The emergency medical services (EMS) system is a complex combination of various providers and facilities that provide three basic medical functions: stabilization, evacuation, and redistribution. Although organizational structures and resources vary worldwide, the fundamental components of any EMS system are essentially the same. This chapter will provide the EMS physician with a vital understanding of the organization of EMS systems and how such design considerations provide challenges and opportunities for patient-centered emergency medical care.
Define the EMS system in terms of the overall medical response to emergencies.
List the original 14 components of an EMS system.
List and describe the components of an EMS system as defined by NHTSA.
Describe the basic types of emergency medical service agencies.
Describe the main differences between urban and rural EMS systems.
Discuss how community groups, corporations/businesses, patient advocacy groups, and health care facilities affect EMS system design.
Define mutual aid and describe how it is employed in EMS system design.
Discuss state, regional, and local EMS councils and/or administrations.
Discuss state, regional, and local medical oversight committees.
PATIENT FLOW WITHIN AN EMS SYSTEM
The entry of a patient into the emergency health care system brings with it a complex cascade of events, with a number of possible outcomes. Figure 12-1 displays a simplified look at the emergency health care system from the time of entry to the time of exit. Most striking to this flow diagram is its serial nature, and therefore, input to one process is limited by its output. This input-throughput-output conceptual model of the emergency health system is essential to consider as one examines the design of EMS systems, as an output limitation such as unstaffed ambulances or hospital crowding will progressively limit the system's ability to function and respond to the demands placed on it.1,2
Patient flow within the emergency health care system.
The majority of patients who enter the emergency health care system do so by making a telephone call to the 9-1-1 system. The Medical Priority Dispatch System (MPDS) or the Association of Public-Safety Communications Officials (APCO) Emergency Medical Dispatch Program are specifically designed to abstract this caller information through a question-driven protocol and direct appropriate resources based on that information. Although a complete discussion of Emergency Medical Dispatch will be covered in Chapter 15, it is important to recognize that nearly all public safety answering points (PSAPs) are able to begin rendering care for the patient over the phone by using prescripted, postdispatch, and prearrival instructions.3-6 The instructions could include directing a bystander to perform CPR, assist with the delivery of a newborn, or direct self-care such as hemorrhage control or aspirin administration. Further, the prioritization of requests for EMS service through any call-taking program based on call severity is essential to the underlying mission of getting the right equipment to the right patient at the right time.
The standard response to a request for service includes sending an ambulance. There are limited circumstances in some systems whereby based on caller interrogation the requestor may be directed to alternative sources of care (eg, a poison control center for an accidental ingestion without any symptoms) or attended to by first responders without transport capability (eg, a request for lifting assistance). Depending on system design, the ambulance that is dispatched could be able to provide care at the BLS level, the ALS level, or in some systems may utilize a BLS ambulance with an ALS intercept (paramedic engine, paramedic “fly-car,” etc). In systems that do not send ALS resources on every request for service, the use of an EMD program often allows differentiating those requests for service that are most likely to require ALS from those most likely to require BLS, and therefore assign resources accordingly. Determining which types of calls get which types of resources is often the responsibility of the 9-1-1 center or the system's medical director.
First responders are essential to the EMS system, particularly for cases of imminent life-threatening conditions such as choking, respiratory arrest, or cardiac arrest. Various systems employ a myriad of first-response deployment models. This could include fire department or law enforcement, and be trained and able to provide care anywhere from the first responder to the paramedic level. Further, depending on the historical influences on system design, these first responders could be dispatched on everything from no EMS requests for service to all of them.
There should exist in the EMS system a careful balance of the type of ambulance response (ALS or BLS), rapidity of response (lights/sirens or not), and necessity of first response. The facilitation of such balance is often the job of the system's medical director and is best determined based on patient outcome data from that system being weighed with the contractual obligations (if any) of the system and tempered by the inherent risks of over- and underresponse.
