Paramedic Care: Principles & Practice Volume 1 Introduction to Advanced Prehospital Care

Chapter 3 EMS Systems

Topics
History of EMS Todays EMS Systems

Introduction
An EMS system is a comprehensive network of personnel, equipment, and resources established to deliver aid and emergency medical care to the community.

Components of an EMS System

Out-of-Hospital Elements
Members of the community EMS providers Communication system Public utilities Fire, rescue, hazmat Poison control centers

Components of an EMS System

In-Hospital Elements
Emergency nurses Emergency and specialty physicians Ancillary services Rehabilitative services

Types of EMS Response

Basic Life Support Advanced Life Support Tiered Response

History of EMS

History of EMS
Ancient times
A good Samaritan provided care to a wounded traveler by the side of a road o Ancient tablets provided healers with step-bystep instructions for patient care o Code of Hammurabi
o

 One particular section of the code was devoted to the regulation of medical fees and penalties

History of EMS
18th and 19th Century
o

Napoleonic Wars
 First efforts of field care developed. Triage, a method of sorting patients by severity, developed.

U.S. Civil War

 Triage and transport of wounded soldiers  Improvised hospitals in houses, barns, and churches

First civilian ambulance service

 Cincinnati, Ohio (1865)  New York City Health Department Ambulance Service (1869)

History of EMS
20th Century
o

World War II
 Transportation to appropriate facilities  Battlefield ambulances

Vietnam and Korean conflicts

 Soldiers treated in battlefield  Evacuation by helicopter

Until the late 1960s, few areas of the United States provided adequate civilian prehospital emergency care.

History of EMS
Post-1960s Developments
Mortician-operated ambulances withdrew due to costs and demand for additional services. o Fire and police departments began providing EMS. o There was growth of volunteer and independent local EMS provider agencies.
o

History of EMS
In 1966, the publication of Accidental Death and Disability: The Neglected Disease of Modern Society addressed EMS
o

Highlighted deficiencies in prehospital emergency care o Set guidelines for development of EMS systems, training, ambulances, equipment

Federal and Private Initiatives

1966-National Highway Safety Act
o

Established the U.S. Department of Transportation (DOT) o Provided matching grants to states for emergency medical services o Funds were also provided for the development of educational programs
 In 1969 the EMTA program developed  First paramedic curriculum followed in 1977

Federal and Private Initiatives

1971
o

White House issued $9 million in EMS grants for EMS demonstration projects o Designed to be models for subsequent system development The Department of Health, Education, and Welfare funded a $16 million five-state initiative for the development of regional EMS systems

1972
o

Federal and Private Initiatives

EMS Systems Act of 1973
Provided funding for a series of trauma projects $300 million allocated to study EMS planning, operations, expansion, and research o Amended in 1976 and 1979 to continue funding for regional EMS systems
o o

Federal and Private Initiatives

Two Items the Legislation Omitted:
o

System finance
 Federal funding was significantly reduced in the early 1980s

Medical direction
 Many services were operating without medical direction

Federal and Private Initiatives

1981
o

The Consolidated Omnibus Budget Reconciliation Act (COBRA) wiped out federal EMS funding
 Funding that remained was placed into state preventivehealth and health-services block grants

The National Highway Traffic Safety Administration (NHTSA) attempted to sustain the efforts

Federal and Private Initiatives

1988
o

Statewide EMS Technical Assessment Program was established

 Defines elements necessary to all EMS systems

Statewide EMS Technical Assessment Program

Elements necessary for an EMS System
Regulation Resources management Human resources/training Transportation Facilities Communications Trauma systems Public information Medical direction Evaluation

Federal and Private Initiatives

EMS Agenda for the Future
Published in 1996 as a comprehensive evaluation of the history of EMS o Focuses on aspects of EMS related to emergency care outside of traditional health care facilities o Casts a vision for the future of EMS in the United States
o

Federal and Private Initiatives

2005
o

The National EMS Scope of Practice Model

 Supports a system of EMS personnel licensure  A guide for States in developing their Scope of Practice legislation, rules, and regulation  Will increase the consistency of the nomenclature and competencies of EMS personnel nationwide

History of EMS
21st Century EMS
o

The terrorist attacks on the World Trade Center in New York City and the Pentagon on September 11, 2001 forever changed EMS and the world
Reuters/Corbis

