A Guide for Enhancing Rural Emergency Medical Services (2005)

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

II-1 SECTION II Introduction Given that crashes will continue to occur, it is important to understand how best to care for the crash victims. The minutes directly following traumatic injury are often critical to saving the victim’s life or minimizing the long-term effects of injury. Both the timeliness and level of expertise at which care is given are critical factors in increasing the survivability of a crash. Emergency care scenarios are markedly different in urban, rural, and remote (i.e., frontier) settings and require strategies tailored to meet each of them. Rural areas face a host of challenges in providing adequate care and treatment to patients from first response through initial stabilization and subsequent emergency treatment. Delivering adequate EMS to widely dispersed populations is very difficult. The time it takes to reach emergency patients is typically longer in rural areas because of the distances between services and rural residents. Likewise, the transport times are typically longer. In addition, in rural communities, there may be less than one emergency call per day. This low volume of calls often means that rural ambulance services cannot financially support themselves, and as a result many of the EMS tasks fall upon trained volunteers. In fact, an estimated 65–75 percent of EMS personnel in rural areas are volunteers. There are various definitions of volunteers as they exist in different configurations, often described as nonreimbursed volunteers, reimbursed volunteers, and paid volunteers. The longer transport times and low volumes of calls result in less frequent in-the-field use of potentially life-saving interventions. Thus, EMS providers have difficulty maintaining their specialized skills, and the frequent and effective use of such treatments can be instrumental in saving the lives of many patients. This guide targets the EMS and highway safety communities. It identifies several objectives and strategies that state EMS directors and local-level system managers and policy makers may pursue on the basis of their existing levels of service and resources. The highway safety community (i.e., state and local highway agencies) should support EMS agencies in implementing these strategies and determine how best to develop partnerships to achieve their common goal of improving highway safety. Strong leadership within the EMS and highway safety communities is paramount to enhancing EMS for injured patients involved in motor vehicle crashes in rural areas. Definition of EMS EMS is widely regarded as including the full spectrum of emergency care, including recognition of the emergency, telephone access to the system, provision of prehospital care, and definitive care in the hospital and rehabilitation. EMS often also includes medical response to disasters, planning for and provision of medical coverage at mass gatherings, and interfacility transfers of patients. The more traditional, narrow definition of EMS is limited to prehospital health care for patients with real or perceived emergencies from the

time point of emergency telephone access until arrival and transfer of care to the hospital (NHTSA, 2001). Because, in rural areas, detection of the crash is particularly critical to the well-being of the victim, this guide will use the broader definition of EMS. That is, objectives and strategies to improve EMS begin with recognition of the emergency (i.e., detecting the crash) and continue through to definitive care in the hospital. Improving EMS to care for motor vehicle crash victims will, in turn, positively affect all patients who require EMS. Objectives There are four main objectives for enhancing EMS in rural areas: 1. Integrate services to enhance emergency medical capabilities, 2. Provide or improve management and decision-making tools, 3. Provide better education opportunities for rural EMS, and 4. Reduce time from injury to appropriate definitive care. Within the four objectives are 24 strategies. These objectives and strategies have been chosen because they cost relatively little and because they can be implemented in a relatively short timeframe. Neither the objectives nor the strategies are prioritized. Because EMS systems around the country exist at various levels of sophistication and in various stages of development, and because system managers and policy makers make decisions based on available resources and a commitment to providing certain levels of service, the best people to determine which objectives and strategies to pursue are the state EMS directors, system managers, and local policy makers. State and local highway agencies should also work with their respective state EMS directors and local system managers to prioritize the objectives and strategies. It is important to point out, however, that the foundation of a sound EMS system is the ability to collect and interpret data. Without this ability, it is difficult to measure the success of implementing these or any objective or strategy. It is recognized that many of the challenges of delivering adequate EMS in rural areas could be overcome by increases in financial resources and modifications to legislation and regulations. Similarly, recruitment and retention of EMS personnel are also a priority in rural areas. However, the finances, legislation, and personnel of EMS systems are seen as higher-level program issues that need to be addressed more at the national or federal level. Therefore, the objectives within this guide do not focus on financial, legislative, and personnel issues. The following sections briefly address these issues in only general terms. The reader is directed to the various EMS visionary documents (e.g., Emergency Medical Services Agenda for the Future [NHTSA, 1996] and Rural and Frontier Emergency Medical Services Agenda for the Future [NRHA, 2004]) that have been developed in recent years and address these issues in depth. Finance Financing EMS systems throughout the country has long been problematic. Although nearly 65–75 percent of all providers in rural America are volunteers, the service is not delivered without significant cost. In some areas of the country, the entire service is supported by volunteer efforts and community support that do not charge for services; SECTION II—INTRODUCTION II-2

