201) 935-4983

James S. Agnew, RN BS EMT-PCapitol Health SystemHarrisburg Hospital ED205 S. Front StreetHarrisburg, PA 17101(717) 782-3311

Hector M. Alonso-Serra, MDUniversity of PittsburghCenter for Emergency Medicine230 McKee Place, Suite 400Pittsburgh, PA 15213(412) 647-1105

Craig S. Aman, EMT-PMedic First Aid/EMP America500 S. DaneboEugene, OR 97402(206) 517-3008

Marilena Amoni, MSNHTSA NTS-40400 7th Street SWWashington, DC 20590(202) 366-4913

Jean Athey, PhDMaternal and Child Health BureauMCHB Rm 18A-39 Parklawn Bldg.5600 Fishers LaneRockville, MD 20857(301) 443-4026

James M. Atkins, MDUniv. Texas Southwestern MedCtr.-Dallas5323 Harry Hines Blvd.Dallas, TX 75235-8890(214) 648-3777

Tom P. Aufderheide, MD FACEPAmerican Heart Assn.AHA/Dept. Emergency Medicine8700 W. Wisconsin Avenue DH-204Milwaukee, WI 53226(414) 257-6060

Juan A. Bacigalupi, NREMT-PSoutheast Mass. EMS CouncilP.O. Box 119766 Bayview RoadHyannis, MA 02601(508) 771-4510

Jane W. Ball, RN DrPH (Facilitator)Natl. Resource Center, EMSCc/o Children’s Hospital111 Michigan Avenue SWWashington, DC 20010(301) 650-8066

Robert R. Bass, MDMIEMSS636 W. Lombard StreetBaltimore, MD 21201(410) 706-5074

Mary Beachley, MS RN CENSociety for Trauma Nurses9018 Hamburg RoadFrederick, MD 21702(410) 706-3932

John M. BecknellJEMS1947 Camino Vida Roble, Suite 200Carlsbad, CA 92018(619) 431-9797

Nicholas Benson, MD (Facilitator)East Carolina UniversityEmergency MedicineGreenville, NC 27858(919) 816-4757

Appendix I EMS Agenda for the Future: Blue Ribbon Conference Participants

BLUE RIBBON CONFERENCE PARTICIPANTS

Ray A. Bias, RN BSNNational Registry of EMTsAcadian Ambulance ServiceP.O. Box 98000Lafayette, LA 70509(318) 267-3333

Rick Bissell, PhDNat. Study Ctr. Trauma & EMS/UMAB701 W. Pratt Street 001Baltimore, MD 21201(410) 328-4251

Joseph J. Bocka, MD FACEPSoutheastern Ohio Regional Med Ctr7 Hillcrest LaneCambridge, OH 43725-9531(614) 439-8511

Thomas Brabson, DOAlbert Einstein Medical Center#1 Well Fleet DriveMedia, PA 19063(215) 456-2314

Allan Braslow, PhDBraslow & Associates80 S. Ban Dorn StreetSuite E420Alexandria, VA 22304(703) 823-1675

William E. Brown, RN MS CENNational Registry of EMTsP.O. Box 29233Columbus, OH 43229(614) 888-4484

Douglas BrownEMS Data Systems Inc.2211 E. Highland AvenuePhoenix, AZ 85016(602) 956-0126

82

David W. BrysonNHTSA/EMS Division400 7th Street SWWashington, DC 20590(202) 366-5440

Nadja Vawryk Button, MS EMT-PHarrisburg Area Community CollegeOne HACC DriveHarrisburg, PA 17110-2999(717) 774-7911

Richard Cales, MDCales & Associates2236 Mariner Square Dr.Alameda, CA 94501(510) 748-0120

Patrick M. CaprezAkron Fire Dept.146 S. High Street, 10th FloorAkron, OH 44308(216) 375-2071

Kevin Chu, MDBeaumont Hospital3601 W 13 Mile RoadRoyal Oak, MI 48073-6769(810) 551-2015

Charles S. ClarkCongressional Quarterly1414 22nd St. NWWashington DC 20037(202) 887-8633

Heidi ColemanNHTSA400 7th St. SW Rm 5219Washington, DC 20590(202) 366-1834

Keith Conover, MDWilderness EMS Institute36 Robinhood RoadPittsburgh, PA 15220-3014(412) 232-8382

Arthur Cooper, MD MSCollege of Physicians & SurgeonsColumbia University506 Lenox AvenueNew York, NY 10037(212) 939-4003

Gail E. Cooper, ChiefCounty of San Diego EMS6255 Mission GorgeSan Diego, CA 92120(619) 285-6429

