EMS systems: foundations for the future

An emergency medical services controversy in Nova Scotia: What is expanded-scope EMS?

Les services médicaux d’urgence d’application élargie (SMU) est un sujet d’actualité qui demeure une énigme pour plusieurs. Une vue d’ensemble des SMU d’application élargie prendrait en considération quatre variations.

La première, les SMU aigus, non planifiés (d’application élargie) inclurait des protocoles de «traitement et de congé» pour des problèmes comme l’hypoglycémie, les traumatismes mineurs et les blessures. Cette variation intégrerait également le concept de SMU à «choix multiples», où les préposés aux SMU évalueraient l’état du patient et auraient le choix de le transporter vers un département d’urgence, vers une clinique ou un autre établissement de soins, ou de le traiter et de lui donner son congé. Dans un tel système, le protocole offrirait la flexibilité aux répartiteurs médicaux d’orienter les appels vers une ligne Info-Santé ou d’organiser un transport non ambulancier. Ce type de SMU pourrait aussi permettre l’application des fonctions traditionnelles des SMU dans de nouveaux environnements, comme par exemple donner aux préposés aux services médicaux d’urgence la responsabilité d’équipes d’arrêt cardiaque dans les hôpitaux..

Les SMU non aigus, planifiés (d’application élargie) incluraient des initiatives dirigées par les SMU qui établiraient un pont entre la médecine d’urgence et la santé publique. Celles-ci comprendraient, par exemple, des programmes communautaires de vaccination, des programmes d’évaluation de l’état de santé à domicile, des soins prénatals et des visites de suivi pour la vérification de plaies, l’administration intraveineuse d’antibiotiques ou de médicaments après une visite à l’urgence, et des programmes d’observance de traitement.

Le «service» d’application élargie fait référence aux initiatives de prévention et d’éducation dirigées par les SMU, comme la prévention des blessures (p. ex. le port du casque de bicyclette, les programmes de contrôle de l’alcool au volant) et l’éducation des citoyens (p. ex. la RCR et l’abandon de la cigarette).

Les SMU cliniques, hospitaliers ou en région éloignée (d’application élargie) intégreraient une nouvelle classe de préposés aux SMU ou dispensateurs de soins intermédiaires qui travailleraient avec les médecins, possiblement par le biais de la télémédecine. Ces préposés s’acquitteraient principalement de tâches spécifiques, comme poser des plâtres, faire des points de suture et extraire des corps étrangers oculaires. Avec une certaine formation post-secondaire, ils pourraient avoir la possibilité de poser des diagnostics et de prescrire des médicaments, un peu comme un «assistant médecin».

Préparez-vous! Les SMU d’application élargie s’en viennent.

Willingness to pay for emergency referral transport in a developing setting: a geographically randomized study

OBJECTIVES

The objective was to identify the correlates of willingness to pay for ambulance transports from a rural city to a regional hospital in Guatemala.

METHODS

An innovative methodology that utilizes a novel randomization technique and satellite imagery was used to select a sample of homes in Santiago Atitlán, Guatemala. The respondents were surveyed at these homes about their willingness to pay for ambulance transport to a regional hospital. A price ladder was used to elicit respondents' willingness to pay for ambulance transport, depending on the level of severity of three types of emergencies: life-threatening emergencies, disability-causing emergencies, and simple emergencies. Simple and multiple linear regression modeling was used to identify the social and economic correlates of respondents' willingness to pay for ambulance transport and to predict demand for ambulance transport at a variety of price levels. Beta coefficients (β) expressed as percentages with 95% confidence intervals (CIs) were estimated.

RESULTS

The authors surveyed 134 respondents (response rate=3.3%). In the multivariable regression models, three variables correlated with willingness to pay: household income, location of residence (rural district vs. urban district), and respondents' education levels. Correlates for ambulance transport in life-threatening emergencies included greater household daily income (β=1.32%, 95% CI=0.63% to 2.56%), rural location of residence (β=-37.3%, 95% CI=-51.1% to -137.5%), and higher educational levels (β=4.41%, 95% CI=1.00% to 6.36%). Correlates of willingness to pay in disability-causing emergencies included greater household daily income (β=1.59%, 95% CI=0.81% to 3.19%) and rural location of residence (β=-19.4%, 95% CI=-35.7% to -89.4%). Correlates of willingness to pay in simple emergencies included rural location of residence (β=59.4%, 95% CI=37.9% to 133.7%) and higher educational levels (β=7.96%, 95% CI=1.96% to 11.8%). At all price levels, more individuals were willing to pay for transport for a life-threatening emergency than a disability-causing emergency. Respondents' willingness to pay was more responsive to price changes for transport during disability-causing emergencies than for transport during life-threatening emergencies.

CONCLUSIONS

The primary correlates of willingness to pay for ambulance transport in Santiago Atitlán, Guatemala, are household income, location of residence (rural district vs. urban district), and respondents' education levels. Furthermore, severity of emergency significantly appears to influence how much individuals are willing to pay for ambulance transport. Willingness-to-pay information may help public health planners in resource-poor settings develop price scales for health services and achieve economically efficient allocations of subsidies for referral ambulance transport.

A descriptive analysis of Emergency Medical Service Systems participating in the Resuscitation Outcomes Consortium (ROC) network

BACKGROUND

The optimal Emergency Medical Services (EMS) system characteristics have not been defined, resulting in substantial variability across systems. The Resuscitation Outcomes Consortium (ROC) is a United States-Canada research network that organized EMS agencies from 11 different systems to perform controlled trials in cardiac arrest and life-threatening trauma resuscitation.

OBJECTIVES

To describe EMS systems participating in ROC using a novel framework.

