Rural Emergency Medical Services

November 1989

OTA-H-445

NTIS order #PB90-159047
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Rural Emergency Medical Services—Special Report, OTA-H-445 (Washington, DC: U.S. Government Printing Office,

November 1989).

Library of Congress Catalog Card Number 89-600774

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, DC 20402-9325

(order form can be found in the back of this report)
Foreword

The problems of health care in rural areas have long occupied a special niche

in policies designed to advance the Nation’s health. Programs for recruitment,

training, and deployment of health care personnel, for constructing health care

facilities, and for financing health care, often have included special provisions for

rural areas. These programs have often also included attempts to mitigate the

negative impacts on rural areas of policies primarily designed for and responsive

to the needs of urban areas. However, some rural areas continue to have high numbers of hospital closures, ongoing problems in recruiting and retaining health personnel, and difficulty in providing medical technologies commonly available in

urban areas. Mounting concerns related to rural residents’ access to health care

prompted the Senate Rural Health Caucus to request that OTA conduct an assessment of these and related issues. The first OTA paper prepared in connection

with this assessment, Defining “Rural” Areas: Impacts on Health Care Policy

and Research, was published in July 1989.

This Special Report, Rural Emergency Medical Services, is the second paper

prepared in connection with that assessment. This report finds that many State

EMS systems are fragmented and lacking resources to remedy EMS problems

in rural areas. Many rural EMS programs lack specialized EMS providers, have

inadequate EMS transportation and communications equipment, and are not part

of a planned regional EMS system. The report describes the availability and distribution of emergency medical service (EMS) resources (e.g., personnel, transportation, facilities) and examines how limited Federal resources can be used to

improve rural EMS. In addition, the report discusses how Federal EMS resources

might be targeted to States’ rural areas.

This report is based, in part, on a May 1989 Rural EMS Workshop that was

cosponsored by the Department of Transportation. Valuable guidance was provided

by an advisory panel, chaired by Mr. James Bernstein of the North Carolina

Department of Human Resources. A number of other experts also provided information and reviewed a draft of the report. The final responsibility for the content of this report rests with OTA. Maria Hewitt was the primary author of this

study.
Advisory Panel—Rural Health Care

James Bernstein, Panel Chair

Director, Office of Health Resources Development

North Carolina Department of Human Resources

Robert Bergland

Executive Vice President and General Manager

National Rural Electric Cooperative

Association

Washington, D.C.

James Coleman

Executive Director

West Alabama Health Services, Inc.

Sam Cordes

Professor & Head

Department of Agricultural Economics

University of Wyoming

Elizabeth Dichter

Senior Vice President for Corporate Strategies

Lutheran Health Systems

Denver, Colorado -

Mary Ellis

Director

Iowa Department of

Kevin Fickenscher

Public Health

Assistant Dean and Executive Director

Michigan State University

Center for Medical Studies

Kalamazoo, Michigan

Roland Gardner

President

Beaufort-Jasper (South Carolina)

Comprehensive Health Center

Robert Graham

Executive Vice President

American Academy of Family Physicians

Kansas City, Missouri

Alice Hersh

Executive Director

Foundation for Health Services Research

Washington, D.C.

David Kindig

Director

Programs in Health Management

University of Wisconsin-Madison

T. Carter Melton, Jr.

President

Rockingham Memorial Hospital

Harrisonburg, Virginia

Jeffrey Merrill

Vice President

Robert Wood Johnson Foundation

Princeton, New Jersey

Myrna Pickard

Dean

School of Nursing

University of Texas-Arlington

Carolyn Roberts

President

Copley Health Systems, Inc.

Morrisville, Vermont

Roger Rosenblatt

Professor & Vice Chairman

Department of Family Medicine

University of Washington

Peter Sybinsky

Deputy Director for Planning, Legislation, and

Operations

Hawaii Department of Health

Fred Tinning

President

Kirksville College of Osteopathic Medicine

Kirksville, Missouri

Robert Vraciu

Vice President

Marketing & Planning

HealthTrust, Inc.

Nashville, Tennessee

Robert Walker

Chairman

Department of Family and Community Health

Marshall University School of Medicine

Huntington, West Virginia

NOTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory

panel members. The panel does not, however, necessarily approve, disapprove, or endorse this report. OTA

assumes full responsibility for the report and the accuracy of its contents.

iv
OTA Project Staff—Rural Emergency Medical Services

Roger C. Herdman, Assistant Director, OTA

Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Elaine Power, Project Director, Rural Health Care (May 1989 to present)

Larry Miike, Project Director, Rural Health Care (August 1988 to June 1989)

Administrative Staff

Virginia H. Cwalina, Administrative Assistant

Carol A. Guntow, P.C. Specialist

Karen T. Davis, Secretary/Word Processor Specialist

Carolyn Martin, Secretary

Report Staff

Maria Hewitt, Study Director

Contractors

Jonathan Chin, University of Maryland

Harvey Wolfe and Larry J. Shuman, University of Pittsburgh

Don G. Stamper, University of Missouri

Other Contributor

John L. Chew, Jr., Department of Transportation
Reviewers

OTA staff would like to express its appreciation to the following people for providing information and assistance.

Susan Baker

Director, Injury Prevention Center

The Johns Hopkins University

School of Hygiene and Public

Health

Baltimore, Maryland

Kathleen A. Cline

EMS Medical Director

Pitt County

Greenville, North Carolina

Jerry Coopey

Office of Rural Health Policy

Health Resources and Services

Administration

Rockville, Maryland

Jake Culp

Office of Rural Health Policy

Health Resources and Services

Administration

Rockville, Maryland

Charles Detwiler

Pennsylvania Department of

Health

Division of EMS

Harrisburg, Pennsylvania

Gerald Doeksen

Department of Agricultural

Economics

Oklahoma State University

Stillwater, Oklahoma

Irene Fraser, PhD

Division of Health Policy

American Hospital Association

Chicago, Illinois

George Garnett, M.D.

Soldotna, Alaska

Michael Gilbertson

Director

New York Department of Health,

EMS Program

Albany, New York

Victor Grimes

South Carolina Department of

Health and Environmental

Control

Divison of EMS

Columbia, South Carolina

Theodore W. Halpin

Scottsville, New York

Norman W. Hanson, Jr.

Chief, EMS, Health Resources

Division

Minnesota Department of Health

Minneapolis, Minnesota

Lawrence Hughes

Division of Health Policy

American Hospital Association

Chicago, Illinois

Ellen Hume

National EMS Clearinghouse

The Council of State Governments

Lexington, Kentucky

Mark S. Johnson

Coordinator, Emergency Medical

Services

Alaska Department of Health and

Social Services

Division of Public Health

Juneau, Alaska

Sandra W. Johnson

Director

Maine Health Information Center

Augusta, Maine

Richard W. Looser

Executive Director

West Alabama Emergency

Medical Services, Inc.

University, Alabama

Sue Madden

Director of the Health Services

Information Division

Public Health Foundation

Washington, D.C.

Carol Miller

Mountain Management

Ojo Sarco, New Mexico

Craig L. Olesen

Medical Education Division

American Medical Resource

Institute

Northbrook, Illinois

Janet Reich

Administrative Director

Rural Support Services Rose

Medical Center

Evergreen, Colorado

Thomas Ricketts

Health Services Research Center

University of North Carolina

Chapel Hill, North Carolina

Dave Samuels

Arizona EMS Physicians

Meza, Arizona

John Spoor, MD

Director of Emergency Services

Mary Imogene Hospital

Cooperstown, New York

Scott Stein

York Hospital

York, Pennsylvania

E. Jerry Spyke

Senior Public Health Advisor

Center for Chronic Disease

Centers for Disease Control

Atlanta, Georgia

Kathleen Stage

National Association EMS

Physicians

Pittsburgh, Pennsylvania

Thorn Swan

Sedro Woolley, Washington

Gene Willard

Texas Department of Health

Austin, Texas

Elizabeth Wennar

U.S. General Accounting Office

Washington D.C.

Connie Yeakley

Oregon Health Division, EMS

Section

Portland, Oregon

NOTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the reviewers. The reviewers

do not, however, necessarily approve, disapprove, or endorse this report. OTA assumes full responsibility for the report

and the accuracy of its contents.

vi
Contents

Page

CHAPTER 1. Summary and Policy Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

EMS IN A RURAL CONTEXT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cardiac Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trauma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OPTIONS FOR FEDERAL POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Federal Initiatives in EMS Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Federal Guidelines or Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Federal EMS Technical Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Federally Sponsored EMS Research and Demonstration Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Federal Incentives for Planning and EMS Systems Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 2. Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

EMERGENCY MEDICAL SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Public Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prehospital Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RURAL AREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 3. The Demand for EMS Services in Rural Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

URBAN AND RURAL DIFFERENCES IN DEMAND FOR EMS SERVICES . . . . . . . . . . . . . . . . . .

Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 4. EMS in a Rural Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

THE CHANGING RURAL HEALTH CARE ENVIRONMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RURAL HEALTH CARE SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Public Access to EMS Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prehospital Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Regionalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 5. Emergency Cardiac and Trauma Care in Rural Areas . . . . . . . . . . . . . . . . . . . . . . . . . . .

CARDIAC CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TRAUMA CARE... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prevention Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prehospital Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital-Based Trauma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Regionalization of Trauma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 6. Federal Policies Toward State Emergency Medical Services . . . . . . . . . . . . . . . . . . . . . .

DEPARTMENT OF HEALTH AND HUMAN SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DEPARTMENT OF TRANSPORTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Section 402 Funds for State Highway Safety Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Section 403 Highway Safety Research and Demonstration Funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DHHS AND DOT ALLOWABLE EMS EXPENDITURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendix A. Rural EMS Workshop Participant\ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendix B. Designing an Appropriate EMS System in Rural Areas: Use of a

Computer Simulation Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendix C. Trauma Service Designation Guidelines of the American College of Surgeons

and the American College of Emerging Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendix D. Oregon Trauma Systems Summary and Hospital Resource Criteria . . . . . . . . . . . . . . . . . . . .

Appendix E. Trauma Care/EMS Legislation Introduced During the 101st Congressional Session . . . . . .

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References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

vii
Contents-Continued

Boxes

Box Page

4-A. Rural EMS Communications: Problems and Potential Solutions as Presented at the

“National Rural EMS Needs Workshop, ” March 1989 . . . . . . . . . . . . . . . . ., . . . . . . . . . . . . . . . . . . . . 28

4-B. Prehospital Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

4-C. EMS Prehospital Personnel: Problems and Potential Solutions as Presented at the

“National Rural EMS Needs Workshop, ” March 1989 .., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Figures

Figure Page

3-1. Death Rates From Unintentional Injury, Suicide, and Homicide by Place of Residence, 1977 -79.. 21

3-2. Motor Vehicle Related Death Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3-3. Population Density . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3-4. Death Rates From Motor Vehicle Crashes by Place of Residence, 1977-79 . . . . . . . . . . . . . . . . . . . . . 23

4-1. A Nodal Concept of EMS for Rural Northeast Missouri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

4-2. Estimated U.S. Air Ambulance Distribution, 1988 .. ... ... ..,.,. ............ ... . 38

4-3. U.S. Helicopter Medevac Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

5-l. States Having All, None, or Some of Eight Essential Components of a Regional Trauma

System According to American College of Surgeons’ Criteria. 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

5-2. StateTrauma Center Designation and Verification Practices, 1986-87 . . . . . . . . . . . . . . . . . . . . . . . . . . 50

6-1. State EMS Program Funding. 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

6-~. State and Community Highway Safety Program Obligations (DOT Section 402)

Fiscal Year 1987—$111,539,200 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Tables

Table Page

3-1. Prevalence of Injuries and Illness Among Patients Transported by Ambulance in Texas, 1988 . . . . 18

3-2. Prevalence of Injury and illness Among Calls for EMS Services in South Carolina, 1988 . . . . . . . . 19

3-3. Number of Episodes of Persons Injured and Number of Associated Restricted-Activity Days

and Bed Days by Whether in Moving Motor Vehicle, Whether at Work, Place of Accident,

and Place of Residence: United States, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

3-4. Average Annual Number of Injuries Per 100 Persons Per Year, by Place of Residence and

Type of Injury: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

3-5. Death and Disabling Injury Rates Among Workers by Industry, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3-6. Passenger Car Occupant Injury by Land Use and Speed Limit, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

3-7. Metropolitan (MSA) and Non-Metropolitan (Non-MSA) Motor Vehicle Fatality Rates-1986,

and Impact of 30 Percent Reduction in Non-MSA Deaths on Achieving the National 1990

Objective for Injury Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

4-1. State EMS Communications, 1986-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

4-~. Currency Certified Prehospital providers by State, 1986-87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

4-3. Ratios of Helicopters to Population by State, 1988, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

4-4. Percent of Community Hospitals With EMS-Related Services in Metropolitan and

Nonmetropolitan Hospitals by Bed Size, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

5-1 . Deaths Attributed to Cardiovascular Disease by MSA/non-MSA Residence, 1986 . . . . . . . . . . . . . . . 44

5-2. Percent oif Persons 18 Years of Age and Over Who Wore Seatbelts All or Most of the Time

When Riding in a Car by Sex, Age. and Residence: United States, 1985 . . . . . . . . . . . . . . . . . . . . . . . . 47

5-3. Percent occurrent Drinkers 18 Years and Over Who Had Driven a Car At Least Once in the

Past Year When They Thought They Might Have Had Too Much To Drink By Sex, Age, and

Residence: United States, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

6-1 . State Expenditures for Emergency Medical Services, By Source of Funds, FY 1988 . . . . . . . . . . . . . 54

6-~. Distribution of preventive Health and Health Services Block Grant Expenditures of State

Health Agencies to Former Categorical Grant Areas, Fiscal Year 1988 . . . . . . . . . . . . . . . . . . . . . . . . . 57

6-3. Preventive Health and Health Services Block Grant Expenditures: Emergency Medical

Services, Fiscal Years 1982-1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

6-4. National Highway Traffic Safety Administration’s State and Community Highway Safety

Program (Section 402) Funding: Emergency Medical Services, Fiscal Years 1967-87 . . . . . . . . . . . . 59

6-5. National Highway Traffic Safety Administration’s Research and Demonstration Program

(Section 403) Funding: Emergency Medical Services, Fiscal Years 1981-88 . . . . . . . . . . . . . . . . . . . . 61

Vlll
Chapter 1

Summary and Policy Options

INTRODUCTION

The average U.S. resident will need ambulance service at least twice in his or her lifetime

and for some of these patients, delays in

receiving emergency care will contribute to

death or permanent injury. The one-quarter of

Americans who live in rural areas, which

occupy four-fifths the country’s land area, face

special problems in receiving emergency care. It

is difficult to deliver emergency medical services (EMS) to widely dispersed populations

quickly and in small rural communities, there

may be less than one emergency call a day. This

relatively low volume of calls may mean that a

rural ambulance service cannot support itself

financially and that rural EMS providers have

difficulty maintaining their specialized skills.

The time it takes to reach emergency patients

may always be longer in some rural areas than

in urban areas because of distances between

services and rural residents. Although problems

relating to population dispersion are not easily

amenable to intervention, many of the problems

rural EMS providers are having in delivering

EMS care can be alleviated with additional

resources and system-wide planning.

Well-organized EMS systems are widely

recognized as essential components of medical

care. For rural residents for whom no local

hospital is available, EMS may be particularly

important in helping residents to achieve physical access to health care. Emergency medical

services cannot replace basic primary care

services, but when medical emergencies occur,

a well-organized EMS system can offer rapid

medical assistance and transportation to a facility equipped to handle the emergency.

Emergency medical services include the personnel, vehicles, equipment, and facilities used to

deliver medical care to those with an unpredicted immediate need outside a hospital and

continued care once in an emergency facility

(128).1 EMS systems are usually organized at

the State or regional level to provide coordinated

delivery in an appropriate geographic area (62).

The primary goals of an EMS system are to:

●

●

●

provide immediate medical assistance at

the scene and while in transit;

provide rapid transportation to a medical

facility;

have a coordinated, tiered level of hospital

care so that the most seriously injured or ill

patients are quickly triaged to specialized

facilities for their care, while the less

severely injured or ill patients are cared for

at less specialized facilities.

Comprehensive EMS systems have been

shown to save lives and reduce disabilities

(76,128). Among the EMS system components

are required are:

quick public access,

on-the-scene emergency care personnel,

rapid transportation,

physicians trained to provide EMS care and

supervise prehospital care,

different levels of hospital care for treatment of patients with emergent conditions

ranging from ‘‘urgent care’ to lifethreatening trauma, and

EMS surveillance systems to facilitate

system evaluation.

A well-organized EMS system may enhance

health care access, but evidence suggests that

not all States have developed EMS systems that

extend to rural areas. What characterizes EMS

systems is their variability. Per capita expenditures for EMS in 1988 ranged from a low of 2

cents in Ohio to nearly $14 in Hawaii (57). As

of 1986-87, only two States, Delaware and

Maryland, had statewide access to EMS services

through a 911 telephone number, while 21

States had only partial 911 EMS access (105). A

lsome include rehabi]i[a~ive c~e in tie definition of an EMS systcm. WhIlc OTA recognizes [hc importance of th~ cormnuum of care required for

many EMS patients, rehabilitative care is not specifically discussed in [his report.

- 1 -
2 ● Rural Emergency Medical Services

few States have directed the care of the seriously

injured to designated trauma centers, but others

do not designate specialized facilities and lack

regionalized systems of trauma care. Some

States have developed model EMS systems that

integrate urban and rural services, while others

have isolated, poorly organized rural EMS

systems with limited resources.

In the 1980s, EMS services have increasingly

become a State responsibility. In 1988, over 80

percent of State EMS funds derived from State

or local sources. Federal funding of State EMS

activities is limited to support through the

Preventive Health and Health Services Block

Grant program (administered by the Department

of Health and Human Services (DHHS)) and

through the Department of Transportation’s

(DOT) National Highway Traffic Safety Administration (NHTSA). In 1988, $13 million of

DHHS’s block grant funds were spent by States

on EMS, while DOT distributed nearly $5

million for EMS through its State and Community Highway Safety Grant Program (section

402 program) (24,57).

Federal EMS expenditures have declined

sharply in the last decade. Following passage of

the 1973 EMS Systems Act, about $30 million

were spent annually on EMS. In the early 1970s,

EMS systems were found to be underequipped,

poorly staffed, and fragmented. Many EMS

services were provided by funeral homes, and

prehospital care providers often lacked basic

medical skills. The EMS Systems Act resources

were targeted to rural areas because they were

more likely to be lacking resources than urban

areas.

Funding through the 1973 EMS Systems Act

is credited with having provided incentives for

regions to plan and upgrade EMS services.

Many communities used EMS Act funds to

improve their communications systems, train

EMS prehospital providers, and regionalize

care. However, the goal of the EMS Act—to

blanket the country with high-quality EMS

programs—was not met before its demise in

1981. In 1981, a number of categorical programs, including EMS, were folded into a block

grant program. With the advent of the block

grant program, EMS spending declined and has

not yet risen to spending levels of the late 1970s

(128).

With new evidence that EMS systems are

fragmented and lacking resources, several Federal initiatives have been proposed to bolster

State EMS systems and target resources to rural

areas. How limited Federal resources can be

used to improve rural EMS systems is the

subject of this report. The report describes the

availability and distribution of EMS resources

(e.g., personnel, transportation, facilities) and

discusses Federal EMS policies that affect these

resources, but does not specifically address

Federal EMS reimbursement policies. This

report is based, in part, on a May 1989 Rural

EMS workshop (cosponsored by DOT and

OTA) and on background papers prepared for

the workshop. (See app. A, list of workshop

participants.)

EMS IN A RURAL CONTEXT

The past decade has witnessed major changes

in the U.S. health care system, including both

how health care is paid for (e.g., implementation

of prospective hospital payment in the Medicare

program) and how health care is delivered (e.g.,

a shift to outpatient services). In some rural

areas

2 a decline in the economy has accompanied these changes, making it difficult for many

rural health care systems that are small and

lacking diversification to adjust to the new

health care environment. Since 1981, nearly 550

rural hospitals have closed (61 ). In communities

with only a single hospital, hospital closure has

meant that local access to hospital-based care is

lost and ready access to emergency care is

diminished.

z~l]e here we nmerous ways 10 deflnc mrd Mew, (his report defines rural axeas as those areas not desiwated as Metropolitan statistical ~e~

(MSAS). Definitions of rural areas are reviewed in OTA’S staff paper, “Defining ‘Rural’ Areas: Impact on Health Care Policy and Research,” published

in July 1989 (50).
Chapter 1-Summary and Policy Options . 3

Many rural areas have difficulty recruiting

and retaining physicians, nurses, and other

health care personnel because of the heavy

demands of rural practice (e.g., longer hours, no

backup) or because the area lacks a hospital or

other resources that attract providers. In some

areas, personnel shortages have been exacerbated by diminished support from Federal

programs such as the National Health Service

corps.

Access to well-trained personnel, essential

equipment, and facilities in rural communities

that lack a local hospital or physician may

sometimes be achieved through cooperation

with neighboring communities that have medical resources. If the availability of health care

services diminishes in rural areas, EMS providers may have to assume new responsibilities.

There may be an increased demand for nonemergency transportation to hospitals and for

urgent primary care services (e.g., delivering

babies). Rural EMS providers are having difficulty providing EMS services even without

these basic problems in the health care system.

Some specific problems of rural EMS systems

are:

●

●

●

●

Many rural areas have sparse and dispersed

populations that are far from care. Poor

roads, or the absence of roads, can delay

EMS transport.

Public access to EMS is compromised by

antiquated communications equipment. Universal access to EMS by telephoning 911 is

desirable but lacking in many rural areas.

Some rural residents must make longdistance telephone calls to obtain emergency assistance. Some rural areas do not

have telephone service.

Radio “dead spots”3 and crowded radio

frequencies interfere with essential communications between rural ambulance crews

and hospital-based physicians.

There are shortages of prehospital care

providers, many of whom are volunteers.

Available rural prehospital care providers

often have a less advanced level of training

than their urban counterparts. Training and

continuing education opportunities are not

available in many rural areas.

Rural EMS providers have difficulty maintaining specialized skills because of a relatively low volume of EMS calls. There are

few innovative teaching strategies being

used to overcome this problem.

There are few rural physicians trained to

provide medical supervision of local EMS

operations.

Rural EMS providers often rely on old

ambulances and ambulance equipment. Air

medical transportation to rapidly access

specialized care is not readily available in

some rural communities.

Rural hospital emergency room physicians

and nurses often do not have advanced

EMS training. Rural hospitals may not

have developed EMS protocols that designate the roles and responsibility for EMS

among rural EMS providers. The role of

the community or local hospital within

regionalized systems of special care, such

as trauma systems, has not been well

established.

Rural areas often lack the resources needed

to address EMS problems.

Information from three States (New York,

Texas, and South Carolina) suggests that in both

rural and urban areas emergency medical services are more likely to be required for medical

conditions (e.g., heart disease and respiratory

distress) than for trauma. Two of the most

common types of EMS care, EMS cardiac and

trauma care, illustrate the special problems of

delivering EMS services in rural areas.

Cardiac Care

Providing cardiac EMS care quickly is essential but difficult in many rural areas. In the case

of cardiac arrest, cardiopulmonary resuscitation

(CPR) must begin within 4 minutes and definitive care within 10 minutes of the arrest (1 16).

Rural EMS systems are at a disadvantage in

Ssome ~r~ ~ea~ are ou~idc the range of available radio equipment.
4 ● Rural Emergency Medical Services

treating cardiovascular emergencies, because

they often lack paramedic prehospital providers,

who are much more successful than basic-level

emergency medical technicians (EMTs) in treating cardiac arrest (52). However, some rural

communities have improved emergency cardiac

care by implementing ‘bystander’ education or

“first responder” programs to improve the

chances that CPR or first aid will be administered quickly and will continue until the ambulance arrives, and by training EMTs to use

automatic external defibrillators. Automatic external defibrillator are particularly well suited to

the needs of rural areas because they are easy to

use, and because the skills needed to use them do

not deteriorate even if the procedure is not

performed often (100).

Not all rural communities, however, have the

resources or conditions that would permit effective use of defibrillator by EMTs. If communities are small, community members are not

trained in CPR techniques, and response times

are 10 minutes or more, a community should

direct its resources to improving these conditions before instituting an EMT defibrillation

program (1 15). Defibrillator are relatively inexpensive, but training and system-wide supervision of prehospital defibrillation programs

may not be. To improve rural EMS cardiac care,

bystander and first responder training programs

could be implemented; where feasible, EMS

response times could be reduced; and physicians, nurses, and EMTs could be trained to

supervise and implement EMT-defibrillator programs.

Trauma Care

Injuries4 occur with nearly equal frequency in

urban and rural areas but tend to be more severe

in rural areas. Injury-related mortality is higher

in rural areas, but basic information is lacking

about when, where, and why rural injury and

injury-related deaths occur.

Because time to definitive care is such a

crucial factor in determining the trauma patient’s outcome, higher trauma-related mortality

might be expected in rural areas due to delays in

detection and response times. In some remote

rural areas, delays are unavoidable, but response

times may be improved by increasing the

number of available ambulances, improving air

medical services, or changing the placement of

ground or air transport.

Reducing delays to care can also be accomplished by shifting the onset of emergency

treatment from the hospital to the prehospital

period. Evidence suggests that a “scoop and

run’ approach is advisable in urban areas, but

enhancing the trauma skills of rural EMTs to

provide more care during the prehospital phase

(without prolonging the time to reach the

hospital) might improve trauma outcomes in

rural areas. Rural basic-level EMTs could be

trained in intermediate skills and become certified to provide more advanced trauma care (i.e.,

become intermediate-level EMTs), although if

they were so trained they might have trouble

maintaining their skills and it is uncertain

whether trauma-related mortality and morbidity

would improve.

Severely injured rural patients should often be

evaluated and stabilized expeditiously in the

community hospital, and then triaged to the

nearest trauma center (21 ,54). According to the

American College of Surgeons, hospitals treating trauma should, at a minimum, have emergency medicine physicians available in the

hospital around the clock. However, 24-hour

physician coverage is often unavailable in rural

hospital emergency rooms, and available physician and nursing staff may not have advanced

trauma care skills. Improving the training of

both emergency room nurses and physicians

would improve rural trauma care, as would

implementation of trauma protocols that help

ensure that a physician and other necessary

personnel are available by the time a trauma

patient arrives at the hospital.

Many States have attempted to regionalize

trauma care by designating or identifying hospid~j~ and ~auma are synonymous teITns.
Chapter I-Summary and Policy Options ● 5

tals according to their level of trauma care

services. Most rural hospitals do not meet the

requirements of even the lowest level of trauma

care but nonetheless have an important role to

play in providing trauma care in rural areas.

Developing specific trauma care guidelines for

rural hospitals might prove helpful to rural

providers and clarify the rural hospital’s role

within the trauma care system. A system that

integrates all levels of hospital care within a

State promotes regionalization and is likely to

improve rural trauma patient outcomes.

Research Needs

Before implementing programs to improve

rural trauma outcomes, it would be useful to

know more about the causes and consequences

of rural trauma, where along the continuum of

care deaths are occurring (e.g., during the

prehospital or hospital phase), and whether

these deaths are potentially preventable. Implementing programs without such information

may lead to inefficient use of limited resources

(24). To begin to understand where, along the

continuum of care, resources could be targeted

to improve the outcome of rural trauma patients,

population-based studies need to be conducted

in rural areas. Ideally, hospital discharge data

would be examined so that the types of care and

outcomes of patients that both live and die could

be evaluated.5 Because hospital discharge data

may not be readily available, studies of trauma

deaths could be conducted to see what proportion of them are preventable. Studies of preventable mortality will shortly be conducted with

support from the Department of Transportation

(24).

Research is also needed to evaluate the

effectiveness of specific EMS interventions

now commonly used. The evaluations must take

place in both urban and rural areas, because

some evidence suggests that some interventions

that are inappropriate in urban areas may be

effective in rural areas. Initiation of fluid

resuscitation for patients who have lost a lot of

blood, for example, is not indicated for patients

in urban areas that are within 20 minutes of a

trauma hospital but may be appropriate in rural

environments where time-to-care may be longer.

The relative effectiveness of public education

and law enforcement in improving injury rates

in rural areas is another area worthy of investigation. Some practices of rural residents probably

contribute to higher injury-related mortality.

