EMS SYSTEM OVERVIEW
A review of the 15 elements of EMS systems identified by the EMS Sys
tems Act of 1973 provides insight into the structure of EMS
systems and the challenges they face.
MANPOWER
In most urban areas, paid public safety and ambulance personnel
provide prehospital care. In contrast, suburban, rural, or wilderness
EMS systems commonly use volunteers. Personnel fall into one of four
licensure levels in accordance with the National EMS Scope of Practice
Model, set forth by the National Highway Traffic Safety Administration.
These are emergency medical responder, emergency medical techni
cian, advanced emergency medical technician, and paramedic. Each
type of provider must master a minimum set of skills. Emergency medi
cal responders are often first on the scene of an emergency. They are
trained to perform CPR, spine immobilization, and hemorrhage control
and to use auto-injectors, automated external defibrillators, and other
basic interventions while awaiting an ambulance. Emergency medi
cal technicians function as part of an ambulance crew. Their training
includes oxygen administration, CPR, hemorrhage control, and patient
extrication, immobilization, and transportation. They assist patients
in using some of their own medications and can administer certain
over-the-counter medications. Advanced emergency medical technician
training includes additional assessment skills plus placement of IVs
and supraglottic airway devices and administration of some medica
tions. Paramedics have the highest skill level. Because of their advanced
level of training, paramedics function under a designated physician’s
supervision.6
TRAINING
Training includes initial provider training and continuing education. As
EMS call volume increases, providers often care for a disproportionate
number of patients with minor medical issues. Maintaining proficiency
in skills to manage critically ill patients may be difficult. Innovative
training methods to ensure skills retention must be sought. Use of com
puterized human patient simulators is one option, both for reviewing
skills and learning new ones.
COMMUNICATIONS
The adoption of 9-1-1 as a nationwide emergency number has greatly
facilitated public access to emergency care. In many systems, the local
public safety answering point has software that provides the number
and location of a caller (enhanced 9-1-1). Widespread use of cellular
telephones has prompted the development of technology to identify and
locate these callers as well, in accordance with Federal Communications
Commission regulations. Emergency call takers are trained to collect
necessary information, dispatch appropriate resources, and offer first aid
or prearrival instructions while the ambulance is en route. Ambulance
personnel should also be able to communicate with the destination hos
pital. Most EMS personnel operate under standing orders and protocols.
However, there are times when providers may require online medical
control, talking directly with a physician for direction.7 Historically,
communications represent the weakest link in disasters. It is important
that EMS communication systems have built-in redundancy to ensure
uninterrupted service.
TRANSPORTATION
Ambulance design must enable EMS personnel to provide care such
as airway and ventilatory support while transporting the patient
safely. Basic life support ambulances carry equipment appropriate for
personnel trained at the emergency medical technician level, such as
automated external defibrillators, oxygen, bag-mask ventilation devices,
immobilization and splinting devices, and wound dressings. They carry
few medications and cannot transport patients requiring IVs or car
diac monitoring. Advanced life support ambulances are equipped for
advanced emergency medical technicians or paramedics, including IV
fluids and medications, intubation equipment, cardiac monitors, and
pulse oximeters. Ground transportation is appropriate for the major
ity of patients, especially in urban and suburban areas. However, air
transport, generally by helicopter, should be considered for critically ill
patients when ground transport time would be long or if the terrain is
difficult to navigate.
FACILITIES AND CRITICAL CARE UNITS
Patients are often transported to the closest appropriate hospital. In
recent years, the number of specialty hospitals has increased, including
pediatric hospitals, trauma centers, burn centers, stroke centers, and
centers with advanced cardiac or resuscitation capabilities.8 Tertiary care
centers provide many of these services and may also have a large number
of critical care unit beds. The decision to bypass hospitals to go directly
to a specialty center, often at a greater distance, is not a simple one.
Although specialty hospitals often have more resources, transporting an
unstable patient past an ED to get to the specialty hospital is not without
risks. Furthermore, bypassing hospitals may have negative financial
consequences for bypassed facilities.1 It is wise to solicit input from the
local medical community before developing destination policies involv
ing specialty centers.
Due to ED overcrowding, even the largest hospitals may not always
have adequate resources to care for EMS patients. This may result in pro
longed offload times of ambulance patients, long wait times for patients
to be seen, and ED boarding of admitted patients. Furthermore, some
EDs may request EMS divert elsewhere.9 Because of these issues, regional
EMS systems should develop methods to monitor available resources
of their receiving hospitals. A secure, Internet-based website of hospital
resources, including ED and inpatient bed availability, is one option.
PUBLIC SAFETY AGENCIES
EMS systems should have strong ties with police and fire departments.
