The Case for a National EMS Model

Weston K. Davis

West Texas A&M

1

Abstract

Emergency Medical Services (EMS) is an important link for the sick and injured to

definitive care. EMS services extend beyond the emergency healthcare needs of the

public. In the United States EMS is a fragmented system with no concise federal

leadership. Patient care outcomes, reciprocity, funding, and recognition are all major

problems facing EMS organizations today. There are many questions as to how a

national EMS model will work, who will pay for it, what are the benefits, and how does

the profession get there? The author compiled much of the work in the EMS field in the

area of creating a national EMS model with a lead federal agency. The overwhelming

response from leaders in the EMS community is that federal leadership is greatly desired

and needed in this profession. The findings all point to the need for a lead federal agency

contained in a national EMS model. This federal leadership will solve many of the

problems in EMS today. These solutions will be for the betterment of everyone involved

in pre-hospital medicine.

2

Theory

EMS has a rich history of coming together to provide care for the sick and

injured. Modern EMS has been doing things the way those before them have for many

reasons. Few things have changed in EMS throughout the years, and this is a problem.

Many of the problems with EMS come from lack of centralized leadership. EMS today

needs strong federal leadership based on a national EMS model. This model will provide

a roadmap for improving a broken system. Positive change must occur in EMS in order

to provide high quality patient care in the future. Without major changes to the field they

will be stuck in the past without advancement. Cultural and operational changes must be

implemented to propel EMS to where it should be in the mind of the public. Top leaders

in the profession have come together to give emergency medical technicians (EMT’s) a

master plan of success in their profession. This plan must be followed or EMT’s will

continue to be step children of a broken system.

3

Introduction

Currently in the United States, emergency medical services (EMS) are provided

by several types and sizes of providers. Cities, counties, private services, and hospitals

all provide EMS services in each state. Each type of provider in each state works from

different laws, regulations, and guidelines. EMS is a highly fragmented system without

clear federal leadership.

In the United States each state is responsible for setting the certification level for

EMT’s. Each level of certification can provide varying levels of care from first

responder at the lowest level to paramedic at the highest. Most states have vast

differences in the skills each level of EMT can provide. It is generally a requirement for

all ambulances to be staffed with a combination of two certified personnel.

The Federal Emergency Management Administration (FEMA) oversees

emergency and disaster mitigation in the United States. FEMA does not play a role in

day to day EMS operations as it does with the fire service. It does make sense, however,

to have a federal EMS agency under FEMA. With EMS aligned under FEMA it will

provide a national one stop for emergency services in the United States.

Many national EMS organizations have proposed plans, white papers, and

presentations that call for a national EMS model. The leadership in EMS wants to bring

about major change to the profession. This author will ask questions of the reports and

plans along with presenting whether a national EMS model is needed.

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Research Questions

There are several questions that need to be addressed as to why there is no

national EMS model. It will be examined why putting such a model into place has been

such a problem in the EMS field. There have been many efforts toward a national EMS

model since the inception of modern EMS in the 1960s (NHTSA, 2007, p.6). An

important question to ask is what all has been done thus far toward creating a national

EMS model? The question of why there is not a national EMS model must be asked.

Patient outcomes in EMS can vary widely with many variables across the nation.

The profession needs to find out why there are different outcomes based on location,

treatments, and transport variables. There are many case studies that compare the

differences between rural versus metropolitan EMS. Generally studies about EMS have

very wide differences in patient care outcomes. Perhaps if there is a national EMS model

these differences can be identified and worked through in order to provide a better

service. The prevalence of physician involvement in EMS will be examined and why

that needs to change.

Does the culture in EMS need better direction in order to bring about much

needed change? This will be a look at how a change can occur in organizations that are

based on decades of conformity. Since the inception of EMS it has been a fragmented

system. This fragmentation allows them to fully explore their skills, knowledge, and

experience. However, this fragmentation causes many of the problems discussed here.

The incentives that EMS personnel have to bring about change will be evaluated. Why

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would personnel want to do more work than what is necessary in order to improve their

profession?

A proposal of how to manage a national EMS model will be discussed. Anytime

there is major change in a profession there must be a roadmap for its success. In order to

understand how to manage such a system perhaps EMS personnel should look toward

other public service agency’s models for answers. Once a system is proposed and put

into place how does everyone that is currently fragmented work together? There will be

many challenges to work through for a national model to work.

Lastly the benefits of a national EMS model will be presented. What is the

expected long term result of this major change? Will pre-hospital care improve?