Only 25 percent of rural residents, for example,

report using seat belts all or most of the time

while driving, as compared to nearly 40 percent

reported by urban residents. Public education,

the enactment of State laws to require seat belt

use, and enforcement of existing laws could

contribute to lower injury-related mortality and

morbidity.

The present impetus to improve EMS systems

centers on the adequacy of trauma care. While

trauma care is an important component of EMS

care, the adequacy of nontrauma-related EMS

services needs to be examined as well. There

appears to be an excess of deaths among trauma

victims in rural areas, but it is not clear to what

extent these deaths are preventable through

medical interventions. It may be that targeting

resources to prevention may be more effective in

reducing fatalities than improvements in trauma

centers. EMS care is more likely to involve

patients with medical conditions such as cardiac

arrest and strokes than trauma, and in the case of

sudden cardiac arrest, rural mortality might

decline with EMS systems improvements such

as implementing EMT-Defibrillator programs.

Whether patients suffering from cardiovascular

emergencies might benefit from other systemwide changes, such as more regionalized care, is

uncertain. A few States have verification and

designation standards for cardiac care facilities,

but most do not.

OPTIONS FOR FEDERAL POLICY

While some problems associated with delivering EMS care in rural areas to widely dis5~e sen~ltivlty Index Rojmt, funded though DoT’s National Highway T’raffic Safety Adnlinis~ation, links statewide computerized crash rf3pOflS

with patient hospital records. This allows investigators to correlate factors such as EMS response time and seat-belt use to patient outcomes (53).
6 ● Rural Emergency Medical Services

persed populations may seem intractable, many

rural EMS problems can be resolved with

additional targeted resources and effective planning and management. Among the most salient

problems confronting rural EMS systems are:

EMS personnel shortages;

inadequate advanced training opportunities

for available EMS providers;

a lack of medical supervision of local EMS

operations;

antiquated equipment (e.g., communications equipment);

poor public access to EMS; and

an absence of regionalized systems of

specialized EMS care, such as trauma

systems.

The Federal role in supporting State EMS

programs has waned in recent years, but evidence of serious impediments to quality EMS

care in rural areas argues for an increased

Federal role. Providing EMS services is largely

a State and local government responsibility;

Federal resources have never been consistently

available or sufficient to rely on for EMS

operations. Limited Federal resources might,

however, successfully be used to:

●

●

●

●

●

It is

promote training of EMS providers,

facilitate the development of national consensus guidelines or standards for prehospital

EMS providers and EMS facilities,

provide technical assistance to States,

support EMS-related research and demonstration projects, and

provide incentives for States to implement

planning efforts.

in these areas that States continue to need

Federal leadership ( 112).

Federal Initiatives in EMS Training

Option 1: Congress could fund the

Department of Health and Human

Services (DHHS) to provide assistance in

improving the supply and level of skills of

rural prehospital and hospital-based EMS

providers. Increased Federal assistance

could include support of EMS training and

continuing education programs, and State

recruitment and placement programs.

Rural areas are suffering shortages of prehospital care providers and are dependent on

volunteer providers who tend to have less

advanced training than their urban counterparts.

Rural hospital-based nurses and physicians may

not have specialized training in EMS care, but

nonetheless provide essential services to EMS

patients. Federal assistance to EMT, primary

care, and nursing training programs could improve the general availability of EMS providers.

EMT programs that are accessible to rural

residents could be targeted, because shortages of

rural volunteer EMTs are particularly acute. As

the cost of EMT training and certification can be

a deterrent for volunteers, States could be

encouraged to subsidize training with Federal

assistance. Providing assistance to State recruitment and placement programs could also improve the availability of EMS providers in rural

areas.

Federal resources could also be directed to

EMS continuing education that is accessible to

EMTs, nurses, and physicians already practicing in rural areas. Making continuing education

courses in emergency medicine available to

rural providers could effectively improve the

rural hospital’s EMS medical response and the

quality of the rural community’s EMS system.

Increased support for EMS-related training and

continuing education could be administratively

handled through. for example, the Health Resources and Services Administration’s Bureau

of Health Professions. Many professional and

nonprofit organizations are involved in EMSrelated training, but there is no Federal agency

that monitors the availability or content of EMS

training.

Option 2: Congress could require DOT to

reevaluate the standard curricula for

prehospital EMS providers.

Although there are recognized shortages of

prehospital care providers, the specific set of
Chapter l--Summary and Policy Options ● 7

EMS skills required in rural and urban settings

is uncertain. A reexamination of prehospital

care training and curriculum is justified because

there is considerable controversy surrounding

the effectiveness of some standard prehospital

interventions in both rural and urban settings.

The standard curricula for prehospital providers,

developed by DOT, could be reevaluated in light

of the unique characteristics of rural EMS

providers (i.e., most are volunteers) and the

demands of rural EMS practice. DOT (NHTSA)

is sponsoring a development conference on

EMS training in early 1990 where both trauma

and nontrauma EMS training requirements will

be discussed. DOT could change the standard

curricula for first responders, and for basic,

intermediate, and paramedic-level EMTs, but

EMT-Defibrillator training would fall outside of

DOT’s authority. DOT’s conference on prehospital EMS provider responsibilities and training

might help clarify what should be included in

EMT curricula and might help reduce the

extreme differences in training that currently

exist.

Federal Guidelines or Standards

Option 3: Federal legislation could facilitate

the development of national consensus

guidelines or standards for prehospital

EMS providers.

There are about 36 recognized levels of

prehospital care providers across the Nation,

and training requirements and levels of responsibility vary markedly by State. The American

Society for Testing and Materials, a voluntary

standard development organization, has published standards for some EMS personnel, but

these have not been widely used. Federal

legislation could ensure that national consensus

guidelines or standards for prehospital EMS

providers be developed following the National

Development Conference on EMS training,

sponsored by DOT, which is to be held in early

1990.

Option 4: Federal legislation could facilitate

the development of national consensus

guidelines or standards for specialized

EMS facilities, such as trauma centers.

Such guidelines or standards might

delineate the role of small rural hospitals in

EMS care.

Some proposed Federal EMS legislation ties

receipt of EMS grants to adherence to a State

plan that includes trauma facility designation

according to national standards. Proponents of

national trauma facility standards argue that few

States have EMS systems that meet essential

criteria, including facility standards, established

by professional organizations (i.e., American

College of Surgeons, American College of

Emergency Physicians) and that such standards

are required to assure EMS quality.6 Opponents

of EMS initiatives tied to facility standards

argue that States have very diverse EMS needs

and that imposing a national standard would

provide little flexibility.

Three-quarters of the States have developed,

or are developing, some type of trauma facility

verification or designation program, but most

adapt standards (like those developed by the

American College of Surgeons) to meet State or

regional needs. Developing national voluntary

guidelines or standards might be preferable to

mandatory standards in light of States’ diverse

needs.7 A consensus development conference,

such as those sponsored by the National Institutes of Health, might provide a forum whereby

national consensus guidelines or standards could

be developed with advisement from profes6Rwogn1zlng ~a( facl]lty stand~ds ml@t not be approprla[c]y applled in all areas, legislators have included prOvi SiOn~ wh~rcb a S[~lC ~~uld gc[

a waiver of [he proposed trauma facllily standards after public notice and hcanngs.

7Ex1sting Fcdcra] rcwlatlon% re~ommcnd ~a[ Fcdcra] hc~lth and ~afc[} programs usc natlona] Vo}unlq con~n$us s(andwd~ ( 1 CFR Chapter ~

- 1978). The Office of Management and Budget Federal standards policy a~u) rccomrncnds the usc of national voluntag consensus slandards (Circular

A-1 19 of November 1982).
8 ● Rural Emergency Medical Services

sional medical organizations and State and local

officials. 8

Some argue that the imposition of facility or

system standards is premature in some areas and

that such standards will doom many areas’

programs to failure. Any guidelines or standards

that are developed could be phased in so that

resources could first be used to improve training

and to upgrade communications and other

equipment. This would help to ensure that when

standards were imposed, personnel and equipmentrelated criteria could be met. Some opposition to

the imposition of facility designation criteria

and triage protocols may be alleviated through

public and provider education.

Federal EMS Technical Assistance

Option 5: Congress could fund DOT and

DHHS to augment technical assistance to

State EMS offices.

The ability of States to provide technical

assistance to EMS providers needs to be improved, especially for those States with large

underserved rural areas. Specific types of technical assistance include:

development of communications systems;

enhancement of management skills (e.g.,

billing procedures, personnel practices);

promotion of public education (e.g., raise

public awareness of EMS system, injury

prevention);

delivering air medical services in rural

areas;

development of statewide or regional EMS

surveillance systems and reporting practices; and

implementation and adherence to quality

assurance programs.

In many of these areas, Federal expertise is

available to assist State EMS program directors.

EMS-related technical assistance to States is

currently available through DOT’s National

Highway Traffic Safety Administration. NHTSA

assembles a team of technical advisors that may

include experts in such areas as rural EMS

delivery, data gathering systems, trauma systems, and the development of legislative proposals.9 The assessment team makes recommendations

to the States after comparing the status of EMS

in the State to EMS system standards established by the assessment team (126). The scope

of technical assistance offered by DOT extends

beyond highway safety issues and is offered

when requested by a State’s EMS office. DOT

supported the development of a computer simulation program for rural EMS system design

that, if adapted to the microcomputer, could be

a useful adjunct to providing technical assistance.10

The Centers for Disease Control (CDC) also

has a technical assistance program through its

Division of Injury Epidemiology and Control.

CDC can offer technical assistance in many

EMS-related areas such as injury surveillance,

but there are areas of expertise that are lacking,

such as EMS systems development. Less than

one-half of State health departments report

having injury reporting/surveillance systems

and when data sources are available, States do

not always use them (47). As EMS planning and

quality assurance are facilitated by such surveillance systems, this appears to be an area where

States may benefit from technical assistance.

Several tools are available for EMS systems

to evaluate their performance. One method

involves comparing a system’s prehospital services for trauma patients to the experience of

other EMS systems. A database that includes the

experience of many providers can be used to

develop norms or a “yardstick” against which

they can compare their patient survival experi8~e ~cncan socle~y for Tcs,llng and Materials (ASTM) has had scvcra] task groups addressing the devc]opmcnt of a nationa] consensus on

guidelines for EMS facilities (ASTM Commitwc F30), bu[ representatives of professional organizations such as ACS and ACEP no longer participate

because of concerns about the appropriateness and applicability of t,he ASTM process to the field of EMS (53,63).

9EMS advl~rs as~mblcd by DOT have provided assistance to eight States this year and plans are to extend assistance to eight more in calender Year

1990 (24).

I~ls computer simulation model is described in app. B.
Chapter 1-Summary and Policy Options ● 9

ence (88). Such a database is central to the Major

Trauma Outcome Study. Here, data on trauma

patients from over 100 hospitals are analyzed to

establish norms (e.g., mortality, complications)

by cause of injury and injury severity (23).

Federally Sponsored EMS Research and

Demonstration Programs

Option 6: Congress could fund DOT and

DHHS to augment their EMS research and

demonstration programs and encourage

the investigation of EMS problems unique

to rural areas and providers. The research

efforts of DOT’s NHTSA and DHHS’s

National Center for Health Services

Research and CDC could be coordinated

to address a broad range of outstanding

research questions.

EMS research and development efforts came

to a virtual standstill following the demise of the

EMS ACT in 1981. Under the EMS Systems

Act (section 1205), the National Center for

Health Services Research (NCHSR) was responsible for EMS applied research. The results

of the NCHSR research conducted in the mid

seventies has greatly influenced EMS practice

and has been useful to rural providers. NCHSRsupported research showed, for example, that

defibrillator could be effectively used by prehospital providers on patients suffering out-ofhospital cardiac arrests.

CDC, through its Division of Injury Epidemiology and Control, has recently established five

Injury Prevention Research Centers and has

funded over thirty 3-year research and demonstration projects.11 DOT has a small research

and development budget, but, these resources

are used to investigate highway-related concerns. Additional funds could be used to expand

and coordinate the research capabilities of

NCHSR, DOT, and CDC.

Although these efforts are noteworthy, there

are numerous outstanding EMS research questions with direct relevance to rural areas that are

not being adequately addressed. These include

such basic questions as, ‘‘is the demand for

EMS different in rural as opposed to urban

areas?’ The results of such research could guide

curriculum revisions and the development of

any new prehospital provider standards or

guidelines. Demonstration projects with an

evaluation component could answer questions

on the relative cost and effectiveness of innovative teaching strategies, such as home instruction using videocassette recorders for EMT

training or rural emergency room nurse and

physician continuing education. Such instruction might help to solve some of the EMT

shortages experienced in many rural areas and

improve the skill levels of existing rural providers.

Federal Incentives for Planning and

EMS Systems Development

Optimally, EMS systems have ongoing, dependable State support. Several States have achieved

self-sufficiency through innovative funding strategies (e.g., special funding through motor vehicle

fees), but many State’s EMS programs are

underfunded and lack coordination. To promote

State EMS system development and planning,

existing Federal EMS program support could be

augmented or new Federal EMS programs

established.

Option 7: Congress could augment support

of existing Federal programs that address

EMS, namely the DHHS Preventive Health

Block Grant Program and DOT’s State

and Community Highway Safety Grant

Program. Consideration could be given to

earmarking funds within these grant

programs for EMS.

The DHHS Preventive Health Block

Grant Program

States can use block grant money for a variety

of purposes, and investment in EMS cannot be

assured without earmarking some portion of the

DHHS block grant for EMS. Earmarking would

1 l~e gan~ were dls~lbuted ~ong five major clcments of inJ~ control: epidemiology, prevention, biomcchanics, acule care, and rehabilltahon

(27). Two of the funded projects relate to farm and rural injuries.
10 ● Rural Emergency Medical Services

be helpful in those States that have not given

high priority to EMS system development; but

it would also mean that States with welldeveloped EMS systems would be required to

expend Federal block grant funds on EMS rather

than on other State priorities.

Augmenting current Federal EMS-related

programs has the advantage of administrative

ease and offers a flexible approach for States

with diverse needs. States could use the additional block grant funds to invest in communications equipment and improve training opportunities within the State. A disadvantage of using

this approach is that it would be difficult to

impose any Federal EMS standards (e.g., designation of facilities) or to tie funds to the

implementation of a State EMS plan, because

under the block grant program the State has the

discretion to use funds as it sees fit. Another

disadvantage of this approach is that it is

difficult to target Federal funds to States with

identified EMS problems or, within States, to

rural areas.

DOT’s State and Community Highway Safety

Grant Program

Augmenting DOT’s State and Community

Highway Safety Grant Program could be a more

effective way to promote EMS system development than augmenting the DHHS Preventive

Health Block Grant Program. Unlike DHHS,

DOT makes EMS money available to States to

implement a State Highway Safety Program that

includes EMS. DOT has established EMS

guidelines for States to follow in developing

their highway safety program. With evidence

that the chances of being seriously injured or

dying if involved in a motor-vehicle accident are

two to three times higher in rural than urban

areas, there is a need to involve State highway

safety programs and transportation experts in

EMS systems development. DOT’s program

contains elements needed to promote EMS

system development, but DOT’s focus is on

highway safety and trauma care. DOT’s EMS

guidelines are, however, generalizable to most

emergency care (e.g., there are provisions for

EMS training and emergency vehicle requirements).

DOT’S grant program funds are now channeled to States through politically appointed

State highway safety representatives. State DOT

highway safety programs have been directed to

coordinate their activities with State EMS

offices, but there are still areas where there is a

lack of coordination.

If additional support were available, many of

the technical assistance, research and development, and training issues could be adequately

addressed through interagency coordination and

agreements. However, certain areas of expertise

are missing from the current Federal EMSrelated agencies, specifically in the areas of

nontrauma-related EMS care and EMS systems

development.

Option 8: Congress could establish a new

EMS categorical grant program within

DHHS.

Rather than augmenting current Federal EMS

programs, a categorical grant program could be

reestablished within DHHS to specifically promote EMS systems planning. The availability of

grants to States could be tied to the development

and implementation of a State EMS plan. Such

a program would reestablish a strong Federal

EMS presence within DHHS, which could be

coordinated with DOT’s EMS program. If such

a presence were established, many problems

related to coordination of current Federal efforts

might be solved or mitigated.12 If new Federal

resources were directed to resolve some rural

EMS system problems, methods to allocate

resources to those areas most in need could help

assure that limited resources are effectively

used.

lz~ere WU an active Interagency CommitlCc on EMS from 1974 to 1981. Since then, a Federal Interagency Committee on Emergency Medical

Services (FICEMS) was chartered by tie Federal Emergency Management Agency (FEMA) but there is a need for improved interagency communication,

particularly in the areas of training, communlcat]ons, and research and development (125).
Chapter 1--Summary and Policy Options ● 11

Targeting EMS Resources To Rural Areas

Option 9: To accommodate the diversity of

rural areas, any Federal EMS resources

provided to States could be tied to

implementation of a comprehensive State

plan that addresses that State’s rural EMS

system problems.

Different approaches could be used to target

Federal EMS resources to rural areas. Resources

can go directly to rural areas, or they can be

allocated to States based on a formula reflecting

their rural population. Under the 1973 EMS

Systems Act, grants could be made to any of 303

EMS service areas, some of them rural areas.

Sometimes, only certain areas within a State

were funded under the competitive grant process. The grant program promoted regional EMS

planning but not necessarily statewide planning.

If funds are to be directed to States and some

funds are to be used to solve rural EMS

problems, how to allocate those funds to ‘rural

areas is an important issue. An allocation

formula might be based on the proportion of the

population that resides in nonmetropolitan areas,

population density, square mileage of the State,

or another indicator of rurality. Each has its

advantages and disadvantages.

The basis used for allocation can have a

substantial influence on the distribution of

funds. For example, over 80 percent of the Idaho

population resided in nonmetropolitan areas in

1980, but that population numbered less than

one million. Texas, on the other hand, had less

than 20 percent of its population residing in

nonmetropolitan areas but had more than three

times the number (over 3 million) of nonmetropolitan residents. An allocation formula based

on the proportion of nonmetropolitan residents

might leave States with very large nonmetropolitan populations at a disadvantage. In other

States, rural EMS problems may be related to

the presence of large disadvantaged populations

(e.g., those lacking in health insurance and with

poor health status). In these States, an allocation

formula based on the composition, as well as the

relative size of the nonmetropolitan population

(e.g., percentage of the population that is

uninsured) might be more appropriate. In some

‘‘frontier’ 13 States, rural EMS problems can be

directly related to large geographic EMS service

areas that are sparsely populated. Here an

allocation formula based on population density

or dispersion might be appropriate.

There may be some rural areas where direct

ongoing subsidies are required to maintain

services. An EMS system is much like a public

utility offering electric or water service, in that

providing services becomes disproportionately

more costly as the number of consumers declines and becomes dispersed over wide areas.

Ongoing subsidies in such situations are not

new; subsidies have been used to finance some

rural electrification projects, and urban mail

services subsidize the more expensive rural

routes. Some communities can form cooperatives or linkages to broaden their service area

and conserve resources, but other communities

are isolated and cannot. Helicopters and airplanes may be used to transport some isolated

patients to a medical facility, but these cannot

replace an appropriate level of first response.

lg~e Iem “frontier” has &n used to describe areas with six or ICSS residents per square mile (50).
Chapter 2

Definition of Terms

EMERGENCY MEDICAL

SERVICES

Emergency medical services (EMS) include the

personnel, vehicles, equipment, and facilities used to

deliver medical care to those with an unpredicted

immediate need outside a hospital and continued

care once in an emergency facility (127). ’ EMS

systems are generally organized at the State or

regional level to provide coordinated delivery in an

appropriate geographic area (62). Implementing

comprehensive EMS systems has been shown to

save lives and reduce disabilities (76,127). The

primary goals of an EMS system are to:

1.

2.

3.

provide rapid transportation to a medical

facility;

provide immediate medical assistance at the

scene and while in transit; and

have a coordinated, tiered level of hospital care

so that the most seriously injured or ill patients

are quickly triaged to, and cared for at specialized facilities, and the less severely injured or

ill patient cared for at less specialized facilities.

In reaching these goals, EMS systems extend

beyond the bounds of what is traditionally viewed as

the “medical system,” often overlapping with other

public safety systems such as local fire and police

services. Rural EMS systems rely heavily on community volunteers and may therefore serve as an

important interface between the public and the local

health care system (85).

EMS systems include several components:

Public Access

Public access to an EMS system is optimally

achieved through a coordinated communications

system. Centralized communications centers may be

accessed directly by telephone or radio using a 911,

800, or designated seven-digit number (sometimes

referred to as universal access). EMS systems can

also be accessed through fire and police departments, hospitals, or telephone operators.

Prehospital Response

Public Safety Response

Prehospital response may begin shortly after an

emergency victim is detected and before EMS

professionals arrive. Bystanders trained in cardiopulmonary resuscitation (CPR) or first aid may

provide assistance at the site or individuals trained

in basic emergency skills may be called to the site as

“first responders” until the ambulance or other

EMS professionals arrive. Fire and police officials

or community members may be trained as first

responders.

EMS Professional Response

After the EMS system has been called. a vehicle

appropriately staffed and equipped is dispatched to

the scene. Depending on the nature of the emergency, extrication may be required, and medical

stabilization or treatment initiated. EMS personnel

select a facility to take the patient to (sometimes

using transport guidelines), and provide transportation to that facility while continually monitoring and

administering care to the patient. Prehospital providers are usually emergency medical technicians who

provide basic life support care, which includes basic

emergency care and CPR, and/or advanced life

support, which may include external defibrillation

for cardiac arrest patients and more invasive procedures such as starting intravenous lines. Prehospital

care providers are ideally provided medical advice

from physicians via vehicle-to-hospital communications. In addition to providing such “on-line”

medical control, physicians may also participate in

‘‘off-line’ medical control through designing medical protocols that guide prehospital providers’ care.

Any in-transit communication of the patient’s condition helps the receiving facility prepare for the

arrival of the patient.

Transportation

Most EMS transportation is provided by ambulances. Helicopters are often used to transport

trauma patients to trauma centers, while airplanes or

helicopters are used to transfer stabilized patients

from one hospital to another. The duration of the

1 Some include ~ehabl]llatlvc ~mc ,n [he dcfinlllon of an EMS sys[em, Whl]e OTA re~ogni~cs [hc lrnp~flan~c of Lhc con~inuum Of CLMC rcqulrcd fOr

many EMS patients, rehabilitative care is not spcci fically d]scusscd in [his report.

–13–
14 ● Rural Emergency Medical Services

transportation phase is dependent on three factors:

physical distance to be covered; mode of transportation (land, air, water); and the type and condition of

the roadway, airway, or water.

Medical Response

There are three levels of medical response:

. Primary medical response involves nonspecialty providers in facilities such as small

community hospitals. Providers at these facilities can resuscitate and stabilize critically ill or

injured patients.

. Secondary medical response offers definitive

treatment by specialty providers (e.g., surgeons, anesthesiologists). Secondary facilities

generally have a physician available 24 hours a

day and lab and x-ray services available within

30 minutes.

. Tertiary medical response involves highly specialized and technical services (e.g., burn care,

spinal cord injury care). Generally, tertiary

facilities such as trauma centers need high

patient volumes to operate efficiently.2

A number of professional organizations have

established guidelines to categorize hospitals by the

level of emergency capabilities. The American

College of Surgeons, for example, has guidelines for

the designation of trauma centers (4). The American

College of Emergency Physicians has issued guidelines that include prehospital care (3) (see ch. 5).

The major factor affecting the outcome of a

critically injured or ill patient is time to definitive

care, therefore, efficient operation of an EMS system

by trained personnel is essential. Trauma patient

outcomes are best when patients are identified,

transported, and cared for within a critical “golden

hour’ (127). For rural residents, this can be achieved

with initial resuscitation and stabilization provided

by prehospital providers at the scene and during

transport; more advanced stabilization at the rural

hospital; followed by rapid transfer to tertiary care

facilities (20,21 ,46,1 28). Optimal EMS care in rural

areas requires that the levels of medical response

located in both rural and urban areas be well

coordinated. EMS systems must also be coordinated

with other public safety agencies such as fire, police,

and disaster programs.

The responsibility of overseeing a State’s EMS

system generally rests with a State EMS director.

The State EMS director may, among other things, be

responsible for training and certifying EMS providers, certifying ambulances and air-medical transportation services, and ensuring the coordination of

levels of EMS care provided within the State’s

hospitals. At the local level, EMS care may be

organized through the county, as a separate department of local government similar to those offering

police and fire protection. Alternatively, EMS services may be offered through an existing municipal

agency. such as the fire department, where providers

may be cross-trained to assume both EMS and

fire-fighting responsibilities. Hospital emergency

departments, private ambulance services, or independent voluntary agencies may also operate and

manage a community’s EMS system (42,75). However EMS services are organized, statewide or

regional EMS patient surveillance systems, such as

trauma registries, can be used by EMS planners to

evaluate the EMS system. All EMS systems need not

only an administrative director, but a medical

director who prescribes, oversees, and is accountable for medical care provided by the service or

system (53). An EMS system may include a single

local service or it may encompass an entire State.

RURAL AREAS

Urban and rural areas are often defined using the

designations of either the Office of Management and

Budget (OMB) or the Bureau of the Census. Rural

areas are the remaining areas not captured in either

OMB’s “metropolitan statistical area” (MSA) designation or in Census’ urban or urbanized area

definitions. Counties are the building blocks of

OMB’s MSAs and are easy to use, because countybased data are readily available. One or more

counties form an MSA on the basis of population

size and density, plus the degree of area-wide

economic integration as reflected in commuting

patterns. MSAs include a densely populated urban

core (called an urbanized area), with at least 50,000

residents, that is part of a county or counties

comprised of at least 100,000 residents. The Census’

zTra~a centers and tra~asys[cms arc one Cornponenl of EMS care and systems. Trauma ccntcrs offer definitive care for the critically injured

patient. For patients with noninjury-rcla[ed medical conditions, the tertiary medical response may involve other specialized hospitals or centers.
Chapter 2--Definition of Terms ● 15

urban and urbanized area definitions rely on settlement size and density without following county

boundaries, making them more difficult to use.3

Both methods identify about a quarter of the U.S.

population as rural or “nonmetropolitan.” but these

populations are not identical. For example, about 40

percent of the Census-defined rural population live

within MSAs, and 14 percent of the MSA population

live in Census-defined rural areas.

This report will refer to nonmetropolitan areas as

rural unless specified otherwise. It seems appropriate to use MSAs to describe ‘‘urban’ and ‘‘rural’

access to, and organization of, EMS services,

because EMS systems are generally organized along

these lines. Specialized EMS services, such as

trauma centers, for example, are generally located

within the more densely populated urban areas of

MSAs and become less available as you move out

into the less populated non-MSAs. Nonmetropolitan

hospitals are generally smaller than metropolitan

hospitals and tend to have fewer specialized services

available (6).

Unfortunately, statistics relevant to EMS are not

presented in a standardized fashion. Comparing

EMS-related data from one source to another,

therefore, is almost impossible. The Department of

Health and Human Services (DHHS), for example,

publishes vital health statistics (e.g.. injury-related

deaths) for metropolitan and nonmetropolitan counties, 4 but the Department of Transportation (DOT)

provides data in their Fatal Accident Reporting

System and National Accident Sampling System

(122) using their own definition of rural.5

In addition to using a standard definition of

‘‘rural, ’ it is important to present data for rural

subpopulations. Dichotomous measures of urbanity/

rurality not only obscure important differences

between urban and rural areas but also wide variations within rural areas. Consequently, there have

been recommendations to implement a standard

rural typology that would capture the elements of

rural diversity and improve use and comparison of

data. Several rural “topologies” or classification

schemes have been developed for nonmetropolitan

areas that may prove useful in presenting rural health

data (50). It would be helpful to use such topologies

to present data on rural injury so that injuries unique

to such environments as farms and mining areas

could be identified.

3For de.alj~ ~nfomatlon on dcfinltlons of ~ra] ~cas, scc ‘‘&finlng ‘R~a] Areas: Impact on Hca]th CMC policy and Rcsc~ch, ” OTA Staff Paper,

July 1989 (available through GPO stock No. 052-003 -01156-5 or by calling the OTA Health Program at 202-228-6590).

