1. Chapter 3 EMS Systems

2. Topics History of EMS Components of an EMS System
National Groups and Associations
NHTSA Standards

3. EMS System
A comprehensive network of personnel, equipment, and resources established to deliver aid and emergency medical care to the community.

4. Out-of-Hospital Components of an EMS System
Members of the Community
Communications System
EMS Providers
Public Utilities
Poison Control Centers
Fire
Rescue
Hazmat

5. Emergency and Specialty
In-Hospital Components of an EMS System
Emergency
Nurses
Emergency and Specialty
Physicians
Ancillary
Services
Rehabilitation

6. BLS
Refers to the basic life-saving procedures such as artificial ventilation and cardiopulmonary resuscitation.

7. ALS
Refers to advanced life-saving procedures such as intravenous therapy, drug therapy, intubation, and defibrillation.

8. Some systems are tiered: BLS arrives first and then, if required, ALS arrives later.

9. History of EMS
EMS systems have developed from the traditional and scientific beliefs of many cultures.

10. Ancient Times
First “protocols” established in Mesopotamia ≈ years ago
Evidence of medications, patient assessment techniques, and bandages were found on clay tablets

11. 18th Century – Napoleonic Wars
In 1797 Napoleon’s chief Physician, Jean Larrey, implemented a pre-hospital system designed to triage, treat, and transport the injured from the field, to aid stations
“the father of EMS”

12. Napoleonic Wars
Baron Dominique-Jean Larrey, came up with this idea of bringing lightweight 2-wheeled vehicles into a battlefield along with a team of surgeons they were called
“ambulance volantes”
A horse-drawn ambulance designed by Baron Larrey

13. Larrey developed the precepts used today
Field Treatment
Larrey developed the precepts used today
in EMS
rapid access to patients by trained personnel
field treatment and stabilization
rapid transport back to the medical facility
provide medical care en route
He also believed in immediate field amputations for badly injured or fractured extremities

14. Civil War
In 1861, during the American Civil War, ambulances were too few, often late, and driven by civilian drunkards and thieves.
A physician named Jonathan Letterman reorganized the field medical service to provide an effective ambulance service for the evacuation of battle casualties

15. Civil War
Many improvised hospitals emerged in barns, houses, and churches
Clara Barton organized the care of the injured in the field, organized the triage and transport

16. 1st Civilian Ambulance Service
Commercial Hospital - Cincinatti, Ohio 1865
Bellevue Hospita New York City Health Department 1869

17. In the first year alone, they responded to about 1,800 calls for help.
Ambulances were dispatched via telegraph from Bellevue Hospital’s Centre St. Branch
Ambulances were staffed with a highly trained surgeon (“ambulance surgeons”)
In the first year alone, they responded to about 1,800 calls for help.

18. Civilian Ambulance Service
As the call volume grew, and appropriate staffing was short, they would staff the ambulances with an orderly and sometimes a janitor, with little or NO medical training.
These people were simply called “ambulance drivers”

19. Twentieth Century WW1 had a high mortality rate
Average evacuation time of 18 hours
WWII had more organized care
Transportation more readily available due to motorized ambulances
Transportation to echelons of care
Still great distances

20. Korean and Vietnam conflicts
Soldiers treated in the field and evacuated to treatment centers (MASH)
Average field treatment to MASH minutes due to the introduction of military helicopters

21. Post-1960s Developments
Mortician-operated ambulances withdrew due to costs and demand for additional services.
Fire and police departments began providing EMS.
Growth of volunteer and independent local EMS provider agencies.

22. 1966
The National Highway Safety Act established the Department of Transportation which provided grants for EMS.
Publication of “Accidental Death and Disability: The Neglected Disease of Modern Society”
Highlighted deficiencies in prehospital emergency care
Set guidelines for development of EMS systems, training, ambulances, equipment

23. 1969
The EMT-Ambulance program was made public. The first paramedic curriculum followed in 1977.

