Resource Management
Resource management involves placing vehicles and personnel in a position to provide the most expeditious response to an emergency. Some communities require, through contract or regulation, a minimal response time. While there is not a national standard response time, many EMS services have accepted a 6- to 10-minute response time. This time is consistent with cardiac arrest studies that indicate the greatest likelihood of return of spontaneous circulation (ROSC) is within 6 to 10 minutes of cardiac arrest.
Traditionally EMS was stationed in standing facilities and many EMS services still utilize this fixed-post staffing method of resource distribution. Using squad buildings, ambulance bays, or fire stations, ambulances respond from these centrally located stations to calls for emergency medical service.
Some EMS services have gone to a dynamic posting method called system status management (SSM) or event-driven deployment. Instead of posting in fixed locations, such as a fire house, the ambulances or emergency response vehicles are "on-the-road" moving to new locations, or posts, that optimize response times. The decision of where to post these resources is typically made after an analysis of historical data of call volume and knowledge of geography and traffic conditions.
Still other systems, trying to combine fixed-post staffing with system status management, provide peak-load staffing. During predictable hours of high demand, additional ambulances are placed in-service at strategic locations.
Specialization
Unique environments, certain occupations, and special circumstances require specially trained Paramedics. Over a dozen subspecialties have been created in EMS. The following are short descriptions of some of the notable subspecialties.
A growing subspecialty in EMS is the area of Specialty Care Transport (SCT). Called to transport sick and injured patients from outlying clinics and critical access hospitals to tertiary care centers, such as trauma centers and cardiac centers, for example, these Paramedics perform critical care interfacility transportation.
Many consider the flight Paramedic as the most highly trained level of EMS provider.51-53 Flight Paramedics transport critically ill patients in either fixed-wing aircraft or rotor aircraft from scenes or other facilities to definitive care. Upon completion of advanced EMS education, with emphasis on critical care medicine and flight medicine, flight Paramedics may test to become certified flight Paramedics.
Frontier/rural Paramedics and woodlands search and rescue teams are tasked with providing patient care in wilderness areas. The Wilderness EMT (WEMT) has special training that fosters critical thinking as well as creativity in an environment where supplies may be limited and patient transport to definitive care prolonged.
Paramedics who provide EMS in a rural setting often have different circumstances and more difficult obstacles to overcome than their counterparts in the city. To prepare for these emergencies many Paramedics take the FarMedic® course, which is specifically directed to the farm emergency. The FarMedic® course teaches how to care for a patient under an overturned tractor (Figure 2-10) and a number of other rural emergencies.
Another area of EMS specialization is medical support for special weapons and tactics (SWAT) teams. Despite careful planning and preparation, casualties do occur in these highly charged operations. Tactical EMS (TEMS) providers are trained on how to provide care to the wounded while in hostile surroundings as well as maintain the health of the SWAT team members on prolonged operations.
Information Systems
In the age of computers EMS began to incorporate information systems into patient care. From electronic patient care reports that are capable of being transmitted prior to the arrival of the ambulance to integrated information systems that permit inter and intra-agency communications, EMS systems are embracing information technology.
Some new challenges have also been presented with this new technology. Patient confidentiality, a fundamental tenet of patient care, is at greater risk for inadvertent disclosure. Recent federal legislation, the Health Insurance Portability and Accountability Act (HIPAA), has placed conditions upon all healthcare providers that protect patient privacy during claims processing, data analysis, utilization review, quality assurance, and practice management.54-59
Integration of Health Services
EMS does not operate independently but is a link between the public and the rest of the healthcare continuum. EMS can be seen as one of the doors to health care, a system within a system. The seamless transition of care from the streets to the hospital ensures the continuation of quality medical care.
A number of healthcare "stakeholders" depend on EMS. Social service workers depend on the assistance of Paramedics to report child abuse, domestic violence, and elder abuse. Trauma surgeons depend on Paramedics to expeditiously transport trauma patients to definitive care at the trauma center. Cardiologists have an interest in the provision of advanced life support and stabilization of cardiac patients in the field, including the identification of high-risk patients using 12-lead ECG.
Figure 2-10 Disentangling a patient under an overturned tractor.
Medical Direction
In 1989, the American College of Emergency Physicians (ACEP) published a position paper, "The Principles of EMS Systems," which called for strong physician involvement in prehospital medicine as well as the active participation of physicians in EMS.
Terms such as medical oversight and medical command illustrate the direct control that a physician has over a Paramedic’s practice.
Medical oversight is present whenever a physician is involved in the quality assurance/quality improvement process and provides direction, either in the form of protocols or education, to Paramedics. This medical oversight is often retrospective and may be remedial in nature.
