Emergency Medical Services At the Crossroads (2007) / Chapter Skim
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2 History and Current State of EMS
2 History and Current State of EMS
Pages 31-72
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From page 31... ...
Though the modern EMS system was instituted and funded in large part by the federal government through the Highway Safety Act of 1966 and the EMS Act of 1973, federal support for EMS agencies declined precipitously in the early 1980s. Since that time, states and localities have taken more prominent roles in financing and designing EMS programs.
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From page 32... ...
. By the late 1950s, prehospital emergency care in the United States was still little more than first aid (IOM, 1993)
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In 1972, the NAS/NRC released another report on EMS entitled Roles and Resources of Federal Agencies in Support of Comprehensie Emergency Medical Serices (NAS and NRC, 1972)
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From page 34... ...
An important feature of the grant program was its emphasis on the need for effective planning at the state, regional, and local levels to ensure coordination of prehospital and hospital emergency care. Across the country, state EMS offices began to emerge.
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From page 35... ...
The Maryland Institute for Emergency Medical Services Systems was established in 1972 and continued to take a strong leadership role in subsequent years. The state elected to provide emergency air and ground transportation as a public service and created a sophisticated trauma system that designates trauma centers on the basis of compliance with standards and demonstrated need (IOM, 1993)
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From page 36... ...
. TABLE 2-1 New Vision for the Role of Emergency Medical Services EMS Today (1996)
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From page 37... ...
, but also exposed many of the technical and logistical challenges that confront the nation's public safety systems. Communications capabilities were shown to be grossly deficient among the units that responded to the World Trade Center attacks, and a lack of interoperability and inadequate communications with rescuers within the towers probably contributed to the deaths of many rescue personnel (National Commission on Terrorist Attacks upon the United States, 2004)
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From page 38... ...
. In addition, as noted above, the events of September 11, 2001, demonstrated that public safety agencies (including fire, police, emergency management, and EMS)
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From page 39... ...
While hospital ED staff often provide direct, on-line medical direction to EMS personnel during transport, time pressures, competing demands, and a lack of trust can at times hinder these interactions. In addition, cultural differences between EMS and hospital staff can impede the exchange of information.
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From page 40... ...
In addition, ED diversion has become commonplace in many major cities, further hindering the performance of EMS. In major metropolitan areas, it is not uncommon for all of the city's trauma centers to request ambulance diversion at the same time.
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From page 41... ...
and emulated by many payers reimburses on the basis of transport to a medical facility. This model ignores the increasingly sophisticated care provided by EMS personnel, as well as the growing proportion of elderly patients with multiple chronic conditions who frequently utilize EMS.
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From page 42... ...
EMS and trauma services are dispersed across wide distances, and recruitment and retention of EMTs and paramedics is a pervasive problem. In rural areas, volunteers make up the majority of the EMS workforce (National Registry of Emergency Medical Technicians, 2003)
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From page 43... ...
Although EMS providers represent a third of the nation's first responders and have a key mission in treating the casualties of a terrorist strike, they received only 4 percent of the $3.38 billion allocated by the Department of Homeland Security for enhancing emergency preparedness in 2002 and 2003 (Center for Catastrophe Preparedness and Response NYU, 2005)
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From page 44... ...
In an effort to coordinate the efforts of these various components of the federal bureaucracy, Congress established a Federal Interagency Committee on Emergency Medical Services (FICEMS)
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From page 45... ...
HISTORY AND CURRENT STATE OF EMS TABLE 2-2 EMS-Related Fiscal Year 2005 Federal Funding 2005 Enacted Millions of Dollars Labor HHS & Education Bill Health and Human Services HRSA Rural EMS Training and Equipment 0.5 Rural and Community Access to AEDs 9 Hospital BT Preparedness 495 Trauma/EMS 3 EMS for Children 20 Traumatic Brain Injury 9 Rural Outreach Grants 39 Rural Hospital Flex Grants 39 Poison Control 23 CDC Prevention Block Grant 131 Injury Prevention (NCIPC) 138 Transportation, Treasury Bill NHTSA EMS Division 4 EMS State Grants 0 Homeland Security Bill Office of Domestic Preparedness State and Local Programs: State Homeland Security Grant Program: 1,100 Law enforcement terrorism prevention grants 400 Urban Area Security Initiative: High-threat, high-density urban area 885 Targeted infrastructure protection 0 Buffer Zone Protection Program 0 Port security grants 150 Rail and transit security 150 Trucking security grants 5 Intercity bus security grants 10 Commercial equipment direct assistance program 50 National Programs: National domestic preparedness consortium 135 National exercise program 52 Technical assistance 30 Metropolitan Medical Response System 30 Demonstration training grants 30 Continuing training grants 25 Citizen Corps 15 Evaluations and assessments 14 Rural domestic preparedness consortium 5 continued
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From page 46... ...
2010. These include increasing the proportion of adults who are aware of the early warning signs of a heart attack and the importance of accessing emergency care by calling 9-1-1 (GAO, 2001b)
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From page 47... ...