SECTION II—INTRODUCTION yet, in other areas, there is a combination of volunteer labor coupled with fee for service to support operational costs. In still other areas, an EMS/fire district tax is implemented. Many experts suggest that most rural EMS issues could be resolved with a significant infusion of money. Although this solution is effective, it may not be practical. It is quite clear that to reduce response times, additional EMS services, placed at locations considered strategic due to the history of calls for service, would reduce response times and improve outcomes. However, adequate funds and resources in rural areas have not been made available. System managers must, therefore, look at alternative solutions to accomplish improved outcomes. This guide focuses on those achievable alternatives. Legislation Most states have EMS legislation that provides for a lead EMS agency. Although much of this legislation is not comprehensive, it does for the most part provide for the delivery of EMS. Although there has been significant progress, many states still do not have comprehensive trauma system legislation that provides for a comprehensive system of trauma care as part of the EMS system. Effective trauma legislation is comprehensive, inclusive, and permissive and includes attributes for protection from discoverability, requirements for autopsies for those involved in motor vehicle crashes, and adequate and stable funding. It is well recognized that comprehensive EMS and trauma legislation is paramount to the success of effective EMS systems; however, legislative changes and improvements may take years to accomplish. Personnel A comprehensive EMS system consists of a team of providers, whose interaction is critical to delivering emergency care to patients (NHTSA, 1996): • Public safety answering points, • Bystanders, • First responders, • Emergency medical technicians (EMTs), • Emergency nurses, • Emergency physicians, • Medical directors, and • Trauma centers. These EMS team members must work together in a systematic approach to deliver EMS, from recognition of the emergency to definitive care. Team members must understand and perform their own roles and responsibilities. In most cases, this requires a high level of discipline, education, and training on the part of each team member. Team members must also interact in a seamless fashion to provide high-quality care to patients and continue to strive to improve the quality of care provided to the patient. In addition to providing care for trauma patients, EMS systems provide other services such as prevention awareness, surveillance, education, rehabilitation, and specialty care (e.g., cardiac, stroke, poison, and pediatrics) to improve overall health care. Exhibit II-1 illustrates the system approach to delivering EMS and the multiple components. Appendix 1 provides more information on the roles and responsibilities of these EMS team members. II-3

The degree of availability of adequate human resources is a central issue for rural EMS. Additionally, the geographic distribution of those resources is also problematic. EMS system managers and policy makers have long recognized this problem, and extensive efforts have been made to address these issues. Recruitment and retention programs, length of service awards programs, and various tax credits and other incentives have been used in an attempt to improve the human resources pool. Unfortunately, the decrease in the availability of active volunteers is not exclusive to EMS. Society has experienced a general decrease in volunteerism for all activities. Rural areas were at one time community-centric. Because of the increasing educational demands of EMS education, cultural changes, and the availability of competing activities for young and old alike, community members are often opting for other, more convenient activities to fill their time. Recruitment and retention of EMS providers remain one of the biggest challenges for EMS systems. Many manuals and specific recruitment and retention programs have been developed, but unfortunately have not ended the decrease in volunteerism (Rural Health EMS System Review at http://www. ruralhealthresources.com/EMSreview/toc.htm). Rather than focus on these issues, which are still receiving a great deal of emphasis by system managers, this guide focuses on potential solutions that will result in using available human resources more efficiently. SECTION II—INTRODUCTION II-4 EXHIBIT II-1 EMS System Approach and Components Source: NHTSA, 2004(b)