Currently EMS receives very little public recognition as compared to fire and police

organizations. Will this problem change with a national model? With a national model

and federal representation will EMS funding in improve as well? With a louder voice

and presence it would seem as though EMS would benefit from a national EMS model.

6

Research Analysis

On December 15, 2003 a report was given to President George W. Bush from a

federal advisory panel calling for a national EMS agency (Federal, 2003, p. 1). The

group pointed out how the fire service and law enforcement both had lead federal

agencies. Currently in the United States there is no lead federal EMS agency. The group

said that the primary objectives of a lead federal agency would be funding and

operational issues of EMS (Federal, 2003, p. 1). Donald Walsh sums up the argument for

a lead federal agency by stating:

“We need to have a common direction for EMT’s and paramedics to follow.

Today, that direction is coming from a diverse and frequently inconsistent group

of local, federal, and state entities, physicians, and others.” (Federal, 2003, p. 1)

The work by Walsh and his peers on the advisory board has been great news for those in

the EMS community. The advisory board has received tremendous national support for

championing the cause of EMS (Federal, 2003, p. 1).

More recently on December 16, 2010 Congressman Tim Walz and

Congresswoman Sue Myrick introduced a bill to bring about a national EMS model

(Myrick, 2010, p. 1). The bill goes on to show what EMS has done for the nation and

why it is important to have a national EMS model. The bill puts forth a lead federal

agency for EMS and calls for finding ways of funding EMS in the future (Myrick, 2010,

p. 2). The bill, if passed, would mean huge advances in the EMS profession. The

advances that have been seen in the fire services due to the United States Fire

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Administration could be replicated with an EMS agency. During the 111th congress the

bill was sent to committee where it died. The bill is expected to be reintroduced in the

future (Doyle, 2011, p. 1).

The most recent call for a national EMS model came on February 14, 2011 from a

joint white paper penned by the International Association of Emergency Medical

Services Chiefs (IAEMSA) and the Emergency Medical Service Labor Alliance

(EMSLA). The white paper recommends a Federal EMS Administration within the

Department of Homeland Security be created (Orsino, 2011, p. 15). The group presents a

case for: (1) National EMS systems improvement, (2) National core mission role of EMS,

(3) Expanded health care mission, and (4) EMS funding (Orsino, 2011, p. 16). President

of EMSLA Jamie Orsino argues that their white paper is something that “everyone in

EMS has already agreed to for a long time” (Doyle, 2011, p. 1). The white paper,

anticipated new bill, and the discussion in the EMS community brings about much

anticipation of great things to come for EMS (Doyle, 2011, p. 1).

Currently in EMS none of the previous efforts have resulted in a national EMS

model or the creation of a lead federal EMS agency. The EMS community will have to

wait and see if any efforts will be provided in the 112th session of congress and beyond.

To date there has been no more solid progress toward a national EMS model.

Currently in EMS the outcomes of patients vary greatly due to where the

emergency happens and who responds to that emergency. There are several factors why

patient outcomes vary greatly. In order to properly evaluate changes in outcomes there

must be a uniform data set, which is not currently available.

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Upon looking at cardiac arrest data it becomes obvious that there is not a true way

to thoroughly evaluate EMS data. A fragmented EMS system prevents true evaluation of

relevant data. Mickey Eisenberg shows that there is no national data set for resuscitations

in the United States (Eisenberg, 2011). The paper put out by Eisenberg shows many

areas that cardiac arrest survival rates could improve with a national standard. Eisenberg

argues that national cardiac arrest standards should be “mandatory” (Eisenberg, 2011). In

his paper Survive Cardiac Arrest Eisenberg shows that EMS must have national research

databases, just like many other professions (Eisenberg, 2011). If there is a national EMS

clearinghouse of data then EMS research can actually move forward.

The white paper put forth by the IAEMSA and EMSLA discusses some possible

reasons why there are disparities in EMS outcomes. The groups make a correlation

between transports and revenue (Orsino, 2011, p. 8). It is reported that in areas that make

less transports there is less funding and vice versa in areas with more transports. The

groups argue that calling 911 in an area that is not able to handle your emergency should

not happen. If there was a national EMS model citizens would not see issues of getting

better care based on where you happen to be. IAEMSA and EMSLA cite a study from

USA Today in 2005 that showed major disparities in cardiac arrest survival rates (Orsino,

2011, p. 8). It was shown that the data varied greatly geographically and that many areas

did not even track data.

