EMERGENCY MEDICAL SERVICE SYSTEMS

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EMERGENCY MEDICAL SERVICE SYSTEMS
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EMS SYSTEMS COMPONENTS
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PREHOSPITAL COMPONENT

• Lay persons trained in CPR
• First Responders
• Emergency Medical Technicians
• Paramedics

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HOSPITAL COMPONENT

• Emergency nurses
• Emergency physicians
• Specialty physicians

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SUPPORT PERSONNEL

• Emergency medical dispatchers
• Law-enforcement personnel
• Firefighters
• Public-safety workers
• Respiratory therapists
• Other allied health technicians

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TEAM CONCEPT

• The EMS system depends on all components working
  together

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HISTORY OF EMS DEVELOPMENT
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PRE-1966 EMS

• Poorly trained driver/technicians
• Minimal equipment
• No physician involvement
• No radio communications
• No systematic approach

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THE WHITE PAPER

• 1966-Report published by the National Academy of
  Sciences. Emphasized the need for organized
  prehospital patient care
  
• Exposed deficiencies in emergency medical care
• Outlined suggestions for improvement

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FUNDING INITIATIVES

• 1966 National Highway Safety Act
• 1971White house Funding
• 1972 Robert Woods Johnson Foundation
• 1973 EMS Systems Act
• COBRA and the end of federal funding

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SYSTEMS APPROACH
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SYSTEMS ADMINISTRATION

• Local EMS agency
• Sets local policies
• Hires medical director
• Manages local resources
• Assures quality of service

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SYSTEMS ADMINISTRATION

• State EMS agency
• Allocates any state and federal funding
• Works for EMS legislation
• Certifies and licenses personnel
• Enforces rules and regulations

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MEDICAL CONTROL

• Medical director qualifications
• Experienced in emergency medicine
• Completed a training program in EMS systems
• Formally certified by government agency
• Frequently rides with field crews

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MEDICAL CONTROL

• Direct duties
• Direct communication with field personnel
• Intervener physician guidelines

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MEDICAL CONTROL

• Indirect duties
• Protocol development
• Triage
• Treatment
• Transport
• Transfer
• Special situations

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MEDICAL CONTROL

• Indirect duties cont.
• Oversee training and education
• Ensures quality assurance
• Systematic chart review
• Audit and evaluation

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PUBLIC INFORMATION AND EDUCATION
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RECOGNITION

• The problem of patient denial of symptoms
• Targeting coronary patients

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SYSTEMS ACCESS

• 911, E 911
• Single access vs. multiple-access numbers

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BASIC LIFE SUPPORT (BLS)

• Cardiopulmonary resuscitation
• Hemorrhage control
• Basic stabilization in trauma cases
• Future involvement e.g.., bystander
  defibrillation

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EMS COMMUNICATIONS
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EASY CITIZEN ACCESS

• Single access number 911, E 911, other
• Multiple access numbers

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COMMUNICATIONS CENTER

• To direct all emergency response agencies
• To coordinate communications between agencies
• To ensure system readiness at all times

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OPERATIONAL NETWORK

• Dispatcher to field units
• Field units to each other

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MEDICAL COMMUNICATIONS

• Field units to hospitals
• Biotelemetry capabilities
• Interhospital network

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COMMUNICATION HARDWARE

• Equipment and supplies
• Radios, antennae, etc.

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COMMUNICATION SOFTWARE

• Policies and procedures
• Designated frequencies
• Radio codes

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EMERGENCY MEDICAL DISPATCHING
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INTERROGATION PROTOCOLS

• Dispatchers medically interrogate the caller
• A standard set of questions are used
• Symptoms are prioritized
• Protocols are approved by the medical director

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RESPONSE CONFIGURATIONS

• Appropriate level of emergency response
• Number and type of personnel to respond
• Mode of response

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SYSTEMS STATUS MANAGEMENT

• Places ambulance for quickest response
• Based on projected call volume and locations
• Used to reduce response times

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PRE-ARRIVAL INSTRUCTIONS

• Life-saving instructions over the phone

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DISPATCHER TRAINING

• U.S. DOT training curriculum
• Formal certification by governmental agency

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DESIRED RESPONSE TIMES

• 4 minutes BLS (CPR)
• 8 minutes ALS (ACLS)

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EDUCATION AND CERTIFICATION
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ORIGINAL EDUCATION PROGRAMS