Garry B. CriddleNHTSA400 7th St. SW, NTS-42Washington, DC 20590(202) 366-9794

James G. CulpHRSA5600 Fishers LaneRockville, MD 20857(301) 443-0835

Drew Dawson, (Facilitator)Montana EMS BureauEMS Bureau Dept. HealthHelena, MT 59620(406) 444-3895

Jonathan A. Dean, EMT-P BSAlexandria Fire Dept.4907 Rentonbrook DriveFairfax, VA 22030

Craig Deatley, PA-C DirThe George Washington Univ.2300 K Street NW Suite 107Washington, DC 20037(202) 994-4372

James W. DennewitzWV EMS Technical SupportNetwork, Inc.P.O. Box 100Elkview, WV 25177(304) 965-0573

James P. DenneyLA City Fire Dept.200 N Main St. Rm. 1060 CHELos Angeles, CA 90012(213) 485-6094

Pamela B. Docarmo, PhD NREMT-PNorthern VA Community College3333 Little River TurnpikeAnnandale, VA 22003(703) 323-3037

O’Brien John Doyle, Jr.Doyle Consulting12893 Floral AvenueApple Valley, MN 55124(612) 431-7352

Peter I. Dworsky, EMT-PJersey City Medical Ctr EMS3569 Buckshore StreetShrub Oak, NY 10588(201) 324-5000

Jeff T. DyarNational Fire Academy16825 S Seton AvenueEmmitsburg, MD 21727(301) 447-1333

Cynthia S. Ehlers, EMT-PEmergency Health Services Federation722 Linekiln RoadNew Cumberland, PA 17070(717) 774-7911

Barbara M. FaiginNHTSA Office of Plans & Policy,NPP-11400 7th St. SW, Room 5208Washington, DC 20590(202) 366-2585

David B. Fairweather, MBAState of Florida EMS Office2002 Old St. Augustine RoadTallahassee, FL 32301(904) 487-1911

EMS Agenda for the Future: Blue Ribbon Conference Participants Appendix I

83

Richard D. Flinn, Jr., MGA PAEmergency Health Services Council5012 Lenker Street, Suite 210Mechanicsburg, PA 17055(717) 730-9000

George Foltin, MD FAAPBellevue Hospital Center205 E 95th Street #12-CNew York, NY 10128(212) 562-3161

Scott B. Frame, MDUniv of Tennessee Medical Ctr at Knoxville1924 Alcoa Hwy.Knoxville, TN 37920(423) 544-9297

Herbert Garrison, MD MPH (Facilitator)Eastern Carolina Injury PreventionProgramUniversity Medical Ctr.P.O. Box 6028Greenville, NC 27835(919) 816-8688

Marilyn J. Gifford, MDMemorial Hospital1400 E Boulder StreetColorado Springs, CO 80909(719) 575-2000

Peter W. Glaeser, MDMedical College of Wisconsin9000 W. Wisconsin Avenue MS#677Milwaukee, WI 53226(414) 266-2648

Valerie A. Gompf, MA EMTNHTSA400 7th St. SWWashington, DC 20590(202) 366-5440

Adina Gutstein, MSN RN EMTMemorial Hospital West1053 NW 85th AvenuePlantation, FL 33322(954) 436-5000

Alison L. Hanabergh, BS EMTNew Jersey State First Aid Council73 Gordon AvenueTenafly, NJ 07670

Joan Harris, MPANHTSA400 7th St. SWWashington, DC 20590(202) 366-1361

James Hedlund, PhDNHTSA NTS-01400 7th St. SWWashington, DC 20590(202) 366-1755

Michael E. Heffron, BBA EMT-IKeteron Emergency Management Systems350 Technology DriveMalvern, PA 19355(800) 982-7645

Robert W. HeiligRobert W. Heilig & Associates930 Tahoe Blvd. #802-262Incline Village, NV 89451(702) 833-0113

Deborah P. Henderson, RN MANational EMSC Resource Alliance1124 West Carson St. Bldg. N-7Torrance, CA 90502(310) 328-0720

Colleen HennessyHRSA5600 Fishers LaneRockville, MD 20857(301) 443-0835

Rick HimesThe Alliance for Fire & Emergency Mgmt6213 Derby DriveFrederick, MD 21701(508) 881-5800

Kevin P. Hinkle, RN CENWestern Berks Ambulance Assn.P.O. Box 2506West Lawn, PA 19609(610) 678-1545

Larry Impson, AS NREMT-PM.E.T.S., Inc.1004A Industrial WayLodi, CA 95240(209) 368-9690

Leonard R. InchSierra Sacramento Valley EMSAgency3853 Taylor Rd. Ste. GLoomis, CA 95650(916) 652-3690

Sandra W. Johnson, MSSANHTSA400 7th St. SW, Room 6125Washington, DC 20590(202) 366-5364

Thomas Judge, EMT-PCapital Ambulance Maine EMS315 Harlow St.Bangor, ME 04401(207) 941-5900

