A Guide for Enhancing Rural Emergency Medical Services (2005)

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V-1 SECTION V Description of Strategies Objectives As mentioned previously, the following objectives will meet the general goal of improving the responsiveness and quality of care for rural EMS: 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. Exhibit V-1 presents strategies developed to meet each of these objectives for improving EMS in rural areas. Strategies for treatment of injured parties at highway crashes can significantly impact the ultimate level of severity experienced, and the length of time spent, in treatment. This is especially true when it comes to timely and appropriate treatment of severely injured persons. Thus, a basic part of a highway safety infrastructure is a well-based and comprehensive emergency care program. The types of strategies included here can be critical to the success of a comprehensive highway safety program. Therefore, an effort should be made to determine whether improvements can be made to this aspect of the system, especially for programs in rural areas. EXHIBIT V-1 Objectives and Strategies for Improving EMS in Rural Areas Objectives Strategies 20.1 A—Integrate services to enhance 20.1 A1—Establish programs with organizations to utilize emergency medical capabilities nontraditional employees as EMS responders (T) 20.1 A2—Facilitate development of regional resources and/or cooperatives (T) 20.1 A3—Integrate support of EMS into rural hospital financing programs (T) 20.1 A4—Integrate information systems and highway safety activities (T) 20.1 A5—Integrate EMS systems into the Safe Communities effort (T) 20.1 A6—Use mobile data technologies that are interoperable with hospital systems (T) 20.1 A7—Require all communication systems to be interoperable with surrounding and state jurisdictions (T)

SECTION V—DESCRIPTION OF STRATEGIES V-2 EXHIBIT V-1 (Continued) Objectives and Strategies for Improving EMS in Rural Areas Objectives Strategies 20.1 B—Provide or improve 20.1 B1—Develop resource and performance standards unique to management and decision-making the specific rural EMS (T) tools 20.1 B2—Identify, provide, and mandate efficient and effective methods for collection of necessary EMS data (T) 20.1 B3—Identify and evaluate model rural EMS operations (T) 20.1 B4—Provide evaluation results to elected and administrative officials at the county and local levels (T) 20.1 C—Provide better education 20.1—C1 Utilize technology-based instruction for rural EMS training opportunities for rural EMS (P) 20.1 C2—Establish an exchange program to allow rural EMS providers to spend a specified number of hours in urban/suburban systems (E) 20.1 C3—Include principles of traffic safety and injury prevention as part of EMS continuing education (E) 20.1 C4—Require first care training for all public safety emergency response personnel, including law enforcement officers (T) 20.1 C5—Educate rural residents about the availability, capability, and limitations of existing systems (T) 20.1 C6—Provide “bystander care” training programs targeting new drivers, rural residents, truck drivers, Interstate commercial bus drivers, and motorcyclists (T) 20.1 C7—Provide EMS training programs in high schools in rural areas (T) 20.1 D—Reduce time from injury to 20.1 D1—Improve cellular telephone coverage in rural areas (T) appropriate definitive care 20.1 D2—Improve compliance of rural 9-1-1 centers with FCC wireless “Phase II” automatic location capability (T) 20.1 D3—Utilize GPS technology to improve response time (T) 20.1 D4—Integrate automatic vehicle location (AVL) and computer- aided navigation (CAN) technologies into all computer-aided dispatch (CAD) systems (T) 20.1 D5—Equip EMS vehicles with multi-service and/or satellite- capable telephones (T) Note: the following pages explain (T), (E), and (P) demarcations. Types of Strategies The strategies in this guide were identified from a number of sources, including the literature, contact with state and local agencies throughout the United States, and federal programs. Some of the strategies are widely used, while others are primarily an

SECTION V—DESCRIPTION OF STRATEGIES experimental idea of a single individual or agency. Some strategies have been subjected to well-designed evaluations to prove their effectiveness. However, it was found that many strategies, including some that are widely used, have not been adequately evaluated. The implication of the widely varying experience with these strategies, as well as of the range of knowledge about their effectiveness, is that the reader should be prepared to exercise caution in many cases before adopting a particular strategy for implementation. To help the reader, the strategies have been classified into three types, each identified by a letter: • Tried (T) – Those strategies that have been implemented in a number of locations and that may even be accepted as standards or standard approaches, but for which there have not been found valid evaluations. These strategies—while in frequent, or even general, use—should be applied with caution, carefully considering the attributes cited in the guide, and relating them to the specific conditions for which they are being considered. Implementation can proceed with some degree of assurance that there is not likely to be a negative impact on safety and very likely to be a positive one. It is intended that as the experiences of implementation of these strategies continue under the AASHTO SHSP initiative, appropriate evaluations will be conducted so that effectiveness information can be accumulated to provide better estimating power for the user, and the strategy can be upgraded to a “proven” (P) one. • Experimental (E) – Those strategies that have been suggested and that at least one agency has considered sufficiently promising to try on a small scale in at least one location. These strategies should only be considered after the others have proven not to be appropriate or feasible. Even when they are considered, their implementation should initially occur using a very controlled and limited pilot study that includes a properly designed evaluation component. Only after careful testing and evaluations show the strategy to be effective should broader implementation be considered. It is intended that as the experiences of such pilot tests are accumulated from various state and local agencies, the aggregate experience can be used to further detail the attributes of this type of strategy, so that it can be upgraded to a “proven” (P) one. • Proven (P) – Those strategies that have been used in one or more locations, and for which properly designed evaluations have been conducted that show it to be effective. These strategies may be employed with a good degree of confidence, but any application can lead to results that vary significantly from those found in previous evaluations. The attributes of the strategies that are provided will help the user judge which strategy is the most appropriate for the particular situation. Related Strategies for Creating a Truly Comprehensive Approach The strategies listed above and described in detail below are those considered unique to this emphasis area. However, to create a truly comprehensive approach to the highway safety problems associated with this emphasis area, four types of related strategies should be included as candidates in any program planning process: • Public Information and Education (PI&E) Programs – Many highway safety programs can be effectively enhanced with a properly designed PI&E campaign. For example, V-3

“EMS Week” is observed annually during the third week of May and brings together local communities and medical personnel throughout the country to publicize safety and honor the dedication of those who provide the day-to-day lifesaving services of the medical “front line.” EMS Week is sponsored by the American College of Emergency Physicians, NHTSA, and the Emergency Medical Services for Children program. The week of May 16-22, 2004, marked the 30th year for the event. The traditional emphasis with PI&E campaigns in highway safety is to reach an audience across an entire jurisdiction or a significant part of it. However, there may be a reason to focus a PI&E campaign on a location-specific problem. While this approach is relatively untried compared with areawide campaigns, use of roadside signs and other experimental methods may be tried on a pilot basis. Within this guide, where the application of PI&E campaigns is deemed appropriate, it is usually in support of some other strategy. In such a case, the description of that strategy will suggest this possibility (see the attribute area for each strategy entitled “Associated Needs”). In some cases, specialized PI&E campaigns are deemed unique for the emphasis area and are detailed in the guide. In the future, additional guides may exclusively address the details regarding PI&E strategy design and implementation. • Enforcement of Traffic Laws – Well-designed and -operated law enforcement programs can have a significant effect on highway safety. It is well established, for instance, that an effective way to reduce crashes (and their severity) is to have jurisdictionwide programs that enforce an effective law against driving under the influence (DUI) or driving without seat belts. When that law is vigorously enforced with well-trained officers, the frequency and severity of highway crashes can be significantly reduced. This should be an important element in any comprehensive highway safety program. Enforcement programs, by nature, are conducted at specific locations. The effect (e.g., lower speeds, increased use of seat belts, and reduced impaired driving) may occur at or near the specific location where the enforcement is applied. This effect can often be enhanced by coordinating the effort with an appropriate PI&E program. However, in many cases (e.g., speeding and seat belt usage), the impact is areawide or jurisdictionwide. The effect can be either positive (i.e., the desired reductions occur over a greater part of the system) or negative (i.e., the problem moves to another location as road users move to new routes where enforcement is not applied). Where it is not clear how the enforcement effort may impact behavior, or where an innovative and untried method could be used, a pilot program is recommended. Within this guide, where the application of enforcement programs is deemed appropriate, it is often in support of some other strategy. Many of those strategies may be targeted at either a whole system or a specific location. In such cases, the description for that strategy will suggest this possibility (see the attribute area for each strategy entitled “Associated Needs”). In some cases, where an enforcement program is deemed unique for the emphasis area, the strategy will be detailed. As additional guides are completed, they may detail the design and implementation of enforcement strategies. • Strategies Directed at Improving the Safety Management System – The management of the highway safety system is foundational to success. There should be a sound organizational structure, as well as in infrastructure of laws, policies, and so forth to monitor, control, direct, and administer a comprehensive approach to highway safety. A comprehensive program should not be limited to one jurisdiction, such as a state SECTION V—DESCRIPTION OF STRATEGIES V-4

SECTION V—DESCRIPTION OF STRATEGIES department of transportation (DOT). Local agencies often must deal with most of the road system and its related safety problems and are more familiar with their problems. Additional guides may detail the design and implementation of strategies for improving safety management systems. • Strategies That Are Detailed in Other Emphasis Area Guides – Any program targeted at the safety problem covered in this emphasis area should be created having given due consideration to the inclusion of other applicable strategies covered in the following guides: – A Guide for Addressing Collisions with Trees in Hazardous Locations, – A Guide for Addressing Head-On Collisions, – A Guide for Addressing Run-Off-Road Collisions, – A Guide for Reducing Collisions on Horizontal Curves, – A Guide for Reducing Collisions Involving Utility Poles, – A Guide for Increasing Seat Belt Use, – A Guide for Reducing Motorcycle Collisions, and – A Guide for Reducing Collisions Involving Drowsy and Distracted Drivers. Objective 20.1 A—Integrate Services to Enhance Emergency Medical Capabilities Strategy 20.1 A1—Establish Programs with Organizations to Utilize Nontraditional Employees as EMS Responders (T) General Description Since the late 1960s when civilian EMS was first conceptualized and implemented, it has become institutionalized throughout the United States at the intersection of the public safety and the medical care systems. EMS is particularly critical to rural and frontier residents because they experience disproportionate levels of serious injuries, and their distance from traditional health resources increases the morbidity and mortality associated with trauma and medical emergencies (see the National Rural Health Association website, http://www.nrharural.org/). Throughout the country, certification criteria are established for first responders, EMTs, paramedics, and emergency medical dispatchers. EMTs and paramedics perform their duties under the direction of a medical director. First responder training varies greatly from program to program yet is often crucial when caring for victims of sudden illness or injury. Armed with basic skills, first responders often can prevent further injury or illness and provide life-saving treatments until EMTs or paramedics arrive. Expansion of first responder training is essential to improving rural EMS care. According to a survey of state EMS directors, the top priority of rural EMS organizations, despite significant effort, continues to be recruitment and retention of emergency providers. Consequently, developing programs with other organizations to expand the number of available people able to respond to emergencies is of growing importance. Conversely, seeking a broader role for existing EMS providers in rural communities could spark interest for others to join the ranks, improve the health services of an area, and improve the financial condition of existing services by generating new revenue streams. V-5

Recruitment and retention efforts will continue to be expanded and improved in the years ahead, with increasing consideration of targeting nontraditional and nonclinical people. Further, successful EMS providers will need to integrate more fully with public health and social service agencies, primary care providers, and other health care facilities to ensure that patients are referred or transported to the most appropriate and cost-effective facility. Care should not occur in isolation; rather, it should be part of a seamless system that provides patients with well-organized, high-quality care. Integration refers to the horizontal and vertical linkage of health care providers to achieve a high degree of continuity of services. EMS integration can help ensure that out-of-hospital care is incorporated into the management of ill or injured patients. Historically, EMS has been effectively linked with the public safety sector (i.e., dispatch, law enforcement, and fire services), with nearby EMS providers for mutual aid, with the emergency departments of nearby hospitals and, in some areas, with designated trauma centers as part of regionally designed trauma systems. Another part of EMS is surveillance. At a basic level, data from past incidents can help to forecast future situations (e.g., locations of highway intersections that may tend to experience frequent crashes and injuries). With the heightened awareness surrounding terrorism, surveillance includes watching for any pattern of injury or illness. On a more day- to-day mode, surveillance is watching over the people in a community and ensuring that their health care needs are being tended to so that local residents do not find themselves in an emergency situation requiring an ambulance. This is good for EMS because it has the potential to reduce the demand of the volunteer service. In summary, the goal of this strategy is for EMS agencies to establish partnerships with organizations they have traditionally not worked with in the past. Drawing from the personnel of these partnering agencies, the plan is to increase the pool or number of EMS responders. Ideally, the employees of these partnering agencies would be trained to the level of first responder, but in the event that they do not achieve this level of training, at least they would have some formal training in EMS response such that if an employee from one of these partnering agencies encounters a crash, he or she can provide some level of first response until an EMT or paramedic arrives at the scene. As these systems and partnerships develop, opportunities also exist to address the needs of special populations that have sometimes been overlooked, including children, the elderly, minority groups, and persons with disabilities. SECTION V—DESCRIPTION OF STRATEGIES V-6 EXHIBIT V-2 Strategy Attributes for Establishing Programs with Organizations to Utilize Nontraditional Employees as EMS Responders (T) Technical Attributes Target Hospital and other health care staff (e.g., home care and nursing home staff); law enforcement; park rangers; state, county, and local highway crews; other fire and rescue staff; postal carriers; utility crews; and other service club (e.g., AARP, Lions Club, Jaycees) members. Expected No studies have been conducted to determine the effect on injury severity of Effectiveness increasing the number of first responders in an area through the establishment of such programs. A potential reason that no studies of this kind have been performed is the difficulty of isolating such an effect to evaluate its expected effectiveness. In the

SECTION V—DESCRIPTION OF STRATEGIES V-7 EXHIBIT V-2 (Continued) Strategy Attributes for Establishing Programs with Organizations to Utilize Nontraditional Employees as EMS Responders (T) Technical Attributes absence of data, anecdotal information regarding improved level of care or perceptions of the community may be useful for demonstrating potential effectiveness (see Appropriate Measures and Data). Keys to Success An effective program for recruiting and retaining people is the number one key for success. This requires networking and establishing good relations throughout the community and with outside agencies or groups. The program will also require communicating to the community, individuals, and management of outside agencies the importance of participating in such a program. This will stimulate interest among individuals, and managers of agencies will find it easier to permit their employees to miss work in order to attend to an injured person involved in an accident. A more long- term goal would be to sell the importance of such a program to outside agencies such that the agencies look to recruit new employees that already have EMS backgrounds or potentially include EMS responsibilities in job descriptions. Another key to success is excellent leadership. As EMS providers are confronted with tough challenges, good people with strong leadership skills are essential. With an increased number of EMS responders, the managers of EMS agencies must work to coordinate services in order to incorporate nontraditional employees into the overall EMS system in an effective manner. Sharing innovative programs and using effective communication will help to increase the success. Potential Difficulties Efforts to improve the value of volunteering one’s time to the local ambulance service have been undermined by increased demands on an individual’s time, more stringent training requirements, and the increased number of two-income families. Also, labor unions may resist increasing the responsibilities of their members unless the members are compensated in some manner. Appropriate The key measurements are the number, type, and level of training of people involved Measures and Data in EMS. Listing the number of nontraditional programs is another measure. In addition to quantitative information, anecdotal information regarding improved level of care or perceptions of the community may prove useful for demonstrating potential effectiveness and the conditions under which it is likely to occur. Associated Needs EMS must have a solid financial foundation to provide its critical safety net services in a high-quality fashion. Organizational and Institutional Attributes Organizational, Leadership of state and local agencies should support, through policy, that workers Institutional receive first responder training. The workers who receive the training should then be and Policy Issues formally recognized for the valuable role they play in the delivery of EMS to their rural community. While the Good Samaritan Law would protect most people operating within their area of training, other legal concerns may need to be identified and solved. Issues Affecting Implementation requires that people be willing to be trained in first response. Traditional Implementation Time materials and resources are readily available for training purposes, but time may be required to develop nontraditional resources for nontraditional personnel. As people are trained, integration within the existing EMS system would need to be worked out. Also, a system of improvement would need to be put in place to ensure that quality services are being delivered.

Information on Agencies or Organizations Currently Implementing this Strategy In Spokane, Washington, postal workers are trained in surveillance (e.g., keeping a lookout for elderly and other citizens that may need health care assistance). If postal workers suspect impending problems, often signaled by mail piling up, they can summon assistance from law enforcement or others to check in. This is an example of a model community partnership that is using the existing postal services in a nontraditional way, which could lower the demand on emergency service response. Another idea worth considering is to expand first responder training to all state and county highway crews, including road maintenance crews, snowplow drivers, and roadside assistance personnel. Currently, most law enforcement and fire service personnel are trained as first responders. Therefore, adding highway crews would increase the number of first responders on the roadways. For example, some maintenance crews for Oregon Department of Transportation (ODOT) (District 11) have received first responder training. These maintenance crews are equipped with medical supplies and equipment such as first responder kits, oxygen bottles, and defibrillators (ODOT, 2002). SECTION V—DESCRIPTION OF STRATEGIES V-8 EXHIBIT V-2 (Continued) Strategy Attributes for Establishing Programs with Organizations to Utilize Nontraditional Employees as EMS Responders (T) Organizational and Institutional Attributes Costs Involved The costs include that of initial training, ongoing continuing education, and medical equipment (as required). In some cases, costs for training courses given to nontraditional employees may be reduced as incentives for training. For example, a hospital in Oregon offered first responder training to maintenance workers at Oregon Department of Transportation at a reduced cost (ODOT, 2002). Costs for medical supplies and equipment such as first responder kits, oxygen bottles, and defibrillators may also be incurred. Furthermore, administrative costs will be involved in coordinating such a program and possibly evaluating the effectiveness of the program. Federal assistance to first responders, EMTs, primary care providers, allied health care providers, and nursing training programs could improve the general availability of EMS providers. Further, resource support would be very beneficial for meeting continuing education requirements. Training and Other This strategy is primarily about the training of individuals. However, trainers themselves Personnel Needs must be trained. Nontraditional forms of training may also be explored, such as self study or Internet-based training courses. Legislative Needs Federal and state regulation should allow for flexibility to pragmatically meet the local needs of rural providers, including regulation of EMS providers and services, scope of practice, system design, funding, training, and other such issues. Further, support of flexible processes for openly negotiating these realities at a cross-border, state-to-state level, is critical. Other Key Attributes None

SECTION V—DESCRIPTION OF STRATEGIES In Pennsylvania, the Pennsylvania Turnpike Commission employs response workers known as Turnpike First Responders (Bodack, 1998). Reports of incidents along the Pennsylvania Turnpike are directed to one central location in Harrisburg—the Turnpike’s communication center. Within seconds, a Turnpike First Responder unit close to the location of the incident is dispatched to the scene ready to help. First responders are prepared for almost any situation, and their job includes a wide range of duties. First responders could be called upon to clear debris from the roadway, transport customers whose vehicles may have broken down, plug and contain diesel fuel leaks, administer cardiopulmonary resuscitation (CPR), and even set up temporary traffic control at the scene of an accident. When a first responder arrives at the scene of an incident, the first priority is to assess the situation and then inform the communication center of the exact details so that the center can, in turn, dispatch the proper assistance, be it towing, fire, or ambulance service. In another program in Pennsylvania, the Western Alliance EMS organization received a mini-grant through the Pennsylvania Office of Rural Health to support a recruitment program. Western Alliance EMS partnered with a local industry to train individuals for the plant’s industrial brigade. Provisions of the grant included an agreement to permit brigade members to respond to emergencies in the vicinity of the plant. For more information on the emergency response programs of ODOT and the first responder program of the Pennsylvania Turnpike Commission, see Appendices 17 and 18, respectively. Strategy 20.1 A2—Facilitate Development of Regional Resources and/or Cooperatives (T) General Description Many rural counties do not have the population or the tax base to support individual county-based EMS systems. Furthermore, in some communities, neighboring EMS squads may work at cross-purposes, resulting in duplication of effort and higher total system costs. By sharing resources across geopolitical boundaries, it is possible to increase provider coordination and make better use of scarce resources (Schoenman et al., 1999). In many cases, formal cooperatives may be developed. A cooperative is an organization that is owned and controlled by the people who use its products, supplies, or services. Although cooperatives vary in type and membership size, they are formed to meet the specific objectives of their members and are structured to adapt to member’s changing needs. Self- reliance and self-help are the hallmarks of cooperatives. Although cooperation, that is, people working together for their mutual benefit, has been practiced throughout human history, the cooperative as a form of business organization began during the Industrial Revolution. Cooperatives were useful for promoting the interests of the less powerful members of society. Farmers, producers, workers, and consumers found that they could accomplish more collectively than they could individually. Rural health care providers may too benefit by forming a regional cooperative. The role of the region in support of EMS activities varies widely from region to region and state to state. Rural providers are often not served by any type of coordinated regional activity. In addition, the role of the regional systems compared with the role of the state is confusing and, at times, conflicting. V-9

The funding support for regional EMS systems has decreased dramatically over the past couple of decades. Healthy regional systems typically have excellent relationships with the lead state agency that regulates EMS. Many regional systems have been privatized as not- for-profit charitable organizations. They promote a variety of fund-raising activities, such as hosting educational conferences, to support the advancement of their local EMS providers. While many regional EMS systems are struggling trying to understand what their role is, many other regional systems have built a strong foundation and are recognized as the driving force behind system improvements. It is the focus and characteristics of these strong systems that are highlighted below. At a minimum, regional EMS systems often are the training, education, and certification arm of the state agency. The regional systems receive funds via the state and have the responsibility to properly administer and distribute the funds. They often provide the EMS educators that in turn teach and test EMS providers. In some cases, the education extends to first responder training. Another common duty of regional EMS systems is data collection and analysis. Armed with this information, regional EMS systems are able to help EMS providers operate their services and plan for future needs. The scope of data collection can be very broad, including emergency run information, response times, medical quality data, and vehicle maintenance records. Mass casualty preparedness is another common component that regional EMS systems provide. They help to create linkages between EMS providers, law enforcement, fire services, public works, government services, hospitals, and so forth. These linkages include planning and policy development, management education and training, telecommunication, training and drilling, procurement of supplies, and crisis counselors. Regionalization can also result in better medical direction and, in some instances, consolidation of agencies. SECTION V—DESCRIPTION OF STRATEGIES V-10 EXHIBIT V-3 Strategy Attributes for Facilitating Development of Regional Resources and/or Cooperatives (T) Technical Attributes Target Emergency service organizations, hospitals, local and state government, and medical suppliers and vendors. Expected It is difficult to quantify the expected effectiveness, in terms of the number of lives saved, Effectiveness through the development of regional resources and/or cooperatives. Documented studies are not available. However, it might be through financial metrics or evidence of improved efficiency and effectiveness, or perhaps qualifications, that regionalization may be deemed effective. For example, agencies might be able to purchase at a discounted price equipment that they would not have been able to procure otherwise. Ultimately, this equipment could improve patient outcomes. As another example, regionalization might be instrumental in enabling agencies to provide advanced life support rather than basic life support so as to be able to improve patient care and outcomes. Regionalization might also enable EMTs to provide prehospital emergency medical care on the basis of protocols rather than calling a physician for orders on each emergency patient. These are just some of the ways that development of regional resources and/or cooperatives can help improve the quality of care and patient outcomes.