Many large EMS systems are run by fire departments. In addition
to providing scene security, public safety agencies can provide first
responder services because they are often first on the scene. Fire and
police automated external defibrillator programs are common.10,11 Police
administration of naloxone to opioid overdose victims is also a growing
trend.12 Such practices have been shown to improve patient outcomes.
Finally, EMS personnel often provide medical support to police and fire
departments in hazardous circumstances.
CONSUMER PARTICIPATION
Public support, both political and financial, is necessary for a good EMS
system. It is important that laypersons contribute to policymaking. One
way to accomplish this is to encourage representation of the public on
regional EMS councils. The public can also participate by volunteering
for local EMS agencies.
ACCESS TO CARE
Successful EMS systems ensure all individuals have access to care
regardless of ability to pay. The EMS system is often a patient’s primary
entry point into the healthcare system. There should be no barriers
preventing access. A more difficult problem exists when terrain or low
population densities result in longer response times for some citizens,
as in rural or wilderness areas. EMS telemedicine programs may be one
way to bring high-level medical expertise to patients in remote areas.13
PATIENT TRANSFER
Patients are often transferred from one medical facility to another for a
higher level of care. Safe and seamless transfer is an important concept
and may be facilitated if transferring and receiving facilities develop
transfer agreements in advance. The Emergency Medical Treatment and
Active Labor Act of 1986 sets forth rules hospitals participating in the
Medicare program must follow. Under the Emergency Medical Treat
ment and Active Labor Act, all patients must receive a medical screen
ing exam and be stabilized before transfer. There must also be explicit
acceptance of the transfer by the receiving hospital.14
COORDINATED PATIENT RECORD KEEPING
Maintaining good medical records is important to any patient encoun
ter. Prehospital medical records must be legible and readily accessible
to hospital providers. Standardization of EMS records among differ
ent agencies within a region helps streamline transfer of information
between prehospital and hospital providers. The adoption of electronic
charting and cloud-based electronic medical record keeping by EMS
systems is a step toward this goal. Electronic charts can be printed out
in the receiving ED or downloaded from a secure Internet website.
Regardless of the system used, EMS agencies must comply with the
Health Insurance Portability and Accountability Act of 1996, designed
to protect the privacy of patient health information.15
PUBLIC INFORMATION AND EDUCATION
EMS systems have a responsibility to train the public on how to access
EMS and use it appropriately. As EMS call volumes rise and available
resources decline, educating the public to use 9-1-1 for true emergen
cies is an appropriate goal. However, given the obstacles that many
patients encounter in accessing office- or hospital-based care, convey
ing this message is not simple. The public needs to know that EMS will
always be there when needed.
Another important message EMS can convey to the public is the
importance of learning CPR, first aid, and basic disaster preparedness.
Recent disasters have illustrated that, at times, the emergency response
infrastructure may be so seriously disrupted that it may take hours
or longer for help to arrive. A public that is adequately prepared and
trained will be in a better position to safely await help.16
REVIEW AND EVALUATION
To ensure proper functioning of an EMS system and high-quality care,
there must be a process for ongoing review and evaluation. This requires
input from EMS providers and active involvement of a physician medical
director. A continuous quality improvement program should be estab
lished to assess system performance and formulate improvements.17
Routine audits of communications, response and scene times, and patient
care records should be performed. Focused audits of conditions such
as cardiac arrest and trauma are valuable. However, obtaining patient
outcomes may be problematic. An unforeseen consequence of the Health
Insurance Portability and Accountability Act is that hospitals are often
hesitant to release patient information, even to EMS services, for fear of
liability.
EMS research is invaluable in advancing prehospital care. It should
not be assumed that what works in the hospital will work in the
prehospital setting. Issues such as limited funding, barriers to getting
patient outcomes, and obtaining informed consent from critically ill
patients, or waivers of consent, can make prehospital research daunt
ing. However, these barriers must be overcome if patients are to receive
quality care.18
DISASTER PLAN
The EMS system is an integral part of disaster preparedness and should
be involved in planning with other agencies and the medical community.
The Omnibus Budget Reconciliation Act legislation of 1981 ended direct
federal block grants to EMS. Because EMS is often not considered to be a
public safety entity, emergency preparedness funding for EMS has fallen
behind that of police and fire services.1 Despite this, EMS agencies must
maintain a high level of disaster preparedness. This involves written
policies and procedures, stockpiling supplies that may be depleted in
multicasualty situations, and participating in regional disaster drills with
other emergency response agencies and hospitals.19
MUTUAL AID
EMS services should develop mutual aid agreements with neighbor
ing jurisdictions so care is available when local agencies are unable to
respond.20 Depending on the size and resources of the system, mutual
aid may be required frequently or only under extreme circumstances.
Addressing in advance details such as reimbursement, credentialing,
liability, and chain of command at incident scenes will streamline the
process.