Donald E. KernsACEP1125 Executive CircleIrving, TX 75038-2522(214) 550-0911

G. L. Kesling, PhD FAAMAUniv Texas Medical Branch at Galveston301 University Blvd.Galveston, TX 77555-1173(409) 772-7448

Mark E. King, BA EMT-PWV Office of EMS1411 Virginia Street, EastCharleston, WV 25301(304) 558-3956


84

Mark Koch, EMT-PYork Hospital1001 S. George StreetYork, PA 17405(717) 851-2311

Jon R. Krohmer, MDACEP1867 Middle Ground SEGrand Rapids, MI 49456(616) 451-8438

Kurt M. Krumperman, MS NREMT-PEastern Paramedics/Rural Metro488 W Onondaga St., P.O. Box 671Syracuse, NY 13201(315) 471-0102

Joanne Lebrun, (Facilitator)TriCounty EMS300 Main StreetLewiston, ME 04240(207) 795-2881

Don Lee, EMT-PLA City Fire Dept.1700 Stadium WayLos Angeles, CA 90012(213) 485-6087

Thomas J. Liebman, BS EMT-PEMMCO East, Inc.1411 Million Dollar Hwy.Kersey, PA 15846(814) 834-9212

Cmsgt. Bob Loftus, EMT-PNational Association of EMTs102 W. Leak StreetClinton, MS 39056(601) 924-7744

Louis V. Lombardo, BSNHTSA400 7th Street SWWashington, DC 20590(202) 366-4862

Brian L. Maguire, MSA EMT-PThe George Washington University2300 K St. NW, Suite 107Washington, DC 20037(202) 994-4372

Donna Maiava, Chief Dir.National Association of State EMS DirectorsHawaii EMS3627 Kilauea Avenue, Room 102Honolulu, HI 96816(808) 733-3921

Gregg S. Margolis, MS, NREMT-PCenter for Emergency Medicine230 McKee Place, Suite 500Pittsburgh, PA 15213(412) 578-3230

Gary McCabeWeld County, Colorado Ambulance Services1121 M StreetGreeley, CO 80631(970) 350-5700

John R. McComasWV EMS Technical Support Network, Inc.PO Box 100Elkview, WV 25071(304) 965-0573

David McCormackInternational Association of Fire Fighters1750 New York Avenue NWWashington, DC 20006(202) 737-8494

Maureen K. McEntee, BA MICPNew Jersey State First Aid Council308 Madison AvenueRoselle Park, NJ 07204(201) 971-5446

Susan D. McHenryVirginia Dept. of Health Office ofEMS1538 East Parham RoadRichmond, VA 23228(804) 371-3500

Claire MerrickMosby7250 Parkway Drive, Suite 510Hanover, MD 21076(410) 712-7463

Mary Beth Michos, ChiefPrince William County Dept. Fire & Rescue1 County Complex Court, MC 470Prince William, VA 22192-9201(703) 792-6806

James R. MillerPrince George’s County Fire Dept.10812 Winston Churchill CourtUpper Marlboro, MD 20772(301) 431-8223

Rene Y. Mitchell, RNPhysio-Control Corp.11811 Willows Rd. NERedmond, WA 98073-9706(206) 867-4294

Jean D. Moody-Williams, RNEMSC National Resource Center111 Michigan Avenue NWWashington, DC 20010(301) 650-8063

Lori MooreInternational Association of Fire Fighters1750 New York Avenue, NWWashington, DC 20006(202) 737-8484

Richard Myers, EMT-PAlexandria Fire Dept.PO Box 402Sterling, VA 20164(203) 838-4652


85

Mark E. Nehring, DMD MPHMCHB5600 Fishers LaneParklawn Bldg., Rm 18A-39Rockville, MD 20857(301) 443-4026

Lawrence D. Newell, EdD NREMT-PMosby Lifeline21031 Powderhorn CourtAshburn, VA 22011(703) 729-3149

Mary M. NewmanCitizen CPR FoundationP.O. Box 911Carmel, IN 46032(317) 843-1940

Robert NiskanenPhysio-Control Corp.11811 Willows RoadRedmond, WA 98073-9706(206) 867-4437

Ruth Oates-Graham, RN NREMT-PDelaware Public Health Dept. JesseCooper Bldg., P.O. Box 637Dover, DE 19903(302) 739-6637

Lauren Simon OstrowJEMS1947 Camino Vida Roble, Suite 200Carlsbad, CA 92018(619) 431-9797

Cliff Petit, RSNAmerican Ambulance Association1234 E. Sibley Blvd.Dolton, IL 60419(708) 201-6400

Marilyn Ann PikeDept. Of Health, Nova ScotiaP.O. Box 488Halifax, Nova Scotia, Canada B3J 2R8(902) 424-8576