SECTION V—DESCRIPTION OF STRATEGIES V-11 EXHIBIT V-3 (Continued) Strategy Attributes for Facilitating Development of Regional Resources and/or Cooperatives (T) Technical Attributes Keys to Success There are many keys to success in forming regional systems and/or cooperatives. For example, cooperatives should be created on a strong organizing business foundation in which members must abide by the rules of the cooperative. Excellent and visionary leadership is a must, and financial support is important. Members must effectively balance the collective good of the cooperative with their individual gains. Other key points on how to make a regional or cooperative agreement work include the following (NHTSA, 2000[b]): • Keep communication open. • Be forthright with the other agencies about what you need and want. • Identify each need specifically. • Understand each agency’s needs. Keep talking until you do. • Do not compete with other agencies and share credit. • Investigate what other states and/or regions are doing and model your efforts after the best you find. • Be prepared to both represent your own agency and respect the needs of other agencies. • Be accessible as a resource and offer your input. • Work out the details. Do not let things happen by chance. • Make sure funds transfer and reimbursements are prompt. • Do not overstate what can be accomplished. • Give awards or certificates of appreciation for those who go “above and beyond.” Other keys to success may be learned from experiences in Michigan. Some of the features of the Michigan Upper Peninsula (http://www.rupri.org/rhfp-track/results/vol2num2.pdf) experience may have facilitated their regionalization efforts. Thus, it might make this type of initiative more difficult to replicate in other areas (Schoenman et al., 2001). However, following are several of the factors related to successes in the Upper Peninsula that have been noted: • A strong history of regional cooperation in the UP, • Key players who have worked together for years, • A nonprofit EMS foundation that has operated in the region for several decades, • Two large area hospitals that demonstrated an interest in strengthening the local health care system, and • An enthusiastic core group of people who represent diverse interests and have been involved since the beginning. Potential There are many potential challenges in developing a comprehensive regional EMS, including Difficulties local providers learning how to deal with change and strong leadership that can lead the process. Many different groups must reach agreement on a multitude of issues, and appropriate funding support is required. In addition, member agencies might have concern over losing autonomy and consequently might not abide by the rules of the agreement or cooperative.

SECTION V—DESCRIPTION OF STRATEGIES V-12 EXHIBIT V-3 (Continued) Strategy Attributes for Facilitating Development of Regional Resources and/or Cooperatives (T) Technical Attributes Lack of real benefits for some members in regionalizing or forming a cooperative may also be a potential difficulty. Appropriate Measurements would depend on what services were provided by the region. It would be Measures and appropriate to measure the number of agencies involved and programs offered at the regional Data level as process measures. Financial metrics involved with those programs can be used for both process evaluation and impact evaluation. Savings generated through participating in a cooperative or at a regional level is an important measure. Also, anecdotal evidence of efficiency and effectiveness can be useful, although not quantitative, for measuring the degree of success (or lack thereof). Associated Special training programs may be needed, which may require getting the help of specialists Needs from this area. Vendors must provide attractive benefits (e.g., discounts for bulk purchases) for cooperatives or regionalization so that cooperatives or regional systems can achieve critical mass to make it of value for the members and vendors alike. Organizational and Institutional Attributes Organizational, The support of state and local government executives will be needed to provide the Institutional and foundation on which to build a cooperative venture. Policy Issues It will be important to craft a policy about how the regional system will operate, how disputes will be settled, and how conformance will be managed. Agreements may need to be developed and signed. Issues Affecting Regionalization and cooperatives involve sharing and pooling each member’s services and Implementation assets. The process of determining the value of each service and asset is complicated and Time can result in intense feelings that draw out negotiations. The inability to reach agreement will slow the process. Also, regionalization and/or a cooperative will likely require capital infusion. The members, and potentially a lending institution, will need to be comfortable with the business plan. Costs Involved Costs will vary depending upon what is included in the regional EMS system and/or the type of cooperative that is formed. In some cases, agencies may be required to pay annual dues to be a member of a cooperative. Training and Leadership and the ability to advance complex issues through groups with varied interests will Other Personnel be two important training and personnel needs. Training may also be needed for compliance Needs with new protocols and/or standards. There may also be a need to train trainers, i.e., to create a cadre of qualified people to do the training. Development of nontraditional training materials may also be necessary. Legislative Legislation supporting the development of regional EMS systems would be helpful, but is not Needs required. Ideally, legislation would provide adequate funding and other resources to improve the quality of emergency services. Other Key Attributes None

SECTION V—DESCRIPTION OF STRATEGIES Information on Agencies or Organizations Currently Implementing this Strategy Many progressive regional systems have gone far beyond the basics. Several examples of very progressive regional systems and/or cooperatives include the following: • Birmingham Regional Emergency Medical Services System (BREMSS), • Michigan’s Upper Peninsula, • North Central EMS Cooperative (NCEMSC), and • Texas Regional Advisory Councils (RACs). These regional systems and/or cooperatives provide a comprehensive array of services. Highlights of these regional systems and/or cooperatives are provided below. More detailed information on these systems is provided in respective appendices. Birmingham Regional Emergency Medical Services System BREMSS is responsible for overall coordination and improvements in the prehospital emergency medical care system within a six-county region in Alabama and the subsequent city jurisdictions. BREMSS works with all components of the EMS system, which includes 180 EMS providers, 19 hospitals (with 10 trauma centers and 12 stroke center hospitals), more than 2,000 EMTs, more than 80 different municipalities, and 18 different 9-1-1 agencies. To achieve overall coordination, BREMSS has been effective in creating collaborative arrangements and agreements between differing components of the EMS system and local governments. Through BREMSS programs, system improvements have been made to increase the quality and quantity of services and improve patient outcomes of emergency medical patients within the region. For example: • EMTs now provide prehospital emergency medical care on the basis of protocols rather than calling a physician for orders on each emergency patient. • BREMSS was instrumental in the movement to add more than 40 new agencies to provide advanced life support rather than basic life support. • BREMSS has developed and administered a regionwide, 12-lead electrocardiogram program, which allows for early recognition and transport of patients having acute myocardial infarctions (i.e., heart attacks). • A state-of-the-art communication system that ties together all hospitals, as well as all major EMS transport agencies, was implemented at no initial cost to hospitals. For more detailed information on BREMSS, see Appendix 3. Michigan’s Upper Peninsula Michigan’s Upper Peninsula relies on small, volunteer corps of medical first response and basic life support providers scattered throughout the area (Schoenman et al., 2001). The only advanced life support providers are located in the far eastern and western edges of the region. EMS oversight in Michigan is provided by county (or multi-county) entities called medical control authorities (MCAs). MCAs are organized by an area’s hospital(s). The principal responsibility of MCAs is to develop protocols for prehospital care. MCAs are composed of volunteers and include a medical director, hospital representatives, and representatives from area EMS squads. Three MCAs serving four eastern counties of the Upper Peninsula have been V-13

collaborating to create a more coordinated, regional EMS system. Rural Hospital Flexibility Program (Flex Program) funds have been combined with significant funds from other sources to support this initiative. The regional system has five main components: • Standardization of EMS patient care protocols; • Collection of prehospital data to support quality improvement initiatives; • EMS training programs at local sites throughout the area; • Strategic placement of ALS services throughout the region; and • Ongoing planning, development, and funding for EMS resources and services. For more detailed information on the regional system in Michigan’s UP, see Appendix 4. North Central EMS Cooperative The NCEMSC, located in Minnesota, is in existence to reduce member costs, improve quality and efficiency, and establish standard specifications for organization supplies and equipment through a joint purchasing program. The cooperative began in 1997 with 3 members and has grown to 434 members located in 17 states as of 2004. Funding for the cooperative is through membership dues. Each member pays the same low dues, and members are guaranteed to save money, or they get their dues back. Vendors, however, are the primary funding source. A minimum percentage of their sales are returned to the cooperative. Several successes from this cooperative include the following: • Basic life support service saved $20,000 on a new ambulance. • Hospital saved nearly $11,000 on one software purchase. • Basic life support service saved $500 on vital signs monitor. For more detailed information on the NCEMSC, see www.ncemsc.org. Texas Regional Advisory Councils A RAC is a voluntary organization established by trauma care entities, including EMS providers and hospitals, within a trauma service area (TSA) for the purpose of improving care of critically injured patients within the TSA boundaries. The state of Texas is divided into 22 TSAs. Other entities, such as local and county government officials, injury prevention organizations, and consumer groups, may also participate. The primary responsibility of the RACs is to develop, implement, and evaluate a regional EMS and trauma care system plan to decrease the number of fatalities and injures in Texas by ensuring that critically injured victims receive the most appropriate and expeditious care within the trauma care resources of the TSA. RACs also identify additional resources (such as grants) needed to upgrade the delivery of emergency health care within their regions. Other responsibilities include acting as a public forum for TSA issues, networking with other RACs to ensure appropriate care across TSA boundaries, state reporting, and distributing state monies. The RACs are also very active in injury prevention and public education programs in an effort to decrease the incidence of trauma. For more detailed information on Texas RACs, see Appendix 5 or visit the Texas Department of State Health Services website at http://www.tdh.state.tx.us/hcqs/ ems/links.htm and follow the “Regional Advisory Councils” link. SECTION V—DESCRIPTION OF STRATEGIES V-14

SECTION V—DESCRIPTION OF STRATEGIES Strategy 20.1 A3—Integrate Support of EMS into Rural Hospital Financing Programs (T) General Description Traditionally, the goal of EMS is to provide immediate medical assistance and rapid transportation to a hospital. Typically, EMS providers offer routine interfacility transportation between health care facilities. In addition, EMS providers commonly deliver emergency medical dispatch care instructions by phone for emergency victims prior to arrival, as well as injury prevention and rehabilitative care. In many rural areas, a rising aging population, increasing numbers of earlier discharges from hospitals, and the closure of many hospitals are influencing a growing demand for EMS. Often, these rural communities suffer from inadequate access to other medical resources, and EMS becomes a safety net for a broad array of nonurgent health services, including primary care. However, the strain of delivering EMS in several rural areas, where morbidity and mortality rates from serious injuries is higher than in urban areas, has reduced expectations that emergency care in such settings will always be fast and effective. One of the unmet needs for rural EMS most often identified by state officials is appropriate financing of local EMS programs. Sparse populations in large geographic areas increase the cost of maintaining EMS, making it impossible for many rural local governments to fund EMS programs through taxes. In any locality, the most significant costs of delivering EMS are born by communication systems, vehicles and equipment, personnel training and continuing education, medical direction, and state and local regulations affecting staffing and licensing. Nationally, most EMS programs are supported by a combination of public and private funds. Federal and state subsidies commonly derive from general tax revenues, service fees, special revenue (e.g., motor vehicle violations or vehicle/driver licensing), and other sources. Third-party payers, including Medicare, Medicaid, private insurance, private pay customers, and special service contracts may also be an important revenue source. Some EMS activities are funded through subscription agreements that allow consumers to prepurchase EMS, thereby ensuring that those subscribers have priority EMS service. Most rural communities do not have the profit potential and volume of business to sustain private-sector EMS, and, as a result, few private EMS services operate in rural environments. It should be noted that outside agency billing has increased revenue for many EMS agencies. The relatively low volume of emergency calls in rural areas, in relation to the high overhead of keeping a prepared staff, leads to an abundance of EMS squads staffed by volunteers. In turn, this may lead to a less stable EMS organization. Many volunteer squads in rural areas do not even charge for their services because either they lack billing expertise or they simply view their function as one of public service. The creation of critical access hospitals (CAHs) is one cornerstone of the Flex Program. Improvements to rural EMS systems constitute another critical component of the program. The Balanced Budget Act of 1997, which provided cost-based reimbursement for CAHs and established the associated federal grant program, provided explicitly for improvements to rural EMS systems. Integration of EMS into rural hospital financing programs via the Flex Program could provide necessary funding support for those organizations. V-15

Integration is defined as the coordination and sharing of resources and personnel and/or the linkage with other community health resources to ensure that care does not occur in isolation and to enhance outcomes. Integration of EMS and hospital operations is very common in rural areas. Often it comes in the form of sharing of staff and training responsibilities. It is also common to see the use of EMS personnel in emergency departments. Some state EMS offices are reporting that rural hospitals are integrating for efficiency and continuity reasons, and integration appears to be increasing because of the nursing shortage. In addition to grant-funded EMS initiatives, there are several reasons why CAH conversion, in and of itself, may affect the local EMS systems (Schoenman et al., 1999). First, CAHs must establish written agreements regarding patient transfers and communications between the CAH and at least one referral hospital. These arrangements could change the provision of EMS in the CAH community and surrounding areas. In more developed systems, CAHs may become part of a more extensive network, which could involve additional hospitals and other types of providers, including EMS providers. Recent legislation making it possible for some CAHs to qualify for reasonable cost reimbursement for ambulance services may provide an added incentive for CAHs and local EMS providers to change to hospital ownership of ambulance services and integrate services. Second, even short of formal inclusion of EMS providers in the CAH network or CAH ownership of an ambulance service, changes in the day-to-day operations of the CAH may have spillover effects for its own emergency department or the local EMS system. For example, CAHs must provide access to emergency care around the clock, but on-site requirements and staffing provisions have been relaxed relative to acute care hospital standards. Likewise, postconversion changes in the CAHs’ scope of services, changes in the community’s support for the facility, improved ties to the network hospital and/or area trauma system, the 96-hour limit on average length of stay, and the number and type of patients transferred by ambulance between the CAH and other facilities may affect the volume and type of patients coming to the hospital emergency room. Another method to increase integration is having EMS programs expand their mission and scope of services to address local health care needs. This could involve broadening the scope of prehospital emergency care provided (i.e., EMS staff would take on a more advanced medical function with patients before they reach the hospital; rather than just stabilizing and treating symptoms while in transit and deferring treatment until they reach the hospital). For example, EMS personnel may become more involved in staffing enhanced regional poison control centers. Other examples are as follows: • Delivering triage for severe injuries or illnesses; • Providing on-the-scene care for less severe injuries, including a follow-up visit to a clinic; and • Serving a public health function that improves access to basic health care by performing – Immunizations, – Sports and preschool screenings, – Blood glucose testing, – Hypertension screening, and – Community education on self-care and prevention for such matters as managing children’s illnesses, diabetes and epilepsy education, and injury prevention. SECTION V—DESCRIPTION OF STRATEGIES V-16

SECTION V—DESCRIPTION OF STRATEGIES V-17 EXHIBIT V-4 Strategy Attributes for Integrating Support of EMS into Rural Hospital Financing Programs (T) Technical Attributes Target Rural ambulance services and rural hospitals. Expected It is difficult to quantify the expected effectiveness, in terms of the number of lives saved or Effectiveness injuries reduced, through integrating support of EMS into rural hospital financing programs. It is implied that through integration, an improved level of care and efficiency is achieved. However, information on these measures is anecdotal at best. Financial metrics may be the only information available to determine effectiveness. In West Virginia, Flex Program grant funds targeted for EMS were used to support feasibility studies of hospital integration with the local EMS system (Schoenman et al., 2001). Results of the studies concluded that integration could be achieved in varying degrees, from simply sharing resources (such as personnel, billing, or administrative capabilities) to outright ownership by the hospital. In West Virginia, the latter model was perceived as having the best potential for improving EMS operations. This perception was based largely on successes demonstrated by one of the state’s hospitals that acquired the local EMS system during the Essential Access Community Hospital/Rural Primary Care Hospital program, which are recounted below. When the local West Virginia hospital acquired the local EMS system in 1997, the county- financed volunteer squad was transformed into a hospital-based operation with two stations operating with a paid staff and full-time paramedic capability. The following improvements resulted: • Response times were sharply reduced because of full-time paid staff and the operation of two stations, rather than one. • The quality of care improved because the staff had more consistent and better training. • Call volume increased because of increased trust in the community. • The level of sophistication of equipment and personnel improved to such an extent that the EMS system is considering becoming a critical care transport provider for the region. • Costs for medical and pharmaceutical supplies were reduced. • Costs for medical liability were reduced. • Hospital funds for capital acquisition became available. • Training programs for paramedic and emergency response teams were integrated. • There were more opportunities for EMS staff to use their skills when based at the hospital. • EMS staff had daily communication with the medical director. • Equipment and biomedical support were shared. • Experts were more available (e.g., marketing, human resources). Another means for achieving EMS integration is to have all local health care providers, including EMS, build more cooperative communication systems and mutually acceptable clinical guidelines and care standards to ensure a continuum of patient care and the confidentiality of patient information. For example, clinical demonstration projects may be developed that expand the skills and scope of practice for certain rural EMS personnel and offer greater flexibility in the licensing requirements for EMS staff.

SECTION V—DESCRIPTION OF STRATEGIES V-18 EXHIBIT V-4 (Continued) Strategy Attributes for Integrating Support of EMS into Rural Hospital Financing Programs (T) Technical Attributes • Full-time billing staff was available with an expertise in the nuances of Medicare and Medicaid regulations, which can enable a better collection rate for ambulance transport fees. In 1998, West Virginia became the first state to receive approval to implement the Medicare Rural Hospital Flexibility Program. Keys to Success A key to success is strong hospital and EMS leadership that guides the process of integration. It is important that the hospital employ managers with an expertise in EMS. It is unrealistic to manage an EMS system in the same manner as an emergency department (Schoenman et al., 1999). Potential Some hospitals are not willing to link with EMS because of increasing liabilities associated Difficulties with owning an ambulance service. Some of the successes identified above for the particular West Virginia hospital may be difficult to attain in today’s environment (Schoenman et al., 1999). Most importantly, movement from a volunteer to a paid staff was facilitated by the fact that Medicare paid on a cost basis for hospital-owned ambulance services at the time, which sharply improved their revenue. Although the Benefits Improvement and Protection Act of 2000 will allow some CAHs that own an ambulance service to obtain cost-based reimbursement from Medicare, to qualify, there must not be any other ambulance providers operating within a 56-km (35-mile) radius of the hospital. All other EMS systems (whether hospital-owned or not) are to be paid under Medicare’s new national fee schedule for ambulance services. Several CAHs in West Virginia that would currently qualify for cost-based reimbursement and are considering acquisition of the ambulance service have expressed concern that they would lose cost-based reimbursement if an independent EMS provider subsequently moves into the operational area. Hospital acquisition of the local EMS squad is not a solution for everyone. Other potential difficulties that have been noted in feasibility studies conducted in West Virginia include the following: • Resistance by local squads to losing their autonomy, • Local squad distrust of the management capability of the CAH or of its long-term viability, • Concern in the community that a hospital-owned system would make it more difficult to elect to bypass the CAH in the event of an emergency, • Concern by the hospital regarding its inability to break even with EMS, and • Continuing barriers to the cross-use of paramedic staff in emergency departments (this is seen as a great potential benefit of basing the EMS squad at the hospital, but one that cannot be realized without changes in state regulations). Appropriate Process measures include the number of CAHs that have integrated EMS in their funding Measures and source by state and metrics that compare financial aspects of integrating services. Data Financial and other data (e.g., of the type noted above for West Virginia) may be used for effectiveness evaluation. Anecdotal information on improved level of care and improved efficiency is another important measure. Associated None identified. Needs

SECTION V—DESCRIPTION OF STRATEGIES Strategy 20.1 A4—Integrate Information Systems and Highway Safety Activities (T) General Description EMS providers perform an important function relative to highway safety beyond the medical treatment and transportation. Specifically, EMS providers collect significant information about the patient, including personal, demographic, and medical information. They also collect information about what the patient and bystanders said were the causes or contributors of the incident (i.e., crashes or other events). In addition, some EMS agencies collect pertinent information about the scene, including road condition, environment, and contributing elements. This first account information is important for reconstructing the situation and learning about causation. V-19 EXHIBIT V-4 (Continued) Strategy Attributes for Integrating Support of EMS into Rural Hospital Financing Programs (T) Organizational and Institutional Attributes Organizational, The type and level of support will vary by institution. Some hospitals that already have an Institutional and excellent working relationship with their EMS organizations will be able to more easily adjust Policy Issues to any changes that working together unveils. The organizational infrastructure may need modification to accommodate integration. Special governance committees may need to be formed. Issues Affecting Many issues can arise, including acceptance by the various governance committees, Implementation obtaining of proper legal advice, valuation of the business (in the case of a buyout or merger), Time and agreeing on terms of the arrangement. Costs Involved According to the West Virginia Office of Rural Health Policy, costs involved may include the following: • Costs for financial feasibility studies; • Legal fees; • Staff training costs (i.e., procedures and guidelines); • Equipment necessary for integration; and • In the case of a buyout or merger, the EMS agency would want to recover the valuation of the business. Training and Hospital and EMS administrators need to perform proper due diligence to understand the Other Personnel benefits and drawbacks of an integrated model. Needs Legislative Legislation should be developed that provides incentives for local EMS programs to become Needs more integrated into the larger health care system. Legislation offering greater flexibility in the licensing requirements for EMS staff may also be necessary. Other Key Attributes None