4DHHS subdlvl&S me~ow]l(an and nonmc~owll~an ~eas into urban and ‘ ‘not ~ban’ places, DHHs defines nonmcwopolitan urban places u areas

with populations of 10,000 or more.

s~cordlng t. DOT, ~bm we= me ~eas Within bound~ie~ fixed by s~a[e or Ioca] officials that have a population of 5,000 Or ITIOK, ad We 1101

within another urban area, Rurat areas are those outside of the boundaries of ‘urban areas ( 122). Approximately one-quarter of the population of MSAS

meet DOT’s definition of ‘rural and nearly one-third of non-MSAs meet DOT’s defirution of ‘urban.
Chapter 3

The Demand for EMS Services in Rural Areas

INTRODUCTION

Medical conditions that may require emergency

medical services (EMS) include medical emergencies, such as heart attacks, and critical injuries such

as those sustained in motor vehicle crashes and

occupational accidents. National data on what medical conditions precipitate an EMS call are not

available, but some State data suggest that EMS care

is needed as frequently, if not more frequently. for

medical conditions, such as heart attacks and respiratory distress, as for trauma (tables 3-1 and 3-2).

This chapter describes urban and rural differences in

demand for EMS services and in injury morbidity

and mortality.

Each person is likely to need ambulance service at

least twice in his or her lifetime, but a population of

10.000 residents generates only one true emergency

call a day (31). Small communities must be prepared

for relatively low volumes of calls that may not be

well distributed over the year. Severe trauma may

occur infrequently, but a community may have to

deal with multiple victims of an automobile crash at

one time.

The demand for EMS services will increase in a

continuous fashion as the size of the service

population increases, but the capacity of the EMS

system to respond increases in discontinuous steps,

especially in small communities. A small community with a two-ambulance system, for example,

cannot meet a 20 percent increase in demand with a

20 percent increase in capacity; acquiring a new

ambulance and staff would represent an increase in

capacity of 50 percent ( 132).

Many nonmedical factors contribute to the demand for EMS services. Some individuals who need

EMS services do not use them because they do not

realize that EMS services are required, lack services

within their area. don’t know how to access the

system, or may be unable to pay for the services.

Conversely, some individuals use EMS services for

nonemergencies. This may occur if other health

services are unavailable or less convenient. or if the

public is uninformed of the purpose of EMS.

URBAN AND RURAL

DIFFERENCES IN DEMAND FOR

EMS SERVICES

There are marked urban/rural differences in EMS

service use in three States where statewide, computerized, ambulance-use data are available (Texas.

South Carolina, New York).1 Ambulance-transported patients in rural Texas are more likely to be

suffering from a heart condition or stroke than urban

residents and less likely to suffer from internal

injuries, injuries to the spine or brain, and lacerations

or penetrating trauma (table 3-1) (1 34). The higher

demand for EMS intervention for acute medical

conditions such as heart attacks or strokes is likely

explained by the older age distribution of rural

residents.2

Ambulance services are used more frequently by

the elderly in rural than urban areas. Over half (54

percent) of ambulance-transported patients in rural

Texas were age 65 or older (29 percent were age 80

or older) as compared to 29 percent in urban areas.

There are similar findings in New York State where

over one-half (54 percent) of patients transported by

ambulance in rural counties were age 60 or older.

compared to 42 percent for urban counties (42).3

South Carolina, in contrast. had less than onequarter of patients age 65 or older among urban and

rural ambulance transports in 1988.

Rural ambulance calls are more likely to be

‘‘urgent, ’ or ‘‘critical in rural than urban areas of

Texas and South Carolina (44,134).4 In Texas, for

example, 44 percent of 1988 rural ambulance runs

were categorized as ‘‘urgent’ and 7 percent ‘‘Cr-itiCal ‘ ‘ as compared to 31 percent, and 4 percent.

respectively, for urban ambulance runs ( 134). A

large percent of rural calls in both Texas and

IThcsc States ~crc identified by ~~lllng the Amcrlc:m Ambulance Associa[l{)n, and part icipan[s of the OTA/DOT Rural EMS Workshop. SLMCX ~1~1

stiIIcwIdc, computcrwcd, ambulan& data that could bc anal) /cd b> mc[ropohuin and nonmc[ropolllan ,ama provided tic labulatlon~ Ibr OTA.

~Thu-teen pcrccnt of the ntxwnctropolitan popuIaIIoIl I\ cldcrl? { i,c,, agc 65 or older) while only 11 pcrccnt of hc mctropollmn populJIIon I\ cldcrl~

( 1 13).

3Ambulancc u[llllatlon data were ava!lsblc for SC!LSC KXI urban and rural coun[]cs (42).

~S1ml]~ Lnfoma[lon WaS not ava]lablc from NCW }’ork.

-17 -
18 ● Rural Emergency Medical Services

Table 3-l-Prevalence of Injuries and Illness Among

Patients Transported by Ambulance

in Texas, 1988a

Percent of transports

Type of illness or injury Total Metro Non-metro

Illness:

Heart complications . . . . . . . . . . . 12.6

Strokes-CVA b . . . . . . . . . . . . . . . . 4.1

Respiratory distress . . . . . . . . . . . 7.4

Diabetic complications . . . . . . . . . 2.7

Gastrointestinal illnesses . . . . . . . 5.1

Convulsions or seizures . . . . . . . . 3.6

Allergic reactions . . . . . . . . . . . . . . 0.5

Fainting . . . . . . . . . . . . . . . . . . . . . 2.0

Infectious diseases . . . . . . . . . . . . 1.0

Emotional or mental distress . . . . 2.6

Other illnesses . . . . . . . . . . . . . . . 12.1

Injury

Lacerations or penetrating

trauma . . . . . . . . . . . . . . . . . . . . 9.4

internal injuries . . . . . . . . . . . . . . . 2.7

Injuries to spine or brain . . . . . . . . 4.5

Multiple injuries . . . . . . . . . . . . . . . 0.5

Fracture or dislocation . . . . . . . . . 10.9

Scrapes, bruises, or cuts . . . . . . . 10.9

Sprains or strains . . . . . . . . . . . . . 4.3

Burns. . . . . . . . . . . . . . . . . . . . . . . 0.6

Drowning, suffocation, or

choking . . . . . . . . . . . . . . . . . . . 0.3

Other injuries . . . . . . . . . . . . . . . . . 2.5

Perinatal care:

Obstetric or gynecological . . . . . . 1.9

High-risk infants . . . . . . . . . . . . . . 0.2

Substance abuse:

Drug overdose or poisoning . . . . . 1.6

Acute alcohol intoxication . . . . . . 0.8

No information available . . . . . . . . 17.2

Total number of patients . . . . . . . 51,853

12.2

3.6

6.9

2.6

4.8

3.7

0.5

2.1

0.9

2.8

12.0

9.7

2.8

4.6

0.5

10.4

11.7

4.6

0.6

0.4

2.7

2.0

0.2

1.7

0.9

16.8

44.527

15.1

7.0

10.9

3.5

7.2

3.0

0.5

1.6

1.4

1.4

12.6

7.5

1.8

3.4

0.7

13.7

6.1

2.1

0.4

0.2

1.6

1.5

0.1

0.8

0.5

19.8

7.326

aThese data are based on ambulance run reports of a representative

sample of Texas ambulanea serviees. There were an estimated one

million ambulamx runs in Texas in 19SS. More than one oonditioncm be

refwted for each patient. Numbers m the table represent the pereent of

ambulance transports for reported types of illness and injury.

~CVA. Cardlcnmacular accident.

80URCE: Texas Department of Health, Austin, TX, August 19S9.

South Carolina are for transportation. In South

Carolina, for example, about 16 percent of ambulance calls in rural areas are for transportation to

medical exams, as compared to 10 percent in urban

areas (44)0

Injury is a major problem in rural areas, particularly injuries sustained in motor vehicle accidents.

Injuries are more likely than other emergency

conditions to require specialized services such as

trauma centers which are usually not immediately

available in rural areas.

Injury

Injury is the leading cause of death among persons

1 to 44 years old (1 19) and is the leading cause of

years of potential life lost before the age of 65 ( 121 ).

Injuries occur as, or less frequently in rural areas

than in urban areas (see table 3-3) and the types of

injuries that occur in these areas are similar (table

3-4).5 When injuries do occur, however, they appear

to be more serious in rural areas; injured rural

residents have more restricted-activity days and bed

days than injured urban residents (table 3-3). This is

especially true for injuries occurring at home.

Death rates from unintentional injuries (both

motor vehicle and nonmotor vehicle related) are

twice as high in remote rural areas than in the largest

cities (figure 3-1 ) and death rates are inversely

related to population density (13). The chance of

dying in a rural area, if severely injured, are three to

four times higher than in urban areas (19,62). Some

evidence suggests that aspects of the EMS system

may contribute to the higher death rates. For

example, younger and generally healthier adults die

from less severe injuries in rural nontrauma center

hospitals than in urban trauma center hospitals (66).

Occupational Injuries

While national injury data do not reflect higher

injury rates in rural areas, certain rural subpopulations have more injuries because of the types of

occupations they practice. Approximately 10 percent of employed rural residents 16 years of age and

older are employed in two of the most hazardous

occupations in America-farming and underground

mining. Farming encompasses a wide range of

activities that may pose health hazards, including the

use of farm machinery and tools and exposure to

chemical fertilizers and pesticides. Mining hazards

include cave-ins, explosions, fires, and the inhalation of dust (78). Work-related deaths occur four to

five times more frequently among mining and

agricultural workers than among workers as a whole,

and disabling injuries occur two to three times more

often (72) (see table 3-5).

Motor Vehicle Crashes

One-third of all injury-related deaths are attributable to motor vehicles. Among those under age 35,

motor vehicle crashes are the leading cause of death

(12). There is wide geographic variation in motor

s~ese data we ]fiit~ tiWfw as they rely on self-reported injuries reported by phone interview (i.e., National Health Interview Smey).
Chapter 3---The Demand for EMS Services in Rural Areas ● 19

Table 3-2—Prevalence of Injury and Illness Among Calls for EMS Services in

South Carolina, 1988a (percent)

Metro Non-metro

Jan.- May- Aug.- Jan.- May- Aug. -

Primary complaint April July Dec. April July Dec.

Total injury . . . . . . . . . . . . . . . . . .

Fracture . . . . . . . . . . . . . . . . . . . . . . . .

Spinal injury . . . . . . . . . . . . . . . . . . . .

Laceration . . . . . . . . . . . . . . . . . . . . .

Abrasion/contusion . . . . . . . . . . . . . . .

Head injury . . . . . . . . . . . . . . . . . . . . . .

Multitrauma/shock . . . . . . . . . . . . . . . .

Hemorrhage . . . . . . . . . . . . . . . . . . . .

Dislocation . . . . . . . . . . . . . . . . . . . . . .

Puncture/stab . . . . . . . . . . . . . . . . . .

Gunshot wound . . . . . . . . . . . . . . . .

Burn . . . . . . . . . . . . . . . . . . . . . . . . .

Total cardiovascular . . . . . . . . . . . . . . . .

Coronary problem . . . . . . . . . . . . . . .

CVA/TIA/stroke . . . . . . . . . . . . . . . . .

Cardiac arrest . . . . . . . . . . . . . . . . . . .

Hypertension . . . . . . . . . . . . . . . . . .

Congestive heart failure . . . . . . . . . . .

Other medical . . . . . . . . . . . . . . . . . .

Vomiting . . . . . . . . . . . . . . . . . . . . . . .

Gastro-intestinal problems . . . . . . . . .

Genito-urinary problems . . . . . . . . . . .

Hyperventilation . . . . . . . .

Respiratory distress . . . . . . . . . . . . . . .

Seizure . . . . . . . . . . . . . . . . . . . . . . . .

Diabetic reaction . . . . . . . . . . . . . . . . .

Insulin shock . . . . . . . . . . . . . . . . . . . .

Fainting . . . . . . . . . . . . . . . . . . . . . .

Unknown medical complaint . . . . . . . .

Total medical . . . . . . . . . . . . . . . . . . .

Psychiatric/behavioral/drugs/alcohol:

Psychiatric/behavioral . . . . . . . . . . . . .

Overdose . . . . . . . . . . . . . . . . . . . . . . .

Alcohol-like impairment. . . . . . . . . . . .

OB/GYN total . . . . . . . . . . . . . . . . . . . . . .

Obstetric-prenatal . . . . . . . . . . . . . . .

Obstetric-emergency . . . . . . . . . . . .

Transport for exam . . . . . . . . . . . . . . . . . .

Nonemergency transport . . . . . . . . . . .

No transport . . . . . . . . . . . . . . . . . . . . .

DOA-total: . . . . . . . . . . . . . . . . . . . . . . . . .

DOA—no transport . . . . . . . . . . . . . .

DOA—transport . . . . . . . . . . . . . . . . . .

Canceled call: . . . . . . . . . . . . . . . . . . . .

False call . . . . . . . . . . . . . . . . . . . . . . . .

Missing/wrong code . . . . . . . . . . . . . .

15

3

3

3

2

1

0

1

0

0

0

0

14

9

2

2

1

1

19

1

2

1

1

6

3

1

0

1

2

33

2

2

1

2

1

1

11

1

13

3

2

1

9

2

7

Total number of patients . ............9,958

27

5

5

5

4

2

1

1

1

1

1

0

11

7

2

1

1

0

16

1

2

1

1

4

3

1

1

1

2

27

2

1

1

2

1

1

11

1

13

2

1

1

6

2

6

12,524

27

5

6

4

3

3

2

1

1

1

1

0

11

7

2

1

1

0

16

1

2

1

0

5

3

1

0

1

2

27

1

2

1

2

1

1

10

1

13

2

2

1

6

2

5

12,888

17

4

2

3

2

1

0

1

1

0

0

0

14

8

2

2

1

1

17

1

2

0

0

6

3

2

0

1

2

32

1

1

1

2

1

1

16

2

11

3

1

1

7

5

5,256

26

6

5

4

4

3

1

1

1

1

1

0

12

7

2

2

1

1

15

0

1

0

0

5

3

2

0

1

2

27

1

1

1

2

1

1

15

1

13

2

1

1

6

1

4

7,572

27

5

5

4

3

3

2

1

1

1

1

1

11

7

2

1

1

0

15

0

1

0

0

5

3

2

0

1

2

26

1

1

1

2

1

1

17

1

11

3

1

1

6

1

4

7,016

aThese data are based on a sample of 192 service providers’ ambulance run repOflS. one primary COmpklnt 1s reported

foreach call Numbersln the table represent thepercentof ambulance servlcecalls forpnmaryc omplamts. Cond!hons

representing less than 1 percent of calls were not Ilsted but are included m totals (e.g., drowning IS included In total

Injury).

KEY: CVA = Cardiovascular accident; DOA = dead on arrival; EMS = emergency medical services, OB/GYN =

obstetrics-gynecology, TIA = transient ischemic attack

SOURCE’ South Carolina Department of Health and Environmental Control, Columbia, SC, September 1989

vehicle crash mortality (figure 3-2) and there is an evidence suggests that a disproportionate number of

inverse relationship between population density and motor vehicle-related deaths occur in rural areas in

mortality (compare figure 3-2 map showing areas general (i.e., not just rural areas with low population

with high motor vehicle crash-related mortality to density) (figure 3-4). More than half (56.9 percent)

figure 3-3 map showing population density). Other of fatal traffic accidents occur in rural areas (as
Table 3-3-Number of Episodes of Persons Injured and Number of Associated Restricted-Activity Days and Bed Daysa

by Whether in Moving Motor Vehicle, Whether at Work, Place of Accident, and Place of Residence: United States, 1987

Number of restricted-activity days Number of bed days

Number per 100 persons per year (per 100 persons per year) (per 100 persons per year)

MSAb MSA MSA

Central Not central Central Not central Central Not central

Type of episode All city city Non-MSA All city city Non-MSA All city city Non-MSA

All episodes . . . . . . . . . 26.6 25.8 27.2 24.0 255.2 277.7 239.9 278.1 80.8 89.6 74.8 83.4

Moving motor vehicle:

Total . . . . . . . . . . . . . 2.6 2.1 2.9 2.0 56.5 70.7 46.8 53.1 17.9 23.7 13.9 19.2

Traffic only . . . . . . . . 2.1 1.6 2.5 1.8 49.3 62.3 40.5 43.8 15.9 20.5 12.8 15.4

Non-moving motor

vehicle . . . . . . . . . 24.0 23.7 24.3 21.7 197.0 204.7 191.7 221.9 62.4 65.6 60.3 63.9

At work c . . . . . . . . . . . . 5.3 5.0 5.4 5.0 96.8 97.9 96.0 100.4 32.2 39.2 27.4 23.0

Not at work . . . . . . . . . . 15.8 16.2 15.4 13.2 170.2 198.2 150.8 216.4 49.3 53.5 46.3 72.0

Place of accident:

At home . . . . . . . . . . 89 9.1 8.7 8.4 56.4 55.9 56.7 85.0 16.7 11.6 20.2 29.6

Street or highway . . 3.5 3.0 3.8 2.4 62.7 78.5 52.0 53.9 20.6 26.7 16.5 17.0

Industrial place . . . . 3.2 2.8 3.4 2.9 52.7 57.8 49.2 53.0 17.5 23.1 13.7 9.3d

Other . . . . . . . . . . . . 6.8 7.1 6.6 6.0 58.5 59.5 57.9 61.1 15.4 16.8 14.5 18.3

%Arnates of activity restnct!on and bed days are based on the present effects of the mpmes no matter when they occurred

bMSA = metropolitan statlsttcal area.

CFor currently employed 18 years Of age and over onlY

dFlgure does not meet standard of rehabhty or precmon.

SOURCE: U S Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics. Current Estimates from the National Health

Interview Survey: United States, 1987, Series 10, No. 186, DHHS Pub. No. (PHS) 66-1594, tables 51, 53, and 55, September 1988.
Chapter 3-The Demand for EMS Services in Rural Areas ● 21

Table 3-4-Average Annual Number of Injuriesa Per 100 Persons Per Year, by Place of Residence and Type of Injury:

United States, 1980-81

MSAb

Central Not central

Type of injury All city city Non-MSA

All injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.2 32.4 34.2 32.6

Skull fractures and intracranial injuries . . . . . . . . . . . . . . . . . . . . . . . . 1.0 1.2 1.0 0.8

Fractures of lower limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.9 0.7 1.0 1.0

Fractures of upper limb, neck, and trunk . . . . . . . . . . . . . . . . . . . . . . . 1.8 1.5 1.9 2.0

Dislocations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.6 0.6 0.6 0.6

Sprains and strains-total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.6 8.0 7.9 6.9

Open wounds and lacerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.0 7.9 8.4 7.8

Superficial injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6 1.7 1.6 1.6

Contusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 4.4 5.7 5.3

Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.0 1.0 0.8 1.2

Toxic effects-nonmedical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.8 0.9 0.8 0.8

All other injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6 4.5 4.6 4.7

a[njuries se~-reported inthet+ealth interview Survey.

bMSA. metropo~tanstahsf@ area.

SOURCE: U.S. Departmentof Health and Human Services, Pubhc Health Service, Centers forDlsease Control National CenterforHealth Statwtics, Types

of hjuries and /impairments Due to hjuries.” Lhted States, Series 10, No. 159, DHHS Pub. No. (PHS) 87-1587, table 6, November 1986

Figure 3-l—Death Rates From Unintentional Injury,

Suicide, and Homicide by Place of Residence, 1977-79

I Unintentional - motor vehicle

40

———————————— Suicide.

Homicide

30 —

20

\

— .--- ”

10 “

Largest Other Other Rural Rural

citiesalarge SMSAC

non- remotee

citiesb

remoted

aResiderlts d Cttles with 1 fIIilliOn or more Population.

bResldents of cmes with population between 250,000 and 1 rnllllon.

CReSlden& of Standard Metropolitan Statistical Area (SMSA) counties,

excluding residents of cities of 250,000 or more.

~Resldents of nonmetropoiitan counhes that do not meet the definition of

“rural remote. ”

eResldents of nonmetropotitan counties that are not adjacent to an SMSA

and have no settlement as large as 2,500 persons.

SOURCE: Susan P. Baker, Brian O’Neill, and Ronald S, Karpf, The /njury

fact Boo& (Lexington, MA: DC. HeaJth & Co., 1984). Reprinted

with Permwslon.

defined by DOT) ( 123) whereas only about one-third

of the population resides there.

What accounts for the excess motor-vehicle

deaths is unclear. Motor vehicle accidents do not

seem to occur more frequently in rural areas. In

1986, nearly one-fifth (18 percent) of people involved in motor vehicle accidents were in rural areas

(as defined by DOT) at the time of the accident (table

3-6). Given that approximately one-third of the U.S.

population is rural (as defined by DOT), this level of

accident occurrence may even be low.

Despite the fact that accidents seem to occur less

often in rural areas, persons involved in rural

accidents are three times more likely to sustain

serious or untreatable injuries than those in urban

areas (table 3-6). Many more rural than urban

accidents occur in areas with higher speed limits—

nearly half (48.7 percent) of the accidents in rural

areas took place in areas with speed limits of 55

MPH, compared to 8.7 percent in urban areas (see

table 3-6). People involved in accidents in higher-speedlimit rural areas are two to three times as likely to

sustain serious or untreatable injuries than those

involved in higher-speed-limit urban areas (2.4

percent v. 0.9 percent) (see table 3-6).

Possible explanations for higher rates of motor

vehicle-related injury and death in rural areas

include (14):

. poorer road conditions and the absence of

safety features such as guard rails;
22 ● Rural Emergency Medical Services

Table 3-5-Death and Disabling Injury Rates Among Workers by Industry, 1988

Deathsc Disabling injuriesd

Workers b Number Rate Number Rate

Industrya(in 1,000s) (in 1,000s) (per 100,000s) (in 1,000s) (per 1 ,000)

All industries . . . . . . . . . . . . . . . . . . . . 114,300 10,600e 1,800 16

Agriculture . . . . . . . . . . . . . . . . . . . . . . 3,100 1,500 48f

140 45

Mining, quarrying . . . . . . . . . . . . . . . . 800 200 25 30 38

Construction . . . . . . . . . . . . . . . . . . . . 6,500 2,200 34 210 32

Manufacturing . . . . . . . . . . . . . . . . . . . 19,500 1,100 6 350 18

Transportation and public utilities . . . 5,800 1,400 24 140 24

Trade . . . . . . . . . . . . . . . . . . . . . . . . . . 27,000 1,100 4 320 12

Services . . . . . . . . . . . . . . . . . . . . . . . 34,600 1,500 4 330 10

Government . . . . . . . . . . . . . . . . . . . . 17,000 1,600 9 280 16

aA~~~Ulture ,ncludes forestry and fishing Mlnlng and quarrying Includes oil and gas extraction. Trade includes Wholesale and retail. serv~~s Includes finance,

insurance, and real estate.

%Vorkersare all persons gainfully employed, mcludmg owners, managers, otherpald employees, the self employed, and unpaid family workers, but excluding

private househo!d workers.

Cunlntentlonal ,njury death (lcD Underlying cau5e of death codes E.800.E949), Death from acc)dent IS a death which occurs wlthm 1 year of the accident.

dDlsabllng ,njury ,5 an injury ~uslng death, permanent dlsabitlty, or any degree of temporary total disability beyond the day of the accident.

e~out 3,900 of the deaths and 200,000 of the Injuries revolved motor vehicles.

f~rlculture rate excludes deaths of ~er~ons under 14 years of age, Rates for other Industry divlslons do not require ttlls adjustment, Deaths of persons under

14 are Included In the agriculture death total

SOURCE National Safety Council estimates (rounded) based on data from the National Center for Health Statistics, State wtai statistics departments, and

State mdustrlal commmsions. Numbers of workers are based on Bureau of Labor Statlstlcs data and include persons aged 14 and over

Figure 3-2-Motor Vehicle Related Death Rates

SOURCE Baker et al., NEJM 316(22) page 1385

. a greater likelihood of travel at extremely high

speeds (65 MPH or greater);

● greater use of utility vehicles (jeep-like vehicles) and pickup trucks, which are associated

with high death rates:

● lack of use of seat belts; and

● greater distances between emergency facilities

and reduced access to major trauma centers.

Higher death rates in rural counties are not

explained by travel in rural areas by residents of

more densely settled areas6 or by a large volume of

Figure 3-3-Population Density

SOURCE: Baker et al., NEJM 316(22) page 1385.

travel on major routes (14). In fact, none of the

Federal interstate highways are distinguishable on

the map as connecting a string of counties with high

death rates (see figure 3-2).

Reducing the motor vehicle fatality rate to no

greater than 18.0 per 100,000 population is one of

the national 1990 objectives for injury prevention

and control (119).7 This goal has been achieved in

U.S. urban areas, where the motor vehicle accident

mortality rate was 17.3 in 1986 (see table 3-7). In

contrast, the rate for rural areas was 28.4. The U.S.

bMolor.vchic]c crash death rates Were a]s~ hlghcs[ in rural ~cas when calculated from National Cenler for Health sUUIStlCS data hal records tie

deceased county of residence instead of the place of accident occurrence.

7The ~o~ for tie year 2000 is 17.0 per 100,000 ppulation ~24).
Chapter 3--The Demand for EMS Services in Rural Areas . 23

Figure 3-4--Death Rates From (Motor Vehicle Occupants) 1990 objective would be achieved if there was a 30

Motor Vehicle Crashes by Place of Residence, 1977-79 percent reduction in the number of rural motor

30

20

10

0

Largest Other Other Rural Rural

citiesalarge SMSACnon- remotee

citiesb

remoted

aReS@ntS of cltles with 1 mllhon or more population

bResldents of cttles with population between 250,000 and 1 mllhon.

cResldents of Standard Metropolitan Statlstlcal Area (SMSA)

cauntles, excluding residents of c[tles of 250,000 or more.

dResldents of nonmetrowlltan count~s that do not meet the definition of

“rural remote. ”

eResldents of nonmetropolltan counttes t hat are not adjacent to an SMSA

and have no settlement as large as 2,500 persons.

SOURCE Susan P. Baker, Brian O’Nelll, and Ronald S. Karpf, The kyury

Fact Book (Lexington, MA D C Health & Co., 1984) Reprinted

with Permlsslon

vehicle fatalities (table 3-7). While there is no clear

explanation for the dramatically higher mortality

rate in rural areas, preventive efforts in rural areas

and improving rural EMS systems could prove to be

effective means of realizing the Nation’s objective.
24 ● Rural Emergency Medical Services

Table 3-&Passenger Car Occupant Injury by Land Use and Speed Limit, 1986

Vehicles Occupants

Serious to untreatable

All injuries (AIS > 1)a

trauma (AIS > 3)a

Number Number Number Number

(in 1,000s) Percent (in 1,000s) (in 1,000s) Percent (in 1,000s) Percent

Urban:

25 MPH or less . . . . 1,342 19.6 2,000 349 17.4 8 0.4

30 to 40 MPH . . . . . 4,064 59.4 6,140 1,281 20.9 25 0.4

45 to 50 MPH . . . . . 839 12.3 1,245 323 25.9 8 0.6

55 MPH . . . . . . . . . 596 8.7 901 232 25.7 8 0.9

Total urban . . . . . . . 6,841 100.0 10,286 2,185 21.2 49 0.5

Rural:

25 MPH or less . . . 161 11.5 252 40 15.9 1 0.4

30 to 40 MPH . . . . . 322 23.0 554 152 27.4 3 0.5

45 to 50 MPH . . . . . 234 16.7 362 109 30.1 7 1.9

55 MPH . . . . . . . . . . 681 48.7 1,137 349 30.7 27 2.4

Total rural . . . . . . . . 1,398 100.0 2,305 650 28.2 38 1.6

U.S. total . . . . . . . . . 8,239 12,591 2,835 22.5 87 0.7

aAls (Abb~~vlated Injury scale) IS Use(j to rate the seventy of trauma, /+ score of 1 indicates minor trauma; 2 Indicates moderate traUma, 3 SerlOUS trauma,

4 severe trauma, 5 crltlcal trauma and 6 maximum trauma (currently untreatable). The scale was developed by the American Assoclatlon for Automotwe

Med}clne.

SOURCE: U.S. Department of Transportation, National Highway Traf’hc Safety Admmistratlon, /Vationa/Acciderrt Samp/ing System, 1986, table 111-21.