SECTION II—INTRODUCTION Brief Overview of EMS Although civilian ambulance services have been operating in the United States since about the 1860s, a formal EMS program was not established in the U.S. Department of Transportation (USDOT) until the Highway Safety Act of 1966. Thus, EMS is still a relatively young field. Appendix 2 provides a chronology of the more important developments in EMS from its official establishment in 1966 until the mid 1990s. In 1996, the National Highway Traffic Safety Administration (NHTSA), which has been a leader in the field of EMS since its inception, developed the first of several visionary documents to guide the future of EMS into the new millennium (see Exhibit II-2). The Emergency Medical Services Agenda for the Future (NHTSA, 1996) serves as a visionary tool for EMS system planners across the nation. Other, spin-off EMS agendas in education, research, and trauma have furthered the spirit and concepts of the original 1996 Agenda. More recently, a draft Rural and Frontier Emergency Medical Services Agenda for the Future (NRHA, 2004) has been developed in a joint effort by the National Rural Health Association, the National Association of State EMS Directors, the National Organization of State Offices of Rural Health, and the federal Office of Rural Health Policy. These documents were reviewed while developing this guide. II-5 EXHIBIT II-2 Recent EMS Visionary Documents Date Description 1996 NHTSA publishes the Emergency Medical Services Agenda for the Future, a document for developing EMS in the United States—a vision that builds on the strengths of America’s diverse emergency resources and expands our country’s emergency medical safety net. 2000 NHTSA publishes EMS Education Agenda for the Future: A Systems Approach, a vision for the future of EMS education, and a proposal for an improved structured system to educate the next generation of EMS professionals. The Education Agenda builds on broad concepts from the 1996 Agenda to create an education system that improves efficiency for the national EMS education process. 2001 The National EMS Research Agenda documents the need for EMS research and for elevating the science of EMS and prehospital care to a higher level. Barriers to conducting EMS research are discussed and innovative solutions offered in eight areas: (1) developing researchers, (2) facilitating collaboration, (3) establishing a reliable funding stream, (4) establishing alternative funding sources, (5) recognizing the need for EMS research, (6) viewing research as necessary for the improvement of patient care, (7) creating reliable information systems, and (8) enhancing ethical approaches to research. 2002 NHTSA publishes Trauma System: Agenda for the Future. This report documents the importance of fully implementing quality trauma systems across the United States to provide optimal care for injured patients and to enhance the country’s readiness to respond to future acts of terrorism. 2004 The draft Rural and Frontier Emergency Medical Services Agenda for the Future defines and prioritizes needs for EMS systems not found in urban/suburban centers. This document does not recreate the 1996 Agenda, but it does elaborate and note variances from it made necessary by the realities of rural and frontier life.

Anticipated Results By implementing the objectives and strategies detailed in this guide, EMS agencies in rural areas will be able to work more efficiently toward their goal of providing the best available care for injured patients involved in motor vehicle crashes. By integrating services, EMS agencies will be able to use the capabilities of other organizations, streamline processes, and develop new and unique functionalities that previously did not exist. Improved management and decision-making tools will enable system managers to make more informed decisions on ways to improve their services. Providing better educational opportunities will improve the life-saving skills of EMS personnel and others who may not have previously been involved in EMS. Finally, various strategies are identified for reducing the time from injury to appropriate definitive care. Thus, by integrating services, making better and more informed managerial-level decisions, becoming better educated, and reducing response times, it is anticipated that the care provided to injured patients involved in motor vehicle crashes will be improved, thereby reducing the number of fatalities attributable to EMS deficiencies. II-6 SECTION II—INTRODUCTION