From a system level, many organizations are involved in making highways safer. When crashes occur, it is vitally important to learn as much about the event as possible so that corrective measures can be implemented to the site that will provide the best outcomes. This information can result in prevention programs and systems by focusing attention on improving education, engineering, and enforcement. All three of these activities together create the greatest change for lasting improvements. Consequently, it is very important to integrate information systems of EMS with other organizations involved with highway safety activities. This integration will provide access to useful information that many can use to make highways safer. For example, databases maintained by highway agencies contain information on crash frequencies and locations. EMS agencies would find this information valuable in determining where to allocate resources (e.g., base stations) and in deploying personnel based upon concentrations of accidents. Identifying areas of high concentration of crashes can also be useful for establishing plans for air transport of patients where ground transport to a trauma center exceeds a certain time threshold (e.g., 1 or 2 hours). The overriding and universal theme for integrating information systems is that EMS and highway safety agencies share a common mission to prevent injuries and save lives. Although they go about it differently, their priorities mesh well. The first step in integrating information systems and highway safety activities is establishing a data collection system. It is important that data collection be standardized among agencies so that data are collected in a uniform manner. Data and a data registry are at the center of most improvement initiatives. Statewide highway safety data systems provide the basic information necessary for effective highway and traffic safety efforts at any level of government—local, state, or federal. State safety data are used to perform problem identification, establish goals and performance measures, allocate resources, determine the progress of specific programs, and support the development and evaluation of highway and vehicle safety countermeasures. Unfortunately, the use of state crash data is often hindered by the lack of uniformity between and within states. The Model Minimum Uniform Crash Criteria (MMUCC) (NHTSA, 2003[a]) was developed in response to state requests for improved and standardized crash data at the local, state, and federal level. When implemented at the state level, the MMUCC provides a minimum set of data elements that are accurate, reliable, and credible within states, among states, and at the national level. Uniform state crash data are used to (1) perform problem identification, (2) establish goals and performance measures, (3) determine progress of specific programs, and (4) support the development and evaluation of highway and vehicle safety countermeasures. Lead EMS organizations across the country, recognizing a large need, adopted NHTSA’s Uniform Prehospital Data Elements in their state EMS data collection systems. The first step to creating a national EMS data set was to agree on a collection of defined data fields that will make up the database. The data set serves as the skeleton of the whole information system. It establishes uniform data elements with definitions of each stage of an EMS event. Data elements include such items as the patient care report number, the mechanism of injury, the number of defibrillation shocks administered, and the names of all hospitals served. Currently, the National Association of State EMS Directors is working with NHTSA and the Health Resources and Services Administration to develop a national EMS database. Such a database would be useful in developing nationwide EMS training curricula, evaluating patient and EMS system outcomes, facilitating research efforts, determining national fee schedules and reimbursement rates, SECTION V—DESCRIPTION OF STRATEGIES V-20

SECTION V—DESCRIPTION OF STRATEGIES addressing resources for disaster and domestic preparedness, and providing valuable information on other issues and areas of need related to EMS care. This work on developing a national EMS database is being conducted under the National EMS Information System grant. It will be important to link key data from this EMS data set to the MMUCC data set. Another important link is the state’s traffic record system. Each state, in cooperation with its political subdivisions, should establish and implement a complete and comprehensive traffic records program. The statewide program should include, or provide for, data for the entire state. A complete and comprehensive traffic record program is essential for the development and operation of a viable safety management system and effective traffic-related injury control efforts. It is also essential for the performance of planning, problem identification, operational management and control, tracking of safety trends, and implementation and evaluation of highway safety countermeasures and activities. A complete and comprehensive traffic record program is the key ingredient to safety effectiveness and management. In the face of a lack of integration of EMS, hospital, and other safety data, NHTSA developed a system for linking crash, vehicle, and behavior characteristics to their specific medical and financial outcomes. Through this linkage, prevention factors may be identified. This Crash Outcome Data Evaluation System (CODES) works as follows: • Data that are collected by law enforcement agencies at the scene of a crash are linked to injury outcome data using probabilistic methods, rather than some unique identifier. As a result, the normal highway safety data set is enriched with medical system data that were collected at the scene, en route to the emergency department, and at the hospital or trauma center upon arrival and/or after discharge. • The types of injuries, their severity, and the costs incurred by persons injured in motor vehicle crashes are described and computerized. • The medical community is, as a result, able to access not only crash outcome data and law enforcement crash reports, but also data from sets such as vehicle registration, driver licensing, citation, and roadway inventory. It will be possible to combine these sources on a case-by-case basis with hospital discharge, trauma registries, EMS runs, and costs, thereby generating more comprehensive information to evaluate the effectiveness and role of medical trauma service in highway safety. Appendix 6 contains further information on CODES. V-21 EXHIBIT V-5 Strategy Attributes for Integrating Information Systems and Highway Safety Activities (T) Technical Attributes Target EMS organizations, government agencies, law enforcement, and highway departments. Expected No studies provide information on the expected effectiveness of this strategy. However, Effectiveness when agencies are working toward the same goal, they should work cooperatively together, and one of the simplest and most logical ways for agencies to work together is through the integration (i.e., sharing) of information. Integration involves more than the simple connection of two systems for the purpose of transferring data. Integration can more accurately be described as the connection and transfer of data between systems for the purpose of combining the functions of each, and the result is new and unique functionality that previously did not exist.

SECTION V—DESCRIPTION OF STRATEGIES V-22 EXHIBIT V-5 (Continued) Strategy Attributes for Integrating Information Systems and Highway Safety Activities (T) Technical Attributes Keys to Success There are many keys to successfully integrating information systems and highway safety activities, including visionary leadership, adequate funding, cooperation between many different players, and information technology support. It is important that each agency/stakeholder involved see a benefit of the cooperative effort in terms of their own goals and objectives. It cannot be emphasized enough that data are only the first part of an information system. Data must be converted into information. The information should be readily accessible and directly applicable to the operations of the stakeholders. Thus, a major part of this effort may include significant revisions to data processing systems, with greater emphasis on end-user accessibility and ease of use. Another aspect of this will be the institution of comprehensive quality control mechanisms to assure the users that the data are valid. Other keys to success in integrating systems and activities include the following (NHTSA, 2000[a]): • Setting Priorities – Finding common ground and setting priorities will probably be the least challenging part of the process. • Sharing Resources – Typically, four types of resources will be shared: funding, information, technical expertise, and human resources. Equipment may also be shared. • Managing Expectations – Common objectives are vital. It is acceptable to go into the process with your own specific objectives, but they must be clearly defined. Finally, a written plan with measurable goals is critical. • Doing Research and Networking – Talk to others who have gone through similar processes. There is no point in making common mistakes. • Maintaining Open Communication – Have formal channels of communication, such as planned meetings, written reports, and single points of contact, as well as encouraging informal communications. • Avoiding Turf Issues – Lay everything out clearly from the beginning, and do not hide anything. Many of the keys to success detailed in Strategy 20.1 A2 are also applicable to this strategy. Potential Difficulties Data privacy is an important issue to be understood. The Health Insurance Portability and Accountability Act of 1996 (http://www.cms.hhs.gov/hipaa/) requires that certain information be stripped out. One potential solution to the problem of maintaining patient confidentiality is to assign a longitudinal patient identifier. For example, in the state of Washington, trauma patients are given a bracelet with a unique identifying number that remains with the patient throughout the process of care. That number is kept with the medical record, but the patient’s name and address are not maintained at the state level, thus preserving confidentiality because the unique number, not patient identifying data, moves from the hospital or EMS agency to the state. It should be noted, however, that if the unique identifier number is preserved in the state crash database, it can ultimately be linked back to private patient data. Therefore, once the linkage and merging of desired data are achieved, it is desirable to also strip out the unique identifier.

SECTION V—DESCRIPTION OF STRATEGIES V-23 EXHIBIT V-5 (Continued) Strategy Attributes for Integrating Information Systems and Highway Safety Activities (T) Technical Attributes The state of Washington has very specific confidentially provisions in its statutes that allow the collection of personal identifiers in addition to the trauma band number. For linking purposes, the experiences of the Office of Emergency Medical Services and Trauma System (Washington State Department of Health) suggest that trauma band numbers by themselves are somewhat inadequate. The reasons for this are that documentation of the trauma band number is sometimes lacking (e.g., missing on one record) and that data entry errors (e.g., keystroke errors) sometimes create problems with both false positives and false negatives. As a result, the trauma band number is useful, but it should not be relied upon solely for adequate linkage. Another area that could create challenges is the information systems themselves. They need to be compatible with each other. In addition, managing large databases has its own set of challenges. Appropriate Achievement of this strategy could be measured by ratings, from system managers and Measures and Data users, on the degree to which systems have been integrated, the user friendliness of the system, and the usefulness of the data that are made available. Associated Needs None identified. Organizational and Institutional Attributes Organizational, Organizations will need to support, by policy, the sharing of information and agree to Institutional and participate in activities that will advance the mission of the local community relative to Policy Issues highway safety activities. This may require formal agreements or development of cooperatives between agencies. Issues Affecting Many issues will impact implementation time, including compatibility of information Implementation Time technology, funding, cooperation, and whether the cooperating agencies have a history of working together. Modification of forms and procedures may take more than a year, and this will normally have to be followed by intensive training of field and office staff. Software will have to be written and/or acquired and tested. Time must be allocated for acquiring new equipment and pilot testing new systems. Costs Involved Cost will vary depending on the scope of the effort. The primary costs will be related to information technology costs. For example, how will data sets be merged or linked? Will new software have to be developed to link systems? Will new hardware have to be purchased? Additionally, staff support will be required to manipulate the data. These costs could be significant, but at the same time, the financial burden can be shared among the agencies. Costs to train personnel on the new system will also be involved. Training and Other Training and personnel needs are dependent on which system and approach are chosen. Personnel Needs When Arkansas developed the prehospital data collection system, a dozen regional training workshops were held around the state during the first year of implementation to instruct users on correctly filling out the data collection form. To maintain the program, about six workshops are conducted on an annual basis (NHTSA, 2000[a]). Legislative Needs Legislation may be needed to modify currently legislated mandates for certain agencies to collect and maintain specific types of data. Other Key Attributes None

Information on Agencies or Organizations Currently Implementing this Strategy Below are two examples where EMS agencies and highway agencies collaborated to integrate their data collection and information systems (NHTSA, 2000[a]). The first example presents the collaborative effort between the Arkansas Department of Health/Division of EMS and Trauma Systems and the Arkansas State Highway and Transportation Department/Traffic Safety Section (TSS) to develop an EMS prehospital data collection system. The second example presents a joint effort by the Wisconsin Bureau of Emergency Medical Services (EMS) and Department of Transportation in creating the Wisconsin EMS Information System (WEMSIS). Arkansas: Development of EMS Prehospital Data Collection System A long-term goal of the Arkansas Department of Health was to develop a state trauma registry. The first step toward this goal was the establishment of a data collection system to collect and capture prehospital data for motor vehicle crashes from emergency providers. This information would help the state more accurately measure the quality of care and would also improve the accuracy of reporting to the NHTSA Fatality Analysis Reporting System (FARS). A project to establish a prehospital data collection system was initiated in 1994. State officials felt that a new data collection system was a vital first step to the development of a state trauma registry. State officials from the two state agencies (EMS and TSS) agreed to a plan to use grant monies available to each to share the cost of implementing a computerized optical scan data collection system. The system would store and analyze prehospital care information collected from licensed EMS providers across the state. The information would be used for regulatory oversight and overall trauma system review and to supplement information in FARS. The partnership between the two state agencies was logical and cost- effective for the state. The two state agencies cooperated on all aspects of the project’s implementation, with EMS taking the lead. Hardware purchases included a flatbed infrared optical mark reader (OMR) scanner and a software package that generates user-defined standard and custom reports. The actual data collection system is housed and operated by the state EMS, which submits data extracts on a regular basis to TSS. The data are also shared with many injury prevention organizations and research groups through the state’s university hospital system. Reports are sent back to the ambulance services and emergency providers for their use in quality management studies. For more information on the Arkansas program, see Cooperation and Partnership: Keys to Success: State Highway Safety and EMS Agencies Working Together to Improve Public Health (NHTSA, 2000[a]). Wisconsin: Comprehensive, Uniform Data Collection About the time that NHTSA published its Uniform Pre-Hospital Emergency Medical Services (EMS) Data Conference Summary Report (NHTSA, 1994[b]), Wisconsin was one of several states struggling with the lack of uniformity in its data. Through state legislation, the state’s EMS board and EMS bureau were charged with drafting a report to include • Recommendations for a uniform data collection system, • Recommendations for collection of post-transport data from hospitals, and • Justification for the number of staff needed to analyze data and disseminate information gathered. SECTION V—DESCRIPTION OF STRATEGIES V-24

SECTION V—DESCRIPTION OF STRATEGIES The result was a list of 65 essential data elements for Wisconsin’s data collection project, essentially a modification of the NHTSA list. Once the data needs were identified, data collection became the primary focus, and collaboration between the state EMS and DOT agencies focused on development of the WEMSIS software. The two agencies shared a cooperative agreement to meet the objective of the program, which was to link crash data using a common data set. Through its combined resources, the program had created a valid tool for EMS data collection. However, the program was dropped a few years after its conception for unspecified reasons. Conceptually, WEMSIS had great potential, especially if widely adopted across the state. It would have allowed providers to collect a wide range of information, such as patient demographics, cause of injury, EMT procedures performed, and DOT safety and crash variables. This tool would have enabled the state of Wisconsin to better analyze the overall effectiveness of EMS. For more information on this disbanded Wisconsin program, see Cooperation and Partnership: Keys to Success: State Highway Safety and EMS Agencies Working Together to Improve Public Health (NHTSA, 2000[a]). Strategy 20.1 A5—Integrate EMS systems into the Safe Communities Effort (T) General Description The USDOT has made a clear commitment to the philosophy that communities are in the best position to effect improvements in motor vehicle and other transportation-related safety problems. When a community takes ownership of an issue, change happens. The Safe Communities approach, developed under the sponsorship of NHTSA, represents a new way community programs are established and managed. All partners participate as equals in developing solutions, sharing successes, assuming risks, and building a community structure and process to continue improvement of community life through the reduction of injuries and costs. A Safe Community expands resources and partnerships, increases program visibility, and establishes community ownership and support for transportation injury prevention programs. As the Safe Community concept addresses all injuries, transportation safety becomes positioned within the context of the entire injury problem. In addition, the Safe Communities approach emphasizes the need to involve the medical, acute care, and rehabilitation communities. These groups need to be actively engaged as integral partners in preventing injuries. Four main characteristics define Safe Communities: (1) injury data analysis and (where possible) data linkage; (2) expanded partnerships, especially with health care providers and businesses; (3) citizen involvement and input; and (4) an integrated and comprehensive injury control system. The EMS Agenda for the Future (NHTSA, 1996) stated that, in the future, the success of EMS systems will be measured not only by the outcomes of their treatments, but also by their prevention efforts. Expertise, resources, and positions in communities and the health care system make EMS an ideal candidate to serve linchpin roles during multi-disciplinary V-25

communitywide prevention initiatives. The NHTSA Safe Communities program provides a proven construct for EMS and other organizations to join forces toward injury prevention. SECTION V—DESCRIPTION OF STRATEGIES V-26 EXHIBIT V-6 Strategy Attributes for Integrating EMS Systems into the Safe Communities Effort (T) Technical Attributes Target The principal target is the Safe Communities program, in which it is envisioned that EMS organizations will work cooperatively with schools, law enforcement, highway crews, local civic groups, local government, health maintenance organizations, and hospitals. Expected It is difficult to quantify the expected effectiveness, in terms of the number of lives saved, Effectiveness through integrating EMS into the Safe Communities effort. Many other safety initiatives have to be accounted for, so there is no real way to determine the actual effect on safety for this type of initiative. Thus, although crash experience needs to be monitored, the impact of this type of programmatic involvement on crashes cannot be inferred. Process measures would focus upon documenting the manner in which EMS organizations are involved in the program and measures of level of activity. Effectiveness analysis would focus upon achievement of program objectives and the costs involved. Surveys can be made of community awareness of, and attitudes toward, the programs and the role of EMS in it. Keys to Success Keys to success include local community leadership, adequate funding, willingness to collaborate, citizen involvement, deployment of a comprehensive injury control model, and celebration of accomplishments. In establishing Safe Communities in rural areas, consideration should be given to the following priorities: identification of the leadership, maximum use of interpersonal communication channels, reliance on local program control, and acceptance of the reality that successful change will only occur slowly (NHTSA, 1999). Some volunteer EMS programs may shy away from a Safe Communities effort because of its injury prevention nature. EMS systems with paid staff will more likely become involved in such programs. Thus, this strategy is geared more toward EMS systems with paid staff. Potential Difficulties It may be difficult to gain and maintain community awareness and interest in the program. Efforts are needed to use public information channels to communicate progress and achievements. Incentives should be sought for those most actively involved. It may take time to get stakeholders communicating freely with each other. It must be recognized and respected that the various community representatives involved will be coming from different backgrounds and organizational cultures and will have various agendas. Patience and strong leadership are needed. Individuals in stakeholder organizations may resist being involved in community safety in new ways. Training and incentives may be needed. Finally, as indicated above, it may be difficult to motivate volunteer EMS personnel to participate in injury prevention programs such as the Safe Communities effort. Appropriate The appropriate measure depends upon the program design. Some of the data often Measures and Data collected include crash and injury cost data. Other data such as community awareness and the number and type of programs and agencies involved are appropriate measures as well. Financial and personnel effort should be measured to analyze productivity measures.

SECTION V—DESCRIPTION OF STRATEGIES Information on Agencies or Organizations Currently Implementing this Strategy There are many excellent examples of Safe Communities programs that have proven results throughout the country. One example of a program is the Wright County, Minnesota, Safe Communities Program, started in 1997 and still active today. The Wright County program was initiated with a grant from the American Association of Health Plans to the local EMS provider. This collaboration was the first ever between an EMS organization and a managed care organization in the development of a Safe Communities program. The results of the effort have been very positive. For more information on Safe Communities of Wright County, visit http://www.safecomm.org and see Appendix 7. Santa Barbara County Safe Communities Injury Prevention Program is another example of an initiative with EMS involvement. This program began in 2001 with a grant from the California Department of Health Services. The Santa Barbara County Public Health V-27 EXHIBIT V-6 (Continued) Strategy Attributes for Integrating EMS Systems into the Safe Communities Effort (T) Technical Attributes Associated Needs This kind of community effort will usually involve some public relations efforts. It may be necessary to seek out some special expertise to put together and implement a plan for this strategy. Organizational and Institutional Attributes Organizational, As a method to reduce crashes and other incidents, organizations need to support Institutional and prevention activities. Within EMS agencies, it may be difficult to expand into injury Policy Issues prevention because it may require a change in the philosophical direction of an agency for this strategy to be undertaken. Interorganizational agreements may be needed, and new organizational infrastructures will be created to implement this program. Issues Affecting Inadequate funding and data will impact implementation time by slowing the development Implementation of effective tactics for improvement. It takes time and patience to create new working Time relationships among organizations, many of which have not interacted previously and come from different organizational cultures. Creating new working relationships cannot be rushed. Costs Involved Costs vary depending on the program designed. Costs may involve staff, office space and equipment, public relations materials and activities, and training. Often grant money is available, and funding may come from local civic groups. Training and Other Specific training is dependent upon the program. Potential training needs include grant Personnel Needs writing to secure funding and facilitator training for the leaders. Training may be needed in association with injury prevention programs. Legislative Needs Legislation may be required to facilitate forming new organizational relationships, as well as to support activities that come out of the program. Legislative support for adequate funding is also desirable. Other Key Attributes None

Department EMS Agency coordinated the program with an aim to engage representatives from all facets of public safety in a coalition to prioritize major causes of unintentional injury in the county and to strategize for the reduction of these injury types. Following an extensive effort to collect data on unintentional injury, the coalition prioritized areas of injury in accordance to incidence, cost, and perceived community interest. This research led to the development of a strategic plan that recommends strategies for intervention. For more information on the program, visit http://www.sbcphd.org/ems/safe_community.html. Strategy 20.1 A6—Use Mobile Data Technologies That Are Interoperable with Hospital Systems (T) General Description More communities are requiring EMS mobile data communications as EMS providers struggle against time to save lives. The more information EMS crews have, the better prepared they are to handle any situation quickly and safely. Mobile data communications are cost-effective, reliable, and secure and can increase productivity, reduce costs, improve services, and increase personnel safety. Mobile data systems using portable and vehicle mobile data terminals (i.e., mobile computers) and wireless communications can provide: • Call information and street directions to get the ambulance crew to the scene quickly, • Automatic vehicle location (AVL) data to send the ambulance along the quickest route, • Critical medical information, • Patient and address history for quicker appropriate action upon arrival, and • The ability to complete run reports from the vehicle. An effective and coordinated response requires radio interoperability, which is the ability to communicate by radio between emergency response agencies dynamically and on demand. Serious natural disasters (such as hurricanes and forest fires), major tragic events (such as the Oklahoma City bombing), and recent acts of domestic terrorism demonstrate the imperativeness of a coordinated response among public safety agencies from various levels of government. Local police, fire, and EMS agencies are the nation’s first responders to these major incidents. All emergency response personnel require safe, reliable, and secure communications with each other, as well as the ability to communicate quickly and directly with other local, state, and federal agencies and area hospitals. This improves the ability to effectively manage the scene of major incidents and to more effectively triage patients to specialized hospitals capable of caring for those patients. It also supports efficient triage of patients at times when the local hospital emergency departments are on divert mode. Local emergency services agencies and hospitals require seamless, coordinated, integrated communications to effectively protect lives and property in their communities. There are many examples where police, fire, and EMS commanders at emergency scenes require reliable, secure, and clear wireless communications with each other at the incident command level and in coordination with local hospitals to carry out their job effectively, in the best interest of the public, and for the safety of the emergency response personnel. Exhibit V-7 provides a sampling of various mobile data technologies. SECTION V—DESCRIPTION OF STRATEGIES V-28

http://www.911dispatch.com/information/mobiledata.html http://www.itronix.com/ http://www.med-media.com/pubsafety/remstat.htm http://www.panasonic.com/computer/toughbook/home.asp SECTION V—DESCRIPTION OF STRATEGIES V-29 EXHIBIT V-7 Samples of Mobile Data Technologies This strategy is closely related to Strategy A7 and all strategies associated with Objective D.