Table 3-7--Metropolitan (MSA) and Non-Metropolitan (Non-MSA) Motor Vehicle Fatality Rates-1986,

and Impact of 30 Percent Reduction in Non-MSA Deaths on Achieving the National 1990 Objective for

Injury Prevention (Motor Vehicle Fatality Rate of 18 per 100,000 population)

1986 1986 Motor vehicle

Us . 1986 Motor vehicle accident death rates

population Motor vehicle accident death rates if 30% reduction in

(in 1,000s) accident deaths (per 100,000) non-metro MVA deaths

U.S. total . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241,036 47,865 19.9 17.9

Metropolitan . . . . . . . . . . . . . . . . . . . . . . . . . . 184,713 31,867 17.3 17.3

Non-metropolitan . . . . . . . . . . . . . . . . . . . . 56,323 15,998 28.4 19.9

SOURCES. U.S. Department of Commerce, Bureau of the Census, StakMca/ Abstract of the (hkd States: 1988, 108 edmon (Washington, DC, U.S.

Government Prmtmg OffCe, 1987); Department of Health and Human Services, Publlc Health Serwce, “Vital Stat@cs of the US : 1986,” vol. 2,

Morta//ty, Pub No. 88-1114 (Washington, DC U S Government Prmtmg Office, 1988)
Chapter 4

EMS in a Rural Context

Several factors may adversely affect the delivery

of emergency medical services (EMS) in rural areas.

This section first describes how the changing rural

health care environment affects the delivery of

emergency medical services. Second, problems in

providing rural emergency medical services are

described as are interventions that may help to

overcome them.

THE CHANGING RURAL HEALTH

CARE ENVIRONMENT

In some rural areas, a decline in the economy has

occurred at the same time as major changes in the

U.S. health care system. These changes include how

health care is paid for (e.g., implementation of

prospective hospital payment in the Medicare program) and how health care is delivered (e.g., a shift

to outpatient services). Making adjustments to the

new national health care environment is difficult for

many rural health care systems because they are

small and lack diversification. Many rural hospitals

that have not diversified and made other transitional

changes are now financially vulnerable. Since 1981,

nearly 550 rural hospitals have closed (61 ). In some

cases, hospital closures do not adversely affect

access to care and are appropriate (e.g., when a small

community has more than one hospital and services

are duplicated). However, in communities with only

a single hospital, hospital closure means that access

to hospital-based care is lost and ready access to

emergency care is diminished. ’

Health care is inaccessible in some rural areas

because of shortages of health care personnel. Six

percent of rural counties (142 of 2,393 nonmetropolitan counties) have no physicians (11 1 ) and approximately one-quarter of rural residents live in areas

that are federally designated health manpower shortage areas (HMSAS).2 Many rural areas have difficulty recruiting and retaining physicians, nurses, and

other health care personnel because of the heavy

demands of rural practice (e.g., longer hours, no

backup) or because there is no hospital or other

resources that attract providers (111). in some areas,

personnel shortages have been exacerbated by diminished support from Federal programs such as the

National Health Service Corps (11 1). Furthermore.

rural areas have been adversely affected by the

increased cost of medical liability insurance coverage. especially for physicians providing obstetric

care (28).

RURAL HEALTH CARE SYSTEMS

Access to well-trained personnel, essential equipment, and facilities in rural communities without a

local hospital or physician may sometimes be

achieved through cooperation with neighboring

communities with medical resources. As the availability of health care services diminishes in rural

areas, EMS providers may be left assuming new

responsibilities. There may be an increased demand

for nonemergency transportation to hospitals and

demand for urgent primary care services (e.g..

delivering babies). Anecdotal evidence suggests that

when a community hospital closes, the local EMS

system has a higher number of calls that are

nonemergent in nature ( 103) and there are delays in

EMS response times (1 34). In these communities.

the EMS system may need to reorient to provide

some urgent care or to coordinate with local

providers to make such care available. Rural EMS

providers are having difficulty providing EMS

services even without these additional pressures.

Problems in public access to EMS, prehospital care,

and medical response are described in the next

section, as are some potential solutions to these

problems.

Public Access to EMS Systems

Sparse population, large, remote. or inaccessible

service areas, poor weather and road conditions, and

limited access to communications may delay detection and reporting of a need for emergency care. An

automobile accident occurring along an infrequently

traveled rural road may not be detected for hours.

When such an accident is detected, access to the

EMS system may be further delayed because phones

or other forms of communication are not available.

Installation of emergency call boxes along major rural

highways. and use of automobile cellular phones3

ZHMSAS Me ~omties, ~~s of ~outlc~, or Spcclfic racllltlcs \V1~ ~nc or fcW,cr ph~sl~lans per 3,()()() or 3,500 population (45 FR 75996).

sRe.lab]c ~ellul~ [clcphonc nc[works arc not Yc[ widely available ( 136)

QThc two States witi statewide 9 I 1 coverage arc Delaware and Maryland ( 105)

-25-
26 Rural Emergency Medical Services

and citizen band radios, could improve public access

in the case of motor vehicle crashes (64,82).

A coordinated communications system that includes a widely recognized method to call for help.

such as telephoning 911, facilitates a quick and

appropriate EMS response. Trained dispatchers can

elicit information about the event and can quickly

marshal needed resources. Appropriately trained

dispatchers can also tell the caller what to do until

trained EMS personnel arrive ( 129). When there is

more than one EMS number in a community.

confusion over what number to call may result in

response delays. As many as 85 emergency numbers

were listed in the Greenville, North Carolina phone

book, covering 17 exchanges (52). Several EMS

agencies in north-central Florida report that some

residents in their service areas have to use longdistance to call them by telephone (75).

Universal access to emergency care via 911 has

been mandated in 14 States, but statewide911 access

to EMS services is actually available in only two

States (table 4-1) (105).4 Twenty-nine other States

are at least half-covered by 911 access (table 4-1)

(105). About two-thirds of States report having a

statewide plan available for EMS communications

(table 4-1),

Many rural areas lack central access and dispatch

systems and those with such systems often have old

equipment that needs to be replaced and upgraded

(82). Furthermore, there is variability in the quality

of EMS dispatching that could be improved by

agreeing on dispatch standards or protocols and by

implementing dispatcher training programs (82).

Only six States report that they certify EMS

dispatchers or telecommunicators (104).5

Access delays may also occur when the public

does not know how to contact the local EMS system.

Public education can be effective in improving

EMS-related knowledge. Nebraska’s EMS public

information program, for example, appears to have

been successful in educating the public on how to

access the EMS system and how to provide some

basic emergency care. According to a statewide

survey, as many as 83 percent of adults knew the

telephone number of the ambulance/rescue service.

over half of the adults had taken first-aid courses, and

37 percent had completed CPR training. In addition.

virtually all of the secondary schools were teaching

CPR (30). Many States, however, lack adequate

EMS public education. A 1987 survey indicated that

four State EMS organizations had no involvement in

public education efforts.6 In the remaining 47

jurisdictions that did have a public education effort,

20 self-evaluated their public education programs as

minimally effective, 23 considered their programs

moderately effective, and only 4 States rated their

educational programs as highly effective (106).7

EMS response time, the time elapsed from notification of an emergency to EMS arrival at the scene,

tends to be longer in rural than urban areas. In the

case of motor vehicle fatalities, the average response

time for rural areas (as defined by DOT) is almost

twice that of urban areas (1 1 v. 6 minutes) (123).s In

many cases, the critical “golden hour’ is exceeded

because of delays in detection and EMS response

time.

Response times can be reduced if an EMS

communication system is in place and emergency

vehicles can be dispatched from the field (e.g.,

redirected when returning from another call). EMS

communications are hampered in many rural areas

by radio “dead spots” that occur because of the

limited range of radio signals or because of geographic barriers. Available radio frequencies allow

communication between a central base station and

an ambulance (or other receiver in the field) that are

20 to 30 miles apart. To reach beyond these ranges,

mechanisms to repeat or relay the signal must be

used (129).

Thirty-one States reported that some rural areas of

their State lacked EMS radio system coverage (82).

Communications equipment such as VHF and UHF

relays, radio-telephone switching systems, microwave relay, and cellular telephones can overcome

4T~ Iwo s~tes with statewide 911 covcragc are Delaware and Maryland ( 105).

STwenty.foW states and tic Dis~i~l of col~bia repofled lha[ they did not ce~ify EMS dispatchers or kltxornmunkatms. [formation was

unavailable on dispatch certification from the rcmaining 20 States (104).

6The four s~te~ wl~ n. EMS organization Involvement in EMS public cducatlon were Arizona, Delaw~e, buisiana, and south Dakota.

TThe four States hat rat~ heir programs as highly effective were Indiana, Montana, New Mexico, and pemsylvania ~ 1 [M).

8Rew~1ng of on-scene ~val times is incomp]e(e, ~ese data arc limited to the 37 States that reported fatal crash scene rc~ponsc times so Pcrcenl

of the time or more in 1987 (123).

gIn tie futwe, mobile satellites may be used to improve rural EMS communications (~2).
Chapter 4--EMS in a Rural Context ● 27

Table 4-l-State EMS Communications, 1986-87

Statewide plan

available for EMS Legislation

Percent of population

with access to EMS service

communications mandating Authority 7-digit Multiple

State system 911 for 911 911 number numbers

Alabama . . . . . . . . . . . . . Yes No Local 60 40 0

Alaska . . . . . . . . . . . . . . . . . . . . . . No No Local 85 10 5

Arizona . . . . . . . . . . . . . . . . . . . . . Yes Yes State 90 NA NA

Arkansas . . . . . . . . . . . . . . . . . . . . Yes No Local 10 70 0

California. . . . . . . . . . . . . . . . . . . . Yes Yes Local 90 NA NA

Colorado . . . . . . . . . . . . . . . . . . . Yes No Local 80 0 20

Connecticut . . . . . . . . . . . . . . . . . . NA Yes State 65 35 0

Delaware. . . . . . . . . . . . . . . . . . . . Yes No Local 100 NA NA

District of Columbia . . . . . . . . . . . No Yes State 10 NA NA

Florida . . . . . . . . . . . . . . . . . . . . . Yes No State 89 NA NA

Georgia . . . . . . . . . . . . . . . . . . . . Yes No Local 60 100 NA

Hawaii . . . . . . . . . . . . . . . . . . . . . . Yes No Regional 95 5 0

Idaho . . . . . . . . . . . . . . . . . . . . . . . NA No Local 50 45 5

Illinois . . . . . . . . . . . . . . . . . . . . NA No Local 50 45 5

Indiana . . . . . . . . . . . . . . . . . . . . . NA No Local 40 45 5

lowa . . . . . . . . . . . . . . . . . . . . . . . . Yes No Local NA NA NA

Kansas . . . . . . . . . . . . . . . . . . . . . Yes No Local 70 30 0

Kentucky . . . . . . . . . . . . . . . . . . . . NA Yes State 33 10 57

Louisiana . . . . . . . . . . . . . . . . . . . NA No Local NA NA NA

Maine . . . . . . . . . . . . . . . . . . . . . . NA No Regional 50 50 0

Maryland . . . . . . . . . . . . . . . . . . . . Yes Yes State 100 NA NA

Massachusetts . . . . . . . . . . . . . . . Yes No Local 39 0 61

Michigan . . . . . . . . . . . . . . . . . . . . NA Yes State 45 NA NA

Minnesota . . . . . . . . . . . . . . . . . . . NA Yes Local 90 10 0

Mississippi . . . . . . . . . . . . . . . . . . Yes No Local 50 50 0

Missouri . . . . . . . . . . . . . . . . . . . . Yes No Local 65 35 0

Montana . . . . . . . . . . . . . . . . . . . . NA No State NA NA NA

Nebraska . . . . . . . . . . . . . . . . . . . . Yes No State 90 0 10

Nevada . . . . . . . . . . . . . . . . . . . . Yes No Regional 80 10 10

New Hampshire . . . . . . . . . . . . . . Yes No Local 30 5 65

New Jersey . . . . . . . . . . . . . . . . . . Yes No Local a27 0 73

New Mexico . . . . . . . . . . . . . . . . . . Yes No Local 70 15 15

New York . . . . . . . . . . . . . . . . . . . Yes No Local 65 10 25

North Carolina.. . . . . . . . . . . . . . . Yes No Local 31 55 14

North Dakota... . . . . . . . . . . . . . . NA No Local 32 68 0

Ohio . . . . . . . . . . . . . . . . . . . . . . . . NA Yes NA 30 70 0

Oklahoma . . . . . . . . . . . . . . . . . . . Yes Yes Local 7 93 0

Oregon . . . . . . . . . . . . . . . . . . . . . . Yes Yes State 90 5 5

Pennsylvania . . . . . . . . . . . . . . . . . Yes No Local 45 40 15

Rhode Island . . . . . . . . . . . . . . . . . Yes Yes State NA NA NA

South Carolina . . . . . . . . . . . . . . . Yes No Local 35 30 35

South Dakota . . . . . . . . . . . . . . . . Yes No NA 60 25 15

Tennessee . . . . . . . . . . . . . . . . . . . Yes No Local 50 30 20

Texas . . . . . . . . . . . . . . . . . . . . . . . Yes Yes State 20 60 20

Utah . . . . . . . . . . . . . . . . . . . . . . . . No No Local 80 10 10

Vermont . . . . . . . . . . . . . . . . . . . . Yes No Local 15 85 0

Virginia . . . . . . . . . . . . . . . . . . . . . . NA No Local 79 16 5

Washington . . . . . . . . . . . . . . . . . . Yes No Local 80 20 NA

West Virginia . . . . . . . . . . . . . . . . . Yes No Local 15 25 50

Wisconsin . . . . . . . . . . . . . . . . . . . Yes No Local 41 30 29

Wyoming . . . . . . . . . . . . . . . . . . . . NA No Local 90 4 6

aLeglslatton pending,

ABBREVIATIONS NA=lnformation not avaflable.

SOURCE: TheNationalEMSClearmghouse, “StateEMSOffce:Communlcafions Programs and DlsasterPreparedness:’ TheCouncflofStateGovernments,

iron Works Pike, Lexington, KY,1988.
28 ● Rural Emergency Medical Services

these dead spots but are often too expensive for rural

communities (82). In addition to equipment costs,

there are training and maintenance costs associated

with the systems (82).

Radio frequency congestion is hampering EMS

communications in many areas. The congestion

occurs because many public safety services (e.g.,

police, fire, local government, highway maintenance, and forestry conservation) share radio spectra. A special emergency radio service spectrum

exists, but it is crowded with unrelated and nonemergency medical licensees. In 1987,40 States reported

having EMS radio communication interference problems (105). The National Association of State and

Emergency Medical Services Directors has recommended that the Federal Communications Commission (FCC) establish a new radio service dedicated

to EMS communications (71). Rural EMS communications-related problems and potential solutions

presented at the March, 1989 “National Rural EMS

Needs Workshop” sponsored by the National Rural

Health Association, are summarized in box 4-A.

Prehospital Care

Prehospital care includes all care provided to an

emergency patient prior to arriving at a hospital. The

care may be provided by any of a number of different

types of providers, ranging from accident bystanders

trained in first aid or CPR to highly trained

emergency medical technicians (EMTs). Fire and

Box 4-A—Rural EMS Communications: Problems and Potential Solutions as Presented at the

“National Rural EMS Needs Workshop,” March, 1989

Problems Solutions

● Public access to EMS services is hampered by . Develop central access/dispatch systems (e.g., 911).

poor communications systems. . Install emergency call boxes along major rural highways.

. The public is uninformed about accessing the . Institute public education campaigns.

EMS system.

. Many rural EMS communications systems are ● Improve and upgrade EMS radio communications systems.

old and outdated.

. Rural areas have many radio ‘‘dead spots. . Expand coverage to wider areas through VHF and UHF

relays, microwave relay, radio-telephone switching systems, and cellular telephones. Investigate use of mobile

satellites.

. EMS radio frequencies are congested in some . Federal Communications Commission (FCC) should desigrural areas. nate additional exclusive VHF and UHF frequencies for

EMS.

. EMS communication are not always planned . Coordinate EMS services with local hospitals, FCCand coordinated with other emergency services. designated frequency coordinators, disaster response,

public service agencies, and local, regional, and State

EMS planning agencies.

. EMS communications vary in quality by State . Develop consensus standards for EMS communications

and area. equipment, radio frequencies, and dispatch centers. Establish standardized EMS communications protocols in each

area or region under physician medical control and

direction.

. Provide technical assistance and training to upgrade

quality.

● Provide quality assurance programs for EMS communications

operations.

. What EMS communication systems are most . Conduct research on the cost-effectiveness of different

suited to certain rural environments is unknown. types of EMS communications systems.

SOURCE: National Rural Health Association, “National Rural EMS Needs Workshop,” March, 1989, proceedings published in JEMS, June

1989. Sponsored by the National Rural Health Association,
Chapter 4--EMS in a Rural Context ● 29

police department personnel may provide prehospital care in addition to other services, such as

extricating victims of motor vehicle crashes and

controlling or preventing fires at the scene of an

incident. Prehospital care may be provided at the

scene of the emergency and while in transit to a

hospital or trauma center. Among the factors that

effect the quality of prehospital care are:

the training of those administering care;

the availability of transportation and of medical

equipment during transport;

communications between prehospital providers

and hospital-based providers; and

the existence of protocols for the type of

medical assistance offered and the transfer of

patients to an appropriate level of care.

Prehospital Care Providers

First Responders-When EMS response times

are long because of an area’s remoteness, road

conditions, or lack of EMS resources, community

members can be trained as ‘‘first responders” to

deliver basic EMS care. First responders administer

first aid, cardiopulmonary resuscitation (CPR) or

other interventions until the ambulance (or aircraft)

arrives at the scene. (See box 4-B---description of

prehospital care providers and their level of training)

( 104). At least 42 States and the District of Columbia

officially recognize first responders as providers of

emergency medical services (104).

Nationwide, over 100,000 first responders have

been trained and certified (see table 4-2) (104), but

States have used different models to deliver this

care. Some first responder programs rely on police,

fire, or medical personnel within the community,

while others rely on trained community volunteers.

In some areas of rural Vermont, for example,

‘‘off-dut y” rescue personnel (known as ‘‘jump

crews’ can be summoned to an emergency via

two-way portable radios from their home or other

remote location to provide basic and intermediate

life support until an ambulance arrives (51). Here,

the first responders are highly trained and experienced. However, it may be difficult to find volunteers that have time for both first response and

ambulance duties. In Idaho, quick response units

(QRU) made up of trained volunteers have been

organized throughout the State to offer basic lifesupport level service (7). First responders have been

used to provide advanced first aid and emergency

care in rural Georgian communities that lack both a

resident physician and an ambulance service. Their

response times of 4 to 5 minutes compared favorably

to the average ambulance response time of 20

minutes (69). Publications and courses are available

for farm families and workers that provide emergency procedure instructions for bystanders of farm

accidents (67).

Emergency Medical Technicians—Ambulance

crews staffed by emergency medical technicians

(EMTs) offer most prehospital care. In urban areas

the EMTs are usually paid, while in rural areas

approximately three-quarters of rural prehospital

EMS providers are volunteers (7). In some “frontier” States characterized by sparse population

settlement (e.g., Idaho), about 90 percent of EMS

prehospital personnel are volunteers (7). Without

volunteers, many rural communities would be unable to support an EMS system. Some rural counties

have no trained EMT providers. These communities

rely on providers whose training is limited to first aid

(45).

In general, rural EMS volunteer providers do not

have as high a level of training as urban providers.

(See box 4-B for a description of the types of

prehospital care providers and their level of training.) Most rural EMTs are “Basic EMTs” and can

provide noninvasive procedures such as first aid,

maintaining an adequate airway, administering oxygen. and CPR. In some States, Basic EMTs are

permitted to perform more advanced skills such as

maintaining intravenous (IV) lines. An average of

134 hours of training are required to become a

basic-level EMT (104). A basic EMT may acquire

additional specialized training to treat patients with

cardiac arrest due to ventricular fibrillation, with

defibrillator. (See ch. 5 for a more complete

discussion of emergency cardiac care.)

Paramedics have the basic skills of an EMT but

are also trained in Advanced Life Support (ALS).

ALS-trained paramedics can start IV lines, give

medications, and intubate a patient whose upper

airway is blocked (see box 4-B. responsibilities of

EMS personnel), Paramedic training usually involves about 750 hours (104). More than two-thirds

of States certify an intermediate level EMT (sometimes called intermediate EMT or EMT-n).10 Their

l~~y.eight s~tes and (he District of Columbia reco~ize intermediate level EMTs ( IW).
30 ● Rural Emergency Medical Services

Box 4-B—Prehospital Providers

First Responders

First Responders are persons trained to provide initial care for patients suffering injury or sudden illness until

EMS providers arrive. Trained First Responders can assess patients, provide basic life support, and render care that

is necessary to prevent medical and injury-related problems from becoming a threat to survival. First Responders

are trained to provide care using only a minimum of equipment and generally do not transport patients. On average,

first responder training involves 44 hours (104).

Emergency Medical Technicians (EMTs)

Emergency Medical Technician-Basic

EMTs provide emergency medical care, and stabilize and transport patients expeditiously to the hospital. They

use supplies and equipment normally carried in an ambulance. The typical EMT-basic is trained using the DOT

National Standard Curriculum for Emergency Medical Technicians-Ambulance (114 hours). Basic EMT

responsibilities include:

. assessing a patient’s condition;

. maintaining an adequate airway;

● administering oxygen;

• performing cardiopulmonary resuscitation (CPR);

. hemorrhage control;

● immobilization of fractures and dislocations; and

. basic rescue-extrication techniques.

Basic EMTs may also acquire additional skills such as use of the automatic or manual external defibrillator

and become certified as an EMT-Defibrillators or EMT-Ds. On average, acquiring defibrillation skills involves 18

hours (104).

Emergency Medical Technician-Intermediate

The EMT-Intermediate has acquired certain advanced skills in addition to the EMT-Basic skills, which permit

the EMT-Intermediate to initiate and continue emergency medical care under the direction of a physician, including

the recognition of medical problems and initiation of appropriate invasive and noninvasive therapy (i.e., IV lines,

limited medications). Many EMT-Intermediates are trained using the DOT National Standard Curriculum (40-55

hours of classroom) but there is much variation in the scope of practice of these providers from State to State.

Emergency Medical Technician-Paramedic

The EMT-Paramedic has acquired extensive skills in advanced life support (ALS) to provide prehospital

emergency care working under both written and/or verbal standing orders of physicians. Most EMT-Paramedics are

trained using the DOT National Standard Curriculum (700-1000 hours) but there is much variation in the number

of hours required to complete the course.

Advanced Life Support (ALS) Skills Include:

. IV therapy including peripheral and central venous lines;

. cardiac care including monitoring, manual defibrillation, and advanced pharmacology; and

. advanced airway management including incubation.

SOURCE: DOT, NHTSA, John Chew, 1989.

Basic-level skills are augmented with some ALS- advanced life support skills must work under the

level skills (68). license of a physician (i.e., they cannot work

independently). ll Although there are standardized

EMTs and paramedics are certified to practice by EMT and paramedic curricula,12 there are about 36

States, or by regions within States. EMTs practicing different types of EMTs practicing throughout the

11~ exception to MS is Wisconsin, where basic EMTs and paramedics ~ licensed ( IW).

12~C Nation~ stand~d ~Cul~ has ~n &velo@ and is publlsh~ by me ~p~rnen[ of TrmSpo~liOn, Nationat Highway Traffic safety

Administration. There are seven standard curricula for the following EMS professionals: Dispatcher; emergency vehicle operator; EMT-Ambulance;

EMT-Intermediate; EMT-Panrnedic; EMS Instructor; Air Medical Crew (24).
Chapter 4--EMS in u Rural Context ● 31

United States (97).13 If number of hours in training

is an indicator of level of skills acquired in training.

there are dramatic differences in skill levels. The

number of training hours required of basic EMTs

ranges from 104 in California to 315 in Hawaii.

Paramedics are trained in 185 hours in Pennsylvania

and 2,278 hours in Vermont (Vermont requires a

6-month internship) (104). Despite the variation in

hours of training required by States, most training

programs adhere to the National Standard Curricula

and meet or exceed established behavioral objectives (24).

Certification requirements for volunteer EMS

providers vary by State. Alabama, for example,

exempts its EMS volunteers from certification (90).

EMT certification requirements may even vary

within a State. In California the regulatory authority

for EMTs rests with local government, so requirements may vary by county. Some States will certify

EMTs who are certified by other States or registered

with the National Registry of EMTs.14 EMTs need

to be periodically recertified, usually every 2 to 3

years (104).

In many rural areas the pool of potential EMS

volunteers is reported to be getting smaller as

economic conditions have made it more difficult for

rural residents to have the spare time required for

volunteer activities (1 12). It may be especially hard

to get volunteers for daytime shifts (60). The

availability of prehospital providers varies by State.

Alabama has less than 1 EMT per 10,000 population, while South Dakota has nearly 5 per 10,000

(see table 4-2) (104). Nationally, there is a shortage

of trained paramedics, and ambulance services in

rural areas often cannot afford to hire those that are

available (39). The availability of paramedics also

varies markedly by State; Mississippi has less than

one paramedic per 100,000 population while Florida

has nearly 5 paramedics per 100,000 residents (see

table 4-2) (104).

Potential disincentives to become trained as an

EMT include the costs of initial training and

recertification, inaccessibility of training, concerns

regarding liability, and fear of contracting contagious diseases such as AIDS. The problem of

providing volunteer EMT training in rural areas may

be alleviated with mobile EMT courses, correspondence courses. or courses adapted to VCRs for home

use. Despite evidence of prehospital personnel

shortages, few States provide financial assistance to

train prehospital providers. According to a 1986

survey, only three States financially support their

first responder trainees, 12 States support EMT

trainees, and 5 States support paramedic trainees

(104).15

The relatively small populations that characterize

rural areas mean a low volume of emergency cases.

In the face of low volumes, it is difficult for the rural

prehospital providers, especially those trained at the

paramedic level, to maintain their skills. Rural EMS

providers could maintain and improve skills through

additional inservice training, locating EMTs and

paramedics in local emergency rooms,16 periodic

case critiques by medical advisers, and training

EMTs in such intermediate skills as advanced

airway management, IV therapy, and/or defibrillation (i.e., upgrade the basic EMT to the Intermediatelevel EMT).

An example of an innovative continuing education training program adapted to the needs of rural

providers is the Idaho EMS Mobile Trauma Training

Unit. Rural EMTs have an opportunity to maintain

or upgrade skills through training programs that

emphasize application of practical skills. In 1984,

the mobile unit made training available to 150 rural

communities throughout Idaho, providing trauma

skills training for about 2,000 EMTs (10).

Idaho has also offered continuing education

programs to EMS personnel throughout the State via

a‘‘telelecture’ program. Through teleconferencing,

lectures by EMS experts have been ● ’attended”

simultaneously by as many as 1.000 EMS personnel

in 71 classrooms widely dispersed throughout the

State (9). The system operates at relatively low cost

but is dependent on a sophisticated statewide

communication system, which includes mountaintop stations connected by microwave links to

regional hospitals and to the Idaho Statewide EMS

l~Much of tie v~atlon in types of EMTs OCCLKS because S[atcs have adopted very different standards for inkmncdialc-level EMTs.

14 Twenty five states and he ~s~c~ of Co]umbia use tic Nationa] Regis~ of Ems’ ex~inalion as tie basis of certification. An additional six States

accept National Registq examinations in Iicu of their State examinations. State policies dlctatc the ability to obtain cross-State certification. The Nauonal

Registry of EMTs facilitates cross-State certification ( 110).

lsFo~y.Wven States responded to tic S~eY

l~egon has fip]ernenl~ a grant-funded, week-long urban ‘‘extcmship” program for rural EMTs (137).
32 ● Rural Emergency Medical Services

-
Table 4-2-Currently Certified Prehospital Providers by State, 1986-87--Continued

Prehospital provider

Number of certified prehospital providers (per 10,000) ratio to population 1986 total

population First First

State (in 1,000s) responder EMT EMT-D EMT-1 EMT-CC Paramedic responder EMT Paramedic

Nebraska . . . . . . . . . . .

Nevada . . . . . . . . . . . . .

New Hampshire . . . . . .

New Jersey . . . . . . . . .

New Mexico . . . . . . . . .

New York . . . . . . . . . . .

North Carolina . . . . . . .

North Dakota . . . . . . . .