TRANSPORT DECISION MAKING
Once on scene, there are generally four possible outcomes. In most systems, anywhere between 20% and 30% of EMS calls result in no transport: Being cancelled on scene or prior to arrival; finding the patient dead on arrival or electing to terminate resuscitative efforts prior to transport; and having the patient refuse transport and/or treatment are the outcomes expected, resulting in no transport. For the majority of requests for service, however, the patient is transported to a destination to provide additional care. Most often, this destination is a local emergency department and that selection is often based on geography, patient preference, and continuity of care.7 In an ever-increasing number of circumstances, local protocol may dictate transport to a specialty care destination. Often emergency departments, these specialty care centers are able to provide advanced care in trauma, burn, stroke, pediatric, cardiac care, or other specialized disciplines. In some communities, the option exists to transport the patient to an alternative care site such as an urgent care center or community health clinic. Although an important destination for EMS during disasters, these alternative care sites are unique opportunities to create a parallel care track in the decidedly serial nature of the EMS system to move patients more efficiently through the health care system. There are challenges to this approach and a more detailed discussion can be found in Chapter 11.
TRANSPORT OUT OF A HOSPITAL
Once at the destination, most commonly an emergency department, there are generally three outcomes. In some cases, the patient may be transferred from that ED to another hospital for specialty care or because of bed availability. Both of these outcomes may affect the EMS system as transfers almost universally result in the use of EMS resources, and in some cases, specialized resources and/or teams. If admitted to the hospital and subsequently discharged, this may be to home, a rehabilitation facility, or a long-term care facility. The latter two may also impact the EMS system as these patients are often transported by EMS due to their continued health care needs and/or inability to safely ambulate or transfer.
EMS system design must take into consideration not only the emergency requests for service, but also the nonemergency and interfacility transport requests. Efficiently utilizing limited and often costly resources in a linear and flow-constricted system is the challenge of EMS system managers, and the role of the EMS physician to ensure the system meets its primary mission of patient care should not be underestimated.
THE COMPONENTS OF AN EMS SYSTEM
Prior to 1973, the components of an EMS system were as varied as the EMS systems themselves and consisted of transportation, not necessarily treatment. When published in 1966, Accidental Death and Disability: The Neglected Disease of Modern Society began focusing on the inadequacies of emergency care in general, and prehospital care in particular.8 In great part prompted by Accidental Death and Disability, and a demonstration project by the newly established Robert Wood Johnson Program, in 1973 Congress passed and President Nixon signed the EMS Systems Act.9
The Act called for a lead agency under the Department of Health, Education, and Welfare and identified 15 components to assist planners with the design of EMS systems stimulated by federal funding from this Act to over 300 regions nationwide. The original 15 components of the EMS Systems Act are included in Table 12-1 and notably lack concepts such as medical direction, financing, performance expectations, or a legal framework within which to operate.9 Although established to promote regionalization, the Act set into motion dozens of differently structured EMS systems that facilitated isolation, without planting the important seed of establishing initiatives to continually fund EMS at the local, regional, or even federal level.
EMS Systems Act Components of System Design9
||Download (.pdf) TABLE 12-1
EMS Systems Act Components of System Design9
|Ensure adequate personnel |
|Establish recruitment, initial training, and continuing education programs |
|Ensure centralized communication |
|Ensure adequate transportation vehicles (air, water, and land) |
|Establish facilities that can continuously operate in coordination with each other and do not duplicate |
|Provide access to specialized critical medical care units |
|Provide for effective utilization of public safety agencies |
|Allow for community participation |
|Provide emergency care without prior inquiry as to ability to pay |
|Provide for transfer of patients to appropriate follow-up and rehabilitation care |
|Provide for standard record keeping |
|Provide public education programs |
|Provide for periodic, comprehensive, and independent review and evaluation |
|Ensure care provision during mass casualties or disasters |
|Provide for reciprocal services (mutual aid) |
The EMS Systems Act did not put the patient at the center of the system, nor did it promote the importance of clinical care as the primary driver of system design. In essence, the Act merely promulgated the pre-1973 concept that EMS systems were merely specialized transportation systems. By the early 1990s, greater interest in the clinical care of patients led to the 1996 National Highway Transportation Administration's release of the EMS Agenda for the Future.5 This document made an important contribution by outlining the following 14 essential components that form the basis for current system design10:
Integration of health care service: As a component of the health care system, the care interaction with EMS should not occur in isolation and should be integrated with other community health resources within the health care system.
EMS research: Research is essential to improve care and allocate resources by determining the efficacy, effectiveness, and efficiency of prehospital care.
Legislation and regulation: Affecting EMS funding, system design, provider credentialing and scope of practice, enabling legislation and its associated regulations significantly affect how all aspects of prehospital care are provided.
System finance: In order to continuously provide essential public safety services, EMS systems, whether public or private, must be financially viable and built upon a strong financial foundation.