• Meet U.S. DOT minimum standards
• Classroom sessions
• Skills labs
• Hospital clinical rotations
• Field internships

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CONTINUING EDUCATION PROGRAMS

• Refresher courses
• In-service training
• Seminars
• Teaching days

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CERTIFICATION LEVELS

• First Responder
• EMT-Basic
• EMT-Intermediate
• EMT-Paramedic

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PATIENT TRANSPORTATION
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TRANSPORT TO APPROPRIATE FACILITY

• Not always the closest hospital
• Based on the needs of the patient
• Based on availability of resources
• Stabilization and transfer agreements
• Coordination by physician medical director

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GROUND TRANSPORTATION

• Equipment lists
• Basic Life Support vs. Advanced Life Support
• Regional standardization facilitates mutual aid
  and disaster response

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GROUND TRANSPORTATION

• The KKK-A-1822 standards
• 1974 ambulance designs ( Type I, II, III )
• Star of Life emblem for certified vehicles
• 1980 electrical improvements to reduce overload

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AIR TRANSPORT

• Developed out of wartime experiences, especially
  in Korea and Vietnam
  
• Permits rapid evacuation of critical civilian
  trauma patients
  
• 1970 MAST program used military helicopters and
  personnel to demonstrate feasibility of air
  transport in civilian applications
  
• Programs today use military, law enforcement,
  municipal, hospital-based, and private services
  
• Fixed -wing aircraft used for transport of more
  than 120 miles

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QUALITY ASSURANCE AND QUALITY IMPROVEMENT
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BACKGROUND FOR PROGRAMS

• To ensure the needs of the patient are met
• To reinforce quality of service by prehospital
  providers
  
• Definition of acceptable quality is excellence
• Programs must be comprehensive and ongoing

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QUALITY ASSURANCE

• Monitors and measures quality of clinical care
• Emphasizes evaluation of clinical data
• Documents effectiveness of care provided
• Helps identify areas that need improvement
• Too often viewed negatively by providers

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QUALITY IMPROVEMENT

• Focuses on customer perceptions of service
• Emphasizes customer satisfaction
• Recognizes, rewards, and reinforces good
  performance

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TAKE-IT-FOR-GRANTED

• Customers expect the best
• Best accomplished through education
• Clinical evaluation and improvement accomplished
  by following Rules of Evidence
  
• Theoretical basis for changes in systems
  practices
  
• Scientific human research must support changes
• Changes must be clinically important
• Changes must be practical, affordable, teachable

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SERVICE QUALITY DEALS WITH CUSTOMER SATISFACTION

• Enhanced through good communication
• More important than technical skills

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RESEARCH

• Provides answers to future questions
• What field interventions reduce mortality?
• Are the benefits worth the risks?
• What is the cost/benefit ratio of prehospital
  medicine?
  
• Is field stabilization possible?

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COMPONENTS OF A RESEARCH PROJECT

• Identify a problem and state a hypothesis
• Do a literature search
• Design the study
• Satisfy patient consent issue
• Begin the study/collect the data
• Correlate the data in a statistical application
• Write the paper, attempt to have the paper
  published

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RECEIVING FACILITIES
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HOSPITAL CATEGORIZATION

• Identifies hospital readiness in advance
• Speeds transport of victims to definitive care
  facilities

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SPECIALTY CENTERS

• Burn
• Trauma
• Pediatrics
• Perinatal
• Psychiatric

• Cardiac
• Neurological
• Poison control
• Resource hospitals

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RECEIVING HOSPITALS

• Should have
• Surgical facilities, critical care units
• Lab, X-ray, blood bank
• Willingness to participate in EMS systems
• Emergency physician on duty
• Willingness to receive all patients
• Willingness to conduct quality assurance
• Willingness to participate in MCI plans and drills

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MUTUAL AID/MASS CASUALTYPREPARATION REQUIREMENTS

• Central coordinating agency
• Integration of system components
• Frequent drills
• Expansion of the communications system
• Standardized regional resources

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SYSTEMS FINANCING
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SYSTEM DESIGN

• Hospital based
• Fire/rescue department
• Municipal third service
• Private commercial business
• Volunteer
• Combination

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FUNDING OPTIONS

• Tax subsidized
• Contributions/fundraising activities
• Corporate sponsorship
• Subscriber plans/prepaid HMO
• Medicare/Medicaid
• Private medical/auto insurance
• User pay
• Public Utility Model