SECTION V—DESCRIPTION OF STRATEGIES V-30 EXHIBIT V-8 Strategy Attributes for Using Mobile Data Technologies That Are Interoperable with Hospital Systems (T) Technical Attributes Target The target of this strategy is the communication systems of EMS organizations, hospitals, and government service providers. Expected The data managed using mobile data technologies can empower everyone involved in Effectiveness EMS. Medics can focus on patient care with a nonintrusive tool to rapidly collect, reference, and communicate data. A patient’s assessment, their treatment, and the underlying care they receive can be enhanced. Administrators can manage resources and link information systems. Quality assurance and quality improvement are provided with unlimited data analysis capabilities to detect trends and modify education. Billing offices are given complete, precoded information, reimbursement-critical data capture capabilities, and automated system interfacing options. Medical direction is provided with accurate, complete information, including the data elements necessary to continually improve guidelines. Doctors, nurses, and hospitals receive legible, timely, wirelessly delivered reports. Dispatch can share run and patient information. Legal staff can decrease liability exposure. Area agencies and hospitals can receive properly formatted, paperless run data. Information is more effectively used when it can be easily and rapidly accessed and distributed. Interfacing with systems such as billing, dispatch, and hospital informatics can be accomplished through a wide variety of open data-sharing and connectivity standards. The wired and wireless real-time connectivity capabilities give agencies a powerful tool to perform many tasks, such as look up patient records, send current findings, communicate with medical devices, and deliver times and mission-critical patient information. Sanddal (2003) conducted a study for the Western Transportation Institute to evaluate the impact of PDAs on EMS response to traumatic injuries. The objective of the research was to compare the effectiveness of a scannable paper-based/desktop patient information system against a PDA-based/desktop system and a previous hard copy reporting system for issues of timeliness, accuracy, completeness and legibility of data, and inclusion or exclusion of prehospital records from the patient’s hospital medical record. Sanddal found that both methods of electronic data collection, scannable bubble sheets and PDA data collection, performed better than the previous paper-based written patient contact forms in measures of completeness, legibility, patient information, care/treatment, and mechanism of injury descriptions. The scannable bubble sheets and PDA systems performed similarly in all measures except for legibility, where the PDA excelled. Sanddal concluded that the improvements in record keeping from both electronic technologies during the prehospital phase of trauma care could impact the eventual outcome of injured patients by allowing for greater continuity of care. Keys to Success An important key to implementing mobile data technologies is clearly identifying the needs of all agencies and hospitals that require communications both internally and with other agencies at emergency scenes during disasters and widespread emergencies. In addition, it is important to thoroughly assess all existing communication systems employed by all agencies and hospitals; to determine specific changes and additions that are required to meet their interoperability needs; and to establish clear, realistic budgetary estimates and priorities for implementing the required changes. Potential Difficulties Potential difficulties include lack of funding, lack of radio infrastructure to support communication needs, and security of the system. Some personnel may resist the use of new technologies. Careful introduction and training are needed to minimize this resistance, as well as to facilitate optimum use of the technology.

SECTION V—DESCRIPTION OF STRATEGIES Information on Agencies or Organizations Currently Implementing this Strategy Several agencies or organizations that (1) are using mobile data systems within their agency, (2) have participated in a demonstration project with such devices, or (3) plan on implementing the devices in the future include the following: • The City of Akron, Ohio; • Washington/Norwich Township Fire Departments (near Columbus, Ohio); V-31 EXHIBIT V-8 (Continued) Strategy Attributes for Using Mobile Data Technologies That Are Interoperable with Hospital Systems (T) Technical Attributes Appropriate The number of agencies operating interoperable technologies is an appropriate process Measures and Data measure, along with documentation of the nature of technologies used, and the manner in which they are used. System downtime is another important process measure. In addition, one can acquire ratings by trauma operational staff and managers of the change in the value of the system, vis-à-vis the aspects listed in the section on effectiveness (above in this table). Where the system can have direct impact on operations, such measures as response time may be used. Associated Needs Competent IT capabilities are needed. Organizational and Institutional Attributes Organizational, Because multiple organizations will be using these systems, the development of a Institutional and regional consortium with joint powers to guide policy matters will be useful. Policy Issues Issues Affecting Many issues can affect implementation time, such as determining the type of technology Implementation that is most appropriate to meet the needs of all associated agencies, securing funding, Time and developing and testing the system. The time required to complete these tasks will be a function of the level of the existing information/communication infrastructure. Costs Involved Costs for these technologies can range significantly depending upon the complexity and sophistication of the system. For example, Perkins Township Fire Department noted that they purchased a system that included software, four hand-held computers, and three printers that use infrared signals to communicate with computers (Brown, 2003). In most cases, the primary costs involved will be hardware and software related. Developing a wireless secure network to transport data may also be of significant cost. Finally, training costs and maintenance costs will also be involved. Training and Other Training needs include working knowledge of public safety technological and system Personnel Needs standards, such as used by the Association of Public-Safety Communications Officials (APCO) Project 25, and experience working with the Telecommunications Industry Association/Electronics Industry Association (TIA/EIA) standards for wireless communication systems. Understanding The Health Insurance Portability and Accountability Act of 1996 (http://www.cms.hhs.gov/hipaa/) privacy regulations will also be important. Legislative Needs The area of mobile communication requires constant support by the state and federal legislature to fund new advancements. APCO provides a comprehensive list of key issues and strategies for improvements (http://www.apcointl.org/about/gov/). Other Key Attributes None

• Mecklenburg EMS Agency (MEDIC) in Charlotte, North Carolina; • Agencies in Northern Shenandoah Valley; and • Pennsylvania Department of Health Emergency Medical Services Office. For more information on use of mobile data technologies within these agencies and organizations, see Appendix 8. Strategy 20.1 A7—Require All Communication Systems to Be Interoperable with Surrounding and State Jurisdictions (T) General Description “Interoperability” refers to connecting two or more information systems for the purposes of enhancing and creating new functionality that did not exist prior to the integration of the systems. In the EMS field, the integration of communication systems is most often associated with connecting systems that reside at the public safety answering point (PSAP). Integration at the PSAP combines previously disparate systems into a single, consistent user interface. This integration has several benefits (http://www.911spec.com/samplewhy.htm). Most importantly, integration can provide new and unique ways of performing tasks that previously were not possible or were difficult to perform. Integrating systems requires the ability of each system to communicate via a common language or protocol. Many 9-1-1 systems incorporate third-party, proprietary products, such as Private Branch Networks (PBXs). It is very difficult to integrate these products because they are proprietary and unable to communicate with other systems. Open systems employ and publish standard methods of communicating through application program interfaces (APIs), thus providing the ability for other systems to communicate and integrate the functionality of each. With the advancement of communication technology, especially 800-MHz trunking, the ability to have a fully functional, interoperable communication system is not only desirable but also achievable. Communication is often sighted as a critical component to effectively managing emergency situations that involve multiple organizations. This strategy is closely related to all of the strategies associated with Objective 4, “Reduce time from injury to appropriate definitive care.” SECTION V—DESCRIPTION OF STRATEGIES V-32 EXHIBIT V-9 Strategy Attributes for Requiring All Communication Systems to Be Interoperable with Surrounding and State Jurisdictions (T) Technical Attributes Target This strategy targets EMS organizations, law enforcement agencies, fire fighting services, local, regional, and state government, hospitals, highway departments, emergency management organizations, poison centers, regional response teams, other health care providers, and Hazmat response teams. Expected By requiring all communication systems to be interoperable, it is presumed that through Effectiveness integrating the functions of the various systems, new and unique functionality will enable agencies to work together more efficiently and seamlessly and improve the quality of care provided to trauma patients.

SECTION V—DESCRIPTION OF STRATEGIES V-33 EXHIBIT V-9 (Continued) Strategy Attributes for Requiring All Communication Systems to Be Interoperable with Surrounding and State Jurisdictions (T) Technical Attributes Keys to Success Keys to success include legislation mandating this requirement, information system technology, communication system infrastructure, adequate funding, and cooperation among all agencies. Moreover, for communication systems to be interoperable and to function properly, the following steps are recommended (Horan and Schooley): • Access critical coverage gaps: EMS is fundamentally dependent on mobile coverage. • Integrate EMS planning into ITS planning and funding: To receive local funding, such systems should be integrated into the transportation planning process because this is the means by which state and local funds are allocated. • Develop a strategic plan and a management plan: These two plans should remove artificial barriers to establishing interorganizational systems. • Provide adequate training to specialists: The new systems will require training at the local level. Data sharing and interoperability are key issues for public safety agencies (Schuman and Meyer). By partnering with transportation agencies, public safety agencies can design regional information and communication systems to serve the broadest public interest. In this manner, agencies will be able to share vital incident management information in real time, while preserving the privacy of nonpublic information on proprietary networks. Finally, visionary leadership is necessary to harness the full potential of new technology. Public safety and transportation agencies are challenged to work together in new ways, to learn to operate new systems, and to share both resources and responsibilities. Potential Difficulties Potential difficulties may arise if participation in such a system is optional. Other difficulties may include lack of funding and lack of technological and communication infrastructure. Appropriate The number of agencies in compliance with interoperability is an important process Measures and measure. Effectiveness can be measured in terms of new functionality that was not Data possible prior to interoperability, as well as anecdotal evidence that supports improved efficiency in operations or improved quality of patient care. Financial data will be needed in order to arrive at efficiency and productivity measures. Associated Needs Vendor support is important to ensure that all equipment has the ability to seamlessly integrate with other equipment. As an example, all participants’ radio systems should be on 800 MHz, and one brand of radio (e.g., Motorola) should connect to another brand of radio (e.g., Standard). Organizational and Institutional Attributes Organizational, Many policy issues will be present, including (1) who owns the system, (2) who will Institutional and manage the system, (3) how upgrades will be handled, and (4) who will operate the Policy Issues system. Everyone involved will be required to establish and comply with the operating rules governing the use of the system. Coordination with the Federal Communications Commission (FCC) over usage of the system will also be necessary.

Information on Agencies or Organizations Currently Implementing this Strategy A good example of a rural county advancing its communication systems to a level of full interoperability is Jeff Davis County, Georgia. Jeff Davis County, located in the middle of Southeast Georgia, boasts one of the most efficient 9-1-1 centers in that part of the country. The centralized center is equipped with a three-position communication system that provides four 9-1-1 trunks, 20 analog telephone lines, and eight radio channels with four trunking radios (Clifton, 2001). Additional system features include telecommunication device for the deaf (TDD), instant recall recording, and tone paging at each station. One year after implementation, the response times to calls have been reduced, and the efficiency of the responding units has improved. Appendix 9 provides additional details on the communication system in Jeff Davis County, Georgia. Objective 20.1 B—Provide/Improve Management and Decision-Making Tools Strategy 20.1 B1—Develop Resource and Performance Standards Unique to the Specific Rural EMS (T) General Description EMS is provided by a myriad of configurations across the United States. High-performance systems have appropriately trained and equipped personnel arrive at the scene of a medical or trauma emergency in a short period of time. This requires that EMS units be stationed SECTION V—DESCRIPTION OF STRATEGIES V-34 EXHIBIT V-9 (Continued) Strategy Attributes for Requiring All Communication Systems to Be Interoperable with Surrounding and State Jurisdictions (T) Organizational and Institutional Attributes Issues Affecting Securing funding, availability of technology and infrastructure, developing cooperative Implementation agreements among the providers, and staff training will all affect implementation time. Time Costs Involved Costs highly depend on system requirements. In most cases, the primary costs involved will be hardware and software related. Current systems often require periodic upgrades and can be very costly as platform systems become obsolete and no longer supported by the providing vendor. However, training costs and maintenance costs will also be involved. Costs to upgrade systems will also be involved. Training and Other Staff who use the system will need to learn the operation of the equipment and the rules Personnel Needs of the system. If a centralized dispatch function is included in the system configuration, additional staff training will be needed. Legislative Needs Support will be required to designate certain radio channels exclusively for this system. Other Key Attributes None

SECTION V—DESCRIPTION OF STRATEGIES strategically throughout the service area 24 hours per day and have a means to rapidly respond to calls for assistance. EMS agencies have typically established a response time standard of approximately 8 minutes for advanced life support. This standard has resulted from considerations other than trauma from crashes. The American Heart Association has conducted studies on the survival rate of out-of-hospital cardiac arrest. Because of that information, most EMS agencies strive to initiate early CPR, followed by early defibrillation, and then the initiation of advanced cardiac life support approximately 8 minutes after cardiac arrest occurs. According to studies, the amount of time to provide these critical steps impacts the survivability of cardiac arrest. The Commission on Accreditation of Ambulance Services uses a time of 8 minutes, 59 seconds to have an advanced life support unit on scene. Based on Standard 1710, the National Fire Protection Association uses a response time of 480 seconds, or 8 minutes, to have an advanced life support unit on scene. Both of these measurements do not take into consideration the population density and the travel distance in providing on-scene coverage, but rather deal with the end result of the arrival of advanced life support in order to reduce deaths due to out-of-hospital cardiac arrest. The Commission on Fire Accreditation International does not have established timeframes for response but relies on local agencies to establish the response times that are appropriate to the level of risk in the community. To further complicate the issue, there is no agreed upon performance measures other than that of response times. Even in urban areas, it is often difficult to maintain the response standards outlined above. Highway networks, traffic congestion, high-rise buildings, and 9-1-1 center incident processing methods all impact the ability to reach patients in need of emergency medical care within short time periods. To date, two primary measures have been used to determine the success of an EMS system: the response to patients in cardiac arrest prior to biological death (discussed above) and the transport of trauma patients to the appropriate level of trauma center. Of these two measurements, only the first (i.e., response to patients in cardiac arrest) requires strict ambulance response times in order to improve the outcome. The response to trauma patients can be dependent upon rapid ambulance responses, but the overall time to a trauma center can be made up during other phases of the emergency, such as the use of air medical transport systems and well-functioning trauma systems that rapidly move patients into an operating room capable of handling the severity of the injury. No widely known reliable studies have evaluated EMS systems based on the performance of the system other than the intervention of medical emergencies to prevent sudden cardiac arrest. Thus, the majority of EMS systems use the cardiac arrest survival potential in developing response times rather than measures based upon data derived from response to traumatic injury. Particularly in rural areas, a better measure may be the response times required to positively intervene in other medical situations. In a rural area, it is unlikely that an emergency can be recognized, the 9-1-1 system can be accessed, an EMS unit can be dispatched, and an equipped and staffed unit can arrive on the scene within the time parameters outlined. This is primarily due to travel distance and dispersed population. Therefore, it is critical to V-35

determine what response times are realistic in a given rural area, taking into consideration the standards set by the various national organizations. More importantly, it is critical to understand the threshold points of response times that have the most potential to positively or negatively impact patient outcomes. In addition, when considering establishment of threshold response times, consideration should be given to accepting slightly greater response times if a higher level of care can be provided to the patient upon arrival of the EMS unit at the site than if no significant medical intervention would be made until arrival at the trauma center. Although research by Liberman et al. (2003) indicates that there is no benefit of having on-site advanced life support for the prehospital management of trauma patients in urban centers, it also indicates that these conclusions may or may not apply to rural trauma patients. Because the tradeoffs between advanced treatment versus time have not been completely answered for rural areas, this consideration is valid when establishing threshold response times. This linkage between quality of care and response times can make direct comparisons between jurisdictions or plans difficult. Finally, establishing optimum staffing resources is an additional dimension to the problem. Resources available to urban EMS systems typically include a medic unit staffed with two people and a first response unit, often a fire truck with four firefighters. This gives a total of six people to handle critical EMS incidents. In rural areas these levels of resources (both in numbers as well as skills) typically are not available. Therefore, it is important to determine an optimum staffing level for a given rural area and strive to attain (or maintain) this staffing level. A task analysis of response activities over a defined time period will allow systems to determine the appropriate number of personnel to have on duty at a given time as responders on EMS units. Currently, there is an effort at the national level to create a guide to EMS performance measures. Ideally, this effort will develop national standards unique to rural EMS. SECTION V—DESCRIPTION OF STRATEGIES V-36 EXHIBIT V-10 Strategy Attributes for Developing Resource and Performance Standards Unique to the Specific Rural EMS (T) Technical Attributes Target The principal target for this strategy is the current status of resource and performance standards available for use by EMS providers, EMS administrators, physicians, hospitals, county and local administrators, fire chiefs, elected leaders, and emergency managers and medical directors. Expected No studies are available to provide a basis for estimating the safety effectiveness of this Effectiveness strategy. However, as resource requirements and performance standards are established for rural EMS systems, it will be feasible to measure the degree of success for similar systems and not to rely on comparisons with systems that service urban areas. This will help ensure that a level of service is available that is based on data rather than political pressure and lobbying efforts of stakeholders. The various political entities must be able to base staffing decisions on verifiable data that best serves the citizens in that locality. Keys to Success One key to success will be to establish resources and performance standards that balance the needs of victims with the reality of rural areas to provide acceptable levels of service. Establishing resource and performance standards will need to involve some level of data collection and analysis.

SECTION V—DESCRIPTION OF STRATEGIES V-37 EXHIBIT V-10 (Continued) Strategy Attributes for Developing Resource and Performance Standards Unique to the Specific Rural EMS (T) Technical Attributes Successful initiation of this kind of action will be more likely to occur when pressure exists to respond to increasing urbanization in rural areas. Thus, it will become clear to those who manage the system that tools must be made available to assist the localities that do not have the staff or expertise to design an EMS system for their community. Potential Difficulties This may generate extensive discussion and disagreement, particularly from those in the EMS community who take the position that all victims should receive the same response time, regardless of location. Others believe that real world situations make it not cost- effective or practical to have EMS units strategically located to provide a response within 8 minutes in areas with a very sparse population and low incident volumes. If, or when, nationally accepted standards are established for rural EMS, some jurisdictions will be unable to meet any standard as set forth. This concern should not offset the need to have these standards. Therefore, mechanisms are needed to mitigate the impact on locations unable to meet the new standards. Added costs, experienced to meet new standards, will create stress on already tight budgets and result in resistance to the adoption of the standards. Basic levels of equipment to meet accepted standards will be necessary. Some agencies may realize that they need to hire full-time EMS workers to meet established standards. Appropriate Process measures include documentation of the existence, scope, and type of standards. Measures and Data Effectiveness measurements should be based upon differences in response times in relation to patient outcome. For example, measurements should look at patient outcomes upon the initiation of definitive advanced life support care (assumed to be present under improved standards) instead of outcomes for patients who do not receive definitive advanced life support care (assumed not to be present in the absence of improved standards). Associated Needs A community planning and integration process is necessary to help the community evaluate the place of EMS services in the community and to determine what resources and performance measures are acceptable. This type of planning will involve EMS agencies, hospitals and medical assistance facilities, governing bodies, schools, service clubs, the business community, and the public at large (Critical Illness and Trauma Foundation, 2003). Appendix 10 provides a model EMS community planning and integration guide to assist communities in building strong EMS systems. Organizational and Institutional Attributes Organizational, The major issues will be what the scope of the evaluation system will be and what Institutional and performance measures and standards apply. The International Association of Firefighters Policy Issues has an EMS performance measurement system that is being instituted in various locations around the United States. This system will measure any participating systems, but, at this point, it does not provide benchmarks for rural systems. The convening authority will be faced with difficult value judgments when setting standards for rural EMS, since an entirely new measurement system may be adopted to replace the cardiac arrest scenario. For the rural EMS standards to be valid, the medical community in the area must be actively involved in establishing the local rural EMS standards, and, ultimately, the medical community at large must be involved in establishing national rural EMS standards. If, or when, nationally accepted standards are established, it is anticipated that separate standards will be established for rural and urban operations. It is imperative that rural standards be presented as appropriate only in rural areas.