Under the old reimbursement system, EMS agencies received two payments per transport. The primary payment was a cost-based, feefor-service rate that reimbursed EMS for the service provided.
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From page 48... ...
Although many rural EMS squads rely on volunteers rather than paid EMS personnel to reduce these costs, doing so results in a less stable system. Federal Regulation of EMS The current organization and delivery of emergency and trauma care is shaped largely by federal and state legislation.
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From page 49... ...
Various people involved in making the decision at the local level, including the hospital administrator, the hospital's attorney, the state EMS office, and others, may all have a different point of view. As a result, providers are making decisions that may compromise care based on their own reading of this complex regulatory environment.
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From page 50... ...
For example, EMS agencies may want to assess patient outcomes following hospital transport; however, patient-specific outcome data often are not shared. EMS personnel may also seek to determine whether a particular patient transported to the hospital is suffering from an air- or bloodborne pathogen or some other malady that may compromise the safety of the transporting EMS personnel.
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From page 51... ...
Complaint Investigation 100 EMS Training Standards 96 EMS System Planning 94 Disciplinary Action of Personnel 90 EMS Personnel Credentialing 90 State EMS Data Collection 88 Air Ambulance Credentialing 84 Ambulance Inspections 84 Ambulance Credentialing 82 Disaster Planning 78 Local EMS Technical Assistance 74 Trauma System Management 72 Local EMS Data Collection 68 Medical Director Education 62 Funding for Local EMS Operations 34 Communications Operations 18 SOURCE: Mears, 2004.
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From page 52... ...
. The technical assistance provided to state EMS agencies is critical.
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From page 53... ...
These emergency call centers are operated primarily by public safety agencies, as well as city and county communications centers, hospitals, and others (see Figure 2-3)
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2-3 Redrawn in grayscale calls are received by primary call centers and then routed to secondary calls centers with dedicated medical dispatch. In other cases, all calls are handled at the primary call center.
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From page 55... ...
. While no statistics are available to provide greater detail about EMS system types nationwide, the Journal of Emergency Medical Serices conducts an annual survey of the 200 largest metropolitan areas in the United Fire department-based Other 45.0% 48.5% Hospital-based 6.5% FIGURE 2-4 Types of EMS systems.
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From page 56... ...
EMS is an element of the response and service delivery of approximately 80 percent of fire departments in America (U.S. Fire Administration, 2005)
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From page 57... ...
These physical structures can provide a strategic location for the EMS units they house, as well as a place for EMS personnel to rest between calls. Fire departments also provide the administrative infrastructure necessary to manage personnel, provide training, and purchase and maintain equipment and supplies.
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From page 58... ...
Medical directors who are hired to supervise fire department–based emergency medical response may be viewed as outsiders, and may defer to the fire chiefs on the way resources should be deployed. Over the past decade, many EMS systems have become integrated with the fire service, although there is significant variation with respect to the level of integration.
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From page 59... ...
In many cases, the locality chooses the latter option. This involves purchasing or leasing ambulance units, hiring EMS personnel to provide direct services and administrative personnel to run the program, and stocking ambulances with necessary medical and communications equipment.
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From page 60... ...
However, the challenge is maintaining a response system that consistently meets the public demand for quality services. Most experts agree that there appears to be a national trend toward decreasing volunteerism and an increase in EMS personnel seeking paid careers.
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From page 61... ...
. Air medical services are believed to improve patient outcomes because of two primary factors: reduced transport time to definitive care and a higher skill mix applied during transport.
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From page 62... ...
Ensuring the delivery of quality EMS to rural populations is also complicated by the makeup and skill level of prehospital EMS personnel and associated issues of management, funding, and medical direction for rural EMS systems. In 1989, the Office of Technology Assessment estimated that three-quarters of rural prehospital EMS personnel were volunteers (U.S.
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From page 63... ...
. As noted in Chapter 1, EMS response times from the instigating event to arrival at the hospital are significantly longer in rural than in urban areas.
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From page 64... ...
Taken together, these factors mean that rural EMS providers may be less proficient than urban providers. A high percentage of rural EMS personnel may be trained only in BLS, and indeed, many rural programs offer only BLS services (Minnesota Department of Health, Office of Rural Health Primary Care, 2003)
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From page 65... ...
. Basic EMS providers and fire departments scattered throughout the area can act as first responders, with fully equipped units responding after dispatch.
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From page 66... ...
. Finally, the lack of capacity of rural public health departments and a limited rural public safety infrastructure result in greater reliance on rural EMS personnel to participate in disaster preparedness relative to their urban counterparts (Spaite et al., 2001)
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From page 67... ...
1998. Prehospital oral endotracheal intubation by rural basic emergency medical technicians.
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From page 68... ...
2006. Souls on board: Helicopter emergency medical services and safety.
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From page 69... ...
1998. New vision for the role of emergency medical services.
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From page 70... ...
1999. Priorities for research in emergency medical services for children: Results of a consensus conference.
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From page 71... ...
Emergency medical treatment and labor act. Annals of Emergency Medicine 40(5)
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