EMS & Its Midlife Crisis

As literary bookends, they make a nice matching set.

     On one end is Accidental Death and Disability: The Neglected Disease of Modern Society, published in 1966, the seminal "White Paper" that inspired the development of modern American EMS. It told a tale of epidemic traumatic injury and death, invisible to a complacent public, unaddressed by community leaders, and exacerbated by overstretched hospitals, insufficient research and an overall lack of organization and cohesion within the healthcare community.

     At the other end is Emergency Medical Services at the Crossroads, the Institute of Medicine's long-awaited overview of EMS as it stands today, released in June. It paints a bleak portrait of an entity mortally threatened by rising call volumes and ever-increasing system needs, invisible to a complacent public, underaddressed by community leaders, and exacerbated by overstretched hospitals, insufficient research and an overall lack of organization and cohesion within the healthcare community.

Systemic Problems in American EMS

• Insufficient coordination
• Disparities in response times
• Uncertain quality of care
• Lack of disaster readiness Divided professional identity
• Limited evidence base

     The more things change...

     "I recently went back and reread the Accidental Death and Disability report," says Bill Jermyn, DO, FACEP, chair of the American College of Emergency Physicians' EMS Committee. "They used the word crisis to describe the situation then. And in the IOM report today, 40 years later, we're still using the term crisis. We need to begin asking ourselves why that is, and what we need to be doing differently."

An Accurate View
     Emergency Medical Services at the Crossroads is one of three reports released by the IOM's Committee on the Future of Emergency Care in the United States Health System. The other two reports addressed overcrowded hospital emergency departments and trauma centers (Hospital-Based Emergency Care: At the Breaking Point) and the challenges of emergency care for children (Emergency Care for Children: Growing Pains). They were three years in the making.

     Charged with developing Emergency Medical Services at the Crossroads was the committee's Subcommittee on Prehospital Emergency Medical Services, which blended EMS and healthcare leaders with others from outside the field. Their efforts were subjected to the sniff-tests of an equally pedigreed troupe of reviewers.

     Between the committee and its subcommittees, the reporting process entailed 19 meetings, testimony from nearly 60 speakers, 11 research papers, numerous site visits and information from "hundreds of experts, stakeholder groups and interested individuals."

     It was an exhaustive effort that produced a comprehensive report that most seem to feel pegs things pretty accurately.

     "All three reports have been warmly received," says Nels Sanddal, president of the Bozeman, MT-based Critical Illness and Trauma Foundation, who served on both the committee and subcommittee. "The most common feedback I've been getting is that the reports describe the current state of affairs very well, and that many systems, while they appear to be doing OK on the surface-responding to calls and providing good patient care-are doing so only because of the dedicated leadership of their directors and the personnel who work for them."

     That is to say, busting our humps has been enough to get us to this point. But there may come a time, the IOM team says-potentially quite soon-when hard work and ingenuity alone will no longer sustain us.

     "We're emergency care workers, and we make do," says Jermyn. "We'll persevere with almost nothing to take care of our patients. That's our goal; that's our mission. But it works against us, because we've stretched and scrimped and saved and always gotten by. We've done whatever it's taken."

     And hence our problems remain unresolved. Perhaps we've been too dedicated for our own good.

Pressing Problems
     The Crossroads report traces the development of EMS following Accidental Death, chronicling its expansion, with ample federal support, in the 1970s; the funding losses and fragmentation of the 1980s; and the wheel-spinning of the 1990s, when documents like the Agenda for the Future laid out so many ambitious goals that have yet to be realized.

     It pays heed to the advances made over those decades, which are indeed substantial: 9-1-1 accessibility to virtually all Americans, rapid responses that facilitate lifesaving care, advanced equipment that enables expanded services. But it also catalogs all the pressing problems of today: the fragmentation and lack of coordination, the ED overcrowding and diversions, the funding shortfalls, the high costs of preparedness, the workforce issues, the paucity of data and evidence bases, and so on.

     Finally, it articulates a grand vision for the future: seamless integration of dispatch, EMS, definitive medical, public safety and public health efforts and interests. Appropriate care without delay. Evidence-based interventions and rapid adoption and adaptation of innovations. Rare diversions and ample standby capacities. System monitoring and transparent performance for a public that's engaged in its own well-being through bystander training and active prevention.

     To get there, the authors make a series of recommendations across several discrete areas.

Building a 21st-century emergency care system
     The emphasis here is on coordination and communication. The authors support greater regionalization-as is done with, for instance, trauma care-as a way of matching patients with the definitive resources most appropriate for them. As with trauma centers, providers and systems would have their capabilities identified and categorized under national standards. Patients would be routed to systems and facilities best-suited to address their conditions.

     "A lot of the report centers around this notion of regionalization," says Sanddal. "What we're envisioning is better integration and accountability of existing healthcare resources to respond to the needs of a geographic area."

     This section also promotes the creation of a lead federal EMS agency under the Department of Health and Human Services (DHHS). "Strong federal leadership for emergency and trauma care," the authors write, "is at the heart of the committee's vision for the future." They believe FICEMS, while valuable, is insufficient to remedy federal fragmentation, as it cannot regulate or allocate funds.

     Other recommendations:

• NHTSA should lead the development of evidence-based protocols for triage, treatment and transport.
• DHHS should lead the development of evidence-based indicators for emergency and trauma care system performance.
• Congress should establish a demonstration program to promote regionalized emergency and trauma care systems around the U.S.
• HIPAA and EMTALA should be refined to better allow the development of integrated systems.
• CMS should reevaluate EMS reimbursement rules with a focus on readiness costs and payment for nontransports.