24. These newly trained Paramedics often referred to themselves as the
Paramedic History
The first few Paramedics were trained in Unfortunately there were no laws that allowed non-physicians to administer ALS.
These newly trained Paramedics often referred to themselves as the
“Impotent Wonders”

25. 1971
White House issued $9 million in EMS grants for EMS demonstration projects.
Designed to be models for subsequent system development
President Richard Nixon was the strong advocate behind the funding!

26. 1972
The Department of Health, Education, & Welfare funded initiatives to develop regional systems.

27. EMS Systems Act of 1973
Provided funding for a series of trauma projects
$300 million allocated to study EMS planning, operations, expansion, and research
Continued funding for regional systems until 1981

28. To be eligible for funding a system must address:
Manpower
Training
Communications
Critical Care Units
Public
Safety
Agencies
Consumer Participation
Transportation
Access to Care
Disaster
Plans
Emergency Facilities
Patient Transfer
Mutual Aid
Standardized Recordkeeping
Public Information and Education
System Review and Evaluation

29. Two Items the Legislation Omitted:
System finance
Medical direction
Two very critical items to function in an EMS system!

30. 1977 First EMT-Paramedic curriculum was developed.
One of the first Paramedic students in LA County

31. 1981
The passage of the Consolidated Omnibus Budget Reconciliation Act (COBRA) wiped out federal EMS funding.

32. 1988 – Statewide Technical Assessment Program
Elements necessary to all EMS systems:
Regulation
Resources management
Human resources/training
Transportation
Facilities
Communications
Trauma systems
Public information
Medical direction
Evaluation

33. EMS Agenda for the Future
Published in 1996 as a comprehensive evaluation of the history of EMS
Casts a vision for the future for EMS in the United States

34. Continued Development of 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

35. Today’s EMS System
Every EMS system must develop a system that best meets its needs.
State- and regional-level EMS systems are often responsible for planning, developing protocols, and establishing standards.

36. Medical Direction (1 of 2)
A medical director is a physician who is legally responsible for all clinical aspects of the system.

37. Medical Direction (2 of 2)
The medical director’s role in a system is to:
Educate and train personnel or their designee
Participate in equipment and personnel selection
Develop clinical/system protocols
Participate in problem resolution and quality improvement
Provide direct input into patient care
Interface with the EMS system
Advocate within the medical community
Serve as the “medical conscience” of the EMS system

38. The medical director can provide on-line guidance to EMS personnel in the field. This is known as on-line medical direction.

39. Off-line medical direction refers to medical policies, procedures, and practices that medical direction has set up in advance of a call, such as standard protocols or standing orders.

40. Protocols are the policies and procedures for all elements of an EMS system.

41. Protocols are designed around the four Ts of emergency care:
Triage
Treatment
Transport
Transfer

42. Public Education
An essential and often overlooked component of EMS is the public.
EMS systems should develop plans to educate the public on recognizing an emergency.
Accessing the system
Initiating BLS procedures

43. Communications
A coordinated, flexible communications plan should include:
Citizen access
Single control center
Operation communication capabilities
Medical communication capabilities
Communications hardware
Communications software

44. Emergency Medical Dispatcher (EMD)
The activities of an EMD are crucial to the efficient operation of EMS.
EMDs not only send ambulances to scenes, they also make sure that system resources are in constant readiness.
EMDs must be medically and technically trained.

45. Education and Certification
Two kinds of EMS education are initial and continuing education.
Initial education is the original training course for prehospital providers.
Continuing education programs include refresher courses for recertification and periodic in-service training sessions.

46. Initial Education
Based on the EMT-Paramedic: National Standard Curriculum published by the U.S. DOT
Establishes the minimum content for the course
Divided into 3 specific learning domains
Cognitive
Affective
Psychomotor

47. Once the initial education is completed, the paramedic will become either certified or licensed.

48. Certification vs. Licensure
Certification is the process by which an agency grants recognition to an individual who has met its qualifications.
Licensure is the process of occupational regulation.