Dealing with improving patient outcomes has been a long and arduous battle for

those wanting a national EMS model. It is assumed that with cardiac arrest alone if every

American received the same care 2,265 lives could be saved annually (Orsino, 2011, p.

8). If the assumptions of IAEMSA and EMSLA are correct the nation could see lower

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healthcare costs overall (Orsino, 2011, p. 9). Through better data collection and a

national standard patient outcomes are bound to be more favorable.

In order to bring about major change in the EMS profession there must change the

attitude of “we have always done it this way”. This is a long standing expression of

many in the EMS field. The EMS field must start doing operations with evidence based

guidelines (Gotschall, 2010, p. 1). EMS needs to evaluate what is being done; and what

changes, if any, need to be made in the field.

EMS personnel have a culture that needs change in order for a national EMS

model to work. The public looks for EMS personnel to solve their problems and take

care of them (HHS, 2004, p. 10). The EMS community needs to share information with

each other in order to measure outcomes. If personnel know that their help will provide

dividends in the future of the profession perhaps they will participate. EMS

organizations must be willing to participate with other healthcare providers (Gotschall,

2010, p. 2). The work with hospitals, emergency management, doctors, and allied health

staff will improve the overall quality of EMS.

In June 2010 the National EMS Advisory Council met and came up with a list of

priorities for EMS. The top issue facing this organization and other large EMS

stakeholder groups is the need for a lead federal EMS agency (Smith, 2011, p. 2). The

issue of a lead federal agency and a national EMS model are at the forefront of talks in

the EMS community.

EMS personnel work much better when they feel they can make changes to the

way EMS works (NHTSA, 1997). In order for a national EMS model to work EMS

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personnel must be willing to change their culture. EMS personnel can from teams, work

with management, and advisory boards in order to accomplish this (NHTSA, 1997). All

members of the EMS team must be willing to work toward a goal of national autonomy.

For any change to be effective it must be accepted and supported by management.

Management must work to treat employees well and show they are valued in order to

bring about change (Daft, 2006, p. 71). EMS must have cultural leadership from national

EMS organizations and advisory panels. Personnel will rally behind the leaders of the

industry when the proper culture is provided (Daft, 2006, p. 73).

As Niccolo Machiavelli states “There is nothing more difficult to take in hand,

more perilous to conduct, or more uncertain in its success, than to take the lead in the

introduction of a new order of things” (Walsh, 1995, p. 147). Management can reduce

employee complaints by involving everyone in the changes (Walsh, 1995, p. 151). It is

the leadership’s responsibilities to show that the changes in the profession are necessary.

Through using evidence based decision making EMS personnel will be more willing to

follow through with these changes.

After all of the discussion of a national EMS model and a lead federal EMS

agency there are still uncertainties. How can they manage all of these changes to a

profession? In order to bring about effective change they can look at several other

national organizations such as the United States Fire Administration, Department of

Justice, and the United States Health and Human Services. All of these organizations and

more provide national oversight and models to fire departments, police departments, and

hospitals respectively. There is no reason to reinvent the wheel with a national EMS

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model. EMS personnel can follow what has already been accomplished by many before

them.

The EMS Education Agenda for the future published by NHSTA recommends a

series of core components for change in EMS. Providing national EMS core content,

national scope of practice model, national education standards, national certification, and

education programs will complete a national EMS model (EMS, 2008). There are several

ways that a national EMS model can work. The consensus in EMS currently is that an

EMS branch under the Department of Homeland Security makes the most sense. The

national EMS core content will work as a blueprint for the managing of a national model

(EMS, 2008). The changes of certifications, nomenclature, operations, and synergy

among all EMS providers will be a major step toward a national model. These are

changes that currently are not possible without one national clearinghouse of EMS

information.

There are many benefits to having a national EMS model. Patient care outcomes

should improve when using evidence based guidelines. Currently only 50% of the

ambulances in the United States have 12 lead ECG capability (Myrick, 2010, p. 2).

When ambulances have the equipment that is clinically justified survival rates will

improve. A lead federal agency in EMS will provide better research capability (Myrick,

2010, p. 2). All EMS organizations will be able to benefit from research already done in

the field.

Reciprocity amongst states with transferring EMS personnel will be much easier.

A national EMS certification will mean that if someone is a paramedic in one state they

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can operate as a paramedic in any state. Currently certified personnel cannot operate as

providers across state lines. In other allied health professions a practitioner must be

accredited in order to perform their work (EMS, 2008). The EMS field can use a federal

accrediting agency in order to have all EMS personnel fall under the same guidelines.