METHODS

Standardized surveys were created by ROC investigators and distributed to each site for completion. These included separate questions for individual hospitals, EMS agencies, and dispatch centers. Results were collated and analyzed by using descriptive statistics.

RESULTS

A total of 264 EMS agencies, 287 hospitals, and 154 dispatch centers were included. Agencies were described with respect to the type (fire-based, non-fire governmental, private), transport status (transport/non-transport), and training level (BLS/ALS). Hospitals were described with regard to their trauma designation and the presence of electrophysiology and cardiac catheterization laboratories. Dispatch center characteristics, including primary versus secondary public safety answering point (PSAP) status and the use of prearrival instructions, were also described. Differences in EMS system characteristics between ROC sites were observed with multiple intriguing patterns. Rural areas and fire-based agencies had more EMS units and providers per capita. This may reflect longer response and transport distances in rural areas and the additional duties of most fire-based providers. In addition, hospitals in the United States typically had catheterization laboratories, whereas Canadian hospitals generally did not. The vast majority of both primary and secondary PSAPs use computer-aided dispatch.

CONCLUSIONS

Similarities and differences among EMS systems participating in the ROC network were described. The framework used in this analysis may serve as a template for future EMS research.

A Comprehensive Framework for Determining the Cost of an Emergency Medical Services System

To determine the cost of an emergency medical services (EMS) system, researchers, policymakers, and EMS providers need a framework with which to identify the components of the system that must be included in any cost calculations. Such a framework will allow for cost comparisons across studies, communities, and interventions. The objective of this article is to present an EMS cost framework. This framework was developed by a consensus panel after analysis of existing peer-reviewed and non-peer-reviewed resources, as well as independent expert input. The components of the framework include administrative overhead, bystander response, communications, equipment, human resources, information systems, medical oversight, physical plant, training, and vehicles. There is no hierarchical rank to these components; they are all necessary. Within each component, there are subcomponents that must be considered. This framework can be used to standardize the calculation of EMS system costs to a community. Standardizing the calculation of EMS cost will allow for comparisons of costs between studies, communities, and interventions.

Primary injury prevention in an urban EMS system

Injury prevention is increasingly recognized as an important part of health care delivery. Emergency Medical Services (EMS) personnel may be called upon to deliver primary injury prevention (PIP) by educating both patients and peers about how to avoid future similar injury. The purpose of this study was to determine EMS provider attitudes toward PIP and knowledge and practice of PIP during day-to-day clinical work. A brief survey was administered to a sample of paramedics assessing their attitudes toward primary injury prevention, how often they practice it, and whether or not they have received any PIP education during their training. One hundred sixty-two paramedics completed surveys. Of those surveyed, 70% believe that PIP should be a core mission of EMS systems, and 82% believe PIP should be implemented at the local or regional level. However, only 33% routinely educate their patients how to modify injury risk behaviors, and only 19% routinely provide instruction about proper use of protective devices. Approximately 63% of our paramedics received any PIP education during their training. A majority of paramedics in our survey believe that PIP should be a routine part of EMS. However, many paramedics have not received any PIP education, and few paramedics practice PIP during their clinical practice.

Would a prehospital practitioner model improve patient care in rural Australia?

BACKGROUND

Existing rural prehospital models have been criticised for being isolated from the healthcare system, and for following inflexible clinical protocols. Greater reliance on clinical judgement and informed decision making in the prehospital setting offer the potential to improve patient care.

METHODS

Soft systems methodology was used to develop and critically appraise the prehospital practitioner model as an alternative to existing models. This approach started from the philosophical viewpoint that prehospital services should be patient centred. Soft systems methodology was used to structure the elements of prehospital systems and the relations between them into metaphors and pictures that could be analysed.

RESULTS

This analysis showed that the most powerful reason for advocating the prehospital practitioner model is that it places prehospital systems within a symbiotic relationship with the healthcare system. Unlike the existing emergency service models or the "chain of survival" model, it is an integrated system that provides a range of services at multiple points during the patient care cycle. Thus, the prehospital practitioner would have roles in the prevention of injury and illness, responding to emergencies, facilitating recovery, and planning future strategies for a healthy community.

CONCLUSIONS

Implementing this new model would see the prehospital system using its available capacity more effectively to fulfill broader public health and primary care outreach roles than is currently the case. Patients would be referred or transported to the most appropriate and cost effective facility as part of a seamless system that provides patients with well organised and high quality care.

Emergency Medical Services Outcomes Project (EMSOP) II: developing the foundation and conceptual models for out-of-hospital outcomes research

Development of methodologically acceptable outcomes models for emergency medical services (EMS) is long overdue. In this article, the Emergency Medical Services Outcomes Project proposes a conceptual framework that will provide a foundation for future EMS outcomes research. The "Episode of Care Model" and the "Out-of-Hospital Unit of Service Model" are presented. The Episode of Care Model is useful in conditions in which interventions and outcomes, especially survival and major physiologic dysfunction, are linked in a time-dependent manner. Conditions such as severe trauma, anaphylaxis, airway obstruction, respiratory arrest, and nontraumatic cardiac arrest are amenable to this methodology. The Out-of-Hospital Unit of Service Model is essentially a subunit of the Episode of Care Model. It is valuable for evaluating conditions that have minimal-to-moderate therapeutic time dependency. This model should be used when studying outcomes limited to the out-of-hospital interval. An example of this is pain management for injuries sustained in motor vehicle crashes. These models can be applied to a wide spectrum of conditions and interventions. With the scrutiny of health care expenditures ever increasing, the identification of clinical interventions that objectively improve patient outcome takes on growing importance. Therefore, the development, dissemination, and use of meaningful methodologies for EMS outcomes research is key to the future of EMS system development and maintenance.