Strategy 20.1 B2—Identify, Provide, and Mandate Efficient and Effective Methods for Collection of Necessary EMS Data (T) General Description Two major considerations in the cost of data collection are (1) the amount and type of data to be collected and (2) the methods for data acquisition, data reduction, and data entry. A complete assessment of any EMS system requires that an analysis be completed on the performance of the system. Typically, the performance of any EMS system is judged using the data that have been collected from previous incident reports. The data are collected by the EMS attendants and may be recorded in written or electronic form. In most EMS systems, the data are stored for legal and historical purposes. In many systems, data that are collected in written form are later entered into database systems to better manage the data and information. More progressive systems use mobile data computers or some form of hand-held computers to capture the information (see Strategy A6). SECTION V—DESCRIPTION OF STRATEGIES V-38 EXHIBIT V-10 (Continued) Strategy Attributes for Developing Resource and Performance Standards Unique to the Specific Rural EMS (T) Organizational and Institutional Attributes Staff must work with stakeholders to ensure that standards are valid and reliable. Finally, by developing resource and performance standards based upon some level of data collection and analysis, agencies will be reducing their tort liability and other legal risks. Agencies will be demonstrating that they are taking a proactive approach in an effort to answer difficult questions instead of the current situation that most agencies find themselves in when they cannot adequately respond to questions concerning the difference in patient outcomes when treated with varying response times and differing levels of patient care administered at the scene and during transport. Issues Affecting It may prove difficult to convene a group that can easily decide on what data and Implementation Time measures need to be used to determine the effectiveness of EMS. Also, a data collection system must be in place that will adequately track emergency response units and then complete a follow-through with patient outcomes. This will require an integrated approach between the prehospital and in-hospital care systems that may take more than a year to operationalize. Costs Involved Costs involved will include the time and effort to determine the appropriate measures, the cost to collect and analyze the data, and the time involved to determine appropriate standards. Training and Other All personnel involved in the affected operations will need to be informed, and some will Personnel Needs need to be trained, regarding the impact of the revised evaluation system on their job and unit. Legislative Needs Legislation may be required to reduce liability of rural systems that decide to adopt standards that may be less stringent than urban systems. Other Key Attributes None

SECTION V—DESCRIPTION OF STRATEGIES National standards have been developed in regards to collection of EMS data. In 1993, 80 EMS data elements were identified and agreed upon at the Uniform Pre-Hospital Emergency Medical Services Data Conference, sponsored by NHTSA. That information was disseminated to the EMS community for action at the state and local level. A great majority of states have followed suit and established data collection systems that use the adopted elements, while some agencies have added data elements that are specific to their state and local systems. To update the work initiated in 1993, the National EMS Information System released an updated version of the NHTSA Prehospital Dataset in 2004 (Version 2.1). This information is now available to EMS agencies, and all states are being encouraged to implement this national standard. According to NEMSIS, as of February 2005, 47 states and the District of Columbia have committed to implementing a standardized reporting system. Several states, such as Ohio, Minnesota, North Carolina, Delaware, and Mississippi, have developed model data systems. Every system depends on various agencies in the state to manage the data. In some cases, the data are archived at the local EMS agency, while in other cases, the data are sent to a central location in the state. Some states have the ability to analyze the data and to provide feedback to local agencies. Other agencies have collected data but are unable to provide usable information from the data. A major issue with the data sets that have been developed is the ease of collection. Field providers routinely complain about the complexity of collecting the data and the time that it takes to document the elements, which field providers may not think are relevant to the care of that specific patient or to key system performance indicators. The minimum data set may not be completely suitable for rural EMS systems. It may be appropriate to eliminate or modify some data elements and add others to improve the quality, completeness, and unit costs associated with collection of EMS data in rural areas. All personnel at EMS agencies need to understand that consistent, long-term collection of data is important and that each agency has the responsibility to collect the minimum set of data. A minimum data set must support analyses of response standards, patient care, treatments administered, and patient outcomes. In many cases, the data collection ends when a patient is delivered to an emergency department. To include the final discharge outcome of the patient, particularly in rural areas, consideration should be given to either extending reporting or linking to trauma center databases. These data can be linked to other data systems, so the information can then be used to gain a better understanding of the ultimate impact of treatments administered at the scene and en route, as well as the response and transport times. A low-cost method of data handling is also needed. Collection of data using pencil and paper is often considered the lowest cost option; however, this option does not allow for efficient and less error-prone data entry. When data reduction is factored into the process, viable options to assist in data collection include the various mobile data technologies, as discussed in Strategy 20.1 A6. Optical scanning systems are also a possibility, but these systems, while significantly more efficient than traditional paper reports, still are less productive than automated data collection systems. Mandating the use of some form of electronic collection systems would assist all agencies in establishing data systems that could be accessed universally in order to evaluate effectiveness and efficiency. V-39

Information on Agencies or Organizations Currently Implementing this Strategy The National EMSC (EMS for Children) Data Analysis Resource Center (NEDARC) is available to help state EMS offices develop their own capabilities to collect, analyze, and use EMS and other healthcare data to improve the quality of care in state EMS and trauma systems. Several states that have developed model EMS data systems include • Ohio, • Minnesota, • North Carolina, • Delaware, and • Mississippi. Additional information on the data systems in these states is provided on the NEDARC website (http://www.nedarc.org/). Recently, the Rural EMS and Trauma Technical Assistance Center was established. This center will serve as a national focal point for the dissemination of information on rural EMS and trauma care. The center will provide services to a wide range of rural EMS providers. This center will ideally be the start of a central repository of rural EMS-related data. Making EMS information centers readily available will permit EMS systems to access information that can assist them in solving system problems. This will enhance current EMS systems by using proven programs or techniques that will enhance the overall delivery of EMS. SECTION V—DESCRIPTION OF STRATEGIES V-40 EXHIBIT V-11 Strategy Attributes for Identifying, Providing, and Mandating Efficient and Effective Methods for Collection of Necessary EMS Data (T) Technical Attributes Target EMS administrators, fire chiefs, state EMS directors, and EMS personnel. Expected The safety effectiveness of this strategy will not be easily or directly quantified. The Effectiveness strategy should provide analysts and decision makers with improved information for making decisions especially tailored to rural EMS conditions. Keys to Success It will be important to separate the essential data elements from others that may be desirable but not critical so that costs can be controlled. It will be critical to the success of this effort to have the involvement of all stakeholders from the beginning in such a way that their opinions, requirements, and concerns are recognized and addressed. A key to success for any information management system is to explicitly define the nature and format of the information that will be produced by the new system and to establish the purpose for each piece of information. The cooperation and enthusiasm of the stakeholders can be encouraged by clearly demonstrating to them the benefits to be derived from changing the system. It may be more appropriate to concentrate on making the current data collection system more user friendly than to attempt to implement a completely new process. Data privacy is an important issue to be understood, especially as related to the Health Insurance Portability and Accountability Act of 1996 (http://www.cms.hhs.gov/hipaa/).

SECTION V—DESCRIPTION OF STRATEGIES V-41 EXHIBIT V-11 (Continued) Strategy Attributes for Identifying, Providing, and Mandating Efficient and Effective Methods for Collection of Necessary EMS Data (T) Technical Attributes Finally, the timeliness of collecting the data and recording the information so that it can be analyzed during evaluations of the system is critical. Potential Difficulties It may prove difficult to get the various agencies to change their existing system if it has been in place for a long time. If EMS data are collected as part of a broader range of enterprise data, then changing that element may cause undesirable ripple effects in the remainder of the system. Additional issues may arise in asking rural EMS providers to change their current data collection methods and data elements. For instance, a scan data system may require the use of a broadband Internet connection, which may not be immediately available in some rural areas. A mandate (or legislative action) requiring the collection of EMS data is difficult to enforce unless the consequences of nonconformance are significant. Appropriate The number of agencies that adopt a new data collection and management system, Measures and Data along with documentation of the nature of those systems, is a good process measure. Effectiveness measures include changes in the accuracy, precision, completeness, timeliness, and reliability of the data. It will also be of interest to determine the average unit time and cost per fully executed report. Associated Needs None identified. Organizational and Institutional Attributes Organizational, States that have data collection systems in place are typically requiring licensed EMS Institutional and agencies to complete the required minimum data set. Should a national standard be set Policy Issues for rural systems that is not in compliance with a state system, that agency may not be able to continue to be licensed in the state. This may require that each state agree to an alteration to their rules and regulations. Changing data elements or minimum data sets will require extensive discussion, debate, and approval at many levels in the stakeholder agencies. Changes to a data system involve many different stakeholders, all of whom need to be involved from the start. Issues Affecting It will require significant time to identify, assemble, and organize all the stakeholders and Implementation Time to proceed through a study process with them. Some states or localities will have a system of regulatory review that must take place prior to making changes to any component of the EMS system. This can result in very lengthy times to make changes or to gain approvals. At times, states may take 2 to 3 years to complete a review cycle for changes to their regulations. Costs Involved There will be a significant cost to develop new data elements to meet rural response needs. There will be an expense to have the elements identified, validated, and adopted by states and EMS agencies. Software development will be a major factor. If computer-based data collection systems (i.e., electronic data systems) are used, hardware and software may have to be purchased. Maintenance and service fees may also be involved with the hardware and software. Similar costs will be involved with optical scanning systems. Additionally, the cost of training must be accounted for.

Strategy 20.1 B3—Identify and Evaluate Model Rural EMS Operations (T) General Description Rural EMS systems in the United States share one common trait – all are unique. In many rural areas across the country, the delivery of EMS has not been a planned or formally organized process. The service has traditionally been provided by volunteers that have functioned within the community, often without the benefit of strategic station placement, or using any formal deployment plan. Thus, service is delivered without a cohesive response or performance plan. Over time, EMS volunteers have been unable to keep up with the increased training requirements and with the time commitments that are required to stay proficient in EMS. The decline of volunteer organizations has often mandated that paid personnel be added to meet the EMS demand. The progression of these systems has not been according to any set plan or standard and has not followed any set protocol or process. The decision to move from a volunteer system to a paid system is most often based on political considerations rather than on a critical analysis of the risk in the community. To further complicate a full understanding of the delivery of EMS in rural areas, most accepted efficacy studies have looked at high-volume EMS systems that have shorter response times and a high emergency incident volume. Thus, no generally recognized and accepted studies have developed a model system based on actual practice in rural areas. There is a need to evaluate the efficacy of existing rural systems to determine which model is best suited to the delivery of EMS in a given rural area. Particular attention will need to be given to the integration of volunteer organizations into the newer hybrid type of system that uses a combination of volunteer and career personnel. Almost every suburban area in the United States has gone through a transition in the development of its EMS systems. Unfortunately, most EMS agencies that must make changes to meet service demands do not draw on similar experiences of other systems. The ability to evaluate a number of different systems that are operational will be a very effective tool for EMS administrators and elected officials. An evaluation system can provide SECTION V—DESCRIPTION OF STRATEGIES V-42 EXHIBIT V-11 (Continued) Strategy Attributes for Identifying, Providing, and Mandating Efficient and Effective Methods for Collection of Necessary EMS Data (T) Organizational and Institutional Attributes Training and Other Training at all levels will be required for any agency that moves to a new data collection Personnel Needs system. Legislative Needs Legislation may be needed to allow for new data collection systems in some states. Other states may require legislation to mandate data collection for all EMS agencies. Other Key Attributes A future implementation guide will be developed on data needs, sources, and analysis. When it is available, it should be consulted as another source of information and ideas.

SECTION V—DESCRIPTION OF STRATEGIES government officials with information on peer systems (i.e., systems having similar demographics and service demands) to benefit from each other’s experience. This should provide better access to information about strategies that have worked well (as well as those that have been less successful). Therefore, the new system can provide guidance for jurisdictions that are faced with enhancing their current system, or in some cases, developing a comprehensive EMS program. Ultimately, these evaluations should be provided to the appropriate agencies, administrators, and officials (see Strategy 20.1 B4). V-43 EXHIBIT V-12 Strategy Attributes for Identifying and Evaluating Model Rural EMS Operations (T) Technical Attributes Target Rural EMS systems, rural EMS administrators, county and local administrators, elected officials, hospitals, rural EMS system operational medical directors, and state health officials. Expected It is not feasible to measure the direct impact of this strategy on crashes. However, what Effectiveness is learned from evaluating a range of rural EMS services will provide a better basis for establishing resource and performance standards (see Strategy B1), as well as guidelines for improving the operation of rural EMS systems. This is expected to lead to better quality of service. The ultimate effectiveness derived from the knowledge from a study would be the cost- effectiveness of the implemented system. Keys to Success One key will be to identify model systems in rural areas that are willing to be evaluated to determine how cost-effectively the system works vis-à-vis the norm. It will be critical to identify system configurations that are most compatible with existing contexts. The support of “champions” who have influence with the systems is also going to be key to achieving full cooperation. Ultimately, success will rest with the ability to convince existing EMS operators that the model system is worth emulating. Potential Difficulties It will be difficult, but crucial, that unique aspects of any existing system be identified and discussed during the evaluation of the system. Every EMS system has unique attributes that may not be reflected in the measures used and that may be difficult to replicate in other systems should those attributes be found important to system improvement. It will be difficult to provide a total evaluation of the system, particularly to identify the factors that were critical in reaching decisions on how the system was implemented. A major difficulty could be discovering political considerations and addressing them in a manner that will allow others to make an application to their contexts. Given the political climate in some jurisdictions, administrators may be reluctant to provide details that may not cast a favorable light on local processes. Appropriate A process measure is the number of systems evaluated. Effectiveness measures Measures and include documenting the resulting set of measures and standards, as well as the Data creation of a set of guidelines or recommendations resulting from analysis of the evaluations.

SECTION V—DESCRIPTION OF STRATEGIES V-44 EXHIBIT V-12 (Continued) Strategy Attributes for Identifying and Evaluating Model Rural EMS Operations (T) Technical Attributes Appropriate measures to use in the evaluation of systems include cost of the system, response performance, patient outcomes, deployment plans, number of EMS units, longevity of the system, attrition of the previous system providers, and number and type of personnel staffed during various portions of the day. Associated Needs Specialists in system evaluation needed to provide oversight and direction for this effort. Organizational and Institutional Attributes Organizational, It will be important to establish a policy of nondisclosure for agencies that are unable to Institutional and share some of their challenges. To understand the efficacy of existing systems, it will be Policy Issues imperative to evaluate the progression of the EMS system over time. To do so, agencies must be willing to fully discuss the issues that surrounded any significant changes that occurred in the system. This may create a dilemma for organizations reluctant to share information that (1) could be used in future litigation against the agency or (2) may reflect negatively on the jurisdiction. Failure to protect confidentiality could result in a product that is less than desirable because it may exclude critical information that would assist in understanding the dynamics of, and means for, meaningful change. Organizations may also be reluctant to discuss the human resource issues of their organization. However, systems depend on personnel for the delivery of the service, so it will be important for each organization to provide honest and candid answers to human resources questions as a part of the process. Issues Affecting A major consideration will be the time required to identify quality systems that will permit Implementation Time evaluations to be conducted. The length of time required for an evaluation will vary according to the data available, the structure and size of the system, and the cooperation received. Costs Involved Costs will include contractors needed to develop the evaluation system and to conduct the evaluations. There may also be some minor costs to agencies participating in the evaluation. Costs will be a function of the number of operations to be evaluated and the degree of complexity of the evaluation system adopted. Training and Other Using a panel of subject matter experts will reduce the need for training of the system Personnel Needs evaluators. The number of personnel requiring training will also be a function of the number of systems to be evaluated and the level of detail of the evaluations. At a minimum, teams of two evaluators will be needed for each system evaluation. Some information and education effort directed at the personnel in the system may be needed to help personnel understand what is being done, why it is being done, how it will benefit them, and what role they will be asked to play in the process. Legislative Needs No legislation is needed. Other Key Attributes None Information on Agencies or Organizations Currently Implementing this Strategy Appendix 11 provides an assessment of the EMS system in Maine.

SECTION V—DESCRIPTION OF STRATEGIES Strategy 20.1 B4—Provide Evaluation Results to Elected and Administrative Officials at the County and Local Levels (T) General Description Rural EMS programs often work without oversight, control, or responsibility to governing bodies. Volunteer organizations or private companies provide EMS to rural areas based on their historical presence in the jurisdiction. In other jurisdictions, paid personnel have been added by the jurisdiction or through private paid systems. In many cases the elected and administrative officials are not involved in the establishment of response or performance standards. Given the lack of direct control of EMS systems in many rural areas of the country, the representatives of the citizens may not be aware of response issues until these issues become media events or until some tragic event triggers a reaction from the elected and appointed officials. The ability to understand what levels of service are normally delivered in similar communities would assist elected leaders in making decisions prior to some threshold event. Providing elected and administrative officials with measures and standards that have been developed from evaluations would give the officials a better understanding of the levels of service offered in their community and the nature of any improvements needed. By understanding the myriad of issues, community leaders will be able to determine the actual level of service provided in the community, what level of service they desire for their community, and the issues related to meeting that level of response. This strategy is closely related to Strategy 20.1 B3. V-45 EXHIBIT V-13 Strategy Attributes for Providing Evaluation Results to Elected and Administrative Officials at the County and Local Levels (T) Technical Attributes Target Elected officials, appointed administrators, EMS program managers, and fire chiefs. Expected Elected officials often make decisions without the benefit of an expert knowledge base in Effectiveness EMS. By educating key officials about the actual performance of exemplary EMS systems, they will learn what levels of service may actually be provided in their community. Further, having a set of measures and standards will allow elected officials to make decisions based on their desired outcomes and more effectively resist political considerations. This approach should be very effective in giving key officials an unbiased assessment of rural EMS systems and how they are designed, administered, and managed. Keys to Success It will be critical that the assessment be objective and founded in accepted practices of similarly situated jurisdictions. The assessment must not be edited or rewritten to meet the desires of the local EMS agency. The use of recognized evaluation expertise will help achieve the desired credibility. The elected body must be open to making changes and understand that the assessment will most likely be a public document available to the entire citizenry. Changes should be made based on the recommendations of the evaluation. Educating the targeted officials and including them from the very beginning of the process will be important activities to facilitate use of the results of the evaluation.

SECTION V—DESCRIPTION OF STRATEGIES V-46 EXHIBIT V-13 (Continued) Strategy Attributes for Providing Evaluation Results to Elected and Administrative Officials at the County and Local Levels (T) Technical Attributes Elected and administrative officials are just a few of the stakeholders that should be involved in planning activities for EMS systems. Appendix 12 illustrates a way for elected and administrative officials to get involved in EMS planning activities, such as reviewing evaluation results. Potential Difficulties The potential cost to enhance the EMS system will be a major factor in the receptiveness of the evaluation. Particular difficulty will be encountered if there is no revenue stream to pay for system enhancements such as new ambulances or paid personnel. Therefore, it will not be enough to just evaluate operations. Successful funding methods also need to be documented. The use of volunteer systems historically creates a difficult situation in which political leaders can make enhancements. Volunteers put in many long hours of training and often raise funds for equipment, supplies, and vehicles. The long hours spent on delivering emergency response further endears the volunteers to the community. Elected leaders may be reluctant to upset the balance of volunteer organizations to make changes, particularly if additional costs are involved. It will be imperative that elected leaders have a strong understanding of the opposition they may experience. Elected officials should plan to address questions and issues that are brought forward as a result of any system evaluation. Appropriate A process measure will be the number and percent of desired political leaders to whom Measures and Data the evaluation results have been presented and the number of systems adopting change due to the involvement of elected and administrative officials at the county and local levels. Associated Needs Public information and education specialists may be needed to put together an effective presentation, or series of presentations, and to guide the process. Organizational and Institutional Attributes Organizational, Given the technical nature of EMS, appointed leaders may not have the expertise to Institutional and understand the local, state, and federal requirements that may be encountered by the Policy Issues EMS system. This is particularly noted when dealing with fee-for-service systems and when seeking federal reimbursement. Some degree of training of officials or access to technical experts may be needed to gain this expertise. Issues Affecting The main issue will be to go through the proper notification to get the evaluation on the Implementation Time agenda of the local governing body. Significant time may also be required to conduct background training for the officials. It may take some educating of the elected and administrative officials in order for this training to become a priority of theirs. Costs Involved Some cost could be incurred should the evaluators travel to the locality to present the evaluation findings to the elected and appointed officials. There may be some costs associated with developing and presenting a PI&E program designed to “train” the officials. Training and Other Some PI&E effort may need to be developed and implemented to help educate local Personnel Needs officials on aspects of EMS with which the officials may not be familiar. Legislative Needs In some states, localities are unable to regulate any programs that are not specifically approved by the state legislative body. In those states, it may be difficult for the local elected leaders to implement changes. It will be especially important in those cases that one or more members of the legislature be sought to champion the effort and to facilitate any legislative actions needed.

