Traffic Safety Facts

Traffic Tech – Technology Transfer Series

Number 350 May 2008

U.S. Department of Transportation 1200 New Jersey Avenue SE., Washington, DC 20590

National Highway Traffic Safety Administration

Background 

Emergency	medical	services	(EMS)	are	configured	differently	

depending	 on	 factors	 such	 as	 size,	 demographics,	 geography,	and	politics	of	the	local	communities	they	serve.	Information	exists	about	the	EMS	configurations	in	the	Nation’s	

largest	cities,	but	information	is	lacking	with	regard	to	less	

populated	areas,	which	comprise	75%	of	the	Nation’s	population.	What	evidence	does	exist	indicates	wide	variability	in	

system	structure	with	little	evidence	to	support	alternative	

configurations	in	terms	of	their	service	delivery.	The	aim	of	

this	project	was	to	pilot	a	survey	that	could	document	the	

presence	and	structural	characteristics	of	local	EMS	systems.	

Such	a	survey	is	needed	to	create	a	typology	of	EMS	configurations	so	they	may	be	evaluated	on	a	common	basis.	

Methods

The	Mid-Atlantic	region	chosen	for	this	pilot	study	included	

Delaware,	Maryland,	New	Jersey,	North	Carolina,	Pennsylvania,	Virginia,	West	Virginia,	and	the	District	of	Columbia.	

This	 region	 was	 chosen	 because	 of	 expected	 variability	 of	

EMS	systems	and	organization	and	because	of	diverse	geographic	and	demographic	composition.	Counties	were	classified	into	five	rurality	levels,	ranging	from	large	metropolitan	

to	completely	rural.	

An	EMS	system	was	defined	as,	“an	identifiable	local	entity	

within	a	State	EMS	system’s	administrative	hierarchy	below	

the	State	level	and	immediately	above	the	level	of	an	individual	provider	agency.”	This	definition	allowed	evaluation	at	a	

level	close	to	localities	served	by	care	workers	and	measurement	of	features	that	went	beyond	the	limits	of	single	agencies.	Most	systems	identified	were	at	a	county	level,	with	a	

handful	 of	 systems	 representing	 multi-jurisdictional	 areas,	

independent	 cities,	 or	 miscellaneous	 systems.	 The	 map	 on	

the	next	page	depicts	how	system	and	non-system	counties	

varied	across	the	study	region.

System	directors	completed	surveys	designed	to	gather	data	

about	system	size,	911	access,	agency	types,	response	configurations,	operating	procedures,	mutual	aid	agreements,	medical	 control,	 and	 funding.	 Certain	 localities	 were	 defined	 as	

non-systems.	Such	counties	were	sent	an	abbreviated	survey.	

Results

System Size. Two	hundred	seventy-three	systems	and	82	nonsystem	counties	were	identified	across	the	survey	region.	No	

systems	were	identified	in	New	Jersey.	The	response	rate	of	

regions	with	systems	was	higher	(86.1%)	than	non-systems	

(56%).	System	size	was	characterized	by	information	on:	(1)	

number	of	EMS	care	workers	(at	all	levels,	including	volunteers);	(2)	annual	number	of	EMS	responses;	and	(3)	annual	

number	of	EMS	transports.	

911 Access.	 Most	 respondents	 (94%)	 report	 availability	 of	

E-911,	but	only	59%	report	that	access	is	available	through	

wireless.	Access	through	wireless	E-911	varies	by	State	and	

rurality.	As	expected,	wireless	E-911	is	less	available	in	more	

rural	systems	and	in	smaller	systems.	

Dispatch, Response, and Transport.	 Most	 respondents	 (60%)	

report	that	multiple	agencies	are	involved	in	first	response	

and	 transport	 activities.	 Most	 respondents	 (70%)	 indicate	

that	a	fire	department	provides	these	services	and	52%	report	

that	the	fire	service	is	the	primary	group	responsible	for	first	

response.	Large	systems	are	significantly	more	likely	to	use	

fire-based	first	response	than	smaller	locales.	Dispatch	was	

reported	to	be	handled	primarily	by	communications	departments	for	48%	of	systems,	with	an	additional	22%	served	by	

a	public	safety	department.	The	agency	that	provided	first	

response,	transport,	and	dispatch	varied	across	the	sample.	

