Chapter 2 Notes

Chapter 2: EMS Systems  Key Terms o Accreditation o Bystander o Certification o Chain of survival o Clinical treatment guidelines o Cognitive offloading o Continuous quality improvement (CQI) o Department of Homeland Security o Emergency Medical Dispatcher o Ethics o Evidence-based medicine (EBM) o Helicopter air ambulances (HAA) o Interoperability o Intervener physician o Licensure o Medical director o National Highway Traffic Safety Administration (NHTSA) o National Incident Management System (NIMS) o National Transportation Safety Board (NTSB) o Offline medical oversight o Online medical oversight o Ontario Prehospital Advanced Life Support (OPALS) Study o Peer review o Prearrival instruction o Professionalism o Prospective medical oversight o Reciprocity o Registration o Research o Retrospective medical oversight o Rules of evidence o Scope of practice o Standing orders o Tiered response o Trauma center  Objectives o Define key terms o List out of hospital and in hospital components of EMS systems o Link key events in the history of EMS to the development of modern EMS o Discuss the importance of the 1966 publication of Accidental Death and Disability: The Neglected Disease of Modern Society as it relates to the development of EMS o Describe each of the 10 components of EMS systems according to the statewide EMS technical assessment program o Identify and discuss the vision and documents that are guiding EMS into the future o Discuss the contemporary problems facing EMS as described in the Institute of Medicine document, Emergency Medical Services: At the Crossroads

o Provide examples of various configurations of EMS systems in the US and how they integrate into the chain of survival o List and describe the purposes of national documents guiding EMS education and practice o Discuss typical components that should be established for local and state level EMS systems o Describe the similarities, differences, and general purpose of the professional organizations and professional journals related to the practice of EMS o Describe the intent of the General Services Administration KKK-A-1822 Federal Specifications for Ambulances o Describe the purpose of categorizing receiving hospital facilities by their capabilities o Explain the purpose and components of an effective continuous quality improvement program o Describe how you can contribute to greater patient safety in EMS o Explain the role of research in EMS o Discuss how evidence-based medicine is enhancing EMS  EMS Out of Hospital and In Hospital Components o Out of hospital: 1. Members of the community trained in first aid and CPR 2. Communications system that allows public access to emergency services dispatch and allows EMS providers to communicate with one another 3. EMS practitioners 4. Fire/rescue and hazmat services 5. Law enforcement officers 6. Public utilities, gas and power companies 7. Resource centers, poison control 8. Divers Alert Network o In hospital: 1. Nurses and EMS practitioners 2. PAs and NPs 3. Emergency physicians 4. EMS physicians 5. Ancillary services, radiology and respiratory therapy 6. Specialty physicians, trauma surgeons and cardiologists 7. Social workers 8. Mental health providers 9. Rehab services  Technological Advances and Health Care Access 2

2. 1862 BC, Edwin Smith purchased “Book of Wounds” explaining treatment of injuries and descriptions of materials needed to make bandages and splints, suture, and how to clean wounds 3. About the same time, King Hammurabi’s code of law contained a section about medical fees based on financial class of patient 4. First ambulances with medical attendants began between 1487-1553 CE o The Napoleonic Wars 1. 1803-1815, horse drawn ambulances staffed with a medical attendant were used to evacuate the wounded from the battlefield; known as the flying ambulances 2. 1870 Prussian Siege of Paris, hot air balloon use 3. 1915 Serbian Army from Albania, French fighter aircraft used to ferry the injured 4. Florence Nightingale organized care for wounded soldiers and trained caregivers significantly improving patient outcomes, known as the founder of nursing o United States in the 19 th Century 1. 1861, Civil War initiated used of ambulances to evacuate casualties 2. 1864, Abraham Lincoln signed a law into act establishing a formal army ambulance plan which was separate from other transport services 3. 1861-1865, Clara Barton coordinated care for sick and injured in the Civil War to improvised hospitals at houses, barns, and churches 4. 1860, Cincinnati established a civilian ambulance service followed by NYC in 1869 5. 1899, Chicago first use of motorized ambulance 6. “The fate of the wounded lies with the one who applied the first dressing” Nicholas Senn, AMA president, 1897  The Twentieth Century o World War I to II 1. Long response times and getting patients to care facility on battle field 2. 1928, first bona fide rescue squad in Roanoke, Julian Wise; growth stunted by Great Depression 3. 1937, first MCI when Hindenburg crashed killing 35 of 97 on board o World War II 1. Due to US entering WWII in 1941, hospital-based ambulance services turned over services to local police and fire departments. EMS training was minimal and many departments tried to put an end to their ambulance service o 1950s 4

