A Troubled State, Part 1: We Can We Learn From Iowa’s Experience?

This is the first of a three-part series written in response to several articles published in the Des Moines Register in April that outlined significant design and response challenges facing Iowa’s EMS system.

Find the original articles at www.desmoinesregister.com.

Much of the EMS community was dismayed when a series of highly critical articles written by investigative reporter Clark Kauffman hit the newsstands and Internet. I was not. I’m sorry our colleagues in Iowa had to be the focus of such reporting, but it’s high time someone called public attention to the sorry state of EMS in the United States. The issues Kauffman raised are not faced by Iowa alone.

The series touched on a number of key points that should be important to us and the focus of legislative and policy activity by proactive EMS organizations, municipal and county leaders, physician groups, hospital administrators and everyone else concerned about the well-being of sick and injured citizens.

In his series of articles, Kauffman raised the following key points:

• EMS is not a mandatory local service in most states.¹ While all states require or provide for law enforcement services in every community, and while most states require or provide for fire-suppression services, only a handful require that EMS be provided throughout the state. In most states the availability of EMS or ambulance services is a matter of local discretion or historical accident.

• Most states do not have established standards for EMS or ambulance responses to requests for assistance. The ability to meet a particular standard is a matter of resource allocation, and most states are unwilling to require particular levels of any service in communities of varying demographics and wealth.

• Although EMS personnel have unfettered access to the bodies and possessions of our most vulnerable citizens, most EMS agencies do not require comprehensive criminal background checks, psychological evaluations or even demonstrations of basic medical competence prior to hire. Often the standard is merely willingness to serve, which can mask a variety of issues.

• Most state EMS offices are woefully underfunded and understaffed. Their existence is a schizophrenic one in which they are charged with “system building” (most often without the funds to do it, thus requiring the cooperation of existing EMS agencies) while at the same time policing those same agencies. When they do seek to carry out their enforcement mandate, it is often at the lowest possible level: sending inspectors to count the number of bandages and other equipment on ambulances, for instance, rather than examining higher-level functions like medical performance and patient outcome. Most have no operational capacity, so unlike state police or fire entities, no state EMS office has a capacity to step in and provide service in a community.

• Volunteers compose a significant but diminishing portion of the EMS community, particularly in rural areas. While mustering volunteer crews to run noncritical ambulance calls may be difficult in many communities, it does not appear to be difficult to organize dozens or hundreds of EMS volunteers to travel to state capitols to oppose laws or regulations that might improve the quality of EMS in their state. Meanwhile, many of those volunteer organizations continue to admit members who conduct themselves inappropriately, and to act more like social organizations that legitimate emergency services.

It’s not just Iowa, folks. Look around.

Essential Public Service

What does essential mean? For purposes of this discussion, let’s assume it means mandatory—a must-have, something somebody must provide. In most states municipalities must provide law enforcement services as a condition of their existence. If they don’t, somebody else will. In the late 1980s the town of Hainesport, NJ, abolished its police department. Within days the town was being patrolled, and calls answered, by the New Jersey State Police. In May 2009 the Spring Lake, NC, police department was stripped of its authority by the district attorney. The Cumberland County Sheriff’s Office immediately assumed responsibility for law enforcement in the town. All states have functional state law enforcement agencies, as do most counties. Most states have some level of state and county fire-suppression capability (though such resources may involve mostly wildland firefighting expertise). One of the features of “mandatory” is that there is a legal requirement that it be provided.

When a citizen calls 9-1-1 asking for help, that citizen expects help will be provided. Whether that actually happens, and the degree to which it happens, is in most states purely a matter of luck.

In a recent survey, the National Association of State EMS Officials asked states a number of questions about the operations and functions of their EMS offices. In the resulting National EMS Assessment, 11 state EMS offices said they were responsible to ensure provision of ambulance service throughout their states. A review of the legislation of those states suggests some may have been incorrect. For example, a review of state statutes and rules found no reference that Alaska, Washington or New York had such authority.

Putting It in Law

A few states have addressed the matter up front; Hawaii, North Carolina and, more recently, Pennsylvania are a few.

Hawaii has a true state-operated, all-inclusive EMS system. The state EMS office, part of the state health department, is responsible for establishing emergency medical services throughout the state, including emergency air-medical services (HRS 321-224). The department can contract with counties for it, and “shall operate emergency medical ambulance services or contract with a private agency in those counties which do not apply [to be the provider]” (HRS 321.228). The state EMS office contracts with someone (county or private entity) to provide the service, receives all patient care reports, bills for the service and receives all revenue generated by patient transport.

North Carolina’s approach is a bit different. State statute requires counties to comply with the administrative rules promulgated by the state office of EMS (NCGS § 153A-250(e)). The state’s administrative rules require that counties shall establish EMS systems (as defined), and that there be a single level of care throughout the county, 24 hours per day (10A NCAC 13P .0201(a) et seq.). A city may not serve as a provider of EMS or franchise ambulance services unless permitted by its county (NCGS § 153A-250(c)).