Ohio

Oklahoma; . . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . .

Pennsylvania . . . . . . . .

Rhode Island . . . . . . . .

South Carolina . . . . . . .

South Dakota . . . . . . .

Tennessee . . . . . . . . . .

Texas . . . . . . . . . . . . . .

Utah . . . . . . . . . . . . . . .

Vermont . . . . . . . . . . . .

Virginia . . . . . . . . . . . . .

Washington . . . . . . . . .

West Virginia . . . . . . . .

Wisconsin . . . . . . . . . . .

Wyoming . . . . . . . . . . . .

1,598

963

1,027

7,619

1,479

NA

NA

1,200

NA

500

7,500

NA

18,000

9,200

2,600

NA

NA

750

NR

NA

NA

NA

300

NA

360

NA

NR

NR

NR

NR

NA

NA

140

1,112

240

1,385

985

41

NA

225

680

2,868

12

853

61

695

4,466

276

28

NA

NA

NA

1.17

NA

0.34

NA

NA

0.44

NA

NA

0.96

0.27

NA

NA

NA

0.50

0.59

NA

NA

NA

4.69

NA

17.53

1.21

1.76

1.57

2.33

2.62

NA

0.70

1.56

1.95

1.33

0.94

4.94

1.27

1.15

2.29

2.26

NA

NA

NA

0.14

0.15

0.16

17,772

6,333

679

10,752

3,305

NA

NA

298

NA

NA

27,940

14,742

1,776

NA

2,310

NA

114

143

NR

150

2,026

1,424

29

NA

300

2,554

256

NR

NR

NA

0.08

0.16

0.06

NA

0.07

0.25

0.24

0.01

0.25

0.09

2,698

11,888

975

3,377

708

2,600

3,243

NA

NA

NA

4,202

23,199

1,300

3,160

3,500

6,078

19,230

3,818

1,225

NA

8,848

9,872

13,400

2,100

350

NR

110

NR

NR

1,300

NR

520

227

7

400

1,704

490

NR

NA

4,803

16,685

1,665

541

5,787

4,462

1,918

4,785

507

2,400

9,857

NR

NA

NA

NA

NR

100

1,229

NR

NA

1,316

1,718

383

NA

NR

765

650

650

NA

NR

NR

NA

NA

NR

872

NR

NR

0.14

0.27

0.17

0.05

NA

1,261

NA

2,500

700

404

NR

250

60

665

175

525

30

0.28

NA

0.52

1.38

1.98

5.15

2.80

4.14

0.15

0.09

0.11

0.06

Note NA =mdlcates Information not avalktie

NR =prowder category not recognized/certifted by State.

aPrehosphal providers can hold more than one Certlficatlon In some States (e.g., certified as a paramedic an an EMT) and therefore the total number of prehospital providers by State cannot be

determmed from this table.

bFlrst responder~lght states do not recognize first responders. An additional 25 States do, but dld not provide Information

CE~+IIStates recognize EMTs Seven States dtd not provide Information.

dEM.~28States do not recognize EMT-Ds. An additional 9 States do, but dld not prowde Information.

eEMT-/-l I States do not recognwe EMTIs An additional 11 States do, but dld not prowde lnfOrmatlOn

fE~T.C~3States do not recc)gnlze EMT-CCS An additional 7 States do, but dld not prowde Information

gPararned/P2 States do not recognize pararnedcs An additional 9 States do, but dld not provide Information

SOURCE. National EMS Clearinghouse, “Tralnlng and Certiflcatlon of EMS Personnel,” January 1989.
34 ● Rural Emergency Medical Services

Communications Center (8). At the present time,

few other States are using teleconferencing or

computers for training.

Given the time and cost of training, it is important

to retain as many volunteer EMTs as possible. There

is little information, however, about how long

volunteers remain in service. In West Virginia,

where volunteer EMTs have to be recertified at least

every 2 years, the average stay for an EMT is a little

over 21⁄2 years (90), In Colorado. 15 percent of

EMTs do not become recertified. Surveys of volunteer prehospital care providers suggest that among

the most important factors that lead them to leave

EMS service are: economic conditions in rural areas;

fear of personal risk; and costs associated with

volunteer work (62). Professionalization of volunteer EMS services and management training may

resolve some other factors that lead volunteers to

drop out, namely interpersonal conflicts, and the

stress and burnout associated with EMS work (11 2).

Providing workers’ compensation for dutyrelated injuries and protection from liability might

help retain experienced rural EMS volunteer providers. New York provides compensation coverage for

almost 400 volunteer squads. following passage of

the Volunteer Ambulance Benefit Law (90).18 Volunteer fire fighters and EMTs would receive a tax

credit of $100 dollars under a Wisconsin bill that

was recently introduced (Wisconsin, Assembly Bill

2). On the Federal level, the Volunteer Protection

Act (H.R. 91 1), currently under consideration by

Congress, encourages States to grant certain volunteers (such as those volunteering for nonprofit EMS

departments) immunity from personal civil liability.

Box 4-C summarized some of the problems related

to maintaining qualified prehospital care providers

in rural areas identified at the March 1989 National

Rural EMS Needs Workshop.

Transportation

EMS transport may be difficult in rural areas

because of small, widely dispersed populations,

geographic barriers, and inclement weather. As

definitive care is often located in distant cities, one

approach to decreasing time to definitive care is to

improve the rural EMS transportation system. Rural

transport may be improved through better organization of existing ground-based resources and by using

air medical transport services.

Ground Transportation

Nationally, there are over 12,000 ambulance

services with nearly 35,000 ambulances (108). Most

States have developed regulations and standards for

the design of ambulance vehicles and equipment

used by EMS personnel, and for various EMS

services and personnel (108). Emergency vehicles

may be classified as Basic Life Support (BLS),

Advanced Life Support (ALS), or Mobile Intensive

Care Units (MICU), depending on their equipment

and staffing. The proportion of ambulance services

staffed by basic EMTs, intermediate EMTs, or

paramedics varies by State. In North Dakota, for

example, only 3 of 130 ambulance services are

staffed by paramedics. In contrast, more than onehalf of ambulance services in Florida, Missouri, and

West Virginia are staffed by paramedics ( 108).

Rural areas with no EMS prehospital system, or

independent but under-utilized systems, may consider linkage models to provide or improve services.

Smaller population centers can be grouped into EMS

service areas and share resources. Recognizing that

complete ALS-level ambulance service coverage

was neither practical nor financially feasible in rural

northeast Missouri, EMS planners developed a

‘‘nodal’ ● concept of EMS. As shown in figure 4-1,

BLS and ALS ambulance services are evenly

distributed throughout the region to promote access

to ALS care and to achieve an ambulance response

time of 30 minutes or less. Most of the region is

within 15 to 20 miles of EMS service, but ALS

response times will likely exceed 30 minutes in

some areas within the region (39).

Air Medical Transport

Rural areas that lack roads or are far from

hospitals are especially dependent on air medical

transport services when medical emergencies occur.

There are currently over 200 U.S. air medical

programs that transport approximately 140,000 pa170nly MasWChWtts, Rh~e Is]and, SOu~ c~olina, and !VisConsin report using teleconferencing as part of the trtining process. Mwlandand south

Carolina repot-l using computers for [raining (104).

Igvo]unteer firefighters already had compensauon coverage.
Chapter 4--EMS in a Rural Context ● 35

Box 4-C—EMS Prehospital Personnel: Problems and Potential Solutions as Presented at the

“National Rural EMS Needs Workshop,” March 1989

Problems Solutions

. There are shortages of volunteer EMS provid- . Outreach to high school groups, the elderly, ethnic

ers in rural areas. minorities and other groups traditionally not involved as

EMS volunteers.

. Make EMS training more accessible to rural residents by

using alternative instructional modes such as videotapes

and correspondence courses.

. Assure the availability of instructors in rural areas by

recruiting and training rural practitioners as trainers.

Alleviate financial burdens of becoming an EMS volunteer by providing tax credits, training scholarships, or

liability insurance.

. The level of training of rural prehospital . Provide financial incentives for rural EMS providers to

providers is substantially below that of urban upgrade their skills in the form of training scholarships,

providers. and tax breaks.

. Develop programs to allow rural prehospital providers to

maintain skills through such devices as accident simulation.

. The EMS standard training curricula does not . Conduct research to determine the knowledge required to

always reflect the needs of rural areas. carry out EMS field operations.

. Provide specialty courses suited to the needs of the rural

provider (e.g., farm rescue).

. Rural EMS providers frequently lack guid- . Designate responsibility for medical control. Provide

ance from physicians. physicians charged with medical control responsibilities

appropriate training and orientation. Develop medical

control consensus standards.

SOURCE: National Rural Health Association, “National Rural EMS Needs Workshop, ” March, 1989, Proceedings Published m JEMS, June

1989. Sponsored by the National Rural Health Association.

tients a year, but evidence suggests that air medical are offered through the military (MAST)19 or are

services are unavailable in many rural areas.

Air medical programs use both fixed-wing aircraft

(airplanes) and helicopters. Airplanes or helicopters

are used in interhospital transfers of critical patients,

such as heart disease patients and newborns requiring intensive care. Helicopters are generally more

suitable than airplanes for transporting patients from

an accident site to a hospital because of their

flexibility in landing at a scene and at a trauma

center. Geography and weather conditions such as

heavy snow storms may, however, limit the use of

helicopters. About 80 percent of helicopter transport

services are hospital-based, 10 to 15 percent are

offered through public agencies, and the remaining

privately run (29).

Helicopter service augments the ground ambulance program and should be used in instances where

time, distance, medical personnel need, or scene

isolation warrant it (97). Air medical services are

usually based at urban tertiary care hospitals. The

service area extends about 150 miles beyond the air

medical base which generally includes rural areas. It

may, however, take a helicopter as long as 90

minutes to travel 150 miles. Fast airplanes are

usually used for longer transports. Sparsely populated States such as Alaska, Texas, Arizona, Montana, and Wyoming rely primarily on airplanes for

their EMS transports. In other areas, most EMS air

transport is provided by helicopters (97).

1’%4AST st~ds for ~]i~ Assistance [O safety and Traffic. Since 1969, 29 MAST programs have augmented some civilian EMS s~s(cms WI~

military helicopters. MAST serves many ruraJ areas (91).
36 ● Rural Emergency Medical Services

Figure 4-1--A Nodal Concept of EMS for Rural Northeast Missouri

o Advanced Basic or Basic Life Support

15 mile radius

o

Advanced Life Support

20 mile radius

SOURCE: East, S. and Tenbrink, T.D., 1989 (see ref. 39)

Many helicopter-transported patients are trauma

patients, but only 15 to 25 percent of helicopter

transports emanate from the scene of an accident—

most (75 to 85 percent) are interhospital transports

(56). Many trauma cases are initially transported by

ground ambulance to a community hospital where

the patient is resuscitated and stabilized before being

transferred to tertiary care via helicopter.

The number of helicopter medical transport services has increased rapidly in the last 20 years

following successful experience with helicopter

transport during the Vietnam war. The availability of

air medical transport, however, varies widely by

State (see table 4-3; and figures 4-2 and 4-3). An

estimated 20 percent of the population lack air

medical coverage, and the greatest voids are in rural

areas (97). Maine, Vermont, and New Hampshire

lack helicopter transport but have programs that

border their States. Some evidence suggests that

providers in rural areas delay requesting helicopter

transport when it is needed (41).

A few areas in the country may have too much

coverage. Missouri, with 2.7 helicopters per million

population has 3 times the national average (.9 per

million) and health planners have suggested that

there be a freeze placed on acquiring new helicopters

(65).

In some rural areas, there may be inadequate

access to air medical transport services because the

low volume and high costs of providing the service

are deemed “uneconomical” by privately run air

medical services. Sometimes service is inadequate

because regionalization is lacking. Several programs
Chapter 4--EMS in u Rural Context ● 37

have, however, successfully extended service into

rural areas using satellite placement of aircraft. The

Missouri Staff for Life program at the University of

Missouri, Columbia, for example, has located one of

its helicopters at a satellite location 62 miles south

of the host facility at a rural level II trauma center.

Satellite placement improves access to transport in

southern Missouri, where over half of the program’s

patient volume is generated. Satellite placement was

tried in northern Missouri but was not feasible

because of relatively low patient volume and a lack

of local providers that could staff the helicopter.

Northern Missouri is now served by a fast aircraft

located in Columbia (97). The Flight for Life

Program in Milwaukee, WI has also used a satellite

helicopter 50 miles south of the host facility to

improve response times in rural areas. Arizona and

Illinois have achieved statewide access to air medical services through a merger of public and private

air transport services. Here, aircraft are used for both

air medical and law enforcement purposes (97).

As helicopter services have proliferated, questions have arisen regarding their costs. appropriate

utilization, and safety. Helicopters cost from 1 to 2

million dollars each and operating costs average

about $650,000 per year (97).20 Surface ambulances,

in contrast, cost about $75,000 and operating expenses average under $200,000 (97). The average

number of patient transports per aircraft is 300-500

patients per year with optimal utilization at 500-700

transports (97). With these costs and necessary

volume, small rural communities cannot reasonably

acquire their own helicopters. However, in many

rural areas, helicopters are the only way to receive

needed emergency medical care quickly. Some rural

areas have a sufficient volume of cases to be served

by private air medical companies. Where volume is

insufficient, States could help ensure that services

are available to rural areas by encouraging State and

private cooperative agreements, by promoting offsite placement of helicopters where feasible, utilizing MAST resources where available, or through

subsidies.

Medical Control

The quality of prehospital care may be compromised if ‘medical control’ is not provided. Medical

control requires adequate communications systems

Table 4-3-Ratios of Helicoptersa to Population

by State, 1988

Rank 1987 Number of Rate/

order State population helicopters million

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

Montana

North Dakota

Arizona

Oklahoma

South Dakota

Missouri

Colorado

Tennessee

Wyoming

Idaho

Nevada

Alaska

Nebraska

Iowa

Alabama

D.C.

West Virginia

Washington

Louisiana

Kentucky

New Mexico

Arkansas

Utah

Mississippi

Ohio

Michigan

North Carolina

Texas

Florida

Illinois

Minnesota

Virginia

Wisconsin

Pennsylvania

South Carolina

California

Georgia

Kansas

Oregon

Indiana

Massachusetts

Connecticut

Maryland

New Jersey

New York

Vermont

Rhode Island

New Hampshire

Maine

Hawaii

Delaware

Total:

Averages:

809,000

672,000

3,386,000

3,272,000

709,000

5,103,000

3,296,000

4,855,000

490,000

998,000

1,007,000

525,000

1,594,000

2,834,000

4,083,000

622,000

1,897,000

4,538,000

4,461,000

3,727,000

1,500,000

2,388,000

1,680,000

2,625,000

10,784,000

9,200,000

6,413,000

16,789,000

12,023,000

11,582,000

4,246,000

5,904,000

4,807,000

11,936,000

3,425,000

27,663,000

6,222,000

2,476,000

2,724,000

5,531,000

5,855,000

3,211,000

4,535,000

7,672,000

17,825,000

548,000

986,000

1,057,000

1,187,000

1,083,000

644,000

243,399,000

5

3

12

10

2

14

8

10

1

2

2

1

3

5

7

1

3

7

6

5

2

3

2

3

12

9

6

14

10

9

3

4

3

7

2

16

3

1

1

2

2

1

1

1

2

0

0

0

0

0

0

226

4,43

6.18

4.46

3.54

3.06

2.82

2.74

2.43

2.06

2.04

2.00

1.99

1.90

1.88

1.76

1.71

1.61

1.58

1.54

1.34

1.34

1.33

1.26

1.19

1.14

1.11

0.98

0.94

0.83

0.83

0.78

0.71

0.68

0.62

0.59

0.58

0.58

0.48

0.40

0.37

0.36

0.34

0.31

0.22

0.13

0.11

0.00

0.00

0.00

0.00

0.00

0.00

—

0.93

aNumber of hel~opters IS based on Assoclatlon of Alr Medical services

(AAMS), formerly the American Assoaatlon of Hosplt al Based Emergency

Alr Medical Serwces (ASHBEAMS). Some nonhosplt al based helicopters

(e.g., public safety services) were excluded from these counts.

SOURCE Mlssourl Health Faclhtles Rewew Committee, “M!ssourl Alr

Ambulance Report—1989,” January 1989.

zOA@lane ~an~po~ation se~lces generally opcra~e at 25 (o 40 per~en[ of tie cost of he]lcopter services kcauw most airplane SCNICt.3S N(? tlOt

dedicated solely to air medical transportation and opcratmg costs are lower (9’7).
38 ● Rural Emergency Medical Services

Figure 4-2-Estimated U.S. Air Ambulance Distribution, 1988a

Rate/million population

0.00

❑ 0.01-0.99

1.00-1.99

2.00-2.99

3.0+

Average of 4.3 Air Ambulance Units per State and an average of 0.93 per million population

%Jumber of helicopters is based on Association of Air Medical Services (AAMS), formerly the American Association of Hospital Based Emergency Air Medical

Services (ASHBEAMS). Some nonhospltal based hel~opters (e.g., public safety services) were excluded from these counts.

SOURCE: The Missouri Health Facxllhes Review Committee, “Mlssourl Alr Ambulance Report,” January 1989.

and commitment from the medical community. It is

sometimes difficult to get rural physicians to provide

medical guidance in the form of practice guidelines

(off-line medical control) and on-scene and transport

medical advice via radio (on-line medical control).

Many emergency room medical directors in rural

hospitals are not EMS specialists and therefore

could benefit from training and orientation regarding

their medical control responsibilities (82).2] Consensus standards for medical control may be particularly useful in rural areas.

Prehospital providers may need advice regarding

where to take an emergency patient. As the triage

decision is often critical to patient survival or death,

the highest available level of medical expertise

should be brought into the triage decision-making

21A tr~nlng COWW for phy~icians on [hc provision of mcdica] con~o] for EMS is under devc]oprnent by tie American cO]kgC Of EITW&31Cy

Physicians (ACEP) (63).
Chapter 4--EMS in a Rural Context ● 39

Figure 4-3--U.S. Helicopter Medevac Programs

Medevac sites

+ 156 Hospital based

* 30 Public service

. 12 Independen t

Two hundred and thirty-one helicopter ambulance services are run in 46 States and the District of Columbia by hospitals, the military and

State and local police-and rescue services as of 1987. At least 19 additional programs are scheduled to start by early 1988.

SOURCE: A. Schneider, Rescue at Risk, The Pittsburgh Press, 1987.

process. This responsibility is usually assumed by

the local emergency department physician (5). Some

areas have designated trauma or critical care centers

and explicit triage policies (see discussion in ch. 5).

In other areas, policies dictate that patients be taken

to the nearest hospital. Critical trauma patients may

be transported to a trauma center after being

stabilized at a local hospital, but in some cases

immediate transport to the trauma center is required.

It is especially important that medical control be

available to prehospital care providers when triage

patterns are not explicit.

Fear of litigation may discourage some physicians

from providing medical control to the local EMS

system. As of 1987, 18 States had enacted legislation

that protects physicians from civil liability when

they assume EMS medical control responsibilities

(109).

Medical Response

Although many of the events precipitating the

need for EMS occur at the same rate in urban and

rural areas, the level of hospital care required to

respond to emergent events is not equally available.

Because large numbers of people are concentrated in

urban areas, the specialized services required to care

for the most acutely ill and injured patients can be

maintained. In rural areas, however, emergent events

occur infrequently, making it economically difficult

to maintain a tertiary-level facility. Furthermore, it

is difficult for rural EMS providers to maintain

specialized skills when they are infrequently used.

When faced with emergencies that require services
40 ● Rural Emergency Medical Services

beyond those available in the local health care

system, rural communities must have a system in

place to stabilize and transport patients. Integration

of levels of care or a referral systems approach to

EMS are, however, nonexistent in many rural areas.

While access to specialized services, such as those

available in a trauma center, is central to a good EMS

system, local resources must be adequate to handle

the majority of EMS cases that do not require these

specialized services. Most calls to an EMS system

can be appropriately handled at a community

hospital. For example, about 90 to 95 percent of

trauma cases can be treated adequately at a community hospital (5), while only 5 to 10 percent of cases

are critical and require more specialized services. In

the evaluation of EMS systems, it is as important to

examine the availability of local hospital resources

as it is to examine access to more distant specialized

resources, such as trauma centers.

When a rural area has a community hospital, it

almost always (98 percent) has an emergency room

but rarely has a trauma center (see table 4-4).22 In

general, there are few specialized emergency physicians (i.e., Board-certified emergency physicians)

and nurses in rural hospitals. Instead, physicians and

nurses tend to be generalists who must provide care

in all of the various hospital specialty areas. They

provide care in the emergency room if and when a

patient presents there. These providers may not only

lack the specialized training required to appropriately manage emergency patients, but they often do

not have the opportunity to frequently practice

necessary EMS skills and maintain proficiency

(53,63). Making continuing education courses in

emergency medicine available to physicians practicing in rural areas could effectively improve the

community hospital’s EMS medical response and

improve the quality of medical control of the

community’s EMS system.

EMS treatment delays may occur in rural hospitals because rural emergency departments are often

not staffed by a physician 24 hours a day. In Idaho,

for example, only 9 of the State’s 48 hospitals have

24-hour physician coverage (108). Many rural hospitals have trouble paying for 24-hour emergency

room physician coverage and opt for rotating,

on-call coverage (87).

Emergency room nurses are usually available

until the physician arrives, and outcomes of patients

with life-threatening emergencies may be improved

by upgrading and maintaining their skills (93). A

survey of nurses providing emergency room care in

rural areas cites understaffing of emergency departments, underqualified nurses and physicians, a lack

of continuing education programs, and the absence

of statewide emergency standards as among the most

serious problems facing rural emergency nurses

(37). As of 1986-87, however, only Arizona, Illinois,

and the District of Columbia had EMS offices that

had set minimum standards for nurse emergency

department practice. Furthermore, a 1986-87 State

survey showed that few State EMS offices were

conducting training programs for nurses (107).23

An innovative approach to continuing education

for rural EMS providers is the use of computer-based

simulation programs similar to those used to instruct

pilots. One such program includes a series of EMS

patient-management problems designed to help

physicians, nurses, and critical care providers sharpen

their ability to make clinical decisions (43).

Regionalization

Many States have designated specialized facilities

for the treatment of trauma, burn, or other types of

emergency patients. Before designating facilities,

States usually adopt standards for personnel and

equipment that must be met before designation can

occur. Some States “verify* facilities that meet the

standard while others ‘‘designate’ facilities that

meet the standards according to the State’s needs.

Under the verification process, as many facilities as

meet the standard may be used for specialized

services. In contrast, under the designation process,

facilities often compete to be designated (108).

Facilities have been verified or designated for their

trauma care, spinal injury care, poison centers,

psychiatric services, burn centers, and cardiac care

(108). Some States have triage criteria that specify

when patients should bypass a nonspecialized hospital for a specialized one (see ch. 5). The presence of

written agreements (sometimes called transfer agree22Whe~e. or ~ol ~ h~spi[~ has a tra~a ~cnler de~nds largc]y on the num~r of hospi(~ kds. Nearly one-lltird of rural hospitals with 20010300

beds have a trauma center.

zJStates EMS offices ~a~ were offering nurw [r~nlng (or providing financia] assistance for training) include Alaska, Illinois, Maryland,

Massachusetts, Nevada, New Jersey, New Mexico, and Rhode Island ( 107).
Chapter 4-EMS in a Rural Context ● 41

Table 4-4--Percent of Community Hospitals With EMS-Related Services

in Metropolitan and Nonmetropolitan Hospitals by Bed Size (under 300 beds), 1987°

Hospital location and bed size Emergency department Trauma center Blood bank

(number of hospitals) Percent Number Percent Number Percent Number

AMetropolitan:

6-24 (22) . . . . . . . . . . . . . . . . . . . . 81.8 (18) — (o) 22.7 (5)

25-49 (122) . . . . . . . . . . . . . . . . . . 83.6 (102) 3.3 (4) 52.5 (64)

50-99 (363) . . . . . . . . . . . . . . . . . . 94.8 (344) 5.0 (18) 69.7 (253)

100-199 (693) ., . . . . . . . . . . . . . . 96.7 (670) 16.2 (112) 77.8 (539)

200-299 (571) . . . . . . . . . . . . . . . . 97.5 (557) 28.2 (161) 84.2 (481 )

Total (1 ,771) ., . . . . . . . . . . . . . . 95.5 (1 ,691) 16.7 (295) 75.8 (1 ,342)

Nonmetropolitan:

6-24 (183) . . . . . . . . . . . . . . . . . . . 94.5 (173) 0.5 (1) 45.4 (83)

25-49 (753) . . . . . . . . . . . . . . . . . . 97.9 (737) 2.9 (22) 49.8 (375)

50-99 (831) . . . . . . . . . . . . . . . . . . 98.7 (820) 6.5 (54) 66.8 (555)

100-199 (526) . . . . . . . . . . . . . . . . 97.7 (514) 16.0 75.5 (397)

200-299 (132) . . . . . . . . . . . . . . . . 97.7 (1 29) 31.8 (42) 87.1 (11 5)

Total (2,425) . . . . . . . . . . . . . . . . 97.9 (2,373) 8.4 (203) 62.9 (1 ,525)

%ommunity hospitals are defmd as short-stay, non-Federal, nonspec!alty hospitals.

SOURCE: OTA analysis of data from The American Hospital Assoclatlon 1987 Annual Survey of Hospitals.

ments) between facilities providing different levels

of care can expedite a rapid patient transfer and may

save a rural hospital the cost of upgrading equipment

and resources.

Social and Political Constraints on Rural EMS

Development

Efforts to upgrade and regionalize rural EMS

systems are sometimes impeded by social and

political factors. Rural areas are frequently characterized by older, less affluent, and more traditional

residents that may be less knowledgeable about the

use and efficacy of emergency medical services, and

be slower to accept new patterns of health care

delivery. Rural residents have been characterized

(even by rural residents themselves) as “parochial,’

“fiercely independent,” distrustful of urban initiatives, and leery of control by State or Federal

Governments (135).

A rural community’s desire for local control and

autonomy is oftentimes antithetical to the effort to

create coordinated, regional EMS systems. In one

New England State, the desire for local autonomy

was intense; each community, regardless of size,

wanted its own physician, its own ambulance

service, and its own hospital (135). This pattern is

neither cost-effective nor conducive to the maintenance of skills by the volunteer ambulance attendants. It has led to an excess of vehicles, an

enormous EMS training burden because of the large

number of volunteers required to staff the service, a

multiplicity of dispatch centers, a suboptimal distri19-758 - 89 - 3 : QL 3

bution of vehicles, and a complicated coordination

task (135). In the mid-1970’s, the region received a

large grant to establish a central communications

center with 911 access for all emergency services.

Although the central communications center was

established, a 911 access system was not because of

opposition from 19 volunteer fire chiefs who wanted

to retain dispatch rights. Consequently, a system of

central dispatch and 911 access remained elusive

goals for this area (135).

Efforts to regionalize services have sometimes

failed even when incentives such as free equipment

are offered in exchange for cooperation. In one

Pacific Northwest rural community, for example,

local leaders decided not to request Federal funding

to purchase much-needed EMS communications

equipment, because they wanted to avoid restrictions attached to Federal funds for EMS even though

the town could not afford the equipment.

Some rural communities oppose governmental

regulation and intervention in the private sector

operation of EMS services and there is often

resistance to the passage of mandatory standards for

EMS providers, vehicles, and facilities. Sometimes.

resistance is simply due to the fact that local

resources may be unavailable to upgrade the EMS

system to meet new standards. Furthermore, national

standards may be viewed as inflexible and not suited

to the unique circumstances of rural areas. Without

standards, however, there is wide variation in the

quality of services available in rural areas. Some
42 ● Rural Emergency Medical Services

local governments have agreed to subsidize a private

ambulance service, but they often have not provided

for performance standards, ambulance regulations,

contracts, or other needed mechanisms of public

accountability for the tax dollars provided (135).

What may appear to outside EMS observers to be

a major improvement in the quality of prehospital

care may not be perceived as such by local residents.