Nearly	 all	 systems	 (98%)	 use	 first	 responders,	 and	 80%	 of	

respondents	said	that	advanced	life	support	transport	was	

most	frequently	dispatched	to	911	calls.	

The	 majority	 of	 respondents	 (86%)	 reported	 using	 volunteers,	 with	 fewer	 serving	 in	 larger	 systems.	 Two-thirds	 of	

respondents	noted	that	call	coverage	is	a	major	concern	due	

to	staffing	shortages,	and	this	is	more	prevalent	among	less	

urban	systems.

Mutual Aid.	Most	respondents	(94%)	report	the	presence	of	

mutual	aid	agreements,	but	the	specific	components	varied	

widely	across	the	sample.	Most		agreements	(88%)	addressed	

service	 coverage;	 one-half	 addressed	 communication	 linkages;	 and	 one-third	 addressed	 licensure	 or	 certification,	

financial	reimbursement,	or	liability	issues.	

Control and Funding.	 Nearly	 all	 respondents	 (96%)	 indicate	

medical	 direction	 is	 present	 at	 the	 system	 level.	 In	 40%	 of	

these	systems,	this	leadership	is	provided	by	in-house	directors	who	are	physicians	hired	by	the	system’s	coordinating	

organization.	 Half	 of	 the	 systems	 receive	 oversight	 from	

external	directors	from	organizations	such	as	local	hospitals.	

Configurations of EMS Systems: A Pilot Study 
Multiple	funding	sources	finance	EMS	systems.	Tax	subsidies	

and	fees	for	services	were	the	most	common	funding	sources.	

There	was	a	strong	relationship	between	funding	source	and	

the	rural-urban	continuum,	with	more	urban	areas	depending	more	extensively	on	tax	subsidies.

Discussion

Nationwide,	EMS	systems	are	heterogeneous.	With	considerable	variance	in	regulations,	rurality,	demographics,	geography,	and	the	different	needs	that	result,	it	is	not	surprising	

that	such	heterogeneity	exists.	Regions	must	select	elements	

based	 on	 needs	 and	 available	 resources.	As	 a	 result,	 EMS	

systems	 incorporate	 multiple	 agency	 types,	 response	 configurations,	and	funding	streams	while	striving	to	best	integrate	these	into	a	cohesive	whole.	

Our	data	verified	many	of	the	expected	distinctions	across	

various	categories	of	system	size	and	rurality.	Despite	variation	observed	in	the	structural	elements	assessed,	answers	

to	 questions	 that	 assessed	 subjective	 opinions	 about	 EMS	

working	environments	indicated	pervasive	system	change,	

positive	 environments,	 and	 adequate	 support	 structures.	

However,	funding	and	staffing	were	concerns	for	a	majority	

of	directors.

The	high	response	rate	suggests	that	a	similar	process	could	

be	executed	on	a	national	scale.	

How to Order

To	 order	 Configurations of EMS Systems: A Pilot Study	 (89	

pages),	 write	 to	 the	 Office	 of	 Behavioral	 Safety	 Research,	

NHTSA,	NTI-130,	1200	New	Jersey	Avenue	SE.,	Washington,	

DC	20590,	fax	202-366-7394,	or	download	from	www.nhtsa.

dot.gov.	Ian	Reagan	was	the	Contracting	Officer’s	Technical	

Representative	for	this	project.	

Figure 1. System vs. Non-System Counties

TRAFFIC TECH	is	a	publication	to	disseminate	information	about	

traffic	 safety	 programs,	 including	 evaluations,	 innovative	 programs,	and	new	publications.	Feel	free	to	copy	it	as	you	wish.	If	you	

would	like	to	receive	a	copy,	contact	Patricia	Ellison-Potter,	Ph.D.,	

Editor,	fax202-366-7394,	e-mail:	traffic.tech@dot.gov.

1200	New	Jersey	Avenue	SE.,	NTI-130

Washington,	DC	20590