Paramedic Care: Principles & Practice Volume 1: Introduction to Paramedicine CHAPTER Fourth Edition ©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. EMS Systems 2

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Multimedia Directory Slide 68Ambulance Service Video

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Standard Preparatory (EMS Systems)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Competency Integrates comprehensive knowledge of EMS systems, the safety and well-being of the paramedic, and medical-legal and ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Introduction Out-of-Hospital Components –Community members trained in first aid and cardiopulmonary resuscitation (CPR) –Communications system –EMS providers –Fire/rescue; hazardous-materials services

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Introduction Out-of-Hospital Components –Law enforcement officers –Public utilities –Resource centers

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Introduction In-Hospital Components –Emergency nurses –Mid-level practitioners –Emergency and specialty physicians –Ancillary services –Social workers –Mental health providers –Rehabilitation services

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Introduction EMS operation begins with citizen activation. EMS dispatch responsible for: –Collecting information –Sending staffed and equipped unit –Providing prearrival instructions

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Introduction First EMS provider to respond: –Police officer –Firefighter –Lifeguard –Teacher –EMR-trained community member

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Introduction Dispatcher will send: –Basic life support (BLS) ambulance –Advanced life support (ALS) ambulance –Tiered response

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Introduction EMS providers decide on: –Medical facility –Type of care needed –Transport time –Local protocols

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS Most significant advances in EMS during last 40 years

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. An EMS Timeline

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. An EMS Timeline (continued)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. An EMS Timeline (continued)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS Early Development –Ancient tablets: step-by-step instructions for patient care; how to create medications.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS Early Development –Code of Hammurabi: governed criminal and civil matters; regulation of medical fees and penalties. –Out-of-hospital care: transport. –Jean Larrey (Napoleon's chief surgeons): first prehospital system using triage and transport.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS Early Development –Ambulances in U.S.: nineteenth century. –Nurse Clara Barton organized triage and transport during Civil War. –First civilian ambulance: 1860 in Cincinnati. –Bellevue Hospital in Manhattan (1869): began to operate ambulance service.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS The Twentieth Century –WWI: high mortality rate of soldiers associated with evacuation time. –WWII: transport to echelons (levels) of care created. –Hospitals experimented with placing physician interns on ambulances.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS The Twentieth Century –Korean War: helicopters moved injured to Mobile Army Surgical Hospitals. –Set stage for trauma system in U.S. –1956: mouth-to-mouth resuscitation –1959: portable defibrillator –1960: CPR

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Medical evacuation helicopters, colloquially called “Dustoff,” saved many lives during the Vietnam War. (Dust off © Joe Kline Aviation Art)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS The Twentieth Century –1966: Accidental Death and Disability: The Neglected Disease of Modern Society (White Paper) –Guidelines for:  Development of EMS systems  Training of prehospital emergency medical providers  Upgrading of ambulances and equipment

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS The Twentieth Century –1970: National Registry of Emergency Medical Technicians established –1972: television show Emergency!; public attention to prehospital care –1973: Emergency Medical Services Systems Act

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS 15 Components of EMS Systems –Manpower –Training –Communications –Transportation –Emergency facilities

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS 15 Components of EMS Systems –Critical care units –Public safety agencies –Consumer participation –Access to care –Patient transfer

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS 15 Components of EMS Systems –Standardized record-keeping –Public information and education –System review and evaluation –Disaster management plans –Mutual aid

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS 1988 NHTSA: Ten System Elements –Regulation and policy –Resources management –Human resources and training –Transportation –Facilities

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS 1988 NHTSA: Ten System Elements –Communications –Trauma systems –Public information and education –Medical direction –Evaluation

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS The Twentieth Century –1980s: Helicopter EMS (HEMS) developed –1996: National Highway Traffic Safety Administration (NHTSA) published EMS Agenda for the Future

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS 14 Core EMS Attributes –Integration of health services –EMS research –Legislation and regulation –System finance –Human resources –Medical direction –Education systems

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS 14 Core EMS Attributes –Public education –Prevention –Public access –Communication systems –Clinical care –Information systems –Evaluation

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS The Twenty-First Century –Result of 9/11:  Department of Homeland Security: coordinates agencies responsible for protecting country.  National Incident Management System (NIMS): prepares country for terrorist attacks and other threats.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. The attacks on New York City and Washington, DC on September 11, 2001, forever changed the face of EMS. (© Reuters)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS The Twenty-First Century –2006: Emergency Medical Services: At the Crossroads  Insufficient coordination  Coordination of transport within regions was limited  Disparities in response times

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS The Twenty-First Century –2006: Emergency Medical Services: At the Crossroads  Uncertain quality of care  Lack of readiness for disasters  Divided professional identity  Limited evidence base

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS The Twenty-First Century –2006:The National Report Card on the State of Emergency Medicine: Evaluating the Environment of Emergency Care Systems State by State