Human resources: The most valuable asset to EMS patients, the human resource, must be composed of a dedicated team with complementary skills and expertise that provide qualified, competent, and compassionate care.
Medical direction: Involving the delegation of authority and acceptance of responsibility, medical direction ensures the standards of medical practice are upheld to ensure optimal care for patients.
Education systems: To meet the evolving standard of care, EMS education systems must meet the cognitive, psychomotor, and technological needs of new and seasoned EMS professionals.
Public education: The EMS system has a responsibility to foster health promotion.
Prevention: The EMS system has a responsibility to promote prevention activities that reduce human morbidity and mortality.
Public access: Prompt and appropriate EMS care must be provided regardless of socioeconomic status, age, or special need.
Communications: Robust systems that allow accurate and timely transfer of information are essential to system success.
Clinical care: Mobility and immediate availability to the entire population distinguishes EMS in its ability to provide medical care to those with perceived need and provide transport to, from, and between health care facilities.
Information systems: Collecting, transmitting, and analyzing valid, reliable, and accurate data are essential to system improvement and integration within the health care system.
Evaluation: System and continuous evaluation is essential to assess the quality of system performance and identify strategies for improvement.
Although system design should take into account the 14 aforementioned components, system performance can, and should, be measured frequently by a variety of different metrics. Early proponents of measuring system performance as a means of optimizing system design included Jack Stout, who was long involved in designing and implementing EMS systems and as early as 1983 promulgated his “10 Standards of Excellence” (Table 12-2), which closely mirror the NHTSA components published 13 years later.11 Stout's “standards” have been replaced in the last decade with accreditation which is often used as a means to measure a system's performance against a set of standards, many of which have a basis derived from the goals and expectations of the Agenda for the Future. The Commission on Accreditation of Ambulance Services (CAAS), the Commission on Accreditation of Medical Transport Systems (CAMTS), and the Joint Commission International (JCI) are all well-established accreditation entities. CAAS is more widely known in the ambulance industry and provides a comprehensive set of standards designed to promote quality patient care.12 CAMTS concentrates on patient care and provider safety and primarily accredits air medical services and ground interfacility services.13 The JCI provide criteria used by international health care organizations to measure performance against a set of expectations and patient care benchmarks.14 Other accreditation entities include the National Academies of Emergency Medical Dispatch which offer accreditation for Emergency Medical Dispatch Programs,15 and the Commission on Fire Service Accreditation International for fire-based EMS operations.16 Although accreditation is a means to accomplish the introspection of system analysis, it is clear that every aspect of the EMS system should be regularly reviewed and measured against the agency's goals. This allows shortfalls to be addressed and either patient outcome or system efficiency to be enhanced.
Jack Stout's 10 Standards of Excellence
||Download (.pdf) TABLE 12-2
Jack Stout's 10 Standards of Excellence
|Clinical performance |
|Medical accountability |
|Dispatching and system status management |
|Access, first responder, and citizen CPR |
|Disaster capability |
|Personnel management practices |
|Stability, reliability, and fail-safes |
|Pricing policies, billing, and collection practices |
|Response time performance |
|Public accountability |
The types of EMS systems are as numerous as the systems themselves. Since current system design evolved from the political, historical, and funding influences of the 1960s and 1970s, they offer varying clinical sophistication provided by a myriad of organizational structures. The following are the more common EMS system designs found in the United States:
Volunteer systems, despite the decline in volunteerism, still provide a significant source of EMS in primarily suburban and rural communities. Challenges include volunteer recruitment and retention; limited funding streams whether from local taxes, fund-raising, or billing for services; and assembling highly qualified staff that can maintain the ever-increasing training requirements and be able to meet the demand for services during peak times, often during the day. Most agencies provide only 9-1-1 service and rarely provide interfacility or scheduled service. Many volunteer agencies have moved to supplemental paid staffing to meet call demand, and there tends to be greater dependence on mutual aid in volunteer systems. Due to the intensive training requirements for ALS providers, it is becoming increasingly rare to find volunteer paramedics and thus meet the local demand for ALS services, often requiring another agency or paid staff to provide ALS.
The number of fire-based EMS systems continues to increase and there may be some benefits seen in optimizing the first response and transport roles when organized in such a structure. Funded primarily from local government, many fire departments are also able to bill for service, providing a rare source of income to a public safety entity. However, legislative and/or regulatory restrictions, such as those found in New York, prohibit most fire departments from billing for services, thus providing an example of how state legislation can significantly affect system design. Similar to volunteer systems, fire-based EMS often provides only 9-1-1 service and rarely provides interfacility or scheduled service.