History of EMS
21st Century EMS (cont.)
o

Attacks pointed out the problems and inefficiencies with the United States emergency response system
 Fragmented and uncoordinated oversight of emergency response

2006
o

National Academies of Science

 Emergency Medical Services: At the Crossroads

Emergency Medical Services: At the Crossroads

Study found that there were significant problems at the federal, state, and local level
o

Government leadership in emergency care is fragmented and inconsistent

Hospital-based emergency and trauma care is scattered across multiple agencies and departments

Other Identified Problems

Insufficient coordination Coordination of transport within regions is limited Disparities in response times Uncertain quality of care Lack of readiness for disasters Divided professional identity Limited evidence base

Todays EMS Systems

Todays EMS Systems

Every EMS system must develop a system that best meets its needs. Certain elements are essential to ensure the best possible patient care.

Todays EMS Systems

Local and State-Level Agencies
o

The first step in developing a comprehensive EMS system is to establish an administrative agency.
 Manages the local systems resources, develops operational protocols, and establishes standards and guidelines

The agency designates who may function within the system and develops policies consistent with existing state requirements.

Todays EMS Systems

Medical Direction
o

The Medical Director is a physician who is legally responsible for all clinical and patient-care aspects of the system.

Ken Kerr

Medical Direction
Role of the Medical Director
o o o o o o o o

Educate and train personnel Participate in equipment and personnel selection Develop clinical protocols Participate in problem resolution and quality improvement Provide direct input into patient care Interface with the EMS system Advocate within the medical community Serve as the medical conscience of the EMS system

Medical Direction
On-line Medical Direction
A qualified physician gives direct orders to a prehospital care provider o May be delegated to qualified personnel
o

 Mobile intensive care nurse (MICN), a physician assistant (PA), or a paramedic

Medical Direction
Off-Line Medical Direction
o

Policies, procedures, and practices that a system physician has set up in advance
 Prospective  Retrospective

Use of Protocols

Public Education
An essential and often overlooked component of EMS is the public. Educate the public
o o o

Recognizing an emergency Accessing the system Initiating BLS procedures

Public involvement may include bystander defibrillation.

Communications
A coordinated, flexible communications plan should include:
o o o o o o

Citizen access Single control center Operation communication capabilities Medical communication capabilities Communications hardware Communications software

Emergency Medical Dispatcher (EMD)

The activities of an EMD are crucial to the efficient operation of EMS. EMDs must be medically and technically trained.

EMS Dispatch
The means of assigning and directing appropriate medical care to patients
o

Includes interrogation protocols, response configurations, system status management, and prearrival caller instructions

An effective EMS dispatching system places the first responding units on scene within 4 minutes.

Education and Certification

Two kinds of EMS education are initial and continuing education.
Initial education is the original training course for prehospital providers. o Continuing education programs include refresher courses for recertification and periodic in-service training sessions.
o

Initial Education
Based on the EMT-Paramedic: National Standard Curriculum published by the U.S. DOT
o o

Establishes the minimum content for the course Divided into 3 specific learning domains
 Cognitive  Affective  Psychomotor

Education and Certification

Certification
o

The process by which an agency grants recognition to an individual who has met its qualifications The process of occupational regulation

Licensure
o o

Registration Reciprocity
o

Is entering your name and essential information within a particular record

An agency grants automatic certification or licensure to an individual who has comparable certification or licensure from another agency

Certification Levels
First Responder Emergency Medical Technician-Basic Emergency Medical Technician-Intermediate Emergency Medical Technician-Paramedic

First Responder
The First Responder is usually the first EMS-trained provider to arrive on the scene. Emergency Medical Responder (EMR)

Emergency Medical Technician-Basic

The EMT-Basic is trained to do all that a First Responder can do, plus other complex skills.

Emergency Medical Technician- Intermediate

The EMT-I should possess all the skills of an EMT-B and be competent in advanced airway, IV therapy, and other skills. Advanced EMT (AEMT)

Emergency Medical Technician- Paramedic

The EMT-P is the most advanced EMS provider.

Expanding Roles
Critical care transport
o

Paramedics manage complicated interhospital transports Used to staff construction sites, oil rigs, and other facilities Accompany specially trained law enforcement officers on tactical operations Triaging and directing patients to the proper nonhospital facilities

Industrial or occupational EMS

o

Tactical EMS
o

Primary care
o

National Registry of EMTs (NREMT)

Prepares and administers standardized tests for EMS responders Establishes the qualifications for registration and re-registration, and establishing a minimal standard of competency Serves as a major tool for reciprocity by providing a process for EMTs

Professional Organizations
Belonging to a professional organization is a good way to keep informed about the latest technology. Organizations assist in the development of educational programs, operational policies and procedures, and the implementation of EMS.