SECTION V—DESCRIPTION OF STRATEGIES In 2004 the Emergency Medical Services Regulatory Board (EMSRB) in Minnesota conducted a pilot project to assess and assist stressed rural ambulance services. Assessments of four volunteer ambulance services in different regions of Minnesota were conducted. The final reports were presented to the ambulance service governing board and city officials. Approximately 1 year after each assessment, the EMSRB plans to follow up and describe the successes and challenges of implementing strategies recommended in each assessment report. For more detailed information on these rural ambulance assessments, visit the Minnesota EMSRB website: http://www.emsrb.state.mn.us/RuralAmbAssess.asp. Objective 20.1 C—Provide Better Education Opportunities for Rural EMS Strategy 20.1 C1—Utilize Technology-Based Instruction for Rural EMS Training (P) General Description Rural EMS systems face many challenges, especially finding ways to effectively train EMS providers. Initial education and continuing education present one of the biggest barriers to both recruiting new members and retaining existing members of an organization. Especially in rural areas, EMS personnel often spend more time in training than they do on runs responding to incidents. EMS education is mandated by the regulating agencies and, like other aspects of medicine, is continuously improving and changing. Because of these changes, it is important to keep EMS providers trained so they are able to deliver the most effective care. Further, because of the low run volume, keeping current with skills is an ongoing challenge for rural providers. The typical methods for education and training are to follow a cascade-type, classroom approach. As an example, a new technique for applying splints is approved. Instructors are trained, and they in turn train other providers in the new technique as well as other folks to be instructors. This approach requires each EMS organization to assign someone with the duty of being the service instructor. The service instructors by the nature of their work must be a competent provider and have the time available to train others. This is an especially difficult position to fill. Colleges and universities have learned that to keep their enrollments up and meet the busy lifestyles of people today, they must bring the education to the people rather than requiring people to come to the education. Further, the education needs to be provided so that it meets the schedules of the students instead of being offered it at a fixed time and location. Technology today allows for this type of distance learning. The idea of distance learning has V-47 EXHIBIT V-13 (Continued) Strategy Attributes for Providing Evaluation Results to Elected and Administrative Officials at the County and Local Levels (T) Other Key Attributes None

sparked a debate about the quality of students trained in a typical classroom setting compared to others that are trained outside of a classroom. Increasingly, the results of technology-based instruction are proving favorable. SECTION V—DESCRIPTION OF STRATEGIES V-48 EXHIBIT V-14 Strategy Attributes for Utilizing Technology-Based Instruction for Rural EMS Training (P) Technical Attributes Target EMS organizations and personnel; medical directors; universities; federal, state, and county regulating agencies; and individuals in rural communities. Expected Several studies have been conducted that illustrate the utility of technology-based Effectiveness instruction for rural EMS training. Sanddal et al. (2004) conducted a study to compare the results of prehospital pediatric continuing education using train-the-trainer and CD-ROM training methods. Pullum et al. (1999) assessed the strengths and weakness of five different training programs used in Montana: • Train-the-trainer, • Local cluster with videotape and guided practicals, • Circuit rider training with interactive videodisc, • Interactive video teleconference, and • Distance education using interactive statewide computer network (i.e., TENKIDS statewide electronic infrastructure). In Texas, Moshinskie et al. (1996) investigated the possibility of using distance education to train EMS caregivers for rural areas where serious shortages of ambulance crews had been reported. Each of the studies concluded that technology-based instruction for rural EMS training was a viable option, if not a better option than traditional classroom training. Appendix 13 provides additional details on the three studies identified above that assessed the utility of technology-based instruction for rural EMS training. Keys to Success Keys to successfully using technology-based instruction for rural EMS training include appropriate funding to provide adequate facilities and technology. Furthermore, strong organizational and medical leadership will be necessary to make the transition to this type of education. Incentives and competition for those being asked, or required, to take the training will improve motivation. The desired outcome of improved EMS operations and results for patients will ultimately also depend upon the quality of the material that is delivered through this vehicle. It is also important that technology-based instruction be accepted as part of the national registry system. Potential Difficulties The lack of funding or information and communication technology could present difficult challenges. There are several modes through which a person can learn. Some people learn best through one mode and others through another mode, or different combinations thereof. The use of computer-based systems may work well for some, but not others. Local support will be needed to back up the instruction, especially for some of the students. It may be difficult to provide individualized assistance at each training station, beyond a call from the central instructional staff.

SECTION V—DESCRIPTION OF STRATEGIES Strategy 20.1 C2—Establish an Exchange Program to Allow Rural EMS Providers to Spend a Specified Number of Hours in Urban/Suburban Systems (E) General Description EMS organizations across the United States can benefit from establishing a personnel exchange program. The initial focus of such a program would be to allow rural EMS providers a chance to work with a sister urban or suburban EMS organization. V-49 EXHIBIT V-14 (Continued) Strategy Attributes for Utilizing Technology-Based Instruction for Rural EMS Training (P) Technical Attributes Local technical support will be needed to maintain the operation of the system. The advanced nature of the technology may be beyond what is available within the agency, requiring either additional training or acquiring additional technical staff (through hiring or contracting). Appropriate Process measures include the number and type of courses offered, students enrolled, Measures and Data and lesson units completed; the number and proportion of students completing their assigned curriculum; and the proportion of time during which the technology is not available upon demand. Effectiveness measures include comparison of pre- and post- test results and observations of change in on-the-job performance. Associated Needs None identified. Organizational and Institutional Attributes Organizational, Organizations will need to establish, by policy, the scope of technology-assisted Institutional and education and how it will be used. They may also have to consider mandating an Policy Issues educational program. To enhance motivation, organizations may need to provide incentives for taking and completing the courses. Issues Affecting It may take significant time to help administrators, such as local medical directors, Implementation Time understand and accept the utility of technology-assisted training. In addition, if the communication/technology systems are not existing and readily available, the improvements needed may take significant time to achieve. Costs Involved Costs include communication equipment and linkage costs, classroom equipment and facilities, and student and instructor time. There may be an opportunity for organizations to share equipment and facilities, as well as communication systems and instructors. Training and Other EMS organizations may need to train someone in the use of the technology to Personnel Needs troubleshoot and to act as a “super user.” Also, all personnel will require minimum training in the use of whatever technology is chosen. Furthermore, instructing with interactive technology is difficult, so the instructors should be trained to use this media effectively. Legislative Needs None identified. Other Key Attributes None

The primary focus of the program would be to allow providers from a rural setting with a low case volume to increase their patient encounters and increase the types of medical and trauma incidents to which they are exposed. This focus would help providers build skills and transfer their learning to members of the rural organization who are unable to participate in this exchange. A number of secondary benefits could be obtained through such an exchange. For instance, the rural provider would get a chance to build a network of contacts with other professionals for possible future assistance. The rural providers may also participate in buying programs, billing services, quality assurance programs, or other things that would be mutually beneficial. At a minimum, the urban providers would benefit from excellent public relations, which in turn would build creditability and good community relations. Overall, these types of relationships could improve the quality of care in a given area and improve the safety for both residents and visitors. It should be noted that similar ride-along programs are used during the initial training of EMS personnel. Before this type of exchange program is implemented on a large scale, a pilot program should be conducted, closely monitored, and carefully evaluated. SECTION V—DESCRIPTION OF STRATEGIES V-50 EXHIBIT V-15 Strategy Attributes for Establishing an Exchange Program to Allow Rural EMS Providers to Spend a Specified Number of Hours in Urban/Suburban Systems (E) Technical Attributes Target The primary target of this strategy is the EMS technician who is involved in runs. The adoption of this strategy requires that providers, county and state EMS agencies, and medical directors be targeted with the information about the strategy’s potential benefits. Expected This strategy should help improve performance by gaining significant experience in a Effectiveness relatively short period considering the rural setting. This strategy could reduce the amount of continuing education required to keep up skills. It should lead to wiser purchasing decisions because of the first-hand experience with different equipment that is more advanced than the equipment available in the rural service. The strategy offers the opportunity to build relationships between multiple services. These relationships would be beneficial in the event of a widespread disaster that requires cooperation between agencies. The strategy could also lead to standardizing medical protocols and sharing in purchasing programs. Keys to Success Significant cooperation between agencies and medical director approval and oversight of the program will be required. Regulatory agencies will need to support this effort and be sure their rules allow for this flexibility. Developing a business model with mutual benefits for all parties will help lead to improved success. Minimizing any medical liability for the providers and organizations will be required.

SECTION V—DESCRIPTION OF STRATEGIES V-51 EXHIBIT V-15 (Continued) Strategy Attributes for Establishing an Exchange Program to Allow Rural EMS Providers to Spend a Specified Number of Hours in Urban/Suburban Systems (E) Technical Attributes Potential Difficulties Insurance constraints and legal liability are two potential difficulties associated with this strategy. Finding hospitals that will accept or support this type of program may be difficult. Furthermore, lack of cooperation, and even competition between providers and organizations, could cause difficulties. Rural providers that cannot be a part of the exchange program because they find it difficult to find time to leave the community may have their advancement negatively affected. This effect may be a problem for volunteers. Union contract limitations may also create difficulties. Appropriate Appropriate process measures include the number of services involved, the number of Measures and Data personnel involved, the time on exchange assignment, and the volume of calls experienced by the participant while in the urban setting. Effectiveness measures include ratings of change of on-the-job performance and comparison of pre- and posttest scores through a test designed to measure change of knowledge. Associated Needs None identified. Organizational and Institutional Attributes Organizational, Organizations will need to outline the scope of care that a provider can perform when Institutional and involved with a different organization. Policies that outline all aspects of the exchange Policy Issues program need to be outlined in a formal agreement. Incentive programs may have to be created by the rural organizations. Issues Affecting Implementation time will be impacted by the effort required to (1) obtain cooperation Implementation Time between services and/or regulatory agencies or (2) ensure that liabilities are covered. Costs Involved Costs highly depend on the model chosen. The primary costs will likely be in the time and effort to develop policies that outline the aspects of the exchange program and limit liabilities. Travel expenses will also be involved. Flex grant monies may be available to offset costs. Training and Other EMS personnel will need to be trained in the protocols of the “other service.” First Personnel Needs responders and local hospitals will also need to understand what the scope of the exchange program is so they are not surprised when they see different personnel on the ambulance service. Legislative Needs None specifically required. Other Key Attributes None

Strategy 20.1 C3—Include Principles of Traffic Safety and Injury Prevention as Part of EMS Continuing Education (E) General Description NHTSA has been the leading agency in developing EMS curricula, including basic, intermediate, and advanced courses. The EMT education programs are most commonly referred to as EMT (EMT-Basic, EMT-Intermediate) and paramedic programs. Several editions of each curriculum have been developed and published since the early 1970s. Each edition of the curriculum has been developed, reviewed, and approved by subject matter experts. The vast majority of the emphasis in the curricula has concentrated on medical education and the treatment of emergency medical and trauma conditions. When a student completes the entire course of instruction, he or she has typically participated in more than 1,500 classroom sessions, clinical participation, and practical scenarios of emergency medical treatment. Unfortunately, there is little preventative services education in any basic or advanced curriculum. The programs end up developing highly trained emergency responders, but there is no formal process to educate EMTs or paramedics about injury prevention or traffic safety. Thus, key local emergency responders do not typically participate in community accident and injury prevention education programs. All emergency medical training programs should implement a module about traffic safety and injury and accident prevention. The module could be developed at the state, county, or local level. Alternatively, existing instructional materials that have been developed at the federal, state, and local levels could be used. For example, the National Highway Institute (NHI) already has courses, as do many T2 centers, and NHTSA published the first “Public Information Education and Relations for EMS – Injury Prevention” modules in 1986. Subsequent revisions served as a tool for state and local levels, focusing specifically on comprehensive primary injury prevention. By including traffic safety and injury and accident prevention programs as part of EMS continuing education, emergency responders can use their experience and expertise to educate the community. This type of public education will serve to reduce the incidence of emergency medical incidents, thereby reducing the demand on the EMS system. A module that includes information on traffic safety, injury and accident prevention, and standard instructional techniques will give emergency responders tools to use in working with their communities and will increase the nonemergency interaction with the citizens whom the EMS agency serves. This program should prove to be very effective over a period of time. By giving EMTs and paramedics information about traffic safety and injury and accident prevention, EMS agencies will be able to expand their scope of work to prevent accidents rather than just respond to emergency incidents. It will be imperative for medical directors and EMS administrators to make prevention activities a key part of an emergency responder’s job. This approach must be supported by all levels of the response team, from the first responders through the hospital emergency department. A proactive prevention program should have long-term impacts on the SECTION V—DESCRIPTION OF STRATEGIES V-52

SECTION V—DESCRIPTION OF STRATEGIES community. In addition, such a program will provide an opportunity for the emergency response personnel to interact with the citizens whom they serve. In turn, the citizens can learn how to prevent accidents, while learning about their emergency services system. V-53 EXHIBIT V-16 Strategy Attributes for Including Principles of Traffic Safety and Injury Prevention as Part of the EMS Continuing Education (E) Technical Attributes Target EMS educators, NHTSA, and EMS personnel. Expected EMS personnel traditionally have not received training in the principles of traffic safety Effectiveness and injury prevention, so no data are available on expected effectiveness. However, by educating EMS personnel in the principles of traffic safety and injury prevention, it is expected that EMS personnel will communicate these principles to the general public, thereby raising the public’s awareness of traffic safety and injury prevention and reducing the frequency of emergency medical incidents and the demand on EMS systems. Keys to Success It will be imperative to work toward a shift in attitudes of the emergency responders. Currently, emergency responders view their role as responders after the emergency occurs. Responders must be trained to see their role as health care providers, with an emphasis on prevention to reduce the incidence and severity of emergency incidents that occur in their community. For this strategy to work, it must go beyond simply informing EMTs and paramedics about prevention activities. The highest return on the investment will be to instruct EMTs and paramedics to teach others. This opens up multiple opportunities to provide public medical education to the community. Another key to successfully including the principles of traffic safety and injury prevention in the EMS educational core contents is, as implied, having these continuing education units (CEUs) recognized for national registration. EMS personnel are already required to take a significant number of CEUs to maintain their registration. If the CEUs for this course are not recognized for national registration, very few individuals will opt for this type of elective continuing education, primarily because of time constraints. Potential Difficulties EMTs and paramedics are attracted to the profession because of the nature of emergency responses. Some EMTs and paramedics will see an emphasis on prevention activities as an intrusion on their primary purpose. Time constraints will pose challenges in two ways. First, additional time will be required in the training programs. An adequate program could add up to 40 hours to the curriculum, particularly if the goal is to teach the EMS students how to be instructors. Adding hours for instructional purposes is often met with resistance. Second, many EMS systems have little down time for EMS providers to dedicate to instructing the public. EMS personnel are assigned to shifts and respond to emergency incidents while on duty. The incident volumes have increased. Thus, offering this type of program on a large scale may require alternative staffing schedules and possible overtime compensation. Appropriate Appropriate process measures are the number of EMS personnel who participate in Measures and Data traffic safety and accident prevention programs and the number of courses offered at a local agency. Effectiveness analysis can include measuring change of knowledge (i.e., administering tests before and after the course) and documenting the number and types of involvement by trained staff in accident prevention programs. Associated Needs Instructional materials may need to be developed if existing course materials are not used. Instructors familiar with the principles of traffic safety and injury prevention will be necessary.

SECTION V—DESCRIPTION OF STRATEGIES V-54 EXHIBIT V-16 (Continued) Strategy Attributes for Including Principles of Traffic Safety and Injury Prevention as Part of the EMS Continuing Education (E) Organizational and Institutional Attributes Organizational, Adding this type of module to the established curricula will require additional contact Institutional and hours to an already extensive program. EMS educators must buy into the program and Policy Issues integrate it into the classroom portion of the curriculum. EMS educators will be on the front line of this change process and must understand and champion the long-term benefits to the community. Another issue will be the individual EMS agencies that have not been involved in any community education programs. For these agencies, including principles of traffic safety and injury prevention as part of the EMS continuing education would require additional work because there may be resistance by current EMTs and paramedics. Given the desire of NHTSA to maximize the benefit of its EMS training, and given the limited time available to place trainees in a classroom, NHTSA may resist widening the focus of its training package to include peripheral topics. This plan must be weighed against other possible programs that may also be beneficial to the EMS agency or to the community. Issues Affecting Development of the course materials will take some time. Alternatively, the adoption of Implementation Time existing curricula will minimize implementation time. If NHTSA becomes involved with the program, its review and revision process will impact the timeframe for implementation. Costs Involved Establishing a proposed curriculum and working through the review process will require research and staff time. Additional costs will be required to develop a standard set of instructional materials that can be used in educating the community. NHTSA is funding a State and Territorial Injury Prevention Director’s mini-grant program (http://207.15.200.54/template200.cfm?sub_cat=220) to involve EMS providers in injury prevention efforts. Training and Other Instructors familiar with the principles of traffic safety and injury prevention will be Personnel Needs needed. Legislative Needs There are no expected legislative needs. Other Key Attributes None Strategy 20.1 C4—Require First Care Training for all Public Safety Emergency Response Personnel, Including Law Enforcement Officers (T) General Description NHTSA assumed responsibility for the development of training courses that respond to the standards established by the Highway Safety Act of 1966 (amended). As a result of this act, the “First Responder: National Standard Curriculum” was developed. The curriculum was developed to train personnel who would arrive on an emergency scene prior to EMS personnel. The program is a 40-hour (minimum) course intended to provide a

SECTION V—DESCRIPTION OF STRATEGIES basic understanding of human body systems and life-saving emergency care procedures. This program is designed for individuals who may be the first people to arrive at the scene of a medical emergency but who do not transport patients in the back of an ambulance (e.g., fire service, industrial, and law enforcement personnel). The first responder program is not intended primarily for individuals whose main duty is the provision of ambulance services. It may, however, be used as a basic introduction to emergency medical care training. Since the late 1970s, the first responder training program has been delivered to thousands of people across the country. During the early years of the program, firefighters and police officers were targeted to receive the training program. Over time, the increased EMS work load in fire departments led the majority of career firefighters to upgrade their training program to the EMT-Basic level. No national statistics show how many firefighters have remained at the first responder level of certification. In rural areas, many public safety agencies have to take on unique roles. For example, law enforcement is one of the few 24-hour services that are strategically located throughout a jurisdiction. Further, police officers are in contact with 9-1-1 centers and can easily be alerted to any emergency in the jurisdiction. Therefore, law enforcement may be able to render patient care prior to the arrival of an EMS unit. At the same time, police officers are faced with a lot of law enforcement training and continuing education. Anecdotal evidence suggests that the number of police officers trained as first responders is probably decreasing and that training centers across the country have concentrated their efforts at the higher-level EMS programs, such as EMT-Basic and paramedic. The result is that no one has emphasized training the true first responder community in EMS. In rural areas, response times are typically longer than in urban areas. This increase in response time results in an increase in time for a medically trained person to arrive on the scene. Through law enforcement officers and firefighters, medical care can begin prior to the arrival of an EMS unit. The American Heart Association has shown that a “chain of survival” is critical to reducing deaths from out–of-hospital cardiac arrest. The early initiation of CPR and automatic external defibrillation (AED) greatly increases a patient’s chance of living. First responder training programs provide training in CPR and AED. Thus, this program enhances the chain of survival through the use of law enforcement and firefighters. The intent of this strategy is not to require all public safety emergency response personnel to complete the first responder training at the level required of the national standard curriculum; rather, the intent is to require all public safety emergency response personnel to complete some level of first responder. Currently, several agencies require first responder training of law enforcement officers, including but not limited to the state of North Carolina and the county of San Mateo, California. In Iowa, the Coralville Police Department includes EMTs as first responder units when responding to medical calls. Coralville is one of three police departments in the state of Iowa that is certified to carry AED units. V-55

SECTION V—DESCRIPTION OF STRATEGIES V-56 EXHIBIT V-17 Strategy Attributes for Requiring First Care Training for All Public Safety Emergency Response Personnel, Including Law Enforcement Officers (T) Technical Attributes Target Sheriffs, police chiefs, fire chiefs, state EMS directors, EMS educators, state police, and wildlife personnel. Expected No studies document the expected effectiveness of this strategy. However, law Effectiveness enforcement is one of the few 24-hour services that are strategically located throughout a jurisdiction. Further, police officers are in contact with 9-1-1 centers and can easily be alerted to any emergency in the jurisdiction. Therefore, properly trained law enforcement officers will likely be able to administer first care prior to the arrival of EMS personnel. Keys to Success Police chiefs, sheriffs, and fire chiefs must buy into the system approach for this program to be effective. An education program will need to be in place to teach police and fire personnel about the advantages to their citizens of this type of program. When programs are delivered to these audiences, it will be important to make the programs relevant to the jurisdiction. Because the level of training may be less than the national standard required for a first responder, guidance from the medical director on level of training and practice will be important. Potential Difficulties The time to train must be established. With law enforcement and fire responsibilities increasing because of terrorism preparation, many people will resist any new or expanded duties. Volunteer firefighters will be the most difficult group to address. This is due to the amount of time that the training takes. Volunteer firefighters in rural areas may not have the time to commit to additional training. The low incidence of accidents and medical emergencies in some rural areas will be a detriment in establishing a need for the amount of training that is required. Appropriate Appropriate performance measures include the number of potential first responders and Measures and Data the number of people who are medically trained or successfully trained as first responders in the locality. The number of person-hours of training may also be a useful measure. Impact measures can include before and after results of tests of knowledge and attitude. Additional measures more directly focused upon the effectiveness of the training in the field can include the proportion of EMS incidents in a locality where first responders were on the scene before an EMS unit, the proportion of EMS incidents in which the first responder gave initial medical assistance, and a rating (e.g., by the EMS unit responding) of the quality of the treatment given by the first responders. Associated Needs Training law enforcement and firefighters as first responders will address only part of the issue. The first responders must then be adequately supplied with medical equipment and AED units to effectively enhance the EMS system. This will require a means to replenish supplies used during an emergency, as well as to maintain the equipment. This can easily be addressed through an equipment exchange and maintenance program with the EMS agency. However, it is imperative that this arrangement be worked out early in the planning process.