Despite being one of the first providers of EMS in the United States in as early as the 1860s, hospital-based providers are not nearly as common as in the past. Such systems are often able to allow prehospital personnel to work in the hospital setting, providing outstanding opportunities to maintain skill sets, particularly with regard to interfacility transfers with critical patients. Some of these systems provide only interfacility transports, others also provide 9-1-1 service. Similar to fire-based EMS, legislative and/or regulatory restrictions in some states either foster or discourage hospital-based EMS systems.
Private EMS companies, whether for-profit or not-for-profit, often operate under a contract with a municipality to provide 9-1-1 services. Many also provide interfacility and nonemergency transport services and first response is typically delegated to the fire department. Private companies will bill the patient or third party for the majority of their revenue. In some cases, these agencies may receive a subsidy from the municipality, or the municipality is paid (a so-called franchise fee) for the right of sole proprietor following a public bid process. More commonly contractual obligations are built into the service agreement between the private company and the municipality to encourage a predefined performance level. These are often penalty based and result in fines paid back to the municipality if certain performance standards (response time, call coverage, clinical performance measures, etc) are not met.
The third-service model is whereby EMS is provided by a governmental department or authority much like law enforcement or fire service is provided. There are multiple variations based on the deployment model (fixed “station” versus system-status management), funding (tax subsidies, billing for service, and combinations of the two), ability to provide first-response capabilities, and ability to provide interfacility transports.
PUBLIC UTILITY AND FRANCHISE
In this model, an EMS agency or authority is overseen by a board of directors and often independent medical oversight. This group establishes the expectations of service delivery, from response time to clinical performance and then contracts with a private company. In the public utility model, the agency or authority owns all assets, determines billing rates and collects revenue, and pays the contractor a set fee. The contractor is then responsible for managing the system to meet the performance standards for the lowest cost in order to realize a profit. The franchise model allows the contractor to collect revenue, but the agency or authority has specific controls over the contractor's assets.
SYSTEM PERFORMANCE CONSIDERATIONS
All of the system types mentioned must manage limited resources in order to provide quality clinical care at the lowest possible cost. A number of techniques are used to accomplish this, and although a complete understanding of system design and performance is beyond the scope of this chapter, the following terms and concepts may be useful for the EMS physician.
The response time reliability (RTR) is a key metric in most systems. RTR may be parsed by geographic area, BLS vs ALS, dispatch priority, etc, and is measured most often in fractiles and not means, often at the 90th fractile. For example, a contract may state that City X is divided into eight geographic zones and each zone must maintain an RTR of 8:59 or less, 90% of the time. Failure to do so may result in fines which are designed to enforce the RTR of the contractor. These fines must be large enough to make it more cost effective to cover the 90th fractile than simply not staffing, and therefore, not meeting the contractual (or community) expectation of service delivery.
In order to meet the RTR, the EMS agency will often need to maximize the efficiency of their EMS units by deploying the number of units required to meet the historical demand, and positioning (and repositioning) them to minimize the response time. Systems generally position their resources in two ways: Static deployment is most often seen in fire-based and volunteer EMS systems whereby an ambulance is located in a station and responds to calls in its primary response area. When the call is completed, it returns to that station but during the time it is not available, that response area remains “uncovered” and requires the use of another resource either from the same agency located at a different station or a different agency (mutual aid) to cover the request in the response area. This leads to often lengthier response times. System status management (SSM) is a technique whereby units are generally not statically deployed but rather are actively moved around the service area based on their use, traffic patterns, and other factors in order to minimize response time in the service area and therefore maximize RTR performance.
The unit hour (UH) and unit hour utilization ratio (UH/U) are two additional key metrics in most systems. The UH is simply 1 hour of a staffed, available ambulance. Thus, an agency that staffs one unit, 24 hours a day, has 24 UHs per day or 154 UHs per week. The UH/U is a fraction of the amount of time a unit (ambulance) is loaded with a patient and being used to generate revenue divided by the number of UHs. A UH/U of 1.0 would mean that the unit is always “loaded” with a patient and therefore doing “work” or generating revenue. The lower the UH/U, the less efficient a system is; thus, a UH/U of 0.1 means that the available units are only generating revenue 10% of the time. This may be allowable in a rural system that must maintain service availability despite a low call volume, but may not be realistic for an urban system with short transport times and large volume. The challenge of system designers and administrators is to maximize the UH/U, while meeting the RTR of the community (or of the contract). Thus, although it is possible to have an RTR in a large city of 3:59, 90% of the time, the number of UHs required to meet that are financially unsustainable.