In one small community, for example, the local

funeral home (one of the last in the State still in the

ambulance business) decided to withdraw from

ambulance service provision in the face of increasing financial losses and the possibility of the passage

of State ambulance regulations. A pair of experienced paramedics from a nearby metropolitan area

took over the service and the town progressed

rapidly from an inadequate, antiquated funeral home

system to a well-equipped and well-staffed basic life

support system with advanced life support capabilities. The public, however, missed the low rates

charged by the funeral home (which had provided

the service largely for public relations reasons), were

unaware of the significant improvement in the

quality of care, and did not understand why the

paramedics spent so much time at the scene of the

EMS incident (to stabilize the patient prior to

transport). They much preferred the funeral home

service.

One strategy that EMS leaders could use to

ameliorate some of the rural constraints on EMS

system-building and regionalization is public education regarding the importance of EMS and how EMS

systems are organized. EMS leaders, for example,

could make presentations at schools, city council

meetings, senior citizen groups, civic clubs, and

health fairs. They can also educate members of the

local media concerning EMS issues, since the media

can be an extremely effective means of raising the

awareness of the public and elected officials.

The functions of State and regional EMS agencies

and councils could be supported as they can serve as

a valuable technical resource for rural providers,

advising them concerning financial management,

liability insurance, and third-party reimbursement;

providing training equipment and courses; and

seeking out public and private financial assistance.

A decentralized structure of county and regional

councils may be effective in rural States marked by

extreme local independence.

EMS leaders could attempt to capitalize on the

competitiveness characteristic of rural towns and

ambulance service providers. For example, if EMS

leaders can persuade the members of a key volunteer

squad of the need for training, and modern equipment and vehicles, their example is likely to pique

the competitive spirit in neighboring squads, who

may then follow suit. The dedication of rural

volunteers is impressive and can be a valuable asset

in building and maintaining an EMS system.

While there are examples of communities that

have resisted EMS systems development, there are

numerous rural communities that have developed

model EMS systems. 24 In the rural Texas panhandle,

for example, an EMS system has been developed to

provide services in a 26 county, 26,000 square-mile

area. The Panhandle Emergency Medical Services

System (PEMSS) was originally federally funded,

but it is now a nonprofit corporation sustained

through fees paid by 56 ambulance services located

within the region. 25 Membership dues provide for

training programs, vehicle and equipment purchases, quality assurance programs, ongoing communications networking, and system evaluation.26

Hospitals in the region are categorized according to

level of care and there are comprehensive prehospital medical and transport protocols. The region has

a single regional medical communications network

that reaches throughout the Panhandles’ vast area

(58).

24DHHS*S Offiw of’ RLWd Health Policy will complete some rurat EMS case studies by early 1990 (32).

25~e pE+fSS mem~rs pay $0,17 ~r individ~l residing in tie member’s service area, FWS range from $45 to $36,000 per year (58),

26pEMSS is ~on~oll~ by a ~~d of ~r~to~ hat governs tie organization with advisement from a regiona] advisory COMIIIlttfX (58).
Chapter S

Emergency Cardiac and Trauma Care in Rural Areas

Caring for victims of cardiac arrest and trauma

represent two of the most common demands of the

emergency medical services (EMS) system. In this

section, the care of patients with these conditions is

used to illustrate the special problems of delivering

EMS services in rural areas.

CARDIAC CARE

Cardiovascular disease is the primary cause of

death in the United States, accounting for nearly half

of all deaths. More than half of cardiovascular

disease deaths are caused by coronary heart disease.

and most of these deaths occur suddenly (sudden

cardiac arrest), usually outside of hospitals (52). ]

Requests for EMS services are more likely to be

related to complications of medical conditions such

as heart disease than for trauma. In rural Texas, for

example, about one in seven calls for EMS services

are attributed to heart complications (see table 3-1).

Coronary heart disease death rates are 25 percent

higher in rural areas but the fact that the rural

population has proportionately more older residents

may largely explain this difference (table 5-1 ).

At present, no more than 5 percent of sudden

cardiac arrest victims are successfully resuscitated,

but the combination of a well-organized EMS

system and the application of a relatively new

technology—the automated external defibrillator—

could raise the proportion of successful resuscitations 2 to as high as 30 percent (52). Factors that

maximize a patients chances of recovering following

cardiac arrest relate to time to care and the skills of

the prehospital provider. Providing cardiac EMS

care quickly is essential but difficult in many rural

areas. In the case of cardiac arrest, cardio pulmonary

resuscitation (CPR) must begin within 4 minutes and

definitive care within 10 minutes of a cardiac arrest

(1 15). Rural EMS systems are at a disadvantage in

treating cardiovascular emergencies because they

often lack paramedics, who are much more successful than basic emergency medical technicians (EMT)

in treating cases of prehospital cardiac arrest (52).

Some evidence suggests that paramedics are as

effective as physicians in diagnosing and treating

acute cardiovascular emergencies (52). The skills of

the basic EMT can, however, be upgraded so that he

or she can use an external defibrillator to improve the

outcomes of patients suffering cardiac arrest.

Manual or automatic external defibrillators can be

used to deliver electric countershocks to patients in

ventricular fibrillations.3 Manual defibrillator require the operator to read an electrocardiogram and

to determine if the heart rhythm warrants the use of

defibrillation. Automatic or “smart” defibrillators.

developed in the early 1980s, perform these functions and deliver a countershock when ventricular

fibrillation is detected. The automatic defibrillator

allows persons with less medical experience and

training to effectively treat critical dysrhythmia (79).

Paramedics and EMTs trained in advanced life

support (e.g., intermediate EMTs) can use external

defibrillator. In addition, basic EMTs can receive

additional training in the use of external defibrillators and be certified as EMT-Ds (EMT-Defibrillators). Basic-level EMTs can be trained to use manual

defibrillation in 16 to 20 hours and to use automatic

defibrillator in about 4 hours (1 00). In the future,

first responders and other community members may

be trained in its use because automatic external

defibrillator are so easy to use (52). Family

members or fellow workers may defibrillate cardiac

arrest victims at home or at work with a recently

developed device that is stationed at home or work

but is connected to a hospital base station by phone.

When a cardiac arrest occurs, the bystander can

activate the device to dial the hospital base station

automatically, and after getting advice from a

physician (based on electrocardiogram readings). a

defibrillating shock can be administered by phone

(36).

Defibrillator, when used effectively by EMTs,

can potentially save one out of five cardiac arrest

victims if used soon after a cardiac arrest (52). and

some studies have found lower cardiac arrest mortality in communities where EMTs have been trained

to defibrillate ( 102). Not all communities. however,

have the resources or the conditions that would

Icoronq hc~ dlxa.w is ~ausc~ bY ~hangcs In tic ~crlcs ]eadlng [~ ~C heafl (~oronq ~crlcs) tha( in[crfcrc with adcqua[c blood floW.

2A successful resuscitation is one that results m [he pahcnt surviving w hospl[al dlschargc (52).

3vcnt~1Cu]N fib~ll]a[lon, tie rhy~m most Of[cn ass~cla[cd wl~ ~~dia~ ~csl, is a Condllion in which the hem mus~les twitch in an uncoordinated

fashion, intcrfcnng with the pumping of blood ( 115).

-43 -
Table 5-l—Deaths Attributed to Cardiovascular Disease by MSA/non-MSA Residence, 1986

Us. MSA Non-MSA

Crudea Crude Crude

death rate death rate death rate

Cause of death Number (per 1 ,000) Number (per 1,000) Number (per 1 ,000)

All causes . . . . . . . . . . . . . . . . . . . . . 2,105,361 8.7 1,533,914 8.3 571,447 10.1

Major cardiovascular diseasesb . 968,240 4.0 696,865 3.8 271,375 4.8

Diseases of the heartc . . . . . . 765,490 3.2 554,564 3.0 210,926 3.7

Ischemic heart disease

(coronary heart disease)d . 520,729 2.2 377,888 2.0 142,841 2.5

Other heart diseasee . . . . . . . . 215,315 0.9 153,527 10.8 61,788 1.1

aThe ~.u~ death ~a~e is ~alculat~by dlv~lng the num~r of resident deaths by the area’s total population.It IS not adjusted to take an area’s age dlstrlbutlon

mto aeeount.

biCD-390-448.

clCD 390-398, 402, 404-429.

dlcr) 410-414.

elCD 415-429.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Vital

Statistics of the United States, 1986, vol. II—Mortality, Part B, table 8-9.

permit effective use of this technique by EMTs.

Furthermore, a few States do not permit basic-level

EMTs trained as EMT-Ds to operate the defibrillation equipment (74).

EMT-D programs are most cost-effective in

communities with more than a thousand people, or

those large enough to expect more than one out-ofhospital cardiac arrest each year. The costs of

instituting an EMT-D program include training and

equipment cost? and the salary of a medical director.

In order to institute an EMT-D program, a medical

director must assure quality control through supervision of trained EMTs.5 In some States, ‘‘standing

orders’ from the medical director permit EMTs to

defibrillate, while other States require direct radio

contact (telemetry) with the medical director.6 Defibrillation, to be effective, must be instituted shortly

after the onset of the heart attack. EMT-D programs

are therefore most effective where cardiac arrests are

witnessed and when CPR is started by bystanders or

emergency personnel within 4 minutes of the

victim’s collapse. In addition, EMT response times

must be short-not more than 10 minutes-or the

chances of survival are slim (1 15,130).

If communities are small, community members

are not trained in CPR, and response times are 10

minutes or more, a community should direct its

resources to improving these conditions before

instituting an EMT-D program (115,130). Because

most cardiac arrests occur at home, in men over 60

years old, some have recommended that CPR

training be targeted to middle-aged women and that

physicians encourage the families of cardiac patients

to learn CPR (52). Several communities have

developed dispatcher CPR programs where an EMS

dispatcher offers CPR instruction to bystanders until

an EMS crew arrives at the scene (52).

Rural providers may have difficulty maintaining

manual defibrillation skills, as some estimates

indicate that a rural EMT-D in a small community

may manage a cardiac arrest as seldom as once every

8 years (100).7 To overcome this problem, practical

skills review should occur at least every 3 months

(52). Automatic external defibrillator (AEDs) are

particularly well suited to the needs of rural areas

because they are easier to use than manual defibrillators and do not usually require recertification (100).

Basic-level EMTs can quickly learn how to place the

defibrillator’s paddles and to start the automated

system. The AED will defibrillate only in the

presence of ventricular fibnllation.8

4Sm~] ~ulomaljc defibrlllators WC ~vai]ab]e for ~[wecn $5,~(~ [o $9,()()(), making ~cm affordable for many rural communities.

5Det~led, ~tep.by-~tep infomallon “n ~lannlng and implementing an EMT-D program Wa.S published in a Ihrec-part artic]c in MC Journal Of

Emergency Medical Services (33,34,35).

6The llcen~e of tic mcdlca] director provldcs the authority for certified EMTs to dia~osc cardiac arrhythmias and IO usc a defibrillator.

7The respn~lblll(y, for rc]atlvc]y few Cwdlac ~est$ (approxlmaLe]y I per 1,~() popu]ali~n per yc~) may be shared by as man) aS 20 voiuntccrs in

a small community (100).

8Ver1ficat10n tha[ ~ Pa[len( is ~ctua]]y in ~~dlac ~cs[ by determination of pu]sclcssness is cri[i~al and Yet difficull for (hc untrained. other conditions

such as seizures might confuse mcdlcally unskilled operators and potentially, a countcrshock could be lethal if administered inappropriately (52).
Chapter S--Emergency Cardiac and Trauma Care in Rural Areas . 45

Improving rural response time to cardiac arrest

calls can be achieved by stationing defibrillator

with one or more on-call EMT-Ds instead of with the

ambulance. EMTs carrying defibrillator can proceed directly to the patient while another EMT goes

to the station house for the ambulance. Some rural

ambulance services are notified by pager or telephone and then respond first to the ambulance

garage, then to the patient. Some services require

ambulances to remain at the garage until at least two

or even three EMTs arrive, which delays response

(loo).

Prehospital care providers may become more

involved in the treatment of patients with acute

myocardial infarction. Thrombolytic agents—drugs

to restore blood flow to the heart-are now common

emergency room treatments for this type of heart

attack. Some evidence suggests that if an adequate

diagnosis is made, patients can safely be given

thrombolytic treatment in the field and transferred

by ambulance (89). This may be a promising

intervention in some rural areas where time to

emergency room care is long.

TRAUMA CARE

Injury 9 occurs with about equal frequency in

urban and rural areas but tends to be more severe in

rural areas (table 3-2). Motor vehicle accidents, for

example, occur with equal frequency (see table 3-5)

but are more likely to occur at higher speeds in rural

areas and result in more serious injuries. Motor

vehicle-related mortality is consequently 1.6 times

higher in rural than urban areas (table 3-6). From 15

to 30 percent of calls for EMS care in rural areas are

related to injuries, but only about one-tenth of these

calls would represent severe or critical injuries.

When severe injuries do occur, they require immediate medical attention and. sometimes, specialized

trauma care that may be far from rural areas. A

number of factors may contribute to the severity of

injury and higher injury-related mortality seen in

rural areas (55):

● there may be long delays between the injury

and its discovery by a passerby;

● it may take a long time to get a patient from the

scene of an accident to a hospital because of

distances between the scene, the ambulance

service, and the hospital;

●

●

●

●

●

prehospital care in many rural areas may be

performed by volunteers with basic EMT or

first aid level training who are unable to

provide advanced airway management or volume resuscitation;

emergency departments in small rural hospitals

may be staffed by primary care physicians

without the knowledge or skills needed for

critical trauma management;

there may be relatively few trauma cases at the

rural hospital, making it difficult for physicians

and nurses to maintain their skills;

rural hospitals may not have 24-hour physician

and ancillary staff coverage (e.g., anesthesia,

X-ray, and lab); and

in situations involving multiple victims, delays

may occur in the initial stabilization of the

patients because there are too few physicians or

nurses available.

As many as 50 to 60 percent of critically injured

trauma patients die before reaching the hospital (5)

and another 20 percent die within the next 4 hours

(66). Some estimate that 20 to 45 percent of those

who reach the hospital alive but eventually die could

be saved if regional systems of trauma care were in

place (16,19). Some argue that less than 10 percent

of the United States has an effective trauma system

in place, but that with additional support, existing

technology and expertise could be organized to

prevent these avoidable deaths (16, 19). Basic information is lacking, however. on when, where, and

why rural injury and injury-related deaths are

occurring. Before implementing programs to improve rural trauma outcomes, it would be useful to

know more about the causes and consequences of

rural trauma, where along the continuum of care

deaths are occurring (e.g., during the prehospital or

hospital phase), and whether these deaths are potentially preventable. Implementing programs without

such information may lead to inefficient use of

limited resources (24),

With available information, it is difficult to know

where to place limited resources. For example. if the

excess motor vehicle-related mortality in rural areas

occurs because of delays in discovering victims who

have had accidents on infrequently traveled rural

roads, improvements in the medical care system will

probably not prevent these deaths. Instead, improvements in road safety or communications (e.g.,

91nJuv and ~auma arc synonymous ~c~s.
46 ● Rural Emergency Medical Services

placing more call boxes along the sides of roads)

may prove effective. Severity of injury in rural areas

may be higher because of a lack of adherence to

effective preventive practices. If, for example, rural

residents are less likely to use seatbelts, are more

likely to exceed speed limits, and drive while drunk,

public education campaigns and better enforcement

of existing laws to support preventive practices

might effectively reduce motor vehicle-related morbidity and mortality.

Because time to emergency care is such a crucial

factor in determining the trauma patient’s outcome,

higher trauma-related mortality might be expected

in rural areas due to delays in detection and response

times. In some remote rural areas, delays are

unavoidable, but response times can be improved in

some areas by increasing the number of available

ambulances, improving air medical services, or

changing the placement of ground or air transport.

Reducing delays to emergency care can also be

accomplished by shifting the onset of emergency

treatment to the prehospital period. If rural EMTs

were lacking the training to provide specific types of

care that would benefit rural trauma patients, investing in EMT training would clearly be warranted.

Training the public in basic emergency care so that

accident bystanders are prepared to offer assistance

until an emergency vehicle arrives could also extend

the “golden hour* needed for trauma patients.

If there were evidence that prehospital care is

adequate, but that deaths are occurring in rural

hospitals that are ill-equipped to provide trauma

care, then resources could be directed to improving

hospital resources and the training of hospital-based

nurses and physicians. It is possible that some rural

trauma patients, needing the specialized services of

trauma centers, are not being transferred to these

facilities quickly, or at all. If this were the case,

improvements in regional systems—specifically,

the institution of protocols guiding the transfer of

patients from a rural hospital to trauma centers—

could be considered. Unfortunately, there is not

much quantitative evidence available to help policymakers rationally allocate limited resources. This

section reviews the available evidence and professional opinion that lend support to specific interventions aimed at improving the outcomes of trauma

occurring in rural areas.

Prevention Education

There is evidence that public education is needed

to improve rural residents’ preventive health behaviors. Only 25 percent of rural residents report using

seatbelts all or most of the time as compared to

nearly 40 percent reported by urban residents. Not

using seatbelts regularly appears to be a particular

problem among young adult males in the rural West.

Here, only 16 percent report using seatbelts all or

most of the time, as compared to 30 percent among

their urban counterparts (table 5-2). Seatbelt use

reduces front-seat, passenger vehicle, occupant fatalities by about one-half (24).

The proportion of alcohol drinkers reporting that

they had driven a car at least once in the past year

when they thought they might have had too much to

drink is generally not that much higher in rural than

urban areas (18 percent v. 17 percent) but among

young adults, especially those in the Midwest,

drinking and driving appears to be a serious problem

in rural areas. Among rural, Midwestern, young

adult males who drink, over one-half report driving

after having too much to drink (see table 5-3).

In addition to public education, States could be

encouraged to adopt seatbelt laws and drunk driving

laws and, where laws exist, actively enforce them.

Thirty-four States have safety belt use laws and such

laws reduce front-seat, passenger vehicle. occupant

fatalities by about 7.5 percent (24).

Prehospital Care

There continues to be considerable controversy

surrounding the appropriate level of prehospital care

for trauma patients. The majority of EMTs in rural

areas are trained to provide basic life support (BLS)

prehospital care. Paramedics are trained in advanced

life support (ALS) which permits them to initiate

treatments including advanced airway management,

administration of intravenous (IV) fluids, and decompression of tension pneumothorax. In the urban

environment, where level I or II trauma centers are

within 20 minutes reach, it may be better to have the

trauma patient rapidly transported to the trauma

center than to take time to provide ALS in the field

(15). Some studies in urban areas suggest that this

“scoop and run” approach is preferable because

while providing prehospital ALS improves the

chances that the trauma patient arrives at the hospital

alive, it doesn’t seem to improve the trauma patients

ultimate outcome (80). There are few controlled
Chapter .5--E mergency Cardiac and Trauma Cure in Rural Areas ● 47

Table 5-2—Percent of Persons 18 Years of Age and Over Who Wore Seatbelts

All or Most of the Time When Riding in a Car by Sex, Age, and Residence: United States, 1985

Both sexes Total 18-29 30-44 45-64 65+ Total 18-29 30-44 45-64 65+

All ages male years years years years female years years years years

Total MSA:

All regions . . . . . . . . . . . 38.9 36.9 32.5 40.1 38.5 36.5 40.6 39.3 44.2 39.0 38.9

Northeast . . . . . . . . . 48.1 46.4 41.5 49.9 47.8 45.5 49.7 47.2 54.3 49.3 46.5

Midwest . . . . . . . . . . 37.9 34.7 31.1 38.0 36.2 32.7 40.6 38.5 45.0 38.5 39.7

South . . . . . . . . . . . . 31.2 30.5 29.0 32.4 31.2 28.0 31.9 31.8 35.0 30.2 28.8

West . . . . . . . . . . . . . 40.5 37.7 30.2 41.6 39.6 41.3 43.1 42.6 46.0 39.8 43.8

Total non-MSA:

All regions . . . . . . . . . . . 25.5 23.7 19.9 26.9 24.4 22.7 27.2 28.5 27.2 29.2 22.8

Northeast . . . . . . . . . 29.4 27.2 26.0 35.2 23.4 20.7a31.6 41.6 32.4 30.5 16.7a

Midwest . . . . . . . . . . 26.6 24.1 21.4 25.7 24.8 25.1 28.8 26.2 31.7 30.3 26.3

South . . . . . . . . . . . . 22.3 21.2 18.6 22.9 22.4 20.2 23.3 25.6 22.6 25.0 19.2

West . . . . . . . . . . . . . 30.2 27.5 15.9 33.8 32.0 26.7 32.8 31.6 29.2 39.3 30.5

aFigure does not meet standard of reliability or precision.

SOURCE: U.S. Department of Health and Human services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Special

Tabulation prepared for OTA from t he 1985 Health Promotion and Disease Prevention Survey.

Table 5-3-Percent of Current Drinkers 18 Years and Over Who Had Driven a Car At Least Once in the Past Year

When They Thought They Might Have Had Too Much To Drink By Sex, Age, and Residence: United States, 1985

Both Sexes Total 18-29 30-44 45-64 65+ Total 18-29 30-44 45-64 65+

All ages male years years years years female years years years years

Total MSA:

All regions . . . . . . . . . . 16.6 22.4 35.6 23.8

Northeast . . . . . . . . . 11.6 16.4 27.4 18.9

Midwest . . . . . . . . . . 22.1 30.3 44.1 33.1

South . . . . . . . . . . . . 15.5 20.1 31.0 20,7

West . . . . . . . . . . . . . 17.6 23.6 40.8 23.5

Total Non-MSA:

All regions . . . . . . . . . . 17.9 22.5 40.5 21.0

Northeast . . . . . . . . . 16.3 20.4 40.9 14.9

Midwest . . . . . . . . . . 22.0 28.5 51.7 27.8

South . . . . . . . . . . . . 14.0 17.4 32.9 14.5

West . . . . . . . . . . . . . 18.6 23.4 34.3 27.4

11.4

7.6

15.8

10.8

12.2

9.6

11 .8a

10.1

6 . 0

a

15.3

2.6 9.5 17.2 9.7 2.4

1.5a 5.8 11.4 6,0 1.1a

5.3a

12.9 21.6 12.2 4.5

1 .9a 9.3 16.3 9.3 2.4a

2.2a10.2 18.8 11.4 1 .5a

2 . 3

a

11.4 19.0 13.1 2 . 7

a

2 . 4

a

10.8 16.2

a

11 .9a

5 . 0

a

1.8a 13.7 24.6 16.7 1.6a

1 .4a 8.6 10.7 11.0 3 . 3

a

4 . 8

a

12,4 26.1 11 .3a2 . 6

a

0.5a

0.2a

—

0.7a

0.9a

0.2a

—

—

0.9a

—

+Igure does not meet standard of rellablhty or preclslon.

SOURCE: U.S. Department of Health and Human Services, Public Health Seervice, Centers for Disease Control, National Center for Health Statistics, Special

Tabulation prepared for OTA from the 1985 Health Promotion and Disease Prevention Survey.

studies of the benefits of prehospital ALS provided

in rural areas, but on theoretical grounds, ALS is

recommended as both appropriate and beneficial

(15,83).

The effectiveness of some of the interventions

included in ALS care have been questioned (18).

There is no evidence, for example, that the pneumatic antishock garment that is standard equipment

on ambulances is effective for victims of penetrating

trauma when ALS is provided; there is little

evidence that endotrachial incubation is useful when

performed outside of the hospital; and there is some

evidence that trying to expedite the administration of

medication by starting IV lines in the field is

ineffective (38).10 Clearly, the effectiveness of the

components of ALS and ALS care in general need to

be further evaluated. Ironically, ALS providers are

located principally in urban areas where they are less

likely to be needed. If rural EMTs were trained to

assume ALS responsibilities, they might have trouble

maintaining their skills without continuing education programs accessible in rural areas. Even if ALS

care were found to be beneficial in rural areas. many

rural areas would find it difficult to compete for, or

afford, the limited number of paramedics and

intermediate-level EMTs that are available.

Hospital-Based Trauma Care

In rural areas where specialized trauma services

are unavailable, the severely injured patient should

be evaluated and stabilized expeditiously in the
48 ● Rural Emergency Medical Services

community hospital, and then triaged to the nearest

trauma center (21 ,54). The quality of trauma care in

rural hospitals can be improved by promoting

physician and nurse education, instituting a trauma

protocol, promoting prompt resuscitation and stabilization of patients before transfer, and implementing a quality assurance program, such as a monthly

case review (131 ). Training opportunities tailored

for rural physicians are available through the American College of Surgeons (ACS). A 2-day Advanced

Trauma Life Support (ATLS) course was designed

by ACS to meet the needs of rural physicians who

must occasionally stabilize and transfer trauma

victims but who do not see major trauma often

enough to develop expertise in this type of care (20).

Since training began in January 1980, about 90,000

physicians have been certified. ’ The American

College of Emergency Physicians offers a 2-day

Basic Trauma Life Support course for basic and

advanced EMTs, nurses, and paramedics, The Emergency Nurses Association sponsors the Nursing

Core Course, and the National Association of EMTs

sponsors a course in trauma life support for prehospital care providers.

When 24-hour physician coverage is unavailable

in a rural hospital emergency room, a trauma

protocol can be implemented to help ensure that a

physician and necessary ancillary personnel will be

available by the time a trauma patient arrives, and

that until the physician arrives, a well-trained nurse

can assume immediate resuscitation and stabilization responsibilities. A rural hospital trauma protocol may begin with communications between prehospital providers at the scene in regard to the nature

of the patients injuries and condition. When notified,

the nursing supervisor can call members of an

established trauma team that includes physicians,

nurses, a laboratory technician, an X-ray technician,

an anesthetist, and possibly a social worker and

medical records clerk. While waiting for the patient

to arrive, the nursing supervisor prepares the needed

equipment and alerts the air medical service to

prepare for a possible transport. Training rural

hospital providers to assume these responsibilities

and implementing such a protocol avoids confusion

and delays. Case reviews help to assure appropriate

rural hospital response and can include physicians

from a regional trauma center (55).

Regionalization of Trauma Care

According to guidelines of the American College

of Surgeons’ Committee on Trauma:

Each region must structure a trauma system in a

manner that ensures the most prompt access to

appropriate care and minimizes the risk of delay in

diagnosis, delay in surgical intervention, and inadequately focused care, which are responsible for most

of the preventable deaths from trauma (4).

The guidelines recognize that in rural areas, an

injured patient may be at substantial distances from

level I or level II trauma centers (see app. C for ACS

criteria for level 1, II, and 111 hospitals) and suggest

that such patients should ideally be treated initially

at the nearest available hospital facility. It is

desirable that,

. such a facility meet the requirements of a Level

III trauma center or at least have emergency staff

trained in advanced trauma life support. Patients

with major injuries should then be secondarily

triaged to more distanced Level I or II trauma

centers, should local resources prove inadequate for

continued care (4). *2 An organized regional trauma

system that restricts specialized care to designated

facilities has been shown to benefit patients with

severe injuries (22).

According to the ACS, ‘‘In the ideal prehospital care

system there is preplanning, ensuring optimal use of

resources between communities and regions to

minimize inefficiency and excessive cost’ (4).

Accordingly, among the essential components of a

trauma system are the legal authority and a formal

process to designate trauma centers, use of ACS

standards in designating the trauma centers, use of

patient volume or population data to ensure that the

number of centers designated for an area are

reasonable, presence of written triage criteria that

form the basis for bypassing nondesignated hospitals, use of monitoring systems, and statewide

coverage (133). A 1987 national survey of State

EMS programs indicated that only two States13 have

1 ITh~ ~ourw and ~cnlfic-tion we ~vailab]c (hrough the American Coilege of surgeons. There is no mforrna[ion avai]ablc on how many of the ccr[iticd

physicians arc rural practitioners or the type of physician certified (e.g., family practitioner, emergency physician).

IZRevised ACS standards mat include a Wction on “Optimal Care in the Ruml SCttlng’ are forthcoming.

lsThe two States wi~ cornprehensiw trauma systems arc Maryland and Virginia.
trauma systems that include components deemed

essential by the ACS Committee on Trauma (133).

At the time of the ACS survey, 2 States met all

criteria, 19 States and the District of Columbia had

designated trauma centers, but lacked statewide

coverage and/or indicated that triage and quality

assurance programs were inadequate, leaving 29

States that had not yet designated trauma centers

(see figure 5-l). Somewhat different results were

found in a survey of State EMS directors. According

to this survey, also conducted in 1987, 14 States

were designating trauma centers and another 22

were developing designation programs. An additional two States had verification programs with

Standards. Only 13 States lacked either verification

or designition.14 and 3 of these States had developed

standards (see figure 5-2).