Pennsylvania has taken a slightly different approach. In 2008, the state amended its code (Act 2, 7, 8 and 9 of 2008) to modify the sections of its code that spell out the responsibilities of various classes of boroughs and townships. Townships are responsible for “ensuring that fire and emergency medical services are provided within the township by the means and to the extent determined by the township.” In other words, townships must make provisions for fire and EMS, but the extent (level of service) and means (by providing it themselves or contracting with another entity) is up to them. The act also provides for an accounting of township funds provided to external entities. It is interesting (perhaps alarming?) to note that these acts do not apply to cities!

In most states, however, there is nothing “mandatory” about EMS. Communities decide for themselves if they will have EMS and, if so, what, when and how it shall be delivered. As with many items that aren’t “hot buttons” with citizens, EMS is often overlooked, neglected and underfunded until a crisis arises—at which point lives may be in jeopardy.

Response Performance Standards

The Register took Iowa to task for not establishing response performance standards for EMS. I wouldn’t consider that a big deal if EMS were a mandatory service at the county level, so there was active involvement of elected officials in setting local standards. It is also not a big deal because high-quality scientific study has demonstrated, time and time again, that ambulance response time does not play a role in patient outcomes, except in a few limited circumstances.^2–5

Except in cases involving cardiac arrest, there is little evidence to support or develop meaningful response performance standards. And to the dismay of many, the number that matters in cardiac arrest is 5 minutes or less for CPR-capable responders with defibrillators (who don’t have to arrive on ambulances). As a component of total “time to definitive treatment” intervals, ambulance response performance matters in cases of acute-onset stroke, ST segment-elevation myocardial infarction and serious multisystem trauma. But those incidents, taken together, amount to less than 5% of most EMS systems’ call volumes.⁶

I am fine with the notion that Iowa does not have state-mandated response performance standards. All EMS is local. If EMS were a mandatory service at the county level, then local elected officials would be required to at least address the issue. If, perhaps, some state funding were provided (or withheld) based on county plans containing certain elements, it would create an incentive for compliance.

Why do I keep talking about counties? I’m not fixated on counties—a regional EMS system made up of multiple counties would be even better, particularly in sparsely populated rural areas. Why not towns? Simple: Most communities are not large enough to support substantial EMS organizations with experienced, educated leadership; with career options and mobility for employees; and with resources to do good quality management and staff education. It has been said that EMS agencies in the United States are small, independent, financially unstable, clinically unaccountable and damn proud of it! We have thousands of EMS organizations in the USA, the average operating perhaps five ambulances. Contrast that with the United Kingdom, where there are a dozen or fewer ambulance services for the whole country, or Australia, where there is one ambulance service per state. The Institute of Medicine, in its authoritative report Emergency Medical Services: At the Crossroads (2006), repeatedly called for the development of systems of emergency care that are regionalized, coordinated and accountable. Despite its strong case, there has been little movement to implement the IOM’s recommendations.

What is stopping the development of regionalized systems of care? Money? Culture? Fear? In the 1970s this was the thrust of Dr. David Boyd’s work with the Department of Health, Education and Welfare (now Health and Human Services) and the EMS Act of 1973. When President Ronald Reagan canned all that, it stopped before it really got started. Since then, there really has been no effort. The latest attempt was the IOM’s Crossroads paper, but not much has yet come from that.

Next month we address the issue of personnel background checks and assessments and discuss critical issues of funding and oversight impacting the work of state EMS offices.

References & Footnotes

1. For purposes of this article, EMS means not just ambulance service, but the entire system that begins with answering a 9-1-1 call for medical assistance and ends at the hospital emergency department or with the discharge of the patient without transport. It includes 9-1-1 centers providing call screening and medical prearrival instructions, medical first response (whether provided by law enforcement, fire or others) and ambulance response, treatment and transportation.

2. Pons PT, et al. Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome? J Emerg Med, 2002; 23: 43–8.

3. Blackwell TH, et al. Response time effectiveness: comparison of response time and survival in an urban emergency medical services system. Acad Emerg Med, 2002; 9: 288–95.

4. Blackwell TH, et al. Lack of association between prehospital response times and patient outcomes. Prehosp Emerg Care, 2009; 13: 444–50.

5. Blanchard IE, et al. Emergency medical services response time and mortality in an urban setting. Prehosp Emerg Care, 2012; 16: 142–51.

6. Myers JB, Slovis CM, Eckstein M, et al.; U.S. Metropolitan Municipalities’ EMS Medical Directors. Evidence-based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehosp Emerg Care, 2008 Apr–Jun; 12(2): 141–51.

Skip Kirkwood MS, JD, NREMT-P, EFO, CEMSO, is a 40-year veteran EMS provider, educator, consultant and chief officer. He has served in EMS systems in nine states and in nearly every conceivable EMS system configuration. He has been the chief EMS officer of a volunteer, not-for-profit ambulance service; a fire-based EMS organization, two hospital-operated ambulance services, and a county-government operated EMS system. He is a member of the EMS World editorial advisory board. Since 1995, he has taught Emergency Health Service Law and Policy as part of the Master of Science degree program at the University of Maryland Baltimore County. Skip is uniquely positioned to examine these matters of law and policy for the EMS community.