SECTION V—DESCRIPTION OF STRATEGIES Strategy 20.1 C5—Educate Rural Residents about the Availability, Capability, and Limitations of Existing Systems (T) General Description In most communities, public awareness of specifics about an EMS system is low. Residents often are unaware of whether their local EMS agencies (first response or ambulance) are staffed by career or volunteer personnel, of the levels to which the agencies are trained (basic, intermediate, or advanced), and of the timeliness of service that the agencies provide. Effective public information, education, and relations (PIER) have long been a key element of an EMS system. Since 1988, NHTSA’s Technical Assistance Team assessments of state EMS systems have evaluated PIER as one of the elements of those systems. In the mid-1990s, a NHTSA initiative trained numerous EMS personnel to serve as spokespeople and PIER leaders. Many of these efforts focused on the delivery of injury prevention and mitigation messages. V-57 EXHIBIT V-17 (Continued) Strategy Attributes for Requiring First Care Training for All Public Safety Emergency Response Personnel, Including Law Enforcement Officers (T) Organizational and Institutional Attributes Organizational, The biggest issue will be the process by which law enforcement and non-EMS fire Institutional and departments implement this program. There may be significant resistance at the core Policy Issues levels to adding this role to already increasing demands of both disciplines. Police and sheriff training academies should integrate first care training into their standard curricula. State fire training programs will need to work with their state EMS agencies to provide the instruction to firefighters. Issues Affecting The ability to have police and fire training groups adopt this approach will be uncertain. In Implementation Time most cases, adoption of the approach will be over a period of years. A funding source will probably have to be established, and this could lengthen the time needed to fully implement this program. Costs Involved Costs will be incurred to develop the course materials. Alternatively, existing materials could be used from the national curriculum. Other costs include instructors, facilities, and equipment to conduct the courses, as well as the cost of time for the attendees. Training and Other Instructors for each course will have to be available in adequate numbers to meet the Personnel Needs demand. Police officers and firefighters may be more receptive to training that is delivered by someone from their respective disciplines. Consideration should be given to working with police and fire academies to develop instructors from their agencies who can deliver first responder programs. Legislative Needs Legislation should not be required in most states or jurisdictions. Other Key Attributes None

SECTION V—DESCRIPTION OF STRATEGIES V-58 EXHIBIT V-18 Strategy Attributes for Educating Rural Residents about the Availability, Capability, and Limitations of Existing Systems (T) Technical Attributes Target Rural citizens and elected officials. Expected No available studies document the effectiveness of this strategy. However, greater Effectiveness awareness by the general public of the capabilities and limitations of local EMS agencies will create informed public discussion and decision making about resource allocation by voters, elected officials, and appointed officials. Keys to Success For this strategy to succeed, standardized measures and terminology must be agreed upon. Frank discussion without fear of threat or embarrassment must occur between rural EMS providers, their communities, and their elected officials. Appendix 10 provides a guide for community planning of EMS agencies. Standardized agency and provider inventory data, standardized incident and patient data, standardized performance and outcome data, and standardized measures of resource input are all required to elevate the level of public policy discussion about rural EMS. Involvement and support of the local media and community leaders will be essential to attract attention to a matter that is generally of limited interest to the public. Potential Difficulties Candid discussion of system limitations may be embarrassing or demoralizing to resource-poor providers and agencies if the discussion is not carefully handled. Lack of accurate baseline data could prevent accurate comparison of needs, processes, and outcomes. Gaining public attention and interest will be a major challenge. Due to low density of population, it will be difficult to gather a sizable number of individuals for discussion sessions. Therefore, means will need to be employed to overcome the long travel distance or to plan on a large number of meetings. Electronic media can be used for holding discussions, including remote conferencing with multiple locations and web-based discussion groups. Appropriate Process measures include the number of citizen contacts, standard media coverage Measures and Data measures (i.e., column inches of articles), and counts of materials distributed. Impact measures would include surveys of publicly elected officials’ attitudes and awareness before and after the implementation of the program. Associated Needs The information to be included will require that an evaluation be conducted of the EMS agency. The information generated from the evaluation will then need to be presented in an attractive and understandable manner to the general public. Organizational and Institutional Attributes Organizational, The primary issue is changing the existing environment into one in which this attempt to Institutional and inform must be inserted. There has been, and continues to be, a general lack of informed Policy Issues policy discussion about EMS in rural areas. Rural EMS system culture has allowed the systems to evolve without significant policy input and public discussion. The result has been systems that are poorly funded, understaffed, and unable to approach the levels of service delivered in more urban areas. Issues Affecting Implementation time will be impacted by processes required to acquire and analyze Implementation Time necessary data, develop a consensus or “case statement,” and disseminate the case statement information throughout rural areas.

SECTION V—DESCRIPTION OF STRATEGIES Strategy 20.1 C6—Provide “Bystander Care” Training Programs Targeting New Drivers, Rural Residents, Truck Drivers, Interstate Commercial Bus Drivers, and Motorcyclists (T) General Description The first person on the scene of an emergency often has a helpless feeling. After someone accesses the 9-1-1 system, there is time before a first responder or EMS unit arrives. When someone is not trained to deal with an emergency situation, minutes seem like hours. During that same time, a patient can be very uncomfortable and may even exacerbate the injury or condition if appropriate care is not rendered or inappropriate care is rendered. In rural areas, it may take an extended time for emergency units to respond, often from very far distances. Bystanders who may be on the scene often do not know what to do. In most cases, bystanders provide emotional support or apply techniques they have read about or heard others talk about. In many cases, having someone there to offer comfort helps the victim during those first critical minutes; however, there are times where a patient could be adversely impacted by well-meaning bystanders. In rural areas where ambulance response times are greater, it would be beneficial to have bystanders trained to an appropriate level. The 40-hour first responder level course is too extensive for bystanders. The number of hours required for the first responder program will prevent all but the most interested person from taking the course. NHTSA is the distributor of the National Standard Curriculum for Bystander Care (Perez et al., 1992). This report describes a program to promote more effective bystander actions in rural highway crashes. This bystander care program explores how the lay public could learn to provide very basic life-saving care to respond to the most critical needs of seriously injured victims. The curriculum addresses how laypersons can call EMS, manage the airway, control V-59 EXHIBIT V-18 (Continued) Strategy Attributes for Educating Rural Residents about the Availability, Capability, and Limitations of Existing Systems (T) Organizational and Institutional Attributes Costs Involved Costs involved with implementing this strategy include data collection and analysis, development of a consensus case statement, training of individuals from rural EMS communities to use the case statement for effective advocacy of EMS issues, and production and dissemination of educational materials (e.g., evaluation results) to the general public. Training and Other EMS agency spokespeople and other EMS advocates may need training to serve as Personnel Needs informed EMS advocates with the ability to address system deficiencies without alienating system participants and their supporters. Legislative Needs None identified. Other Key Attributes None

bleeding, and avoid getting hurt. Because bystanders (i.e., the public at large) are the first link in the out-of-hospital “chain of survival,” instruction in CPR will greatly increase the probabilities that out-of-hospital cardiac arrest victims will survive. By making a bystander care course available to new drivers, rural residents, truck drivers, Interstate commercial bus drivers, and motorcyclists, people who arrive at accident sites first will be able to provide a higher level of care than what is currently available. It is possible that this strategy could be developed in conjunction with NHTSA’s “First There First Care Bystander Care for the Injured” program. SECTION V—DESCRIPTION OF STRATEGIES V-60 EXHIBIT V-19 Strategy Attributes for Providing “Bystander Care” Training Programs Targeting New Drivers, Rural Residents, Truck Drivers, Interstate Commercial Bus Drivers, and Motorcyclists (T) Technical Attributes Target New drivers, truck drivers, Interstate commercial bus drivers, motorcyclists, local, county, and state agencies that have representatives who drive regularly during working hours, rural residents, and other citizens that spend a great deal of time driving their vehicles. Expected Only one study was found that evaluated the results of a bystander care program Effectiveness (Noland, 1996). In the mid 1990s, 120 EMS personnel were trained as bystander care instructors within the Central Iowa EMS Region. Subsequently, they trained more than 2,000 laypersons within the region. A preliminary analysis of the program indicated that participants, as a result of successfully completing the course, would be more likely to stop and provide assistance, would be better able to perform correct sequential interventions, and would be better able to provide complete and accurate information when calling 9-1-1. It was concluded that the program provided excellent preparation for layperson bystanders who arrive at the scene of traumatic injury, and this preparation benefits individuals traveling throughout the largely rural region. If this program could be incorporated in all new drivers’ education programs, in 10 years, an entire generation will be trained as “bystander responders.” This will be a very effective method to initiate immediate care, particularly in areas not served by a normal rapid EMS response. Keys to Success This type of a program will probably need a “champion” within a key governmental agency or a high-profile organization to gain the attention and support needed. For this method to be effective, a significant number of people must complete the training program. Therefore, it will be important that the program have the enthusiastic backing of community leaders and the cooperation of the media. In addition, incentives would need to be offered for people to attend (e.g., getting local shop owners and manufacturers to offer premiums, gifts, discounts, etc., to people who successfully complete the course). Potential Difficulties Gaining a widespread acceptance of this type of program may be difficult. A federal, state, or private agency should take the lead on informing the general public about the benefits of such a program. A means must then be in place to provide the training on an ongoing basis. It will then be important for rural areas to support this program for their residents and encourage others to participate in the training. Publicizing the need for bystander’s assistance will require a well-thought-out program so that residents do not lose confidence in their EMS service.

SECTION V—DESCRIPTION OF STRATEGIES V-61 EXHIBIT V-19 (Continued) Strategy Attributes for Providing “Bystander Care” Training Programs Targeting New Drivers, Rural Residents, Truck Drivers, Interstate Commercial Bus Drivers, and Motorcyclists (T) Technical Attributes Appropriate Process measures include the number of bystander courses offered and the number of Measures and Data persons successfully completing the training. Effectiveness measures include the number of times bystanders, trained under the program, were first on the scene and provided assistance prior to arrival of an EMS unit or first responder. Ratings of quality of bystander care given prior to first responder arrival on scene (e.g., by the responding EMS team) will also be important to obtain. Change in student knowledge and ability before and after the training can be tested and used to evaluate effectiveness, although in a less direct manner than other measures suggested here. Associated Needs None identified. Organizational and Institutional Attributes Organizational, This type of program has been in operation since 1992. A review should be conducted to Institutional and evaluate locations where this program was instituted. Policy Issues A means to train and monitor instructors should be in place but should not be burdensome or create a bureaucracy. Issues Affecting Obtaining a primary sponsor and the review of a program will take 1 to 2 years. The Implementation Time information is currently available in different formats, so it should not be reinvented. This program will be one that will take years to realize the benefits. It is also one that must be ongoing, both for training new people and for maintaining skills of those who have previously been trained. Costs Involved Costs associated with this strategy will include the production of course materials for trainers and students, development of an instructional system, and cost to deliver the program (e.g., space and equipment, as well as instructor time). Given that this would be an additional level of EMS training, some states may see the need to regulate the instruction in the classes and to institute a formal testing process. Thus, the state will incur costs for this additional level of supervision and/or regulation of the program. Training and Other Instructors will have to receive training in the new curriculum. It is recommended that Personnel Needs personnel already trained in EMS serve as instructors. Legislative Needs All states will need to have “good Samaritan” laws in place to protect bystanders who render aid. Bystander responders are rarely held liable for helping in an emergency. Only in cases where an individual bystander responder’s response was deliberately negligent or reckless or when the responder abandoned the victim after initiating care have the courts ruled that good Samaritan immunity did not apply. Appendix 14 provides several examples of existing good Samaritan laws. Other Key Attributes None

Information on Agencies or Organizations Currently Implementing this Strategy Appendix 15 provides information related to “bystander responder” training programs developed specifically for motorcyclists. Strategy 20.1 C7—Provide EMS Training Programs in High Schools in Rural Areas (T) General Description EMT programs have been in existence since the late 1960s. NHTSA assumed responsibility for the development of EMS training courses that respond to the standards established by the Highway Safety Act of 1966 (amended). An EMT course is one of a series of courses making up a national EMS training program for prehospital care. The curriculum, “Emergency Medical Technician-Basic: National Standard Curriculum,” is the cornerstone of EMS prehospital training. The EMT-Basic curriculum is a core curriculum of minimum required information, to be presented within a minimum 110-hour training program. This curriculum is intended to prepare a medically competent EMT-Basic to operate in the field. It is recognized that the majority of prehospital emergency medical care will be provided by the EMT-Basic. This includes all skills necessary for the individual to provide emergency medical care at a basic life support level with an EMS agency, fire department, ambulance service, or other specialized service. EMT is the basic level of care that is delivered by most EMS agencies. As such, personnel certified to this level are needed by every EMS agency in the United States. In rural areas, it may be difficult to find enough people who want to be certified EMTs. A significant time commitment is required just to complete the course. EMT classes typically take four to six months to complete, with many running 2 nights per week for 3 hours each class. Thus, there is always a desire to seek out a pool of potential EMTs so that they can begin their training process. A potential pool of EMTs may be available in local high schools. Often students may be interested in helping the community or have a desire to establish a career in EMS. By teaching EMT courses as an elective in high school, students can earn high school credit toward graduation and work toward EMT certification. In turn, this will provide a qualified pool of EMTs to assist in their rural communities. A secondary benefit of this program is that some students may decide to pursue a medical or public safety career as a result of the course in high school. In the long term, EMTs may then be prepared to move to the advanced life support level of certification after they complete high school. SECTION V—DESCRIPTION OF STRATEGIES V-62

SECTION V—DESCRIPTION OF STRATEGIES V-63 EXHIBIT V-20 Strategy Attributes for Providing EMS Training Programs in High Schools in Rural Areas (T) Technical Attributes Target This strategy primarily targets high school students, but will also need to involve administrators from schools, hospitals, and EMS operations. Expected This program can be very effective in training personnel to an EMT-Basic level. Schools Effectiveness throughout the country have tried this approach, and even though the results are anecdotal, the results are consistently positive. Many rural EMS organizations end up with personnel that provide EMS care in their respective communities for several years. Keys to Success An instructor who understands educational methodology for young adults (i.e., how to teach high school students) will be important in the success of this program. Given the maturity level of many high school students, the instructor will have to require that the students meet all standards as set forth in the curriculum. The support of the local EMS agency will be important. Should a high school begin an EMS program, the local EMS agency must be willing to accept graduates of the program as volunteers or employees. Should the EMS agency desire not to work with students, there will be no means for the students to exercise their skills. The participation of representatives of the EMS agency in the instruction will also be important, so that students can have the opportunity to see first hand what an EMS operation involves, as well as to get questions answered by those directly involved. The school administration must buy into the process. It is very possible that the instructor will not be a teacher at the high school, so the process for class management, supervision, and control must be addressed in the planning process. In addition, it will be important in establishing the credibility of the program that a high percentage of the students who enroll in the program and apply for national registration pass the examination. Potential Difficulties There may be some reluctance in school systems to add a noncore program to their curriculum. Given the importance that is placed on testing and passing standards of learning programs, high schools may not approve putting new programs into the high school that do not specifically enhance standardized test scores. Maturity of the students can be a factor. Given the activities that will be required of a certified EMT, students must be mature and able to handle medical emergencies and trauma-related events. Child labor laws should also be considered in developing this type of program. Another potential difficulty is that jurisdictions frequently have statutory or regulatory minimum age requirements for becoming an EMT – 18 years of age in most states. Appropriate Process measures include the number of rural high schools offering EMS courses, the Measures and Data number of EMS instructors in rural areas, and the number of students that enroll in high school level courses. Impact measures include measures of learning achieved and the number and percentage of EMTs who have come from this source. Associated Needs School systems will need to have a cache of equipment to use for practical applications and for student practice.

Information on Agencies or Organizations Currently Implementing This Strategy Several highs schools have implemented EMS training programs, including but not limited to the following: • The Rising Star program gives high school seniors an opportunity to take college courses and prepare them to work or volunteer in EMS. The program is offered at SUNY Rockland Community College. Upon completion, students earn 8 college credits, as well as certification as a New York State EMT, Nationally Registered EMT, CPR for healthcare providers, and Pre-Hospital Trauma Life Support. • At Winter Springs High School, the Community Emergency Response Team (CERT) program has become a permanent part of the curriculum (Perry, undated). In addition, school board employees, bus drivers, teachers, and other administrators have received CERT training. SECTION V—DESCRIPTION OF STRATEGIES V-64 EXHIBIT V-20 (Continued) Strategy Attributes for Providing EMS Training Programs in High Schools in Rural Areas (T) Organizational and Institutional Attributes Organizational, School systems will have to address how to integrate this type of training program into Institutional and their course elective system. Should that not be possible, then EMT courses could be Policy Issues held at the high school immediately after school and/or on weekends. A policy will need to be in place that allows high school students to gain practical experience through observation at EMS units or in emergency departments. EMS educators will need to have the necessary support from elected school boards and top administrators to deliver EMS programs at local high schools. Issues Affecting Given that the curriculum already exists, primary time elements for implementation will Implementation Time include locating and training instructors and establishing a formal program at a high school (including provision for space, equipment, and materials). Establishing a list of best practices that have been in place and have been successful can reduce the implementation time. Costs Involved Primary costs will involve equipping classrooms for the program. Additional cost may be incurred to obtain a set of instructional materials. Students will incur the cost of books for the class. Training and If sufficient numbers of EMT instructors are not available, then high schools may want to Other Personnel consider sponsoring a certified teacher to become an EMT instructor. There will be no Needs other personnel needs. Legislative Needs States may have to pass legislation to allow for this type of program in high schools. State EMS agencies may have to alter rules to permit persons without high school diplomas to enroll in EMT courses, and exceptions may need to be noted in the child labor laws. Other Key Attributes Given the nature of dealing with illness, serious injuries, and death, some students will not be able to handle the related stress. Consideration should be given to only permitting seniors to enroll in the program or to permit only those who are 17 or older enroll in the program. Psychological testing may also be required to screen student applicants.

SECTION V—DESCRIPTION OF STRATEGIES • The Montgomery County, Maryland, High School Fire Science Program is a national award-winning, 1- or 2-year program for high school juniors and seniors to educate and train students to become EMS providers or firefighters in Montgomery County. • The Neptune High School in Neptune, New Jersey, joined forces with Jersey Shore University Medical Center and Neptune Township administration to establish a school-based program that prepares high school students for certification as EMTs (Indhal, 2004). Objective 20.1 D—Reduce Time from Injury to Appropriate Definitive Care Strategy 20.1 D1—Improve Cellular Telephone Coverage in Rural Areas (T) General Description The ability to report emergencies via cellular telephone is taken for granted by most Americans. Yet in rural areas, cellular telephone coverage is often limited to areas immediately adjacent to Interstates and major state highways. Depending on the particular cellular carrier, even these major transportation routes may have long segments that are not covered. As a result, persons experiencing medical emergencies or traumatic injuries in rural areas are often unable to use cellular telephones to access emergency services. A related issue is incompatibility of equipment and lack of interoperability between cellular telephone carriers. Common networking allows some cellular users to roam freely between networks, even when the discrete network of their originating or home carrier is not available. Others (e.g., Nextel) have built closed networks that do not permit this interoperability. Cellular networks are built and operated as purely private business ventures, under license from the FCC. Service areas and network development are driven solely by market forces, resulting in little attention to areas that are not densely populated. In urban areas, 9-1-1 centers report that a significant and steadily increasing percentage of requests for emergency services arrive via cellular telephone. The FCC’s recent “Phase II” automatic location initiative has required cellular carriers to provide accurate location information (i.e., latitude and longitude) of cellular telephone calls to 9-1-1 centers using a variety of technical means, including triangulation and global positioning system (GPS) information. Compliance with this Phase II requirement is not widespread. Current information on Phase II compliance can be found on the National Emergency Number Association website at http://nena.org/dot/. For emergency response to be effective, reporting must be effective. Effective reporting is dependent on at least two factors. The reporting party must be able to access the communication system and be able to accurately report the location of the emergency. This strategy is closely related to Strategy D2. V-65

SECTION V—DESCRIPTION OF STRATEGIES V-66 EXHIBIT V-21 Strategy Attributes for Improving Cellular Telephone Coverage in Rural Areas (T) Technical Attributes Target Cellular telephone carriers and public utility regulatory agencies, including the FCC. Expected No studies document the expected effectiveness of this strategy. However, many people Effectiveness are using cellular telephones to access EMS. More than 100,000 people use cellular phones to call 9-1-1 every single day, and in some jurisdictions, more than 50 percent of all incoming calls are from cellular phones. Improving cellular telephone coverage in rural areas will enable more people to access EMS. Keys to Success For this strategy to succeed, affordable incentives must be found to induce private cellular carriers to extend service to areas that currently lack an adequate customer base to support profitable operation of that segment of the cellular telephone network. In addition, those same companies will also need incentives (or be required by regulation) to ensure interoperability between carriers, at least with respect to calls directed to the 9- 1-1 system. Potential Difficulties The principal barrier to the expansion of cellular telephone networks in rural areas is economic. Because the cellular telephone networks are purely a private-sector proposition, network development and expansion are driven by demand for services from subscribers willing to pay for cellular services. In remote areas, there is no sufficient subscriber base to underwrite the cost of network development. Appropriate Process measures for this strategy would include the number of rural highway miles that Measures and Data are covered by at least one of the cellular telephone networks at the conclusion of the program that were not covered at the beginning. This should be accompanied by graphic displays of the sections of highways that were added, indicating when that change occurred. In addition, the accessibility of cell phone service needs to be measured in terms of the proportion of subscribers in the region who can use the available service, through either interoperability or redundancy of services available. Impact measures would include the change in the count of emergency calls before and after highway coverage is improved. A more direct measure would involve the change in the time from the occurrence of the event to the arrival of an EMS service on scene. Associated Needs None identified. Organizational and Institutional Attributes Organizational, Public underwriting of the cost of cellular telephone infrastructure, or requiring carriers to Institutional and incorporate costs of emergency system expansion into the rate base to be shared by all Policy Issues subscribers, is controversial as a policy matter. Issues Affecting The time required to implement cellular coverage in rural areas will directly correlate with Implementation Time the level of funding provided to the project. If no funding is provided, improved coverage will not occur or will occur only when areas become sufficiently populous to support the cost of the required infrastructure. If sufficient funding were available, the entire nation could conceivably be covered in a 5- to 10-year period. There will likely be several generations of change in cellular communication technology during that interval. Costs Involved Costs will vary depending upon a myriad of factors in a rapidly changing environment. The public costs of contribution to this effort could in significant part be mitigated by in- kind contributions (e.g., public land for location of tower sites and eased regulatory requirements for towers on public land).