Guidelines for trauma care systems have been

developed by a number of professional organizations and by the Joint Committee on the Accreditation of Healthcare Organizations (JCAHO). Both the

1987 ACS guidelines and those published by the

American College of Emergency Physicians (ACEP)

take into account some of the unique features of rural

health care. According to ACEP guidelines, some

Figure 5-l—States Having All, None, or Some of Eight Essential Components of a Regional Trauma System

According to American College of Surgeons’ Criteria, 1987

n t s

All component s

. . . . . . . . . . .

. . . . . . . . . . 

SOURCE. J.G West et al , “Trauma Systems. Arrest Status—Future Challenges,” J A M A 259(24) 3597-1445, June 24, 1988

14 Dc.lwatloll involves ,dentlfylng a IImllcd number of hospi[als meeting s~Cified ~rl(crla 10 serve tie Lrauma ncedi of [hc SlalC. In COnlraSt,

vcriticalion involves certifying any number of hospitals that mcc[ specified critcrla ( 108).
50 ● Rural Emergency Medical Services

Figure 5-2-State Trauma Center Designation and Verification Practices, 1986-87

I

I

SOURCE: National EMS Clearinghouse, “Emergency Medical Services: Transportation Systems and Available Facilities,” 1988.

features of a trauma care system deemed “essential’ in the urban environment are “desirable” in

rural setting (see app. C).15 Universal access through

911, for example, is essential in urban systems but

desirable in rural areas. Few States with hospital

trauma verification or designation programs are

using the ACS or ACEP guidelines. Less than

one-third (9) of the 32 States that reported the type

of standards used in their programs reported using

the ACS standards, according to the 1987 survey of

State EMS directors. Instead, most had adapted ACS

or ACEP guidelines to meet State or regional needs

(108).

Some States have too many designated trauma

centers. In Missouri, for example, there are 62

designated trauma centers, or 1 per 80,000 residents.

This exceeds the recommended ratio of 1 trauma

center per 350,000 residents (133).16 Evidence

suggests that some rural areas underutilize available

resources. In one region in the Southeast, for

example, relatively few life-threatening emergency

IsEleven components (i.e., medical direction, prevention, communication, training, triage, prehospital care, transportation, hospital care,

rehabilitation, public education, and medical evaluation) of system management, prehospital care, hospital facilities and rchabditatlon services arc

described as essential or desirable in urban and rural settings, ACEP defines an urban systcm as one that encompasses at least one metropolitan area with

250,000 persons. Rural systems are lacking any single population center (3).

l~e r~ommend~ ratio is bad on the average annu~ (ra~a rate of one case per 1,~ people and ACS’S recommenda~ion for a minimum of 350

patients per year at a level 11 trauma cam facili[y.
Chapter 5—Emergency Cardiac and Trauma Care in Rural Areas ● 51

cases were being transferred from rural hospitals to

adjacent urban specialty hospitals (93).

Many rural hospitals cannot meet the requirements of an ACS level III hospital, but nonetheless

have an important role to play in providing trauma

care in rural areas. Specific trauma care guidelines

for rural hospitals without level 111 resources might

prove helpful to rural providers. Oregon, for example, designates a fourth level of trauma care,

specifically to meet the needs of rural hospitals, A

level IV hospital requires an ACLS-trained nurse to

be in-hospital and immediately available, and an

ACLS and ATLS-trained physician to be on call and

promptly available (e.g., within the hospital, but not

necessarily in the emergency room). (See Oregon

hospital criteria in app. D.) The Oregon system ties

the resources of the urban level I and 11 hospitals to

the level 111 and IV hospitals to improve their

trauma-related services. Level I and 11 hospitals

must provide training for rural providers, provide

feedback on patients referred to their hospitals by the

level 111 and IV hospitals, and must provide peer

review of trauma cases as part of a regional quality

assurance program. Furthermore, Level I hospitals

must provide telephone and onsite consultations

with physicians of the community and outlying areas

as part of an outreach program (25). There would

perhaps be less controversy surrounding triage

criteria if rural hospitals could establish their role in

providing care and formalize beneficial relationships with specialty hospitals. The availability of

rapid and aggressive treatment at the local level

before and during transport to definitive care will

likely improve rural trauma patient outcomes.
Chapter 6

Federal Policies Toward State Emergency Medical Services

States use many different sources to fund their

emergency medical services (EMS) activities and

EMS resources vary dramatically by State. In 1988,

over 80 percent of States EMS funds come from

State or local sources (57), Only 14 percent of State

EMS resources derive from Federal sources (figure

6-l). This, however, varies markedly by State.

Nebraska, for example, relies entirely on Federal

support while Florida relies entirely on State funds.

In 1988, per capita spending for EMS varied from a

low of $0.02 per capita in Ohio to nearly $14 per

capita in Hawaii (table 6-1) (57).

Federal support of State EMS programs derives

from two sources, the Department of Health and

Human Services (DHHS) and the Department of

Transportation (DOT).

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

DHHS support of State EMS comes through the

Preventive Health and Health Services Block Grant.

EMS was among other categorical health programs

that were folded into the block grant in 1981

following passage of the Omnibus Budget Reconciliation Act of 1981 (Public Law 97-35). The block

grant program consolidated a wide range of activities (42 U.S.C. 300w-3(a)(l)):

1, rodent control and fluoridation programs;

2. hypertension control;

3. health services for defined populations, comprehensive programs to deter smoking and

alcohol use among children and adolescents,

Figure 6-l-State EMS Program Funding, 1988

State funds:

General State Revenues

and State special funds

(e. g., motor vehicle

registration )

Federal

Blo

I

l Funds

Other Federal funds

(e. g., Federal Department of Transportation

%ther Federal, other State, or prwate

Section 402)

SOURCE: The National EMS Clearinghouse, “The EMS Office, Its Structure and Functions,” The Council of State Governments, Iron Works Pike, Lexington,

KY, 1988.

-53 -
54 ● Rural Emergency Medical Services
Chapter 6---Federal Policies Toward State Emergency Medical Services ● 55
56 ● Rural Emergency Medical Services

4.

5.

6.

7.

and other risk-reduction and health education

programs;

comprehensive public health services;

demonstrating the establishment of home

health agencies in areas where the services of

such agencies were not available;

feasibility studies and planning for EMS systems and the establishment, expansion, and

improvement of such systems; and

services to rape victims and for rape prevention.2

Under the block grant program, States can allocate funds to the seven service areas to suit their

needs. In 1988, $13 million of block grant funds

were spent on EMS, representing about 15 percent of

all Preventive Health Block Grant funds available

that year (table 6-2). Some States spend none of their

block grant funds on EMS (e.g., Alabama, Kentucky), while others spend most of their block grant

funds on EMS (e.g., West Virginia, New Mexico)

(57) (table 6-2). More than twice as much money,

about $30 million per year, had been available for

EMS through the Federal EMS categorical grant

program established following passage of the Emergency Medical Services Systems Act of 1973

(Public Law 93-154).

The 1973 EMS Systems Act program emphasized

the development of regional systems to coordinate

emergency medical services. Under the program,

each of 303 defined EMS regions was eligible to

receive grants for up to 5 years, after which they

were to become self-sustaining (127). Rural areas

were targeted for assistance. At least 20 percent of

appropriations were made available to EMS systems

serving rural areas. Furthermore, special consideration was given to applicants from rural areas seeking

grants or contracts to support research in emergency

medical techniques, methods, devices, or delivery.

A State’s share of DHHS Preventive Health and

Health Services Block Grant funding was frozen at

its share of categorical grants that the State received

for fiscal year 1981, the year legislation was enacted

that combined categorical programs-including EMS

services—into block grants. The block grant allocations to States do not reflect population distribution3

because the categorical grant program had been a

competitive one. Table 6-3 summarizes Preventive

Health and Health Services Block Grant funding and

the amount of these funds that States choose to spend

on EMS since conversion from categorical to block

grants in 1982, through fiscal year 1988. Since

1983, 4 States have allocated between $12 million

and $17 million of block grant funds to EMS

activities (table 6-3).

The impact of the imposition of the block grant

program on State’s EMS activities was evaluated in

a 1986 General Accounting Office (GAO) report.

GAO compared overall State EMS expenditures in

six States5 for 1981 (the last year of the categorical

EMS Federal program), 1983 (the first year under

the block grant), and 1985 (127). By 1985, total

EMS funding had not returned to 1981 levels but

EMS funding was increasing, primarily because of

increased State funding of EMS activities. By 1985,

States were assuming one-half of EMS costs as

compared to 27 percent in 1981 (127).

DEPARTMENT OF

TRANSPORTATION

The DOT EMS program began with the Highway

Safety Act of 1966 (Public Law 89-564), which was

enacted following two national studies showing

major deficiencies in EMS services (70,81). Under

the Act, DOT funds States to develop highway

safety programs that include provisions for emergency services. DOT funding must be linked to its

highway responsibilities. DOT’s emphasis is therefore on the prehospital stage and the initial stages of

hospital care for highway-injured patients, as well as

on prevention and intervention activities that are

highway-related (53 FR 11255). The State and

Community Highway Safety Grant Program is

referred to as the section 402 program. State funding

under section 402 is apportioned among the States

based on a State’s population and public road

mileage. 6 In 1987, nearly $5 million were available

11984 legislation subsequently added grants for demonstration projects for the treatment of children for trauma or critical care (Publlc Law 98-555).

zReplaced in 1986 by **victims of =x Offen=s and for PreventIon of sex offenses” (public Law 99-646 and Public Law 99-654).

sAn exception to ~is are block grants funds earmarked for the ‘‘sex offenses’ category, which are allocated according to population (53 FR 27766).

‘41982 was a Uansition year from the categorical program to the block grant pmgrm.

5The sjx States ~al GAO studicxj were California, Florida, Iowa, Massachusetts, Pennsylvania, and Texas.

6Seventy.five ~.ent of funds UC allocated based on population and 25 percent are b~~~ on tie pub]ic road mileage. A portion of funds is ah

resewed for Indian tribes (23 U.S.C. 402(c)).
Chapter 6---Federal Policies Toward State Emergency Medical Services . 57

.

0000000 0 000 0 0000 0
58 ● Rural Emergency Medical Services

-
Chapter 6---Federal Policies Toward State Emergency Medical Services ● 59

Table 6-3-Preventive Health and Health Services

Block Grant Expenditures: Emergency Medical

Services, Fiscal Years 1982-88

Block

Fiscal year grant total

1982 . . . . . . $32,1 74,000a

1983 . . . . . . . 85,746,000

1984 . . . . . . . 81,822,000

1985 . . . . . . 86,564,000

1986 . . . . . 88,701,000

1987 . . . . . . . 84,129,000

1988 . . . . . . . 87.966.000

EMS

expenditures

$ 4,776,000

17,612,000

15,132,000

16,216,000

16,407,000

12,929,000

13.175.000

Percentage

spent on EMS

14.8

20.5

18.5

18.7

18.5

15.4

15.0

a Block grant totals are low in 1982 because this was a transitional year.

SOURCE: Public Health Foundation, 1220 L St , N W, Washington, DC

20005, NOV. 3, 1989

to States through the 402 program (table 6-4). This

represents about one-fifth of Federal EMS resources

and about 3 percent of all EMS expenditures (i.e.,

State and Federal) (figure 6-1 ).

DOT also has research, development, and demonstration funds to support State or local agencies in

the areas of highway-safety personnel training and

research, accident investigation procedures, and

emergency service plans (referred to as the Section

403 program). In 1988, DOT allocated just over

700,000 through the section 403 research and

demonstration program.

Section 402 Funds for State Highway

Safety Plans

DOT has determined that the following seven

programs have been the most effective in reducing

accidents, injuries, and fatalities, and DOT supports

inclusion of countermeasures in these areas into

State’s Highway Safety Programs (53 FR 11255):7

1. Alcohol and Other Drug Countermeasures.

2. Police Traffic Services.

3. Occupant Protection.

4. Traffic Records.

5. Emergency Medical Services.

6. Motorcycle Safety.

7. Roadway Safety.

DOT has guidelines for State Highway Safety

Programs and to receive funds, a State must have its

highway safety program approved by DOT. The

guidelines related to EMS are as follows (23 CFR

204.4):

Each State, in cooperation with its local political

subdivisions, should have a program to ensure that

Table 6-4-National Highway Traffic Safety

Administration’s State and Community Highway

Safety Program (Section 402) Funding:

Emergency Medical Services,

Fiscal Years 1967-87

NHTSA EMS Percentage

Fiscal year sec. 402 total sec. 402 total spent on EMS

1967-76 ... .$639,157,700

1977 . . . . . . 125,700,100

1978 . . . . . . 168,699,600

1979 . . . . . . . 167,096,000

1980 . . . . . . 190,243,000

1981 . . . . . . 169,991,900

1982 . . . . . . . 92,582,300

1983 . . . . . . . 91,845,200

1984 . . . . . . . 95,077,800

1985 . . . . . . 120,619,000

1986 . . . . . . 116,827,500

1987, . . . . . . 111,539.200

$89,074,300

16,996,500

22,686,900

13,535,500

18,771,900

12,721,900

5,438,800

4,964,800

4,466,800

5,332,600

5,315,200

4,708.900

13.9

13.5

13.4

8.1

9.9

7.5

5.9

5.4

4.7

4,4

4.6

4,2

SOURCE: Traffic Safety Program, National Highway Traffic Safety Administration, U.S. Department of Transportation, “FY 1987 Summary of State and Community Highway Safety Obligations

(Section 402),” Nov. 13, 1987.

persons involved in highway accidents receive

prompt emergency medical care under the range of

emergency conditions encountered. The program

should provide, as a minimum. that:

1.

2.

3.

4.

5.

6.

7.

8.

There are training, licensing, and related requirements (as appropriate) for ambulance and

rescue vehicle operators, attendants, drivers, and

dispatchers.

There are requirements for types and number of

emergency vehicles including supplies and equipment to be carried.

There are requirements for the operation and

coordination of ambulances and other emergency

care systems.

There are first aid training programs and refresher

courses for emergency service personnel, and the

general public is encouraged to take first aid

courses.

There are criteria for the use of two-way communications.

There are procedures for summoning and dispatching aid.

There is an up-to-date, comprehensive plan for

emergency medical services, including:

a. Facilities and equipment.

b. Definition of areas of responsibilities.

c. Communications systems.

This program should be periodically evaluated

by the State and the National Highway Traffic

Safety Administration should be provided with

an evaluation summary.

70~er ~ca$ may & funded, but only If thc S[alc can provldc a specific ra[lonalc and convincing informauon that this ls a special needs area
60 ● Rural Emergency Medical Services

Table 6-4 summarizes section 402 funding

through NHTSA and the percent of total funds that

have been expended on EMS. In 1987, over $4.5

million was expended on EMS, representing 4

percent of all section 402 funds (figure 6-2). The

availability of section 402 money dropped precipitously in 1982 at the same time the DHHS categorical EMS program was replaced by a block grant

program (for which funding was also decreased

significantly). The portion of section 402 funds used

for EMS has declined by a factor of 3 in the last 10

years (i.e., from 13 to 4 percent), in part because of

increased funding of other program areas, such as for

alcohol countermeasures and occupant protection.

Some 402 funds have been earmarked for occupant

safety and other programs.

Section 403 Highway Safety Research and

Demonstration Funds

DOT funds training, research, planning, and

demonstration activities in the area of integrated

prehospital/hospital trauma care delivery systems

through section 403 of the Highway Safety Act (23

U.S.C. 403)(124). With the 1981 merger of DHHS’s

EMS program with other categorical programs into

the Preventive Health and Health Services Block

Grant, DHHS support for EMS research and development, and demonstration grants ceased, leaving

DOT as the only Federal source for these types of

EMS activities. In 1988, 7 percent of section 403

funds (i.e., $705,000) were spent on EMS. EMS

research and development funding has more than

doubled from 1981-88 (table 6-5).

DHHS AND DOT ALLOWABLE

EMS EXPENDITURES

Both DOT’s and DHHS’s programs in which

EMS is included contain quite a wide range of

allowable activities; e.g., in DOT’s program, traffic

records, and in DHHS’s program, rodent control, are

other allowable activities. Congress has earmarked

a significant portion of funds for some of these

activities but has never done so for EMS. The source

of Federal funds places limits on the kinds of EMS

activities and equipment that a State is allowed to

finance with these funds. DOT’s funds must be used

for highway-related EMS services—i.e., principally

victims of motor vehicle accidents—so understandably, DOT’s funding priorities emphasize prehospital EMS activities and trauma care. EMS

equipment purchases were not permitted under the

EMS Systems Act, and until 1988 were not permitted under the block grant program. In 1988, however, Congress changed the law so that block grant

funds could be used “for the payment of not more

than 50 percent of the costs of purchasing communications equipment [emphasis added]. . .’ (Public

Law 100-607). EMS grant support through DOT

may be used by States for training and major

equipment, including up to 25 percent of the cost of

an ambulance (47 FR 40791).8

CONCLUSIONS

Providing EMS services has become more of a

State function in the last decade. Federal support for

EMS through both DHHS and DOT decreased

sharply in the early 1980s, falling to approximately

half of previous levels. Federal support now accounts for only 14 percent of State EMS expenditures. The primary goal of the 1973 EMS Systems

Act, to blanket the country with quality EMS

services, has not been realized. State-to-State variability in EMS systems is marked, and within States,

rural areas are more likely to lack resources and

comprehensive systems than urban areas. Several

States have established dependable, constant sources

of funds to support their EMS systems. Other States,

however, have not become self-sufficient, remain

dependent on Federal sources, and have fragmented

EMS programs.

Most State EMS directors view providing EMS as

the primary responsibility of the State and local

governments and the shift of EMS responsibility to

the States as appropriate (1 12). Federal resources

have never been sufficient or consistently available

enough to rely on for EMS operations. Federal

resources have been successfully used, however, to

provide incentives for States to implement planning

efforts, to promote training of EMS providers, to

provide technical assistance, and to conduct EMSrelated research. It is in these areas that States

continue to need Federal leadership (112).

Recent congressional interest in rural-oriented

health care legislation and EMS/trauma-related legislation may make additional Federal resources

available for rural EMS. During the 101st congressional session, several bills were introduced that

relate to EMS and trauma care systems, (See bill

8DOT Wil] provide more SUppOrI if tie State documents higher than 25 percent highway safely ambulance utilization.
Chapter 6-Federal Policies Toward State Emergency Medical Services ● 61

Figure 6-2-State and Community Highway Safety Program Obligations (DOT Section 402)

Fiscal Year 1987—$1 11,539,200

Seat belt

Traffic

National Maximum

Planning and

19.1 Speed Limit ( NMS L)

ad m i n is t rat i o n

6.4

records

5.4

Police traffic

services--non=

.2

32.3

/

A AIcohol

c o u n te r m e as u res

IN M SL

strain

*“Other” program areas include school bus driver training, motorcycle safety, and pedestrian safety, plus the other standard areas.

SOURCE: Associate Administrator, Traffic Safety Program, National Highway Traffic Safety Administration, U.S. Department of Transportation

Summary of State and Community Highway Safety Obligations (Section 402),” Nov. 13, 1987.

Table 6-5-National Highway Traffic Safety

Administration’s Research and Demonstration

Program (Section 403) Funding: Emergency

Medical Services, Fiscal Years 1981-88

NHTSA EMS Percentage

Fiscal year sec. 403 total expenditures spent on EMS

1981 . . . . . . $5,759,000 $305,000 5.3

1982 ., . . . . 4,555,000 440,000 9.7

1983 . . . . . . . 4,300,000 242,000 5.6

1984 . . . . . . 6,240,000 305,000 4.9

1985 . . . . . . . 8,383,000 334,000 4.0

1986 . . . . . . . 8,558,000 515,000 6.0

1987 . . . . . . 10,872,000 656,000 6.0

1988 . . . . . . 9,909,000 705,000 7.1

SOURCE Personal communication, Traffic Safety Program, National

Highway Traffic Safety Administration, U S. Department of

Transportation, Feb. 15, 1989.

digests in app. E.) The Emergency Medical Services

and Trauma Care Improvement Act of 1989 (S. 15),

for example, introduced in January 1989, would

"FY 1987

establish a National Clearinghouse on EMS and

Trauma care, and establish grant programs to

support the development of State trauma care

systems. A July amendment to S. 15 would establish

a separate grant program to improve rural EMS

(Cong Record, S8521, July 10, 1989). The Comprehensive and Uniform Remedy for the Health Care

System Act of 1989 (S. 1274) includes provisions

for an EMS grant program and directs resources to

States with rural areas. The legislative proposals

vary in their approach to the problems facing EMS.

Some propose a more active Federal role in system

development and include national standards for

certain EMS facilities. Others provide for additional

funds for EMS systems but give States discretionary

spending authority. Many legislators have recognized the special problems of rural EMS programs

and have attempted to direct resources to these areas.
Appendix A

Rural EMS Workshop Participants

Workshop held May 4 and 5, 1989. Cosponsored by: The Department of Transportation, National Highway Traffic

Safety Administration and The Office of Technology Assessment

John C. Anderson

Cle Elum Family Medicine Center

Cle Elum, Washington

Paul Anderson

Chief

Bureau of Emergency Medical

Services

Boise, Idaho

Stuart Brown

Director

Division of Injury Epidemiology and

Control

Center for Disease Control

Atlanta, Georgia

Jonathan Chin

Graduate Program

Department of Emergency Health

Services

University of Maryland

Baltimore County, Maryland

Terry Dimon

Nurse Manager

Emergency Department

Memorial Hospital of Laramie County

Cheyenne, Wyoming

Mary Ellis

Director

Iowa Department of Public Health

Lucas State Office Building

Des Moines, Iowa

John Johnson

Director

Emergency Medical Services

Porter Memorial Hospital

Valparaiso, Indiana

Ellen MacKenzie

Associate Director

Center for Health Services Research

Johns Hopkins University

Baltimore, Maryland

Kim Maull

Professor & Chair

Department of Surgery

University of Tennessee Medical

College

Knoxville, Tennessee

Maureen McArdle

Trauma Coordinator

Emergency Medical Services

San Diego, California

Susan McHenry

Director

Division of Emergency Services

Virginia Department of Health

Richmond, Virginia

William R. Metcalf

Director

Emergency Medical Services

Colorado Department of Health

Denver, Colorado

Stu Reynolds

Northern Montana Surgical

Associates

Havre, Montana

Don Stamper

Manager

Emergency Services

Staff for Life

University of Missouri

Columbia, Missouri

Robert F. Tredwell

Consultant

Brooksville, Maine

Carl Van Cott

Communications Director

Office of Emergency Medical

Services

State of North Carolina

Raleigh, North Carolina

Harvey Wolfe

Chairman

Industrial Engineering Department

School of Engineering

University of Pittsburgh

Pittsburgh, Pennsylvania

Barak Wolff

Bureau Chief

Bureau of Primary Care/EMS

Sante Fe, New Mexico

Richard Zuschlag

President

Acadian Ambulance Service, Inc.

Lafayette, Louisiana

-63-
Appendix B

Designing an Appropriate EMS System in Rural Areas:

Use of a Computer Simulation Model

A computer simulation model (called RURALSIM)

has been designed to allow planners to examine how their

present emergency medical services (EMS) system functions and to determine the effects introducing changes

into their systems. 1 The model also allows planners to set

goals for long-term system improvements and to determine if the goals can be met with available resources.

RURALSIM was intended to help local decisionmakers

allocate scarce EMS funds efficiently and to address

specific questions such as:

●

●

●

●

Are an appropriate number of emergency response

vehicles in the area?

Are they appropriately located within the region?

Are the personnel on these vehicles trained at the

appropriate level to serve the population in the area’?

Are helicopters and fixed-wing aircraft required as

part of the system and where should they be located?

In this section, the computer simulation model is

described as are its attempted implementation in several

rural areas.2

The Computer Simulation Model

RURALSIM analyzes the effects of changes in the

EMS system in terms of a number of performance

measures such as response time, level of response, and

vehicle utilization. The model uses local EMS demand

and response data to generate predicted occurrence and

responses at various times of day for a given area. The

planner can hold the area’s demand for EMS services

constant and then alter the configuration of system

resources, The effects of introducing changes such as

vehicle placement and relocation strategies, vehicle

dispatching policies and alternative forms of prehospital

care can then be evaluated. EMS planners can use

RURALSIM to evaluate the cost of alternative EMS

configurations that achieve the desired goals, can modify

the system’s goals relative to cost constraints, and

maximize system effectiveness given a particular cost

base.

RURALSIM can take into account several different

attributes of the region under study. These can be divided

into five categories:

1. technological configurations of an EMS system

including access, communications, vehicle and

resource deployment, field treatment, transportation, and definitive treatment facilities;

2.

3.

4.

5.

different placement strategies for response and

transport vehicles including first responders, Basic

Life Support and Advanced Life Support providers,

and the availability of rescue land and air vehicles;

characteristics of the region’s environment including populations and the affect of particular population attributes, geography, roads, and weather

conditions upon EMS demands, and response

capabilities;

policies and operating rules for the different EMS

system components including dispatch policies;

vehicle re-allocation, transport. and first responder

policies; and hospital designation policies, which

affect patient transport; and

changes in demand patterns caused by population

fluctuations and/or seasonal population shifts.

The model defines demand as a request for either

emergency field treatment or routine transportation services. Within these two categories, demand is further

subdivided according to type of case and severity level.

Emergent case types may include: cardiac, trauma (nonmotor vehicle related), and motor vehicle accident, and

non-trauma/non-cardiac. Special categories of incidents

(e.g., basic manufacturing, mining, river) can also be

included. For each type of emergent incident, three levels

of presenting severity are typically defined: life threatening, severe, and minor/moderate. In addition to classifying demand by type and severity. RURALSIM also

allows for variation in the demand rates by time of day and

day of week.

RURALSIM must not only generate the emergency

incident according to type, severity, and time, but must

also determine its location. In order to do this, a network

model is used to represent the region’s transportation

system. The area’s primary roads, important secondary

roads, intersections, and population clusters are modeled.

Once an incident has been generated, the access

component models the process which occurs between the

time of the incident and the time when initial contact is

made with the EMS system. The events which occur in

this period include incident detection, possible aid

rendered by a citizen, and EMS system access utilizing

public telephone, radio, call box, or direct contact. Given

the complexity of the access problem and the unavailability of representative data, this process is modeled in terms

of the probability that an incident is witnessed, the time

for discovery of unwitnessed incidents and the time to

I The de~elopm~[ of tie Cmputer slmu]a[lon model occur-red from 1979 to the mid- 1980s by researchers al the Unlvcrs]ty of Piusburgh, Health Operalwns Research

Group WIIJ supp~ from tie U.S. Dcpu[rnen[ of Transporta[wn (Shuman and Wolfe, 1989).

2fJour ~ra] sl[es wme used IO &velop R1.JRAL.SIM: 1 ) Amostoock. Penobsco[, Plscataqus, Waldo, Hancock, and Washington Courmes m Maine; 2) Camden, Mdler,

and Morgan Coun[Ies (Lake of the Ozarks) m Mlssoun; 3) Craig, Delaware, Mayes, Muskogee, and Okmulgee Courmes m Oklahoma; and 4) Indiana Coun[y m

Pennsylvarua.

-64 -
Appendix B--Designing an Appropriate EMS System in Rural Areas: Use of a Computer Simulation Model ● 65

contact the EMS system. These access probabilities and

parameters must typically be estimated by EMS planners

since little data are available. They may be varied in

different simulation experiments in order to assess their

effects.

Three types of communication functions are considered in RURALSIM: the initial request for assistance to

activate (access) the EMS system: communications between the EMS dispatch center and the ambulance vehicle

base station; and communications between the EMS

dispatch center and a responding vehicle away from the

base for the purpose of directing or redirecting the vehicle

to or from an incident scene and for the purpose of

relaying medical information and receiving medical

command. The system access is assumed to be via

telephone and is modeled as a time delay. Randomly

generated time delays are also introduced depending on

the type of dispatch facility available (e.g., with or without

911), and the means of communication with the base

stations. Communications between the dispatch center (or

medical command) and a vehicle away from base are not

explicitly modeled (e.g., number of radio channels, etc. )

but are assumed to be available for the purpose of

redirecting or calling off a vehicle.