Medical command implies a more immediate and direct involvement in patient care. The physician’s authority can be exercised either on-scene or over-the-air at the time of an emergency, referred to as on-line medical control. Physicians can give medical direction via the base radio and exercise medical command (Figure 2-11).
More commonly, the physician’s authority is exerted through a written set of instructions, called protocols. The protocols can be used by the Paramedic in specific situations in the absence of the physician.65-67 These preauthorized medical orders, or standing orders, are often given to Paramedics in a flowchart format called an algorithm. An algorithm is a logic tree that simply states: if this, then do that; if not this, then do this other thing. Algorithms can be useful during an emergency when time is of the essence.
Figure 2-11 Radio communications permit the physician to have direct access and control of the Paramedic in the field.
Finance Systems
The means of financing EMS systems is typically driven by community capabilities. For example, a fire-based EMS system may be supported, in part or in whole, from property taxes, whereas a volunteer EMS rescue squad may receive its funds from taxes collected in a special district similar to a fire district. Other volunteer ambulances or fire districts may depend on community generosity by seeking donations.
The majority of EMS—be it commercial, hospital-based, or any other configuration—is funded by billing a fee-for-service. In a fee-for-service system, the patient is billed a charge that is customary for such a service in the area. Payment for ambulance service may come from the patient but is usually paid by the patient’s health insurance.
One of the largest payers for EMS is Medicare. Medicare reimbursement is paid according to a schedule established by the Centers for Medicaid and Medicare Services (CMS) which is part of the federal Department of Health and Human Services.
Grants for special projects or research are also available to EMS services from government agencies or groups (e.g., the Centers for Disease Control and Prevention (CDC), the Maternal and Child Health Bureau, or the EMS for Children program).
One of the difficulties facing EMS is the inconsistency in funding. Driven by patient transportation, as opposed to the emergency medical care provided, payments have been erratic and undependable. The CMS has attempted to modify the federal Medicare rules to account for not just transportation but emergency medical care as well.
Some health insurance organizations have tried to eliminate payments by limiting the definition of a medical emergency to these conditions, listed in a discharge diagnosis, that without immediate care and treatment would result in harm to the patient’s health. Any medical condition that does not fall under this definition and could have been treated later and at less expense to the insurance company is thus not a covered condition. This limited retrospective view of an emergency fails to take into account the patient’s fears and anxiety when suddenly faced with an unknown illness or injury.
Many health insurance carriers have adopted a more flexible and a reasonable approach to defining an emergency. These organizations use the prudent layperson standard to establish medical necessity. The prudent layperson standard simply places the proverbial "average person" in the situation and asks if that average person would reasonably think, under those conditions, that this problem was an emergency.68-72 This approach allows for the inclusion of human factors such as fear and anxiety.
National Healthcare Systems
Medical care in the majority of the world is a government-operated enterprise, a social welfare system of sorts which ensures the health and well-being of the citizens within its borders.
Health care in the United States is more of a medley of private payment and public funds, private physicians, and government-run treatment centers. This unique blend of different approaches to healthcare delivery has resulted in a healthcare system that provides numerous opportunities, as well as remarkable inefficiencies.
Previously the majority of health care was provided on a fee for service basis, or pay as you go, with a certain amount of medical care provided gratis to the poor or uninsured. However, the pressures of modern economics have generally encouraged all healthcare providers to embrace the concept of managed health care.
Managed health care is a system where there is a purchaser of services, such as a large corporation or the government. The purchaser in turn obtains health insurance for its workers via private sources, such as Blue Cross/Blue Shield, or governmental sources, such as state-run Medicaid or federal Medicare programs.
These insurers then gather groups of healthcare providers—physicians as well as allied healthcare providers—and obtain a reduced rate in exchange for a guaranteed client base. These savings could only be possible because of the economies of scale. The managed healthcare insurance plan then mandates that patients seek treatment from this preferred medical group, in essence managing the care that the patient will receive by providing medical care for the lowest price.
A multiplicity of managed care arrangements exist. However, generally managed care can be broken down into three basic configurations.
The first and earliest system is the health maintenance organization (HMO). The HMO provides payments to healthcare providers at a negotiated annual per capita rate. These rates are based on practice history of the insured patients and helps to prevent fluctuations in payments, thus making expenses, costs, and budgets more predictable.
The next configuration is the preferred provider organization (PPO), a modified fee-for-service schedule, that permits patients to choose their healthcare provider from amongst a roster. Although there is increased flexibility for the patient with the PPO, some limitations still exist in terms of the patient’s choice of provider if not on the roster.
