Original Contribution

What a Prehospital Care System Needs

08/10/2009

Prehospital emergency care is a vital public service, but for systems to function adequately, they must have certain elements available and working in coordination. We know what these elements are: In 1973 the U.S. Congress enacted the Emergency Medical Services Systems Act, which, in funding EMS systems throughout the country, identified 15 components as essential to EMS systems. These were: communications, training, manpower, mutual aid, transportation, accessibility, facilities, critical care units, transfer of care, consumer participation, public education, public safety agencies, standard medical records, independent review and evaluation, and disaster linkage.

We have developed a proposal for a prehospital system assessment and analysis matrix that utilizes six essential/universal prehospital system elements derived from the components proposed in the EMS Systems Act and the National Highway Traffic Safety Administration's 1998 EMS Agenda for the Future. Considering active global prehospital emergency medicine and prehospital care development efforts, we hope this matrix can assist international prehospital experts and system planners in their work.

Introduction

Prehospital EMS is a vital public service. Modern western prehospital care systems were developed from the need to respond and provide immediate care in trauma and cardiovascular emergencies. One consequence of modern globalization is an increased incidence of traumatic and cardiac-related emergencies in developing countries, as they struggle with rapid urbanization and industrialization. As noted, early access to and public participation in the emergency care system is of great importance to these nascent international systems.

Adequate functioning of prehospital care systems depends on the availability and coordination of different elements. These elements include an informed public capable of recognizing medical emergencies, a network of ambulances and transport units able to provide specialized care to the most seriously ill or injured, a universal emergency number, and well-trained prehospital and emergency department personnel.

Historical Perspective on U.S. Prehospital Care Systems

Between 1963 and 1966, the National Academy of Sciences convened a group of experts to discuss the public health concerns of trauma in the United States. Their findings were published in 1966.¹ This landmark publication led to the development of organized prehospital care systems in the United States. Soldiers injured on the battlefields of Vietnam, they noted, received faster medical care than those injured in motor vehicle accidents on U.S. highways, and more people died in the United States in motor vehicle accidents each year at the time than died during the entire Korean War.

The 1966 National Highway Safety Act authorized the Department of Transportation to fund communication and education for EMS, as well as purchases of ambulances and equipment. Nearly a decade later, Congress enacted the Emergency Medical Services Systems Act of 1973, which funded and authorized the Department of Health, Education and Welfare to develop EMS systems throughout the country.² As part of this systematic approach to EMS care, authorities designated more than 300 regional EMS management entities. The law identified the 15 components listed in Table 1 as essential to EMS systems. Later, in 1998, the National Highway Traffic Safety Administration developed the Emergency Medical Services Agenda for the Future,³ which described attributes of EMS systems essentially derived from proposed elements of the EMS Act (Table 2).

Proposed Comparative Analysis Matrix

We propose an assessment and analysis matrix to be used for developing international prehospital care systems. The tool is based on six essential universal prehospital system elements derived from the EMS Systems Act and Agenda for the Future. The matrix utilizes the elements of public education and consumer participation; accessibility and communications; manpower and training; response time and transportation; quality assurance and medical supervision; and disaster management and emergency response (see Table 3). The matrix needs to integrate these six essential elements and analyze them in the context of current standards, system observations and recommendations for improvement/change. This method allows a thorough systematic evaluation with potential for a comprehensive overview of strengths and elements that require improvement.

Discussion

The prehospital care system was initially developed to respond and provide immediate care to trauma and cardiovascular emergencies. Today EMS providers' scope of practice is much broader, but the essential principle is still the same: to provide prompt medical care to those in need. Out-of-hospital care is the initial link for emergency care systems and in some studies has demonstrated to be an important determinant of patient outcomes in cardiac arrest.^4,5 In cases of trauma, the importance of accessing care within the first hour post-injury has been a fundamental tenet of system planning for 30 years.^6-10

Historically, the first publication that described the need for the development of an integrated and organized trauma system was the 1966 document Accidental Death and Disability: The Neglected Disease of Modern Society.¹ Many developing countries are experiencing a greater need for prehospital systems because of urbanization and changing population demographics, leading to greater death rates from trauma and cardiac illnesses. While emergency medical services systems may take a variety of forms, they usually contain some components similar to those found in the United States, with authors suggesting utilizing U.S. system elements for assessment and development efforts.^11,12 In evaluating EMS abroad, it may be useful to compare developing systems with current and acceptable international standards. Developing such an approach can lead to creative and effective solutions for prehospital care assessment in countries with developing systems. Our assessment matrix can complement such a process, offering an objective evaluation tool for system development and comparative analysis.

Conclusion

Considering active global prehospital emergency medicine efforts, we hope this universal assessment matrix can assist prehospital public health experts and system planners in their development and comparative analysis efforts. This tool should be validated in an effort to objectively understand its utility and practicality.

Table 1: 15 Elements of EMS, from the 1973 EMS Systems Act

Communications
Training
Manpower
Mutual aid
Transportation
Accessibility
Facilities
Critical care units
Transfer of care
Consumer participation
Public education
Public safety agencies
Standard medical records
Independent review and evaluation
Disaster Linkage

Table 2: 14 Attributes of EMS Systems, from the Agenda for the Future

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

Table 3: Needs Assessment and Comparative Analysis Matrix

1. System element: Public education and consumer participation

Current standards: Readily available public education programs; educated consumer standards

City/system observations: [user fills in]