1. Development of mobile army surgical hospitals close to the front lines to reduce transportation times 2. Casualties began being moved by helicopter due to mountainous terrain and lack of road system; patients often stabilized in Korea and then airlifted to Phillipines for further care 3. 1956, pioneered use of mouth-to-mouth resuscitation 4. 1958, Army gave Crowley $100k grant to study effects of shock leading to four-bed trauma unit which became Maryland Shock Trauma Center 5. Crowley further developed Golden Hour concept, developed helicopter medevac systems, and shaped development of EMS systems 6. 1959, first portable defibrillator used at Johns Hopkins 7. 1960, Peter Safar, CPR refined and deemed effective for resuscitation o 1960s 1. Early 1960s had very poor prehospital care and untrained providers, no radio communication, and minimal equipment 2. 1966, publication of Accidental Death and Disability: The Neglected Disease of Modern Society , also known as the “White Paper” spelled out deficiencies in prehospital care, training of providers, and suggested upgrading ambulances and their equipment 3. 1960, LA was the first fire department to place medical personnel on engine, ladder, and rescue companies 4. 1966, Highway Safety Act created initial guidelines for EMS 5. 1966, Pantridge developed portable defibrillator 6. 1967, Peter Safar trained black men and women in Pittsburgh at the Freedom House as EMS providers which later developed into a paramedic program 7. 1969, first paramedic program in Miami by Nagel 8. 1969, Seattle, first mobile coronary care unit staffed by firefighter paramedics and physicians; saved 31 lives in first year o 1970s 1. 1970, National Registry of EMTs established 2. 1973, Congress passed Emergency Medical Services Systems Act, providing funding for a series of project related to trauma care; lead to development of regional EMS systems which required 15 components to be eligible for funding  Manpower, training, communications, transportation, emergency facilities, critical care units, public safety agencies, consumer participation, access to care, patient transfer, standardized record keeping, public information and education, system review and evaluation, disaster management plans, mutual aid 5

1. 1996, National Highway Traffic Safety Administration (NHTSA) published the document that examined what had been learned prior and tried to create a vision for the future of EMS by developing 14 EMS attributes  Integration of health services  EMS research  Legislation and regulation  System finance  Human resources  Medical direction  Education systems  Public education  Prevention  Public access  Communication systems  Clinical care  Information systems  Evaluation 2. Proposes 5 integrated components for the future of EMS education  Core Content  Scope of Practice Model- initially published in 2007 and revised in 2019; goal was to develop a comprehensive list of knowledge, processes, and procedures for each EMS practitioner certification level based on tenets of evidence-based medicine, facilitate reciprocity, standardize professional recognition, and ease the burden of individual states in creating their own educational and certification materials  Educational Standards- initially published in 2009 and updated in 2021, shifted away from detailed educational curricula and moved toward educational outcomes and standards; can create own curricula to meet standards  Education Program Accreditation  Certification- 2020 creation of Recognition of EMS Personnel Licensure Interstate CompAct (REPLICA) which allowed EMS providers licensed in one state to practice in another state; became useful for covid pandemic o EMS at the Crossroads 1. 2006, National Academies Institute of Medicine published “…at the Crossroads”. Described prehospital emergency care as “a stark example of how standards of care and clinical guidelines can take root despite an 7