The last configuration is called point of service (POS). POS has qualities of both an HMO and a PPO. In a POS program the patient is allowed to choose a healthcare provider from amongst a list of preferred care providers (PCP) but may elect to see another "out of system" provider, without a referral, at a substantially higher copayment and/or deductible, similar to a fee-for-service arrangement. The employer, in turn, gets the advantages of cost savings whenever the patient/employee participates in the managed care program. The POS is gaining increasing popularity with patients and employers alike.
Conclusion
From its early beginnings, when hearses were used as ambulances and the patient might be lucky enough to have an ambulance driver with basic first aid training, EMS has evolved into a highly complex system of emergency responders who provide the public with an emergency medical safety net and who work as part of the larger healthcare system.
KEY POINTS:
• Emergency Medical Services (EMS) became recognized as part of the public health services in the late 1960s.
• The historical evolution of American health care began with physicians making house calls to treat the sick and injured.
• Following World War II, medicine began to concentrate less on infectious diseases and more on chronic diseases, such as cancer, stroke, and heart disease.
• Health insurance made it more affordable to receive health care. However, technology has significantly increased costs. To curb rising costs, the federal government has taken a greater role in healthcare policymaking.
• Public health was advanced by nurses who sought to improve sanitation and decrease morbidity and mortality as a result of infectious diseases.
• The Public Health Service is a key portion of the Department of Health and Human Services overseen by the Surgeon General.
• Deriving from once crude horse-drawn carriages used as far back as Roman times, the concept of the ambulance developed from the trials of several wars.
• While the tools of war became more devastating, the field care of soldiers improved. During the American Civil War the military field medical service was reorganized and became the forerunner of the modern trauma system.
• Stemming from the Geneva Convention in 1864 the American Red Cross, founded by Clara Barton, was created to provide aid in a time of war to the sick and wounded of the armed forces.
• Hospital-based civilian ambulance services began to appear in the United States during the 1860s.
• The emergence of civilian EMS came from the first volunteer rescue squad in Virginia, 1921. Many of these "independent," or non-hospital-based services, developed from local volunteer fire departments.
• A paradigm shift occurred as ambulances were seen as more than just fast rides but rather as a way to deliver faster medical care to the patient.
• The White Paper addressed public health concerns regarding traffic accidents and led to the development of stronger educational programs for emergency care providers.
• New drug therapies and defibrillators developed as a result of research in sudden cardiac death.
• Television helped demonstrate the role of emergency services to the public.
• The EMS Act of 1973 amended the Public Health Service Act of 1944 and outlined needed improvements in the EMS system.
• The National EMS Education Agenda for the Future established a core content, scope of practice, educational standards, accreditation, and certification.
• National EMS Core Content listed the knowledge and skills necessary for the provision of emergency care.
• The National EMS Scope of Practice delineated the four levels of EMS providers.
• Replacing the National Standard Curriculum, the National EMS Education Standards serve as the basis for EMS instruction and provide direction for EMS educators.
• EMS Education Program Accreditation assures students that their education meets national standards.
• A license is issued by a state, giving the license holder the right to perform a function.
• Completion of a specific educational program leads to certification.
• The EMS system provides a coordinated response of resources with other public safety agencies. The EMS system also constitutes a vital link with the rest of the healthcare system by providing rapid response and emergency treatment.
• Expectations of performance for each provider are maintained through the state medical practice act and physician oversight.
• The 9-1-1 system created a public safety access point (PSAP) to provide immediate public assistance.
• A wide variety of EMS system configurations provide EMS to communities ranging from urban to rural.
• Resource management involves placing vehicles and personnel in a position to provide the most expeditious response to an emergency.
• Subspecialties exist in EMS. Some include training as a Specialty Care Transport (SCT), Flight Paramedic, Wilderness EMT, or Tactical EMS.
• EMS systems use information technology to incorporate information systems into patient care.
• A key component to an EMS system is medical oversight and command performed by emergency physicians.
• In a fee-for-service billing system, the patient is billed for service but the cost is usually covered by the patient’s health insurance. Most EMS systems are funded this way with Medicare being the largest payer.
• A health maintenance organization (HMO) provides payment to a specified group of healthcare providers at a negotiated annual rate in turn for health care for employees.
• The preferred provider organization (PPO) is similar to a HMO but permits patients to choose their healthcare provider from among a roster.
• A point of service (POS) configuration contains qualities of both an HMO and PPO by allowing patients to choose a healthcare provider or see another "out of system" provider without referral.