Currently the paramedic level is the only one that has a voluntary accreditation (EMS,

2008). Currently accreditation in EMS does not mean anything to most organizations.

Accreditation is an important first step toward having national certification level

standards.

Information management will be easily accomplished with everyone using the

same data. Currently there is a loosely put together national database for EMS. The

National EMS Information System (NEMSIS) is voluntary and only a few states provide

data. A national database could provide electronic patient records that are available each

time a patient is treated (Myrick, 2010, p. 3). In resuscitation, for example, there are no

national standards for cardiac arrest (Eisenburg, 2011). A national EMS model would

provide the ways and means of gathering and disbursing relevant data.

Funding, communications, and recognition on a federal level will all improve

following the creation of a lead federal agency from a national EMS model. Currently

NHTSA does not have the ability or statute to provide the much needed changes to EMS

(Myrick, 2010, p. 3). Some states have grants to EMS organizations for certain

applications. A lead federal agency would have the ability to provide much needed

federal grants. These grants, according to Myrick (2010) would “spur innovation to the

delivery of field EMS (p. 3). In the United States EMS is regarded as the backup plan for

when other forms of healthcare fail. EMS is the safety net for modern healthcare

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(Orsino, 2011, p. 7). EMS is a critical infrastructure service provided that does not get

public recognition like fire and police organizations. A lead federal agency would

provide the missing link to the public to provide for public relations. Communication

amongst all members of the healthcare community will improve with a national EMS

model. EMS, emergency departments, and other public safety organizations should be

interconnected with data sharing (Myrick, 2010, p. 2).

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Findings and Recommendations

There is much work that needs to be done to improve EMS in the United States.

Providing a national EMS model that creates a lead federal EMS agency is a great start to

improvement. In order to provide excellent services the EMS profession must make

major changes.

Many advocates calling for a national EMS model agree on the major aspects of a

system. According to Eisenberg (2011) “EMS has long been an orphan in the federal

system (p. 1). A lead federal agency would give EMS clear oversight and a pathway for

improvement. The Institute of Medicine compiled this list of issues facing EMS today:

disparities in response times, uncertain quality of care, insufficient coordination, lack of

readiness for disasters, divided professional identity, and limited evidence base (Orsino,

2011, p. 7). These issues can call be solved by a national EMS model.

It is shown that EMS has never had a master plan to follow (EMS, 2008). The

work of NHTSA and the white paper published by IAEMSAC along with EMSLA

provides this needed master plan. Each document gives step by step direction to those

that need direction in congress as how to proceed. There is no doubt that Sue Myrick and

Tim Walz will join together again as they did before and file another bill on behalf of

EMS. These two representatives have taken a major step, based on recommendations

from EMS professionals, toward a national EMS model.

Currently there is a report out by the Journal of Emergency medical services

(JEMS) that shows how many of the proposed changes are already taking place. The first

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major change is the nomenclature of EMS certifications. Currently each state has the

ability to name each level what they wish. Soon EMS personnel will see four levels (1)

Emergency Medical Responder, (2) EMT, (3) Advanced EMT, and (4) Paramedic

(Cason, 2011, p. 1). EMS personnel will soon see a uniform list of skills that can be

performed at each certification level (Cason, 2011, p. 1). There will be more EMS

agencies working toward a standard accreditation (Cason, 2011, p. 1).

Overall if many in the EMS community have their way many changes will be on the

horizon for this profession. EMS professionals must be willing to embrace major change

for the betterment of themselves, their patients, and their careers. Working with

politicians and industry leaders the goal of a national EMS model can be realized. Each

person involved in EMS must make a conscious effort to work toward the goal of federal

recognition. If current practitioners do not make changes their industry will not be able

to thrive in the long run.

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Conclusion

EMS is in need of a national EMS model. Pre-hospital public healthcare

organizations must come together and follow proposed plans for change. In order to

provide quality healthcare into the future changes must be made to EMS. These changes

have been outlined by many leaders in the EMS community. It is the responsibility of

EMS professionals to provide feedback and suggestions through their chain of command

to establish a comprehensive national EMS model. The next steps will be to follow

through and edit an established model. It is now up to congress to re-introduce and pass

comprehensive EMS legislation. It is the responsibility of everyone concerned with pre-

hospital healthcare to contact their representatives to make this a possibility.

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