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. History of EMS The Twenty-First Century –2001: national medical helicopter fleet expanded from 300 to 900 –2008: record number of helicopter EMS crashes with fatalities –2009: NTSB hearings

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Fire-based systems Third service Private (profit or nonprofit) Hospital-based systems Volunteer Hybrid (combination of any of these)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Chain of Survival –Continuum of care that begins once emergency occurs –Ends when patient completes care and returns to normal activities of daily living

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Chain of Survival –Bystander care –Dispatch –Response –Prehospital care –Transportation –Emergency department care –Definitive care –Rehabilitation

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Levels of Licensure/Certification –Emergency Medical Responder (EMR) –Emergency Medical Technician (EMT) –Advanced EMT (AEMT) –Paramedic Each level: unique role, set of skills, knowledge base.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Education –2005: National EMS Core Content published by NHTSA –2005: The National EMS Scope of Practice

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Local- and State-Level Agencies –Administrative oversight agency –Planning board –Define who may function within system –Policies consistent with state requirements. –State EMS agencies: allocate funds; enact legislation.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Medical Oversight –Medical director: physician legally responsible for all clinical and patient- care aspects of system. –Prehospital care providers are medical director's designated agents.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Medical Director's Roles –Educate and train personnel. –Participate in personnel and equipment selection. –Develop clinical protocols in cooperation with expert EMS personnel. –Participate in quality improvement and problem resolution.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Medical Director's Roles –Provide direct input into patient care. –Interface between EMS system and other health care agencies. –Advocate within medical community. –Serve as “medical conscience” of EMS system.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems On-line medical direction: qualified physician gives direct orders to prehospital care provider by radio or telephone. Intervener physician: on-line medical direction may not exist; paramedic relinquishes responsibility to physician.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Off-line medical oversight: medical policies, procedures, practices that system medical director has established in advance of call. –Prospective medical oversight –Retrospective medical oversight

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Clinical protocols: policies and procedures of all medical components of EMS system; responsibility of medical director.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Four “Ts” of Emergency Care –Triage –Treatment –Transport –Transfer

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Public Information and Education –Recognize emergency –Access system –Initiate basic life-support procedures –Prevention (before emergency) –Teachable moments

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Providing disease and injury prevention education to the public has become an important role of EMS in the twenty-first century. (© Dr. Bryan E. Bledsoe)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Communications –Heart of regional EMS system –Coordinates components into organized response to urgent medical situations –Citizen access (911) –Single control center

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Communications –Operational communications capabilities –Medical communications capabilities –Communications hardware –Communications software

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. The EMS communications center is truly the heart of the modern EMS system.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Communications –Emergency medical dispatcher (EMD):  Sends ambulances to scene  Ensures system resources in constant readiness to respond  Both medically and technically trained

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Communications –EMS dispatch: assigns and directs appropriate medical care to patients.  Interrogation protocols  Response configurations  System status management  Prearrival caller instructions

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Education and Certification –Initial education: completing course following National EMS Education Instructional Guidelines published by U.S. DOT.  Cognitive  Affective  Psychomotor

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Education and Certification –Continuing education: refresher courses for recertification and periodic in-service training sessions; mandatory. –Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Licensure/Certification –Certification: agency or association grants recognition to individual who has met its qualifications. –Licensure: occupational regulation. –Registration: enter name and essential information within a particular record.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Licensure/Certification –Reciprocity: agency grants automatic certification or licensure to individual who has comparable certification or licensure from another agency.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems National Registry of EMTs (NREMT) –Nonprofit entity –Prepares and administers standardized tests for EMS provider levels –Establishes qualifications for registration and biennial reregistration –Establishes national minimum standard of competency

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Professional Organizations –National Association of Emergency Medical Technicians (NAEMT) –National Association of Search and Rescue (NASAR) –National Association of EMS Educators (NAEMSE) –National Association of EMS Physicians (NAEMSP)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Professional Organizations –International Association of Flight and Critical Care Paramedics (IAFCCP) –National EMS Management Association (NEMSMA) –National Council of State EMS Training Coordinators (NCSEMSTC)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Professional Journals and Magazines –Academic Emergency Medicine –American Journal of Emergency Medicine –Annals of Emergency Medicine –Emergency Medical Services –EMS World

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Professional Journals and Magazines –Journal of Emergency Medical Services (JEMS) –Journal of Pediatric Emergency Medicine –Journal of Trauma: Injury, Infection and Critical Care –Prehospital Emergency Care

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems The Internet –Websites designed for EMS providers –Updated content and news –Accredited continuing education programs –International EMS discussions; networking

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Ambulance Service Video Click here to view a video on the topic of ambulance service.here Back to Directory

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Patient Transportation –Medical oversight designates facility based on needs of patient; availability of services. –Transported by ground or air –Fixed-wing aircraft when patients transported long distances –Vehicles licensed; meet local and state EMS requirements