To maximize UH/U while achieving the call coverage expected of the community, many systems will perform a demand analysis to temporally identify where the demand lies. This can be as simple as graphing the number of calls for each hour of the day for each day of the week. This allows the administrator to add UHs when the demand is there (days and perhaps early evenings) and decrease the UHs during lower demand (overnights, perhaps weekends). Adding or removing UHs requires adjustments in staffing, and subsequently a “peak-load staffing plan” may be developed to staff the units during the hours they are needed as personnel costs are the largest expense for nearly all systems. The process of performing a demand analysis to determine UHs and system status plan necessary to meet the RTR of the system, and developing a peak-load staffing plan to meet the UH needs, then optimizes the UH/U which ultimately results in a more efficient and financially viable system, irrespective of the system type.
EXTERNAL EFFECTS ON SYSTEM DESIGN
There are a number of factors independent of the type of EMS system that affects how EMS is provided within the system. The most obvious is geography. Urban areas typically have a large enough call volume and demand for services, that many different service delivery models can exist, most often fire-based, private, or public utility/franchise models. Urban environments more often than not have response time performance expectations in the case of an external contractor that provides such service. Challenges faced within these systems include the sheer volume of calls in a relatively small geographic area resulting in rapid call turnover, the violence and safety risks inherent to some urban environments, and thus, the physical and emotional fatigue placed on the EMS provider. This can result in high employee turnover which can limit the clinical experience of the workforce. This urban environment also offers challenges and great opportunities in the realm of public health interventions (eg Public Access Defibrillation programs, community CPR training, car seat checks, bicycle safety), as well as disaster preparedness for all types of chemical, biological, radiological, nuclear, and explosive hazards. This may mean additional opportunities for the EMS system to engage in specialty teams such as tactical, urban search and rescue, and other special operations disciplines.
Rural areas have unique challenges as well. Although the 9-1-1 system reaches more than 98% of the US population, it is disproportionately absent in rural settings, making access more difficult.17 Further, the robust communications infrastructure taken for granted in the urban and suburban setting may limit the coordination and use of resources common in other settings. The robust first-response systems found in most urban and suburban areas are often lacking, simply because of the extremely sparse population, making response time performance measures that are standard in the urban and suburban environment impossible in the rural areas. Due to the lower volume over a higher area, the challenges of skills retention and ensuring adequate clinical experience place higher reliance on continuing education which, although facilitated by distance learning technology, may not meet the needs of the provider. Often critically ill patients must be transported significant distances and perhaps even further if requiring specialty care not available at a local or critical access hospital. Funding such rural systems often requires significant tax subsidy to offset a lower call volume and payer mix. Rural areas are disproportionately served by volunteer agencies, thus the challenges of the volunteer agency type add to those caused by geography. There is generally an increase in use of air medical transport services, which may in fact be the primary source of ALS in the rural and wilderness community. Aside from system design, many of these factors also require the EMS medical director to adjust scope of practice or medical protocols to account for the unique nature of the rural or wilderness environment.
Irrespective of the geography, there are other external factors that may affect system design, its performance, and its administrative and medical oversight. The most obvious is the often state-specific enabling legislation that may limit the operating territory and type of ambulance service, require determination of public need through a certificate of need process in order to operate, define the levels of care provided or minimum equipment required, or establish state-wide or regional standards of medical care. Elected officials such as mayors, city councils, and county/parish executives may affect system design through influences on contracts for ambulance services. In some cases, business and industry may have direct influences on system design (eg, a large industrial facility having its own fire and ambulance service), or may influence indirectly by promoting the use of certain products or equipment that may or may not have medical evidence to support their use but are often associated with increased cost (eg, disposable medical equipment or patient carrying equipment). In some cases, health care facilities can have significant influence on the system. The most obvious are those systems that are hospital based, but more subtle influences may exist through interfacility contract agreements or other service contracts.