almost total lack of evidence to support their use”. Current EMS delivery systems suffer in a number of key areas  Insufficient coordination- uncoordinated among providers; adjacent jurisdictions often unable to communicate with one another; different radio equipment and different frequencies  Disparities in response times- mostly geographic; communication between 911 dispatch and EMS  Uncertain quality of care- no standardized measures of EMS quality, training, and certification, accreditation, and no accountability for performance  Lack of readiness for disasters- little or no disaster response training  Divided professional identity- EMS personnel often lack respect from medical professionals and public safety  Limited evidence base- little evidence base for many practices routinely used in EMS o National Report Card on the State of Emergency Medicine o Published in 2006 by American College of Emergency Physicians (ACEP); primarily focused on hospital emergency departments but touched in EMS issues o Emergency services are so overstressed that quality of care is compromised; includes issues such as inadequate funding, patient overcrowding, lack of alternate care facilities, problems with medical liability, effect of illegal immigration o Each state given a letter grade on emergency care in that state o Helicopter Air Ambulance Recommended Improvements o 2001, federal reimbursement improved and fleet expanded from 300 to 900 o 2008, numerous air ambulance crashes which led to National Transportation Safety Board making improvements in the industry o EMS Compass o 2014, numerous groups developed performance measures and benchmarks to improve EMS systems of care o 2016, EMS Compass released its first set of performance benchmarks and encouraged EMS systems to incorporate them into quality management and performance improvement programs o EMS Agenda 2050 o 2016, revision to EMS Agenda for the Future o 2018, EMS Agenda 2050 published; described medical services in 2050 as collaborating with community partners and integrated into regional systems of care, providing care that is data-driven, evidence-based, and safe; six core values 8

certification of providers, enforcing all EMS regulations, and appointing regional advisory councils 3. At regional levels, regional council is responsible for management of the local system’s resources, developing operational guidelines, and establishing standards and guidelines 4. Within the council, a planning committee develops a budget and selects a staff capable of managing EMS council 5. Council develops quality control and improvement to evaluate system’s effectiveness o Medical Oversight: Roles of the Medical Director 1. Educate/train personnel 2. Participate in personnel/equipment selection 3. Develop clinical treatment guidelines 4. Participate in quality improvement/problem resolution 5. Provide direct patient care input 6. Interface between EMS and other health care agencies 7. Advocate within the medical community 8. Serve as the “medical conscience” of the EMS system o Public Information and Education 1. EMS should have a plan to educate the public on recognizing an emergency, accessing the system, and initiating basic life support 2. Patients are more likely to listen to advice and consider lifestyle changes following an emergency (teachable moment) 3. Public education can include role modeling, community involvement, leadership, and prevention 4. First part is having the public recognize an emergency; this could reduce cardiac arrests by recognizing cardiac symptoms 5. Second part is system access; this can include calling, texting, or a smartphone app 6. Third is that they must know basic life support such as CPR and bleeding control o Effective communications 1. Citizen access- enhanced 911 allows automatic location of the caller and callback ability 2. Single control center- all public service agencies should be dispatched from the same communications center in order to ensure best use of resources 3. Operational communications capabilities- dispatch can manage all aspects of the system, emergency units can communicate with one another and other agencies for mutual aid, hospitals can communicate with other hospitals 10

4. Medical communications capabilities- EMS can communicate with receiving facility and transmit patient information prior to arrival; also includes telemedicine consults and record of health information within an electronic health record 5. Communications hardware- radios, telephones, GPS and vehicle tracking capabilities  Interoperability- allows personnel from different jurisdictions to communicate with one another 6. Communications software- radio frequencies, satellite and computer programs to track ambulances 7. EMS Dispatch  Dispatchers must have training in telecommunication skills, medical interrogation, giving prearrival instructions, and dispatch prioritization  Nerve center of an EMS system; the means of assigning and directing appropriate medical care to patients  Dispatch plan should include interrogation protocols, response configurations, system status management, and prearrival caller instructions  1974, Phoenix Fire introduced prearrival instructions to initiate lifesaving first aid with dispatchers help  1985, Seattle EMS initiated instructing callers in CPR  No improved outcomes based on response time of 8 minutes as previously established; significant role of lights and sire response in ambulance crashes o Initial and continuing education programs 1. Initial education- EMS practitioner education programs; includes three domains  Cognitive- facts or information knowledge  Affective- students assign emotions, values, and attitudes to that information  Psychomotor- hands-on skills in lab and clinical settings  All paramedic programs must be accredited  Primary accrediting organization is Committee on Accreditation of Education Programs for the Emergency Medical Services Professions (CoAEMSP), which is an entity of the Commission on Accreditation of Allied Health Programs (CAAHEP) 2. Continuing education- Commission on Accreditation of Prehospital Continuing Education (CAPCE) is national continuing education certifying 11