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Patients may be transported by ground or air. Medical helicopter transport was introduced in the 1950s during the Korean War. (© REACH Air Medical Services)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Fixed wing aircraft, as well as helicopters, have become an important part of patient transport in the modern EMS system. (© REACH Air Medical Services)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Patient Transportation—Ambulances –Type I: conventional cab and chassis; module ambulance body mounted; no passageway between driver and patient compartments. –Type II: standard van, body, and cab form integral unit; raised roof.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Type I ambulance.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Type II ambulance.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Patient Transportation—Ambulances –Type III: specialty van with forward cab and integral body; passageway from driver compartment to patient compartment. –Medium-duty truck chassis: built for rugged durability and large storage and work areas. –Diesel: developed for fuel economy.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Type III ambulance.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Some EMS systems have elected to use medium-duty ambulances that are built on a commercial truck chassis.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. The diesel, unibody ambulance is becoming increasingly popular because of cost, fuel economy, and safety. (© Acadian Ambulance Services)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Receiving Facilities –EMS systems organize hospitals into categories. –Identify readiness and capability –Staff to receive and treat emergency patients –Trauma centers; chest pain centers; stroke centers; specialized care capabilities

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Receiving Facilities –Specialty facilities:  Burn, trauma, pediatric, psychiatric, perinatal, cardiac, spinal, poison –All receiving facilities:  Emergency department; surgical facilities; lab and blood bank; medical imaging capabilities; critical and intensive care units

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Mutual Aid and Mass-Casualty Preparation –Ensures help available when needed –Transcends geographical, political, historical boundaries –Disaster plan for catastrophes –Incident command system –Mutual-aid agreement

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Quality Assurance and Improvement –Guidelines for Quality Improvement  Leadership  Information and analysis  Strategic quality planning  Human resources development and management

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Quality Assurance and Improvement –Guidelines for Quality Improvement  EMS process management  EMS system results  Satisfaction of patients and other stakeholders

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Quality Assurance and Improvement –Quality assurance (QA) program: maintains continuous monitoring and measurement of clinical care delivered to patients. –Problem-identifying mechanism

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Quality Assurance and Improvement –Continuous quality improvement (CQI): ongoing effort to refine and improve system in order to provide highest level of service possible. –Problem-solving methodology –Plan, do, check, act

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Quality Assurance and Improvement –Rules of Evidence  Must be a theoretical basis for change  Must be ample scientific human research to support the idea  Must be clinically important  Must be practical, affordable, teachable

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Quality Assurance and Improvement –Ethics: rules or standards that govern conduct of members of a particular group or profession. –Prehospital providers have ethical responsibility to patients and public.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Quality Assurance and Improvement –Customer satisfaction: service quality. –Medical errors:  Skills-based failures  Rules-based failures  Knowledge-based failures

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Quality Assurance and Improvement –High-risk areas of EMS practice:  Hand-off  Communications issues  Medication and airway issues  Dropping patients  Ambulance crashes  Spinal immobilization  Death pronouncements

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Quality Assurance and Improvement –EMS system must have clear protocols –Must be understood by all providers –Standardization and organization of drugs and their packaging helps to minimize medication errors. –Medical error prevention –When in doubt, ask for help.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Research –Component of EMS system for moral, educational, medical, financial, practical reasons. –Outcome studies required to justify funding and ensure future of EMS. –Paramedics play valuable role in data collection, evaluation, interpretation of research.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Evidence-Based Medicine (EBM) –Conscientious, explicit, judicious use of current best scientific evidence in making decisions about care of individual patients –EMS personnel proficient in prehospital care; exercise sound clinical judgment

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems Evidence-Based Medicine (EBM) –Be familiar with current and past research pertinent to prehospital care. –Be able to integrate that knowledge into care of patients. –Neither clinical experience nor external evidence alone is enough. –Ensures providing patients best care at lowest price

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems System Financing –EMS can be:  Hospital based  Fire or police department based  Municipal service  Private commercial business  Volunteer service  Some combination

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Today's EMS Systems System Financing –Fully tax-subsidized municipal systems –All-volunteer squads supported solely by contributions –Fee-for-service revenue (third-party payers) –Subsidized by local taxing entities

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Summary Evolution of EMS over thousands of years Many innovations result of lessons learned from military conflicts. EMS today result of federal legislation; investment from private foundations.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Summary EMS provides continuum of care. EMS is total team effort. EMS systems designed with patient as highest priority. Each system has administrative agency. EMS systems activated by single, universal number (911).

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Summary Centralized communications center Emergency response: BLS care less than 4 minutes; ALS care less than 8 minutes. Ground and air transport follows established protocols. Mutual-aid agreements ensure continuum of care during multiple- casualty incidents.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Summary Hospitals categorized according to readiness to provide essential or specialty services within region. EMS providers trained according to U.S. DOT Instructional Guidelines. Continuous quality improvement program documents EMS system's performance.

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Summary Ongoing research validates actions of prehospital providers through scientific evaluation. EMS systems need strong, stable financial plans.