49. 4 Certification Levels First Responder
Emergency Medical Technician-Basic
Emergency Medical Technician-Intermediate
Emergency Medical Technician-Paramedic

50. The First Responder is usually the first EMS-trained provider to arrive on the scene.

51. The EMT-Basic is trained to do all that a First Responder can do, plus other complex skills.

52. The EMT-I should possess all the skills of an EMT-B and be competent in advanced airway, IV therapy, and other skills.

53. The EMT-P is the most advanced EMS provider.

54. Members of EMS are filling a growing number of nontraditional roles:
Critical care transport
Industrial or occupational EMS
Tactical EMS
Primary care

55. National Registry of EMTs (NREMT)
Prepares and administers standardized tests for the First Responder, EMT-Basic, EMT- Intermediate, and EMT-Paramedic
Establishes the qualifications for registration and re-registration, and for establishing a minimal standard of competency

56. National Registry of EMTs (NREMT)
Not recognized in the state of Massachusetts
NCTI is registered as a certified training institution once student passes state exam
Can register with the NREMT to obtain NR status after receiving certification from the state

57. Belonging to a professional organization is a good way to keep informed about the latest technology.

58. Professional Organizations Include:
National Association of EMTs
National Association of Search and Rescue
National Association of State EMS Directors
National Association of EMS Physicians
National Flight Paramedics Association
National Council of State EMS Training Coordinators
National Association of EMS Educators

59. A variety of journals are available to keep the paramedic aware of the latest changes in this ever-changing industry.

60. These Professional Journals Include:
Annals of Emergency Medicine
Emergency Medical Services
Prehospital Emergency Care
Journal of Emergency Medical Services
Journal of Emergency Medicine

61. Patient Transportation
Patients should be taken to the nearest facility whenever possible.
Medical direction should designate the facility.
Patients may be transported by ground or air.

62. The helicopter has become an integral part of prehospital care.

63. Military helicopters frequently assist civilian EMS systems.

64. A Type I Ambulance

65. A Type II Ambulance

66. A Type III Ambulance

67. Not all receiving facilities are equal in emergency and support service capabilities. Local systems and regions categorize hospitals based on capabilities.

68. Mutual Aid and Mass-Casualty Preparation
A formalized mutual aid agreement ensures that help is available when needed.
Agreements should be between neighboring departments, municipalities, systems, or states.
Each system should also put a disaster plan in place for catastrophes that can overwhelm available resources.

69. An EMS system should have a disaster plan in place that is practiced frequently.

70. Quality Assurance and Improvement
Quality Assurance is designed to maintain continuous monitoring and measurement of the quality of clinical care.
Continuous Quality Improvement (CQI) is designed to refine and improve an EMS system, emphasizing customer satisfaction.

71. An EMS system must be designed to meet the needs of the patient
An EMS system must be designed to meet the needs of the patient. Therefore, the only acceptable quality of an EMS system is EXCELLENCE!

72. Customer satisfaction can be created or destroyed with a simple word or deed.

73. Research (1 of 2)
Research programs are essential for moral, educational, medical, financial, and practical reasons.
Future EMS research must address the following issues:
Which interventions actually reduce morbidity and mortality?
Are the benefits of a procedure worth the risk?
What is the cost-benefit ratio?

74. Research (2 of 2)
Has your organization participated in research?

75. The Components of a Research Program (1 of 2)
Identify a problem.
Identify the body of knowledge on the subject.
Select the best design for the study.
Begin the study and collect raw data.

76. The Components of a Research Program (2 of 2)
Analyze the data.
Assess and evaluate the results.
Write a concise, comprehensive description of the study for publication in a medical journal.

77. Evidence-Based Medicine (EBM)
Current standards accepted by physicians and other health care providers in clinical medicine
Conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients
Combines clinical expertise with the best available clinical evidence from systematic research

78. System Financing EMS funding can come from a variety of sources.
Fee-for-service from Medicare, Medicaid, private insurance companies, or private paying patients is common.
Public Utility Models are becoming increasingly popular.

79. Summary History of EMS Components of an EMS System
National Groups and Associations
NHTSA Standards