In some cases, community groups may exert pressure on elected officials to advocate for a certain delivery system or more likely the expectations of that system. For example, with the right subsidy, almost any jurisdiction can achieve an ALS response on every request for service in less than 5 minutes from the time of call. Most communities do not wish to provide the (very large) subsidy required to meet the aforementioned response time requirement, even if there is little evidence to support ALS on every EMS call and a 5-minute response time to every request for service. Community expectations, such as response time, tax levies, services provided, etc, can have significant influences on the type of system. Further, patient advocacy groups may not directly influence system design, but they may influence the scope of practice within that system. For example, a patient advocacy group may lobby the local, regional, or state EMS oversight bodies to add a certain medication or training to the scope of practice. In some cases, that may represent a minuscule number of EMS contacts per year, and so the balance of medication cost and rotation, along with training, may not be cost-effective in every system.
Although most EMS systems are designed to accommodate the majority of the demand for service, no system can afford the excess capacity in order to meet every request for service, all of the time, particularly in circumstances of excess demand due to mass casualty incident or epidemic. Mutual aid is an important component of any system design, and its reliance to ensure uninterrupted service varies, often due to system type (eg, generally more often utilized in volunteer systems than commercial ones), and may be an infrequent occurrence or a daily one. Often defined in enabling legislation or intermunicipal agreement, mutual aid has three essential components: they are formal agreements; the resources are coming from “outside” the system; and they are reciprocal. One of the earliest definitions of mutual aid can be found in the EMS Systems Act whereby mutual aid is defined as an agreement that provides “for the establishment of appropriate arrangements with emergency medical services (EMS) systems or similar entities serving neighboring areas for the provision of EMS on a reciprocal basis where access to such services would be more appropriate and effective in terms of the services available, time, and distance.” Although it is essential that every system has a process for sending and receiving mutual aid, the frequency of use may be indicative of the challenges faced by the system itself.
ADMINISTRATIVE OVERSIGHT OF EMS SYSTEMS
EMS systems generally have two different types of oversight: administrative and medical. At the state level, there is typically a lead agency such as a State EMS Office or Bureau of EMS that has administrative oversight of the state EMS system. In most states, this lead agency is under the State Department of Health, while the remainder often houses it in a State Department of Homeland Security, Department of Public Safety, Department of Transportation, or as a stand-alone department. The lead agency is often managed by a state EMS director who provides administrative direction for the lead agency and is often a nonphysician. Approximately a third of states have a regulatory board, while two-thirds have an advisory board that work in concert with the state EMS director. The roles and responsibilities of the lead agency vary tremendously in role and function as a result of the empowering legislation. Generally the lead agency will have a regulatory role, a leadership role, and a facilitator role.
The regulatory role may include establishing minimum standards for training and equipment carried by EMS personnel and processing, verifying, and awarding certification or licensure to EMS providers, agencies, or vehicles. The lead agency may establish regional or local oversight and may also designate EMS receiving facilities such as emergency departments, alternative destinations, or specialty care such as stroke, cardiac, or trauma centers.18
The leadership role may include providing model policies, procedures, or protocols to EMS services within the state, or facilitating the creation of those through advisory boards or medical oversight boards. The state has an important leadership role in system planning, particularly with regard to disaster and public health preparedness, as well as communications infrastructures. Injury prevention and emergency medical services for children programs are often administered by the lead state agency. Lastly, the state often serves as a main repository for data collection and tracking and in some cases, defines how that data will be collected and processed, or provides the very system that is used for field data entry.
Equally important to the regulatory and leadership roles, the state has an important facilitator role with other state departments, such as Fire, Homeland Security, Health, Narcotics Enforcement, and so on, which have important effects on how the EMS system in the state is able to practice—particularly with regard to scope of practice and enabling legislation. The state agency is also vital for facilitating the state mutual aid plan and interacting with the state emergency management office as well as ensuring strong working relationships with neighboring states.
Based largely from the EMS Systems Act of 1973, many states have some form of regional administrative oversight that work in concert with the lead state agency. Generally, the use of a regional structure is authorized by the empowering legislation for the EMS system. These regional oversight bodies may be defined by hospital catchment area, political jurisdiction (county or legislative boundaries) or be completely arbitrary. Generally composed of regional “councils” or “coordinating entities,” they may be appointed by the governor, state EMS director, or defined for autonomous appointment by the enabling legislation. These regional councils often advise lead EMS agencies on policy direction and act as EMS advocates. Depending on the state, these bodies may establish standards or coordinate care by recruiting and credentialing providers, providing training, establishing operating authority for EMS agencies, establishing protocols and policies for patient care, and providing for regional quality assurance programs.