SECTION V—DESCRIPTION OF STRATEGIES Strategy 20.1 D2—Improve Compliance of Rural 9-1-1 Centers with FCC Wireless “Phase II” Automatic Location Capability (T) General Description The benefits of complete implementation of Strategy D1 (Improve cellular telephone coverage in rural areas) could in large part be lost because vast areas of rural America are not discretely addressed. While the increased proliferation of cellular telephones over the last 20 years has greatly facilitated access to emergency services, it has also created certain difficulties. Particularly in rural areas, callers using cellular telephones are often not aware of their precise location and thus cannot describe the location of the emergency to 9-1-1 call-takers. This in turn leads to confusion and delay of emergency responders. In 2003, between 30 and 50 percent of calls to 9-1-1 centers arrived via cellular telephone. Thus, a significant portion of calls to 9-1-1 centers may not carry important location information. In response to this problem, on June 12, 1996, the FCC adopted a Report and Order that created rules to govern the availability of basic 9-1-1 services and the implementation of Enhanced 9-1-1 (E9-1-1) for wireless services. This rule requires that wireless telephone carriers provide geographic location information as part of the data stream that accompanies each wireless call to 9-1-1, much as landline calls to 9-1-1 provide the exact street address of the hard-wired telephone from which the call is made. At the same time, the commission also adopted a Further Notice of Proposed Rulemaking to develop additional means of ensuring that mobile service providers implement the best possible E9-1-1 systems. Although much progress has been made, this effort has been stalled through effective resistance by the wireless telecommunications industry, the willingness of the FCC to grant waivers and extensions to the industry, and ongoing litigation of how the costs of meeting the “Phase II” standards will be distributed. In December 2004, Congress passed the “Enhance 9-1-1 Act of 2004,” which authorized the creation of a national E9-1-1 V-67 EXHIBIT V-21 (Continued) Strategy Attributes for Improving Cellular Telephone Coverage in Rural Areas (T) Organizational and Institutional Attributes Training and Other There appear to be no special personnel needs to implement this strategy. Once a Personnel Needs mandate is in place and funding is available, infrastructure development will be performed by the respective cellular carriers. Legislative Needs High-level policy decisions will be required at the national level for this initiative to move forward. Alternatively, individual states or political subdivisions might elect to underwrite local infrastructure development through direct negotiations with cellular carriers. Other Key Attributes None

Implementation Coordination Office. This legislation is designed to speed E9-1-1 implementation and improve coordination among all levels of government. The USDOT has taken an active role to enhance E9-1-1 services. For example, a HYPERLINK "http://www.itspublicsafety.net/wireless_actionplan.htm" Wireless E9-1-1 Priority Action Plan (Wireless E9-1-1 Steering Council, 2003) was developed that outlines the six most urgent priorities: • Establish support for statewide coordination of implementation of wireless location technology and identify points of contact within each state for each of the stakeholders. • Help to convene stakeholders in appropriate 9-1-1 regions in order to facilitate more comprehensive, coordinated implementation of wireless location technologies. • Examine cost recovery/funding issues at the state level. • Initiate a knowledge transfer and outreach program to educate public safety answering points (PSAPs), wireless carriers, and the public about wireless location issues. • Develop a coordinated deployment strategy encompassing both rural and urban areas. • Implement a model location program. The USDOT also funded the New York State Wireless Enhanced 9-1-1 Project to facilitate the development of wireless E9-1-1 in New York State (Bailey and Scott, undated [a, b]). The goal in supporting this project was to document how things were accomplished and lessons learned, thereby making the process smoother for other state and local organizations in developing and implementing E9-1-1 systems. The USDOT is also obtaining input from the EMS community in the area of ITS technology development (ITS America Public Safety Advisory Group Medical Subcommittee, 2002). The technical capability for providing location information is well established. Cellular companies can meet the FCC standards through incorporation of GPS technology in telephone instruments, or they can establish the location through triangulation between fixed cell towers. Either methodology provides acceptable results. At the other end of the connection, the 9-1-1 center receiving the call must be capable of receiving, decoding, and displaying the location information provided by the cellular carrier. This requires complete and accurate map data, as well as telephone termination equipment capable of integrating the location and map data. Much of rural America is served by small (i.e., one- and two-position) 9-1-1 centers whose staff double as receptionists, records clerks, jail staff, and a variety of other functions. These centers, which often operate on extremely limited budgets and which frequently have aging or limited-capability equipment, may not be equipped to receive and use wireless E9-1-1 data even if the data are made available. This strategy is closely related to Strategy 20.1 D1. SECTION V—DESCRIPTION OF STRATEGIES V-68

SECTION V—DESCRIPTION OF STRATEGIES V-69 EXHIBIT V-22 Strategy Attributes for Improving Compliance of Rural 9-1-1 Centers with FCC Wireless “Phase II” Automatic Location Capability (T) Technical Attributes Target Rural 9-1-1 centers and municipal, state, county, and local governments. Expected There are many documented cases of callers dialing 9-1-1 to report an emergency when Effectiveness the callers do not know where they are located and cannot sufficiently describe the location, and by the time emergency services arrive at the scene, it is too late. Keys to Success For this strategy to be successful, funding must be provided to agencies to procure the necessary equipment and connectivity for Phase II implementation. In addition, full implementation of Strategy D1 is required to ensure the necessary coverage. Some consolidation or centralization of rural 9-1-1 centers could also facilitate more effective implementation. Accurate electronic maps and updated hardware that can capture automatic number information (ANI) and automatic location identification (ALI) information from cellular telephones are required for all areas to be serviced. Potential Difficulties Resolution of the cellular telephone coverage and Phase II ALI capabilities lies at an uncomfortable intersection of public-sector regulation and private-sector implementation. Because the cellular telephone industry is an entirely private-sector venture, regulatory pressure is likely to be met with continued resistance. Limited availability of public funds poses a challenge to the options for public sector funding of network and center development. Because of the “shared workload” nature of many 9-1-1 call center staff, there is likely to be local resistance to consolidation of 9-1-1 centers. This issue has been ongoing in the State of Oregon, where the most populous counties have a single 9-1-1 center and rural counties often have between three and seven 9-1-1 centers. Appropriate A key process measure is the number, or percentage, of 9-1-1 centers adding Phase II Measures and Data capabilities. It will also be important to document the reasons that noncompliant centers have not attained Phase II compliance. Finally, the estimated cost for achieving compliance should be documented. Impact measures will include the change in the percentage of calls for service that have ALI and change in response time to crash locations. Associated Needs Associated needs include information concerning interjurisdictional cooperation, availability of incentives for regional cooperation and consolidation, and access to advocacy and partnering groups. Organizational and Institutional Attributes Organizational, First, the magnitude of the problem must be established. Second, policy-making officials Institutional and must be made aware of the issue and the potential consequences of noncompliance. Policy Issues Third, a focus (such as state 9-1-1 program offices) must be identified and encouraged to champion the cause. Issues Affecting The solutions to this problem are largely financial. If adequate funding were available, Implementation Time two large industries (cellular telephone and telecommunication equipment) stand available to provide the necessary solutions in a moderate timeframe (i.e., 1-2 years). Costs Involved Costs include those associated with achieving adequate cellular coverage (Strategy D1), establishing necessary data networks for transfer of ANI and ALI information, Phase II–compliant 9-1-1 telephone termination equipment, and developing and maintaining accurate base maps. Training will be a minor cost component compared with capital investments.

SECTION V—DESCRIPTION OF STRATEGIES V-70 EXHIBIT V-22 (Continued) Strategy Attributes for Improving Compliance of Rural 9-1-1 Centers with FCC Wireless “Phase II” Automatic Location Capability (T) Organizational and Institutional Attributes Training and Other Personnel may need to be trained on any new equipment that is purchased. Personnel Needs Legislative Needs Organizations must comply with FCC regulations concerning wireless Phase II automatic location capabilities. Other Key Attributes None Strategy 20.1 D3—Utilize GPS Technology to Improve Response Time (T) General Description Once system access has been achieved and emergency response personnel dispatched, the next controllable system variable is the travel of responders and response vehicles to the scene of the emergency. The availability of GPS and other computer-based navigation technology provides an opportunity to improve the ability of rural responders to travel efficiently to the scene of an emergency and to eliminate or minimize the dependence on printed maps. Effective use of GPS requires the availability of accurate maps, including GPS coordinates. Response vehicles need to be equipped with GPS location and navigation technology, and the GPS coordinates of all homes and businesses need to be recorded and available for use (currently these data are kept in 9-1-1 system master street address guides that are not directly accessible by responders). In addition, the emergence of “telematics” capabilities of GPS-based automated crash notification systems such as OnStar and ATX Technologies could link all private, public, and commercial vehicles directly to the closest response agency. This strategy is closely related to Strategy 20.1 D4. EXHIBIT V-23 Strategy Attributes for Utilizing GPS Technology to Improve Response Time (T) Technical Attributes Target 9-1-1 centers, emergency response vehicles, and new vehicle purchasers. Expected GPS-based computer-aided navigation (CAN) systems have been shown to reduce Effectiveness response times for emergency responders by up to 15 percent (Wilcox, 2004; also see Appendix 8). Automated crash notification (ACN) systems such as OnStar have been found to reduce the notification interval in emergency situations and to allow effective location of vehicles involved in collisions where occupants may be unable to request assistance by other means. In Nebraska, several state, local, and private agencies evaluated three GPS, messaging, and communication technologies to determine their capacity for improving day-to-day law

SECTION V—DESCRIPTION OF STRATEGIES V-71 EXHIBIT V-23 (Continued) Strategy Attributes for Utilizing GPS Technology to Improve Response Time (T) Technical Attributes enforcement, emergency response, and highway maintenance (Mid-America Transportation Center, 2000). The study was conducted in northeast and north central Nebraska where existing topographic features, structural obstructions, and atmospheric conditions make two-way, low-band radio and wireless telephone communication unreliable in so-called “dead” spots. Participating agencies acknowledged that the technologies would enhance their existing communication systems, but in many cases, they indicated that significant modifications or improvements to the technologies would be required before the agencies would consider complete replacement of current communication equipment and protocols. Appendix 16 provides more details on the Nebraska study. Keys to Success For this strategy to be successful, emergency vehicles need to be equipped with systems that can communicate location data to emergency dispatch centers. Accurate street network maps (“routing-capable”) must also exist. Moreover, both emergency responder systems and telematic systems for private vehicles are dependent on the existence of effective wireless data communication networks. Potential Difficulties There are significant costs associated with providing public safety grade CAN equipment to agencies and vehicles. Even with a national mandate for the inclusion of ACN telematics systems in newly purchased vehicles, 5-10 years would be required before substantial proportions of the U.S. vehicle fleet included these systems. Appropriate Process measures include the number of systems installing GPS technology and the Measures and Data costs associated with this. Measures of effectiveness will be change in the percentage of responses in which GPS technology was used, change in average response time, comparison of response time between centers using GPS technology and centers operating without it, change in proportion of cases in which ACN was in operation, and change in response time between centers having ACN and other types of conditions and centers with similar areas and distances from EMS base to the site of the crash. Associated Needs Geographic information system (GIS) databases are necessary to support effective public safety CAN systems. Organizational and Institutional Attributes Organizational, Beyond cost, there is very little institutional resistance to implementing CAN in public Institutional and safety agencies. Many agencies, particularly those in urban areas, have already Policy Issues implemented some form of CAN for police, fire, and EMS vehicles. Rural communities, having lesser resources, have been slower to adopt CAN technologies. A mandate for private vehicle ACN (such as the OnStar system) would represent a significant national public policy initiative. Today’s ACN alternatives require both an ACN- equipped vehicle (~$500-600 per vehicle) and a monthly service fee. With an estimated 18 million new vehicles sold in the United States each year, the cost of mandatory ACN system installation could add $9 billion per year to the cost of motor vehicle purchases. This cost would likely decline as the benefits of mass production make ACN systems more of a commodity than a novelty or luxury item. Issues Affecting Implementation time will be subject to availability of funding, time required for education Implementation Time of emergency communication and response personnel, procurement cycles, installation of vehicle and dispatch center systems, and evaluation and upgrading of existing GIS map bases sufficiently to support CAN routing. Developing digital maps and upgrading hardware in 9-1-1 centers may take 1-3 years to implement once adequate funding has been procured.

SECTION V—DESCRIPTION OF STRATEGIES V-72 EXHIBIT V-23 (Continued) Strategy Attributes for Utilizing GPS Technology to Improve Response Time (T) Organizational and Institutional Attributes Costs and policy debates over the possibility of mandating CAN for private vehicles could result in extensive time before a mandate is adopted, if it ever is. Costs Involved Costs will be significant, including procurement and installation of a dispatch center, vehicle computers, communication networking, and procurement of software and geographic information needed for system operation. Training and Other Initially these projects will place a significant burden on public safety IT services. Once Personnel Needs installed, minimal training in GIS administration will be required for end users. Legislative Needs Legislation may be needed for funding the development of necessary data communication networks; GIS databases; and the necessary hardware, software, and communication links. In addition, public policy issues associated with mandatory ACN system installation in private vehicles should be considered during legislative initiatives. Other Key Attributes The Center for Injury Sciences at the University of Alabama at Birmingham is conducting a project to integrate ACN technology with an organized trauma system to expedite identification of vehicle crashes with injuries and the delivery of appropriate medical care (FHWA, 2003). The project is employing remote electronic data collection by emergency medicine personnel and using these data to route patients to the appropriate medical facility. In addition, real-time collision parameters will be used to predict the likelihood of injury in a given crash. This project is closely related to Strategy A6. Strategy 20.1 D4—Integrate Automatic Vehicle Location (AVL) and Computer-Aided Navigation (CAN) technologies into All Computer-Aided Dispatch (CAD) Systems (T) General Description Prompt delivery of emergency assistance to sick and injured persons is, conceptually, a simple matter. The location of the emergency is identified, the location of the appropriate emergency response resource is identified, that resource is alerted, and the alerted resource travels by the fastest route to the scene of the emergency. Two discrete processes can be made more efficient through the use of AVL and CAN technologies. • AVL technology permits rapid and accurate identification of the closest appropriate emergency response resource (known in emergency services terms as the “T4-T5” interval, or “dispatch time”). • CAN technology permits the responders to travel most efficiently to the scene of the emergency, thereby reducing the response interval (known in emergency services terms as the “T6-T7” interval, or “travel time”). Many public safety dispatch centers currently use some form of CAD system to track and record the movements of police, fire, and EMS vehicles. A 1999 survey by the U.S. Department of Justice’s (DOJ’s) Bureau of Justice Statistics reported that 56 percent of

SECTION V—DESCRIPTION OF STRATEGIES local police departments use CAD, while 70 percent of sheriff communication centers use CAD. Yet most of these systems are not equipped with AVL systems. Thus, they must use surrogates (station locations or response districts) to determine the closest response vehicle to a particular incident. As long as vehicles remain in-station, this surrogate is acceptable. However, as vehicles move about the response zone, frequently the “home station” vehicle is not the closest vehicle to the scene of an emergency. AVL technology mitigates that problem by providing real-time location data to the CAD system. While CAD systems are common in many jurisdictions, AVL and CAN systems are less frequently found. Unlike consumer-grade vehicle navigation systems, public safety AVL and CAN systems require wireless data connections between vehicles and their communication center. Acceptable publicly owned or commercial wireless data networks are less common in rural areas. As one moves away from the largest cities, another variable enters the equation. In many areas, consolidated communication centers serve multiple law enforcement, fire rescue, and EMS agencies. Decisions to implement new and costly technologies require the agreement and participation of multiple governing and funding bodies, thereby further complicating the implementation process. This strategy is closely related to Strategy 20.1 D3. V-73 EXHIBIT V-24 Strategy Attributes for Integrating Automatic Vehicle Location (AVL) and Computer-Aided Navigation (CAN) Technologies into All Computer-Aided Dispatch (CAD) Systems (T) Technical Attributes Target Public safety dispatch centers, emergency response vehicles, and CAD vendors. Expected CAD systems have been shown to provide more effective control of public safety Effectiveness response assets. GPS-based CAN systems have been shown to reduce response times for emergency responders by up to 15 percent (Wilcox, 2004; ESRI, 2003). Keys to Success For this strategy to be successful, emergency vehicles need to be equipped with systems that can communicate location data to emergency dispatch centers. Accurate street network maps (“routing-capable”) must exist. Moreover, emergency responder CAN systems depend on the existence of effective wireless data communication networks linking the vehicle with a dispatch center. Potential Difficulties Significant costs are associated with providing public safety grade CAN equipment to agencies and vehicles. In 2003, these costs were as high as $100,000 per dispatch center and $10,000 per emergency vehicle, including computers, software, and wireless connectivity. Appropriate Identification/dispatch and response times will be key measures for comparing both Measures and Data (1) before and after implementation and (2) against centers operating without the technology. Process measures should include the number of units and centers properly equipped and operating. Associated Needs GIS databases are necessary to support effective public safety CAN systems.

SECTION V—DESCRIPTION OF STRATEGIES V-74 EXHIBIT V-24 (Continued) Strategy Attributes for Integrating Automatic Vehicle Location (AVL) and Computer-Aided Navigation (CAN) Technologies into All Computer-Aided Dispatch (CAD) Systems (T) Organizational and Institutional Attributes Organizational, Beyond cost, there is very little institutional resistance to implementing CAN in public Institutional and safety agencies. Many agencies, particularly those in urban areas, have already Policy Issues implemented some form of CAN for police, fire, and EMS vehicles. Rural communities, having lesser resources, have been slower to adopt CAN technologies. Establishment of agency policy at the highest executive level may be necessary to develop the data communication networks and GIS databases and to identify funding for necessary hardware, software, and communication links. Issues Affecting Time components include availability of funding, time required for education of Implementation Time emergency communication and response personnel, procurement cycles, installation of vehicle and dispatch center systems, evaluation and updating of existing GIS map bases to support CAN routing, and installation and testing of the final system. Costs Involved Costs include procurement and installation of dispatch center and vehicle computers and communication networking and procurement of software and geographic information needed for system operation. Training and Other Initially these projects would place a significant burden on public safety IT services. Once Personnel Needs installed, minimal training is required for end users. Legislative Needs None identified. Other Key Attributes None Strategy 20.1 D5—Equip EMS Vehicles with Multi-Service and/or Satellite-Capable Telephones (T) General Description More than 48,000 credentialed EMS vehicles are in the United States today. Although the vast majority of these are found in urban and suburban areas, a significant number of these serve mixed small city, suburban, rural, and frontier areas. It is generally required by state regulation, and almost always desirable, for EMS vehicles to have the capability of communicating with other medical and public safety resources. Routine operational communications are normally conducted via public safety two-way radio systems. From 1970 until today, there have been efforts to extend these systems to allow for communication between EMS vehicles and on-line medical resources. However, particularly in rural areas, the cost of constructing and maintaining dedicated private radio networks has often proved prohibitive. EMS systems often rely on older communication methodologies that permit communications only when in close proximity to the receiving hospital. The continued improvement of cellular telephones and the availability of multi-mode and satellite-capable cellular telephones puts on-line medical consultation well within the reach of every rural EMS provider at a reasonable cost. It should be emphasized that the use of

SECTION V—DESCRIPTION OF STRATEGIES multi-service and/or satellite-capable telephones is not intended to replace existing communication systems. V-75 EXHIBIT V-25 Strategy Attributes for Equipping EMS Vehicles with Multi-Service and/or Satellite-Capable Telephones (T) Technical Attributes Target The principal target is the communication between EMS vehicles and medical consultants. The EMS agencies will be the responsible agency targeted to accomplish this. Expected This will permit any EMS vehicle away from the terrestrial cellular telephone system to Effectiveness access on-line medical consultation via satellite communications while at the scene or en route to the emergency department. It is presumed that the availability of this communication will allow earlier application of quality treatment than would otherwise be available should the patient have to wait until arrival at the trauma center to receive the same treatment. Keys to Success For this strategy to succeed, rural EMS providers must be persuaded that maintenance of on-line medical communications is to their benefit. In addition, funding to allow procurement of multi-service, satellite-capable telephone instruments ($1,000 each in 2004) and per-minute charges should be provided. Immediate availability of medical consultants, upon calling, is fundamental to the success of this approach. Potential Difficulties Many remote EMS agencies have worked for so long without on-line medical communication that there is a misperception that it is neither necessary nor beneficial. Appropriate Process measures to employ include the number and percentage of units having the Measures and Data desired communication equipment, the number of runs on which the equipment is used, the number and percentage of cases in which use of the equipment has a significant bearing on the outcome of the run, and the number and percentage of cases in which the desired medical consultation is not available or is delayed in becoming available. An estimate of time spent in satellite communication by EMS operators on runs is another measure of system output. Terrestrial satellite coverage is a measure of secondary interest. Effectiveness may be evaluated using measures such as the percentage and type of runs where the satellite communication had a significant impact on the outcome and related anecdotes of representative cases. In addition, the change in the distribution of time, from arrival on the scene until administration of the appropriate treatment, due to use of the technology may be of interest as a secondary measure of effectiveness. Associated Needs None identified. Organizational and Institutional Attributes Organizational, The magnitude of the need must be established. Consensus of the EMS medical Institutional and community and EMS medical directors must determine whether this level of on-line Policy Issues medical control is required or desired. Issues Affecting Once priority is established and funding made available, telephone instruments and Implementation Time service are immediately available from commercial sources. Costs Involved In 2004, the costs were approximately $1,000 per EMS unit needing the capacity, plus approximately $1.00 per minute of satellite communication time.

Information on Agencies or Organizations Currently Implementing this Strategy The EMS program in Alaska is beginning to purchase mobile satellite telephones to help provide coverage in “dead spot” areas. In Mississippi, EMS agencies are also pursuing the benefits of satellite technology. SECTION V—DESCRIPTION OF STRATEGIES V-76 EXHIBIT V-25 (Continued) Strategy Attributes for Equipping EMS Vehicles with Multi-Service and/or Satellite-Capable Telephones (T) Organizational and Institutional Attributes Training and Other No significant training needs. Personnel Needs Legislative Needs Funding for enhanced rural EMS communications is desirable. Other Key Attributes None