Supporting a high-quality EMS workforce
     Committee members endorse a national scope of practice for EMS personnel, with licensing reciprocity between states. States should accept national certification, they say, as a prerequisite for state licensing and local credentialing. As well, states should require national accreditation of paramedic education programs.

     Naturally, substantial attention is paid here to recruitment and retention issues. Familiar issues are cited-lack of career path, provider safety, etc.-though the report offers few solutions beyond making it easier for providers to move between states. The authors also urge new staffing models for rural EMS, possibly including consolidation/regionalization of transporting services, with augmentation by nontransporting quick-response units, and the consideration of paid staff.

     Another recommendation is that the American Board of Emergency Medicine creates a subspecialty certification in EMS.

Advancing system infrastructure
     EMS infrastructure across the U.S. is uneven, and rapid improvements in technology have left behind systems that can't afford to upgrade. This section addresses not only communications and data technologies, but even areas like transport (ground and air) safety.

     Its key recommendation is that EMS agencies, hospitals, public-health and public-safety bodies and offices of emergency management develop integrated and interoperable communications and data systems. The authors cite the wireless interoperable networks already being developed by some states.

     Other recommendations:

• States should assume regulatory oversight of the medical aspects of air-medical services.
• EMS leaders should be involved in all stages of development of the National Health Information Infrastructure.

Preparing for disasters
     As stressed as it is in its day-to-day operations, the American emergency care system is even worse off when it comes to major disasters. And the EMS personnel who are among the first to respond to such events are, in terms of funding and training and equipment, among the least supported in doing so.

     That reality is weighed in terms of the many threats (terrorism, natural disasters, accidents, pandemics) to which EMS providers must be prepared to respond. To improve EMS readiness, the committee concludes, the entire spectrum of government agencies charged with aspects of major-incident management-DHHS, the Department of Homeland Security, the Department of Transportation, etc.-must regard EMS as being as important as other public-safety entities in planning and operations. Further, Congress should substantially increase funding for EMS-related disaster preparedness.

     Relatedly, disaster preparedness must be incorporated into EMS training, continuing education, credentialing and certification, and competencies in it must be maintained.

Optimizing prehospital care through research
     The brightest minds of EMS have been talking about research at least since the Agenda for the Future was published in 1996, but many EMS interventions are still based on tradition or convention, rather than solid evidence bases. The authors examine a series of barriers to EMS research, including informed-consent laws, HIPAA and the Federalwide Assurance Program (FWA).

     FWA agreements are required for research groups receiving federal monies to participate in research involving human beings. Made between such entities and the federal Office for Human Research Protections, they bind researchers to federal laws and standards for the protection of human subjects. An FWA agreement covers multiple research projects, meaning specific permissions aren't required for each one. But they can inhibit the acquisition of population-based outcomes data for patients treated in emergency and trauma-care settings. These patients, including those initially treated by EMS, yield data that's typically stored at nonacademic, community-based medical facilities that don't participate in federally funded research, and hence don't have FWA agreements in place. Therefore, this potentially useful data can't be utilized in federally funded projects. Congress should modify these regulations, the committee suggests, to allow acquisition of limited patient outcomes data without FWA agreements.

     It also urges federal agencies that fund emergency and trauma-care research to target money specifically for EMS/prehospital research, with a focus on systems and outcomes.

Recommendations To Reality
     It's all quite a body of work, but comprehensive reports about what EMS in America needs aren't rare. They come along every so often, generate lots of discussion and maybe a project or two, then fade away, and business largely continues as usual. If you don't believe it, go review Accidental Death and Disability or the Agenda for the Future.

     Can Emergency Medical Services at the Crossroads succeed where previous efforts have not? Can it prompt real, lasting change?

     "If you keep doing the same thing, you'll get the same results," says Jermyn, who is also EMS medical director for the Missouri Department of Health and Senior Services. "I don't know what the answer is, but we obviously need to be doing something different to convince the public, and therefore our legislators, that we have a real problem."

     One step toward that is the series of workshops planned to follow up on the IOM's reports, disseminate their findings and ignite discussions about ways to bring their recommendations to reality.

     "The goal is to make sure that the broadest possible emergency care representation is aware of the reports and their implications, and really get down to discussing how we can help, and how we might impact emergency care where the rubber meets the road," says Sanddal. "We really want the feedback about how it might play in Peoria."

     Once versed on the issues, providers can then make their cases to their communities and elected leaders.

     "What's important," says Jermyn, "is that we use this opportunity to help the public finally realize that we have a serious problem on our hands. We need to be frank about the problems within the system. And we have to develop the political will to change. If we don't develop that will, our legislators aren't going to do anything."

     In the meantime, there are steps every EMS provider can take.

     "As a service director, I'd be thinking about forging even more direct relationships within my community," says Sanddal, "to make sure that not only do we have that horizontal integration occurring at the community level-between public health, public safety, the healthcare community and so forth-but that as a community at large, we are well-integrated into the other resources of surrounding communities.

     "As providers, the only way we can get better at what we do, and really contribute to the outcomes of our patients, is by engaging in ongoing performance--and quality-improvement processes that are multidisciplinary, that cut across agencies and really allow us to figure out how to do what we do better. That can be threatening sometimes, but it will go a long way toward achieving the recommendations contained in the report."

     For the complete reports, see www.iom.edu.

We welcome your thoughts on this topic. E-mail nancy.perry@cygnusb2b.com.