This summer the prepublication of the long-awaited Institute of Medicine's report on EMS became available from the National Academies Press in PDF format. One of three reports commissioned by the National Academy of Sciences and the U.S. Department of Health and Human Services, this document was funded in 2003 by a grant from the Josiah Macy Jr. Foundation. The study was a cooperative effort by the NAS, HHS, Health Resources and Services Administration, the Centers for Disease Control and Prevention, and the U.S. Department of Transportation's National Highway Traffic Safety Administration.
The purpose of the study was to build on past efforts and contributions, including the 1966 document that gave rise to the first national efforts to build an EMS system, Accidental Death and Disability: The Neglected Disease of Modern Society. Subsequent publications such as Injury in America in 1985 and Emergency Medical Services for Children in 1993 also helped identify deficiencies in the EMS system. The IOM looked to report on how much change has occurred in EMS since the original reports.
The committee was tasked with examining the full scope of emergency care, from 911 and medical dispatch to hospital-based emergency and trauma care. Because the committee was weighted heavily with people from the field of emergency medicine academia, however, there has been some concern over the small number of researchers with EMS field experience on the committee.
The committee produced three reports: Hospital-Based Emergency Care: At the Breaking Point; Emergency Medical Services: At the Crossroads; and Emergency Care for Children: Growing Pains. These reports provide three different perspectives on the emergency care system, all of which have significant effects for fire-based EMS. The series identifies fragmented prehospital and hospital-based systems and attempts to provide a common vision for the future of emergency care.
Emergency Medical Services: At the Crossroads describes the progress of EMS over the last four decades and the fragmented system that exists today. It explores a variety of issues that affect the delivery of prehospital EMS, including communications systems; coordination of the regional flow of patients to hospitals and trauma centers; reimbursement of EMS services; national training and credentialing standards; innovations in triage, treatment and transport; integration of all components of EMS into disaster preparedness, planning and response actions; and the lack of clinical evidence to support much of the care that's delivered.
The report will have a significant impact on the fire-based EMS, especially since the last two decades have seen more fire-based EMS systems developed. For example, many fire departments transitioned from just a primary first responder role first to BLS and then to ALS ambulance service. This was done at great expense to city and county governments, yet the IOM reports consider current EMS systems around the country to be somewhat of a failure. Whether fire-based EMS has failed to perform may trigger a lot of emotional responses, but remember that the government agencies and researchers involved in the IOM study had limited research on which to evaluate the system.
The lack of research, quality education and support of field-level personnel by fire-based EMS organizations is seriously affecting the credibility of fire-based EMS, which in turn affects its funding. As budgets tighten, look for the people controlling budgets to ask for justification.
I recently attended a county commission meeting in Colorado where three fire districts had successfully merged operations. However, the mechanism to allow for their capital expenditures had not been secured, and the chiefs were attempting to finalize the long-term funding source by asking for a mill or fire district tax. The previous tax districts would be dissolved, and the economies of scale from combining the three districts would result in major savings and increased efficiencies in many of their operations.
A very obstinate county commissioner repeatedly asked for statistics and numbers. What the commission heard instead were more than three hours of the typical anecdotal and passionate pleas from citizens. Time and time again we have argued that fire-based EMS is the best model for community. However, we fail to prove it, and many of the conclusions in the IOM report reflect that same lack of data, outcomes and seamless system design.
To facilitate more data and a more comprehensive pursuit of EMS, the IOM report calls for Congress to establish a demonstration program that would be administered by the Health Resources and Services Administration to promote regionalized, coordinated and accountable emergency care systems throughout the country. IOM calls for Congress to establish a lead agency for emergency and trauma care within two years of this report's publication. This lead agency should be housed in HHS and not in DHS or the DOT. IOM recommends that a national EMS agency should have primary programmatic responsibility for the full continuum of emergency and trauma care.
The IOM committee recommends $88 million over five years to fund the operations of a national EMS administration. The committee also recommends that HHS, DOT, DHS and the states elevate emergency and trauma care to a position of parity with other public safety entities in disaster planning and operations. While significant federal funding is available to states and localities for disaster preparedness, emergency care in general hasn't been able to secure a meaningful share of these funds because the money has been folded into other public safety functions that consider emergency medical care a low priority.
The recruitment and retention of EMS personnel is cited in the IOM as a major challenge for EMS systems in the future. Although EMS workers have indicated in surveys that their work provides them with a sense of accomplishment and belonging in the community, their overall job satisfaction is often very low due to concerns regarding personal safety, stressful working conditions, irregular hours, limited potential for career advancement, and excessive training requirements for the modest pay and benefits that most EMS providers receive.
The report emphasizes the need to develop national core contents for providers at various levels and asserts that all EMS education must be conducted with the review of a qualified medical director. The lack of qualified emergency medical dispatchers is another area identified as a problem in the EMS system. Emergency medical dispatchers are very poorly paid; their median annual salary in 2003 was below $29,000. Given the stress associated with their jobs, it's not surprising that 911 call centers experience high turnover.
In 1996, the NHTSA's EMS Education Agenda for the Future: A Systems Approach expected that national EMS certification would be accepted by all state EMS offices as verification of entry-level competency. It envisioned that all EMS graduates would complete an accredited EMS training program and would obtain national certification to qualify for state licensure. The IOM report identified that the National EMS Scope of Practice Model Task Force has created a national model to aid states in developing and refining their scope-of-practice parameters and licensure requirements for EMS personnel. The committee supports this effort and recommends that state governments adopt a common scope of practice for EMS personnel, with state licensing reciprocity.
The IOM study recommends training a new generation of investigators to increase the scientific study of EMS. Part of the $88 million is earmarked for the development of multi-center research networks and the funding of EMS general clinical research centers that will focus on EMS and trauma care. The IOM report places a heavy emphasis on the involvement of emergency and trauma care researchers in the federal grant review and research advisory processes. It's absolutely necessary to improve research coordination through a dedicated center or institute to help continue to justify EMS operations.
Over the past decade, an increasing number of residency-trained emergency physicians have completed a one- or two-year fellowship in an EMS curriculum developed by the Society of Academic Emergency Medicine. However, there are still very few actively engaged EMS medical directors who are providing the kind of real leadership needed for fire-based EMS systems to monitor and evaluate their clinical practice. IOM is looking for the physician community to increase the number of EMS residency opportunities and promote board certification in EMS.
The IOM report will be a stepping stone for greater coordination and promotion of EMS at a federal level. Some have called the IOM report an initiative to put the “M,” or medicine, back into EMS. Look for federal funding to be tied to the IOM recommendations. Expect to see all aspects of EMS evaluated for their outcomes and greater control of the clinical aspects by EMS physicians. In the 40 years since Accidental Death and Disability: The Neglected Disease of Modern Society, we still don't have national coordination or standardization of EMS.
Those responsible for EMS still need to ramp up their research and evaluations of their systems. The IOM report should be distributed to all fire-based EMS officers, and organizations should look for ways to combat the issues in the IOM report. If we don't start putting some science into our processes, fire departments will be subject to mandates or forced to relinquish some of their responsibilities for EMS.
The IOM report, Emergency Medical Services: At the Crossroads, can be purchased at www.nap.edu/catalog/11629.html. Individual chapters also are available.
Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has an associate's degree in fire management and a master's degree in public administration.