Local administrative oversight is generally limited to county or municipality issues. This typically relates to any local ordinances that regulate the provision of emergency services. In those jurisdictions with private, public utility, or franchise model EMS systems, the local administrative oversight may be significant in the form of developing performance standards, awarding contracts, and ensuring contract performance. The local administrative oversight often coordinates inter- and intracounty (or parish) mutual aid as well as coordinating with the State Department of Health or Emergency Management during disaster declarations. Local communications systems to include both radio and data communications, as well as public safety answering points, may fall under local administrative oversight as well.
MEDICAL OVERSIGHT OF EMS SYSTEMS
Similar to the administrative oversight of EMS systems, medical oversight may have state, regional, and agency levels. At the state level, the state medical director may be the same position as the state EMS director, may be the chair of an advisory or regulatory council, or may be a separate position entirely. The responsibility of the state medical director often includes overall state level medical supervision particularly with regard to protocol development and scope of practice consideration. The state EMS medical director often has an important liaison role with medical professional organizations and regional/local medical directors. A joint position statement on the role of state EMS medical directors from NAEMSP and ACEP is an important resource and reference document.19
A regional medical director may establish and uphold/oversee standards, if delegated from the state. This may include the regional credentialing of providers, the training of those providers, the creation of protocols and policies, and most often the regional quality assurance program. The responsibilities and authority of the regional medical director most often are codified in the enabling legislation and regulation.
The agency medical director is responsible for the clinical care provided by the EMS service and establishes and oversees internal, or agency-specific medical policies, provider credentialing, and quality assurance at a minimum. Section 2 in this text provides a more thorough overview of medical oversight, but it is important to recognize that in most states there are at least two, if not more levels of medical oversight and the responsibilities of each may be different, but equally important in ensuring strong clinical care. An important resource for all EMS physicians is the joint NAEMSP and ACEP position statement on the role of an agency EMS medical director which outlines the many roles the medical director may have depending on the type of system.20
At the state, regional, or local level, medical oversight committees may work with, or in place of, appointed medical directors to facilitate the medical oversight of the EMS system. These committees or councils are often composed of physicians representing various constituents and users of EMS. For example, a local or regional medical oversight committee may be composed of physicians from the local hospitals, whereas a state medical oversight committee may be composed of physicians from various regions around the state. The powers of such a body are often defined in enabling legislation and may include approving protocols, identifying the scope of practice, or defining the education requirements of EMS providers. In many cases, these committees or councils ensure appropriate checks and balances in the oversight of such EMS systems to ensure that the needs of the community are met.
The design, administration, and medical oversight of an EMS system are complex and rooted in the history of the EMS system. It is important that the EMS physician familiarize themselves with the different system designs, challenges, and opportunities that each provide, as well as review the enabling legislation, administrative, and medical oversight that is unique to each state to understand the many roles for EMS physicians and how to ensure that the system is meeting its intent to provide high-quality, evidence-based medical care and transportation.
Patient flow within the EMS system is generally linear with key inputs and outputs which affect system design and efficiency.
The EMS Agenda for the Future identified 14 essential components that form the basis for current EMS system design.
The types of EMS systems are as numerous as the systems themselves and generally include volunteer, fire-based, hospital-based, private, third-service, public utility, and franchise systems.
A basic EMS system performance characteristic is response time reliability, which can be optimized by utilizing system status management along with peak load staffing plans to efficiently deploy the unit hours needed to achieve performance goals.
The EMS system can be affected by a number of factors including geography, enabling legislation, elected officials, and consumer groups.
Mutual aid is an important component of system designs and its reliance to ensure uninterrupted service varies often due to system type.
Administrative oversight of EMS systems may be provided by a director and councils or committees and include regulatory, leadership, and facilitator roles.
Medical oversight of EMS systems often has layers at the state, regional, and local levels and may be provided by a single physician working with a medical oversight committee or council.
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et al. Characteristics and outcome among patients who dial for the EMS due to chest pain. Int J Cardiol. October 20, 2014;176(3):859–865.
et al. Changes to DA-CPR instructions: can we reduce time to first compression and improve quality of bystander CPR? Resuscitation.
et al. Comparison of Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD) relating to cardiac arrest calls. Resuscitation.
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DA. How well do General EMS 911 dispatch protocols predict ED resource utilization for pediatric patients? Am J Emerg Med.
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