Professional Organizations Include:

National Association of EMTs National Association of Search and Rescue National Association of State EMS Directors National Association of EMS Physicians National Flight Paramedics Association National Council of State EMS Training Coordinators

Professional Journals
A variety of journals are available Journals provide an abundant source of continuing-education material

These Professional Journals Include:

Annals of Emergency Medicine Emergency Medical Services Prehospital Emergency Care Journal of Emergency Medical Services Journal of Emergency Medicine

Patient Transportation
In general, patients should be taken to the nearest facility whenever possible. Medical direction should designate the facility
o

Based on patient need and availability of resources

Patients may be transported by ground or air.

Patient Transportation
All transport vehicles must be licensed and meet local and state EMS requirements. Regional standardization of equipment and supplies is most effective in facilitating interagency efforts during disaster operations.

Patient Transportation
The helicopter has become an integral part of prehospital care. Trauma care systems use law enforcement, municipal, hospitalbased, private, and military helicopter transport services.

Patient Transportation
KKK-A-1822 Federal Specifications for Ambulances were developed in 1974. It identified 3 types of standardized ambulances. Revisions in the standards have improved overall features.

Type I Ambulance
Conventional cab and chassis on which a module ambulance body is mounted, with no passageway between the drivers and patients compartments

Jeff Forster

Type II Ambulance
A standard van, body, and cab form an integral unit

Jeff Forster

Type III Ambulance

A specialty van with forward cab and integral body. It has a passageway from the drivers compartment to the patients compartment
Jeff Forster

Receiving Facilities
Hospitals are placed into categories that identify their readiness and capability. All receiving facilities should have the following capabilities:
o

Emergency department with an emergency physician on duty, surgical facilities, a lab and blood bank, x-ray capabilities, and critical and intensive care units

Receiving Facilities
Emergency facilities should have:
A documented commitment to participate in the EMS system o A willingness to receive all emergency patients in transport o Medical audit procedures to ensure quality care and medical accountability
o

Mutual Aid and Mass Casualty Preparation

A formalized mutual aid agreement ensures that help is available when needed. Agreements should be between neighboring departments, municipalities, systems, or states. Each system should also put a disaster plan in place for catastrophes that can overwhelm available resources.

Quality Assurance and Improvement

The only acceptable quality is excellence. Quality assurance and improvement programs must be dynamic and comprehensive.

Quality Assurance and Improvement

Quality Assurance is designed to maintain continuous monitoring and measurement of the quality of clinical care.
o

A problem with QA programs is that they tend to identify only the problems and therefore focus only on punitive corrective action.

Quality Assurance and Improvement

Continuous Quality Improvement (CQI) is designed to refine and improve an EMS system, emphasizing customer satisfaction.
o

Evaluations of such aspects as billing and maintenance

CQI focuses on recognizing, rewarding, and reinforcing good performance.

Research
A formal, ongoing research program is an essential component of the EMS system. An area that will rely heavily on research is funding.
o

Managed care will force EMS systems to scientifically validate their effectiveness and necessity.

Research
EMS research must address the following issues:
Which prehospital interventions actually reduce morbidity and mortality? o Are the benefits of certain field procedures worth the potential risks? o What is the cost-benefit ratio of sophisticated prehospital equipment and procedures? o Is field stabilization possible, or should paramedics begin immediate transport in every case?
o

Components of a Research Program

Identify a problem Identify the body of knowledge on the subject Select the best design for the study Begin the study and collect raw data

Components of a Research Program

Analyze and correlate your data in a statistical application Assess and evaluate the results against the original hypothesis or question Write a concise, comprehensive description of the study for publication in a medical journal

Evidence-Based Medicine (EBM)

Current standards accepted by physicians and other health care providers in clinical medicine Conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients Combines clinical expertise with the best available clinical evidence from systematic research

System Financing
EMS funding can come from a variety of sources. Fee-for-service from Medicare, Medicaid, private insurance companies, or private paying patients is common. Public Utility Models are becoming increasingly popular.

Summary
History of EMS Today's EMS Systems