W. Frank Poole, EMS CCTIAFC4025 Air Ridge DriveFairfax, VA 22033(703) 273-9815

James N. Pruden, MDSt. Joseph’s Hospital & Medical Center703 Main StreetPaterson, NJ 07503(201) 754-2240

Rodolfo C. RamirezFHWA10326 Peric Ct.Manassas, VA 22110(202) 366-6409

Carolyn Rinaca, EMT-P RNNewport News Fire Dept.15437 Laurelwood DriveCarrollton, VA 23314(804) 247-8767

Paul Roman, REMTASTM Committee F-30 on EMSP.O. Box 202Shrewsbury, NJ 07702

Billy Rutherford, VPJFR Inc.7932 Lake Pleasant Dr.Springfield, VA 22153(703) 440-0914

Nels D. Sanddal, Pres/CEOCritical Illness & Trauma Foundation300 N. Willson Avenue., Suite 3002Bozeman, MT 59714(406) 585-2659

Steve Schmid, EMT-P RNFerno70 Weil WayWilmington, OH 45177(513) 382-1451

Joseph W. Schmider, Dir.Bucks County Emergency HealthServices50 N. Main StreetDoylestown, PA 18901(215) 348-6100

Dave Schottke, MPH621 East Capitol StreetWashington, DC 20003(202) 546-9342

Paul Winfield Smith, MedNational Council State EMS Training Coord.CT Dept. Public Health Office EMS150 Washington StreetHartford, CT 06106(860) 566-7336

Richard B. SnavelyJohns Hopkins University AppliedPhysics LabJohns Hopkins RoadLaurel, MD 20723-6099(301) 953-6379

Myra M. Socher, BS NREMT-PTriMed, Inc. & George Washington Univ.Suite 5012030 Clarendon Blvd.Arlington, VA 22201(703) 524-7780

Leslee Stein-Spencer, RN MSIllinois Dept. of Public Health525 West JeffersonSpringfield, IL 62761(217) 785-2080

Rina SteinhauerMosby7250 Parkway Dr., Suite 510Hanover, MD 21076(410) 712-7463

Andrew W. Stern, EMT-PNew York State EMS69 Capitol PlaceRensselaer, NY 12144(518) 474-2219


86

Walt A. Stoy, PhD EMT-PCenter for Emergency Medicine230 McKee Place, Suite 500Pittsburgh, PA 15213(412) 578-3233

Daniel R. Swayze, MEMS EMT-PMedical College of PA/Hahnemann Univ.Allegheny General Hospital320 East North Avenue, Rm. 133APittsburgh, PA 15212(412) 359-6704

Robert Swor, DONAEMSP23000 NottinghamRevry Hills, MI 48075(810) 551-2015

Susan L. Tittle, RN MSNNERA1124 W. Carson St., Bldg N-7Torrance, CA 90502(310) 328-0720

Don Vardell, MSAmerican Red Cross8111 Gatehouse Rd., 6th FloorFalls Church, VA 22042(703) 201-7718

Richard W. Vomacka, BA REMT-PAAOS3223 State Route 43Mogadore, OH 44260(216) 836-0600

John H. Walsh, EMT-PNorthshore AmbulanceP.O. Box 61Lynnfield, MA 01940-0061

Bruce J. Walz, PhDDept. Emergency Health ServicesUMBC5401 Wilkens AvenueBaltimore, MD 21228-5398(410) 455-3216

Roger D. White, MDMayo Clinic200 First St. SWRochester, MN 55905(507) 255-4235

Vincent Whitmore, NREMT-PCity of Alexandria Fire/EMS900 Second StreetAlexandria, VA 22314(703) 838-3847

Ken Williams, MAEmergency Medical Services for ChildrenChildren’s Hospital111 Michigan Avenue, NWWashington, DC 20010(301) 650-8062

Michael D. Yee, AS EMT-PPittsburgh Emergency Medical Services700 Filbert StreetPittsburgh, PA 15223(412) 622-6927

Marty Young, RN EMTLife Link III336 Chester StreetSt. Paul, MN 55107(612) 228-6801

Glen Youngblood, REMT-PThe EMS InstituteP.O. Box 9317Stamford, CT 06904-9317(203) 325-7068

Adam Zakroczynski, EMT-1Medical Devices International3849 Swanson Ct.Gurnee, IL 60031(800) 323-9035

Joseph Zalkin, BSHS EMT-PWake County EMS331 S. McDowell StreetRaleigh, NC 27601(919) 856-6020

Herschel Zettler, NREMT-P (Facilitator)2427 Ponderosa DriveAugusta, GA 30904(706) 787-6582


DOT HS 808 441August 1996

NTS–42

emergency medical services - nhtsaas nhtsa embarks on 30 years of leadership in the field of...

Documents