The EMS system response function is concerned with

ambulance vehicle dispatch, prehospital treatment, and

patient transport. As input to the model, each ambulance

vehicle must be specified according to its type (BLS,

ALS, Rescue, or First Responder), base station, crew

availability, level of crew training, and shifts in service.

The heart of RURALSIM is its ‘ ‘dispatcher”’ module,

A series of decision rules has been programmed into

RURALSIM to replicate the manner in which the

simulated region’s dispatchers would function. The

dispatcher must assign the different types of vehicles in

accord with the perceived severity of the incoming call. If

primary and secondary vehicles are not available,

RURALSIM can search for the closest available vehicle,

reassign a vehicle, or queue the patient until an appropriate vehicle becomes free.

Time spent at the scene is determined by the type and

severity of the incident, and the highest level of capability

of the responding vehicles (BLS or ALS). Two variables

are involved in the field transportation function-the

decision to transport and the choice of destination.

Patients may not be transported if their condition does not

warrant it, or if transportation is refused. Destination for

emergency patients is typically a hospital within the

region or an adjoining area. Location, type and severity of

the incident typically determine the receiving institution,

Patients picked up at a hospital may be transported to

another hospital, an extended care facility, or the patient

residence.

The internal workings of the definitive care treatment

facilities (hospitals) in the region are explicitly excluded

from the model since little is to be gained by their

inclusion and their introduction would furthcr complicate

the model. Hospitals are modeled primarily as destinations for the transportation of patients.

RURALSIM collects relevant information on each

simulated patient which describes the incident type and

location. response times, and the resolution of the case.

Output information on each patient includes: incident

type, seventy level, location, time of incicient, time

dispatch contacted, time each responding vehicle contacted, time each vehicle left its respective base or

location, time each vehicle arrived at the scene, time

patient transported (or left scene), time patient arrived at

receiving facility, and time each vehicle was back in

service. From these profiles, response times, delay times.

and total EMS service times can be determined for each

incident.

A number of measures of effectiveness are utilized to

facilitate the comparison of alternative configurations and

policies. These include average BLS and ALS response

times, time first vehicle arrives at scene, percent of

patients serviced (vehicle at scene) within 4 minutes of

contacting the dispatcher, percent of patients serviced in

more than 10 minutes, the average time for each

component of the incident (access, dispatch, response,

field treatment, and transport), and vehicle utilization.

Other measures such as the number of times a vehicle is

unavailable for emergent requests and average patient

waits can be included.

A number of EMS options for improving an area’s

EMS system can be evaluated by RURALSIM. The

model allows planners to develop innovative strategies to

use available resources to reduce the response time for

critically injured patients and thus improve the care

delivered at the scene.

Options to improve EMS access that can be considered

in the modeling exercise include using more efficient

communications systems, improving response (by enabling care to be delivered to the scene with an acceptable

response level), improving transportation, improving

skill maintenance of prehospital providers and improving

the hospital or clinic response capability. In a rural area

the options must be chosen with respect to available

services and individuals; the size and distribution of

population clusters; and the social, cultural, economic,

political, and geographic constraints and incentives characteristic of the specific community.

Three major groups of options are available to a

community:

. those that facilitate the development of a new rural

EMS system;
66 ● Rural Emergency Medical Services

Ž those that provide linkages for small population

clusters and;

Ž those that offer solutions to specific problems in an

existing rural EMS system.

The first option group is, in reality, a process for

building an EMS system from scratch. The simulator can

help develop a set of steps for building an effective EMS

system in a rural area. The second option group pertains

to those communities that already have some form of

EMS, but do not appear to have the resources required to

achieve a desired level of service, These options include

an evaluation of various configurations of communities

cooperating with each other in order to provide a more

effective system. Finally, there are options which are

directed at specific problems facing a functional EMS

system (e. g., communication systems). For any specific

EMS area, options from any or all three groups might be

important to evaluate through simulation.

During field testing of the model in several rural areas,

numerous shortcomings of the simulation model were

noted. These shortcomings included:

● it required data that was not available in rural areas;

● it was so complex, it required reconfiguration before

it could be used in different rural environments;

. results from simulations were not available in time

for local planners to use the information; and

. a rational EMS system as specified by the model was

not implemented because there were limited planning resources within the region and because of

various social and political constraints.

Example: Aroostoock County, Maine

The population of Aroostoock County, Maine was

approximately 100,000 at the time of the field test. The

population was scattered among 71 towns (most with a

population under 1,000) most of which were spread over

a 7,500-square-mile land area. At the time of the study, the

county was served, somewhat sporadically. by 12 independent BLS ambulance providers. The development of

a countywide system and/or the introduction of ALS

capabilities was being considered.

The impact of several EMS system changes were

evaluated including:

●

●

●

using an ALS non-transporting unit which operated

out of the region’s hospitals and from some of its

more rural clinics;

downgrading several very low volume BLS units to

IRP status; other BLS units were redeployed to

provide both first response and transportation in

conjunction with an ALS (non-transporting) unit;

a transport vehicle unit was created to provide

interfacility transportation from the rural hospitals to

the State’s tertiary and secondary care facilities (a

trip of up to 4 hours or more in some cases).

The results of this seemingly ideal and cost-effective

alternative were for the most part very promising:

Average response times for a number of areas would be

reduced by up to 2 minutes. However. even though the

number of BLS vehicles deployed was reduced while an

ALS capability was introduced, the rural nature of the area

was not conducive to an acceptable ALS response times

that remained relatively high (12.5 to 14.0 minutes).

Further, the long-haul transfer vehicles were not utilized

with the anticipated frequency, and hence, did not lead to

significant system improvement.

While RURALSIM provided planners with a considerable amount of information, much of its potential value

was not realized, in part because there were delays due to

data limitations and because RURALSIM needed to be

reconfigured. Primary reasons for selecting Maine as the

first test site were its computerized EMS data system, the

only such statewide system in existence at that time. and

the sophisticated staff. However, in a number of cases, the

data requirements of RURALSIM exceeded the capabilities of Maine’s system necessitating either manual

compilation or the development of alternative methods to

estimate demand. Neither the local providers, nor the

local communities were willing to accept a more efficient

and effective EMS delivery system if it meant giving up

a certain amount of local autonomy and independence.

The Future of RURALSIM:

Microcomputer Adaptation

RURALSIM can’t be used directly by most rural EMS

planners because it requires a mainframe computer. The

costs associated with modeling also limit its use. The

model is so complex that a single simulation could cost

several hundred dollars. Since RURALSIM’s development, rapid advancements in personal computers have

occurred and RURALSIM’s could be adapted to the

microcomputer. Adapting the computer model to a

microcomputer would allow rural areas with microcomputers to conduct their own simulations and work with the

system interactively.

A microcomputer version could be simplified and used

for the training/education of rural EMS planners and

administrators. A number of different rural EMS scenarios could be developed which the ‘‘planner’ could use to

test-out possible alternative EMS improvements. The

microcomputer-based model could also serve as a technical planning tool that could be incorporated into a

technical assistance program.
Appendix C

Trauma Service Designation Guidelines of the

American College of Surgeons and the

American College of Emerging Physicians

Hospital and Prehospital Resources for

Optimal Care of the Injured Patient by the

Committee on Trauma of the American

College of Surgeons

This report was prepared by the Task Force of the

Committee on Trauma of the American College of

Surgeons (ACS). In June of 1986, the Board of regents of

the American College of Surgeons approved this report

and authorized its publication as an official College

document.

It is generally recognized that this document is a set of

guidelines representing current thinking for optimal care

of the injured. Further revisions may be indicated as

systems are developed to meet the complex demands of

severely injured patients.

Levels of Care

The three levels of care suggested in this document

represent the best possible use of community resources.

The organization of trauma services within the community or region must address the development of a good

prehospital system. The concept of taking the severely

injured patient to the nearest hospital is no longer

acceptable.

Levels I and II—Invariably, in planning for regional

trauma needs, physicians, administrators, and health

planners must address how many hospitals should be

designated. Factors that must be considered include

maintenance of skills and experience, costs, population

density, and geography. The following guidelines are

offered to assist in this planning. General surgeons in

Level I centers might be considered to have adequate

experience in trauma surgery if they treat approximately

50 severe and urgent injury cases per year. Based on the

number of surgeons in each institution, this will translate

into 600 to 1,000 patients treated in a Level I hospital, and

350 to 600 patients treated in a Level II hospital. Since

each community must decide on the number of appropriate trauma facilities necessary to meet its commitment to

excellence in trauma care, it must consider the number of

severe and urgent injuries to be handled as well as its

ability to address its factors of geography and its ability

to concentrate its resources.

Level III—The Level II hospital generally serves

communities that do not have all the resources usually

associated with Level I or II institutions. However, as the

following tables show, a Level III hospital reflects a

maximum commitment to trauma care (commensurate with

resources. Planning for care of the injured in small

communities or suburban settings usually calls for

transfer agreements and protocols for the most severely

injured. Designation of the Level III hospital may also

require innovate use of the region resources. For

example, if there is no neurosurgeon in a large, sparsely

populated region it may require that a general surgeon be

prepared to provide the emergency decompression of

mass lesions. Transfer to the most appropriate Level I or

II hospital can then be arranged after the patient’s life

saving operation has been carried out. Another example

is the staffing of the Level III hospital. In many instances

it will be impractical to require a general surgeon to be

in-house. With modern communication systems it seems

reasonable that the surgeon should be promptly available

and in a great majority of instance meet the patient in the

emergency room on arrival. On-call personnel such as

laboratory, x-ray, and operating room nurses also can be

activated and respond promptly to the hospital when the

first notification of a critically injured patient is received.

The intent of this flexibility should be clear: to provide the

best possible care even in the most remove circumstances.

-67-
68 ● Rural Emergency Medical Services

The following table shows levels of categorization and their essential (E) or desirable (D) characteristics.

LEVELS

I II Ill

A. HOSPITAL ORGANIZATION

1.

2.

Trauma Service E E E

a) Specified delineation of privileges for the Trauma Service must be made

by the medical staff Credentialing Committee.

b) Trauma team – organized and directed by a general surgeon expert

in and committed to care of the injured, all patients with multiple system

or major injury must be initially evaluated by the trauma team, and the

surgeon who will be responsible for overall care of a patient (the team

leader) identified. A team approach is required for optimal care of patients with multiple-system injuries. (See Appendix A, on page 11.)

Surgery Departments/Divisions/Services/Sections

(each staffed by qualified specialists)

Cardiothoracic Surgery — E D .

General Surgery E E ‘E

3.

4.

Necrologic Surgery E E —

Obstetrics-Gynecologic Surgery D D

Ophthalmic Surgery E D ‘-

—

Oral Surgery - Dental D DOrthopaedic Surgery

Otorhinolaryngologic Surgery

E

E

E

D

Pediatric Surgery E D

Plastic and Maxillofacial Surgery E D

Urologic Surgery E - D -

Emergency Department/Division/Service/Section E E E

(staffed by qualified specialists) (see note 7)

Surgical Specialties Availability (see note 2)

[n-house 24 hours a day:

General Surgery E E’

Necrologic Surgery E’ E’

NOTES:

1. The emergency department staff should ensure im- 2. Requirements may be fulfilled by senior residents

mediate and appropriate care for the trauma patient. The capable of assessing emergent situations in their respecemergency department physician should function as a tive specialties. They must be capable of providing surgical

designated member of the trauma team and the relation- treatment immediate/y and to provide the control and

ship between emergency department physicians and other surgical leadership for the care of the trauma patient. When

participants of the trauma team must be established on a residents are used to fulfill availability requirements, staff

local level, consistent with resources but adhering to specialists must be on-call and promptly available.

established standards and ensuring optimal care.

SOURCE. The American College of Surgeons, Hospital and Prehospital Resources for Optimal Care of the Injured Patient, 1987
Appendix C—Trauma Service Designation Guidelines of ACS and ACEP ● 69

SURGICAL SPECIALTIES continued

LEVELS

I II Ill

On-call and promptly available from inside or outside hospital:

Cardiac Surgery E D

General Surgery E

Necrologic Surgery D

Microsurgery Capabilities E D

Gynecologic Surgery E D

Hand Surgery E D

Ophthalmic Surgery E E D

Oral Surgery (dental) E D

Orthopedic Surgery E E D

Otorhinolaryngologic Surgery E E D

Pediatric Surgery E D

Plastic and Maxillofacial Surgery E E D

Thoracic Surgery E E D

Urologic Surgery E E D

5. Non-Surgical Specialties Availability

In-hospital 24 hours a day:

Emergency Medicine E

5 E’ E

Anesthesiology E’ E

6,7 E’

On-call and promptly available from inside or outside hospital:

Cardiology E E D

NOTES:

3. The established trauma system should ideally ensure

that the trauma surgeon will be present in the emergency

department at the time of the patient’s arrival. When sufficient prior notification has not been possible, a designated

member of the trauma team will immediately initiate the

evaluation and resuscitation. Definitive surgical care must

be instituted by the trauma surgeon in a timely manner that

is consistent with established standards.

4. An attending neurosurgeon must be promptly available

and dedicated to that hospital’s trauma service. The inhouse requirement may be fulfilled by an in-house

neurosurgeon or surgeon (or physician in Level II facilities)

who has special competence, as judged by the chief of

neurosurgery, in the care of patients with neural trauma,

and who is capable of initiating measures directed toward

stabilizing the patient and initiating diagnostic procedures.

5. In Level I and Level II institutions, requirements may

be fulfilled by senior level emergency medicine residents

capable of assessing emergency situations in trauma patients and providing any indicated treatment. When residents are used to fulfill availability requirements, the staff

specialist on call will be advised and be promptly available.

6. Requirements may be fulfilled by anesthesiology

residents capable of assessing emergent situations in

trauma patients and of providing any indicated treatment.

When anesthesiology residents are used to fulfill availability

requirements, the staff anesthesiologist on call will be advised and available promptly.

7. Requirements maybe fulfilled when local conditions

assure that the staff anesthesiologist will be in the hospital

at the time or shortly after the patient’s arrival in the hospital

During the interim period, prior to the arrival of the staff

anesthesiologist, a certified nurse anesthetist (CRNA) capable of assessing emergent situations in trauma patients

and of initiating and providing any indicated treatment will

be available.
70 ● Rural Emergency Medical Services

B.

Chest Medicine E D —

Gastroenterology E D —

Hematology E ‘E D ——-———

Infectious Diseases E D

Internal Medicine ————— —— . .

E “E E

Nephrology E ‘E ‘D

Neuroradiology D

Pathology E E D

Pediatrics E E D

Psychiatry E D ‘-

Radiology E E D—

SPECIAL FACILITIES/RESOURCES/CAPABILITIES

1. Emergency Department (ED)

a) Personnel

1. Designated physician director E E E —

2. Physician with special competence in care of the critically E E“ E

injured who is a designated member of the trauma team

and physically present in the ED 24 hours a day

3. RNs, LPNs, and nurses’ aides in adequate numbers — 

E E ‘E

b)

E E E

Equipment for resuscitation and to provide life support for

the critically or seriously injured shall include but not be

limited to:

1. Airway control and ventilation equipment including

Iaryngoscopes and endotracheal tubes of all sizes,

bag-mask resuscitator, pocket masks, oxygen, and

mechanical ventilator

2. Suction devices E ‘E E

3. Electrocardiograph-oscilloscope-defibrillator E E E

4. Apparatus to establish central venous pressure monitoring E E E

5. All standard intravenous fluids and administration devices, E E E

including intravenous catheters

6. Sterile surgical sets for procedures standard for ED, such E E E

as thoracostomy, cut-down, etc.

7. Gastric Iavage equipment E E E

8. Drugs and supplies necessary for emergency care E E E

9. X-ray capability, 24-hour coverage by in-house technician E E E

10. Two-way radio linked with vehicles of emergency transport E E E

system

11. Skeletal traction device for cervical injuries E E E
Appendix C—Trauma Service Designation Guidelines of ACS and ACEP ● 71

LEVELS

I II Ill

2.

3.

4.

5.

6.

Intensive Care Units (ICUs) for Trauma Patients

ICUs may be separate specialty units.

a) Designated medical director — E E E

b) Physician on duty in ICU 24 hours a day or immediately E E D

available from in-hospital

c) Nurse-patient minimum ratio of 1:2 on each shift E E E

d) Immediate access to clinical laboratory services E E E

e) Equipment:

1. Airway control and ventilation devices E E E

2. Oxygen source with concentration controls E E

3. Cardiac emergency cart E E E

4. Temporary transvenous pacemaker E E E —

5. Electrocardiograph-oscilloscope-defibrillator E E E

-

6. Cardiac output monitoring E E D

—7. Electronic pressure monitoring E E D . —

8. Mechanical ventilator-respirators E E E

9. Patient weighing devices E E E —

10. Pulmonary function measuring devices —— E E E

11. Temperature control devices E E E

12. Drugs, intravenous fluids, and supplies E E E

13. Intracranial pressure monitoring devices E E D

Postanesthetic Recovery Room (surgical intensive care unit is acceptable)

a) Registered nurses and other essential personnel 24 hours E E E

a day

b) Appropriate monitoring and resuscitation equipment E E E

Acute Hemodialysis Capability (or transfer agreement) E D D

Organized Burn Care E E E

a) Physician-directed burn center staffed by nursing personnel

trained in burn care and equipped properly for care of the

extensively burned patient,

OR

b) Transfer agreement with nearby burn center or hospital with a

burn unit — —.——

Acute Spinal Cord/Head Injury Management Capability E E E

a) In circumstances where a designated spinal cord injury rehabilitation

center exists in the region, early transfer should be considered;
72 ● Rural Emergency Medical Services

7.

8.

transfer agreements should be in effect

b) In circumstances where a head injury center exists in the

region, transfer should be considered in selected patients;

transfer agreements should be in effect

Radiological Special Capabilities

a) Angiography of all types E E D

b) Sonography E D

c) Nuclear scanning E D

d) In-house computerized tomography with technician E E

Rehabilitation Medicine E E E

a) Physician-directed rehabilitation service staffed by nursing

personnel trained in rehabilitation care and equipped properly

for care of the critically injured patient,

OR

b) Transfer agreement when medically feasible to a nearby

rehabilitation service

C. OPERATING SUITE SPECIAL REQUIREMENTS

Equipment-Instrumentation

1.

2.

3.

4.

5.

6.

7.

8.

Operating room adequately staffed in-house and immediately available E E D

24 hours-a day

Cardiopulmonary bypass capability E D

Operating microscope E D

Thermal control equipment:

a) for patient E E E

b) for blood E E E

X-ray capability E E E —

Endoscopes, all varieties E E E

Craniotome E E D

Monitoring equipment E E E

D. CLINICAL LABORATORY SERVICE (available 24 hours a day)

1. Standard analyses of blood, urine, and other body fluids E E E

2. Blood typing and cross-matching E E E

3. Coagulation studies E E E

4. Comprehensive blood bank or access to a community central blood E E E

bank and adequate hospital storage facilities

.

5. Blood gases and pH determinations E E E
Appendix C—Trauma Service Designation Guidelines of ACS and ACEP ● 73

I

LEVELS

II Ill

6. Serum and urine osmolalitv E E D* y

7. Microbiology E E E —

8. Drug and alcohol screening E E D“

“Toxicology screens need not be immediately available but are desirable. If not available, results should be included

in all quality assurance reviews.

E.

F.

G.

H.

1.

QUALITY ASSURANCE

1.

2.

3.

4.

5.

6.

7.

Organized Quality Assurance Program E E E — — — . ——-..——.

Special audit for all trauma deaths and other specified cases E E E

(see Appendix G on page 42) ————————- ——— ————. —— —— — ——— ——

Morbidity and mortality review E E E ——— ————— -.

Trauma conference, multidisciplinary (see note 8) E E

-

—. ————-—— .—— —.—-—— —

Medical nursing audit, utilization review, tissue review E E E —. ———

Trauma registry review (see note 9) E E - ‘

- E

Review of prehospital and regional systems of trauma care E D D

OUTREACH PROGRAM E D

Telephone and on-site consultations with physicians of the community

and outlying areas

PUBLIC EDUCATION E

Injury prevention in the home and industry, and on the highways and

athletic fields; standard first-aid; problems confronting public, medical

profession, and hospitals regarding optimal care for the injured

TRAUMA RESEARCH PROGRAM E

TRAINING PROGRAM

1. Formal programs in continuing education provided by hospital for:

a) Staff physicians E

E D

D D

E D

b) Nurses E E D

C) Allied health personnel E E ‘

-D — ——. . ... —..——. —— 

d) Community physicians E E D . —. — —..—.— ——

NOTES:

8. Regular and periodic multidisciplinary trauma confer- 9. Documentation of severity of injury (by trauma score,

ences that include all members of the trauma team should age, injury severity score) and outcome (survival, length

be he/d. This conference will be for the purpose of quality of stay, ICU length of stay) with monthly review of statistics.

assurance through critiques of individual cases.
74 ● Rural Emergency Medical Services

Guidelines for Trauma Care Systems

[These guidelines were developed by the American College of Emergency American College of

Physicians Trauma Committee and were opproved for publication by the Emergency Physicians

Board of Directors on September 18, 1986. These guidelines supersede the Dallas. Texas

previous position statement on trauma are (February 1982:11:105). American College of Emergency Physicians: Guidelines for trauma care systems. Address for reprints: American College of

Ann Emerg Med April 1987:16:459-463.) Emergency Physicians. PO Box 619911,

Dallas. Texas 75261-9911

PREAMBLE

Trauma, defined as serious bodily injury, constitutes our most expensive

yet connectable national health problem.1 Trauma remains the leading cause

of death for persons 1 to 37 years of age and the leading cause of disability for

persons of all ages. The overall cost of accidental injury currently exceeds

$90 billion annually. 2 Although some areas have already organized and integrated the emergency medical services (EMS) system components and providers that are essential to optimizing trauma care, others have failed to develop adequate trauma care systems or to acknowledge that such an

approach is necessary.

The American College of Emergency Physicians has long maintained a

commitment to the comprehensive care of ill and injured persons, including

treatment, education, and research. The ability to respond appropriately to

the needs of trauma victims requires the skills and efforts of the entire

health care team. EMS systems should provide treatment for seriously injured patients in an organized and timely fashion. Trauma care is but one

aspect of EMS, however, and special provisions for trauma victims should not

be permitted to fragment the remainder of the emergency medical care system.

Trauma care represents a continuum that is best provided by an integrated

system extending from prevention through rehabilitation and requiring close

cooperation among specialists in each phase of care. A systems approach to

trauma care acknowledges this continuum, improving quality and reducing

mortality. Since 1976 the Committee on Trauma of the American College of

Surgeons has periodically published guidelines describing resources for trauma care.3 Because optimal treatment requires systems that encompass all

aspects of care, however, the Trauma Committee of the American College of

Emergency Physicians has developed these guidelines, which complement

those of the American College of Surgeons by defining the components and

providers that are essential to urban and rural trauma care systems [Figure)

Emergency physicians should provide leadership in trauma care, not only

by developing and managing systems, but also by directing prehospital care,

providing emergency department resuscitation and stabilization, and facilitating a smooth transition to inhospital care. The American College of Emergency Physicians recognizes that inhospital care for the seriously injured IS

best provided by facilities whose governing bodies, administrations, and

medical staffs are committed to excellence in trauma care, and that definitive, long-term treatment iS best provided by specialists who are specifically

traincd in trauma care.

The American College of Emergency Physicians encourages all medical

providers to work together to afford optimal care to all injured persons in the 

most efficient manner possible. Such relationship between emergency physicians at other members of the trauma care team must be established
Appendix C—Trauma Service Designation Guidelines ACS and ACEP . 75

locally and cannot be mandated by the government or other

parties. Individual systems are therefore encouraged to develop criteria that reflect local needs and resources.

These guidelines have been developed for the purpose of

assisting regions to plan, implement, operate, and evaluate

new and existing trauma care systems; they are not

intended to be used for certification. Additionally, to continue defining and clarifying individual aspects of trauma

care systems, the American College of Emergency Physicians will publish appendices to this document periodically.

GUIDELINES

Trauma care systems entail three dimensions,

incorporating four providers and 11 components in two

settings (Figure). The following section describes

individual components as either essential (E) or desirable

(D) for each provider in each setting.

Example

I. Provider # 1 Urban” Rural†

A. Component #l E E

B. Component #2 E D

C. Etc

I. System Management Urban Rural

A. Authority and Responsibility

Urban

E

E

E

E

E

Rural

E

E

E

E

E

EMS and trauma system

care

Administrative staff, familiar

with and experienced in

EMS and trauma system

management

Prevention/public education

a. Public education programs

b. Legislative advocacy

programs

Training

3.

4.

5.

6.

a.

b.

Clinical training for

prehospital providers4

System utilization

information for

community physicians,

nurses, and prehospital

providers

Communications

a. Regional plan

b. 911 access

c. Central control for

medical direction and

dispatch, including

appropriate training for

dispatchers

d. Linkage development

e. Equipment procurement

Data collection

a. Adequate personnel

b. System registry

Participation

Medical audit

E E

E

E

E

D

Each system should establish

its authority commensurate

with its responsibility to

provide trauma care, seeking

enabling legislation when

required.

Central Administrative Agency

E

E

D

D

E

D

7.

8.

9.

E E E E

B

Each system should identify a

broad-based group of providers

and consumers that IS

ultimately responsible for

system management.

1. Master plan for system

development, including

criteria for each component,

to be used for planning,

implementation, operation,

and evaluation

a. Prehospital criteria, a

including triage,

treatment, and

transportation

b. Hospital criteria,3

including facility numbers

and levels, patient

volumes, and staff/

equipment standards

2. Medical director, familiar

with and experienced in

E E

a.

b.

c.

d.

Staff with expertise in

quality assurance,

statistics, and computers

Equipment and storage

Criteria for evaluating the

system and its

components

Quality assurance

E E

E

E

D

D

E E

E E

E E

program, including

feedback loop for

demonstrated problems

Transplantation program

E

E

E

E

coordination for potential

donors

Certification and

Decertification. Each system

should develop and implement

policies and procedures for

certifying and decertifying

providers, including personnel,

transportation, and facilities.

Finance. Each system should

identify adequate resources, by

line item, for planning,

c.

D

E E

E E
r

Components

Medical Direction

Prevention

Communication

Training

Triage

Prehospital Care

Transportation

Hospital Care

Rehabilitation

Public Education

Medical Evaluation

Urban Rural

Implementation, operation, and

evaluation. E E

E. Emergency/Disaster

Preparedness. Each system

should develop a regional

disaster plan that integrates

EMS, trauma care, and disaster

management system resources. E

1. Regional plan for all

providers E

2. Central control through

local emergency

management association D

E

E

D

II. Prehospital Care

A. Management Agency Each

system should identify an

agency that is ultimately

responsible for prehospital care.

In some instances this function

may be fulfilled by the central

administrative agency. E

I Administration

a. Medical director, familiar 

with and experienced in

prehospital care E

b. Support staff, familiar

with and experienced in

prehospital management E

2 Training

a Sufficient experienced

staff E

E

FIGURE. Three dimensions of trauma care systems.

b. Curriculum 4 integrated

with system

3. Criteria

a. Protocols3 integrated with

system

4. Certification and

decertification

a. Consistent with state and

local criteria

b. Standardized clinical

examination

5. Data collection integrated

with system

6. Medical audit integrated

with system

B. Ambulance Standards. Each

system should establish

standards for land and air

transportation, subject to

legislative regulations.

1. Personnel

2. Equipment3

3. Process for ambulance

certification and

decertification

C Communication System. Each

D

E.

system should develop a

prehospital communication

system that is fully integrated

with the remainder of the EMS

and emergency/disaster

preparedness systems.

1. Central control for medical

direction and dispatch

2. Equipment

a. Minimize radio dead

space

b. Equip all vehicles and

aircraft

Emergency/Disaster

Preparedness Plan. Each system

should develop a prehospital

emergency/disaster preparedness

plan that IS fully integrated

with the remainder of the EMS

system.

Prevention/Public Education

1. Injury prevention

2 First aid and CPR

Ill Hospital Facilities

A. Trauma Hospital.s Each system

should identify an appropriate

number of trauma hospitals to

provide immediately available

surgical care for seriously

injureed patients

Urban Rural

E E

E E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

D

D

D

E

E

E
Appendix C—Trauma Service Designation Guidelines of ACS and ACEP ● 77

1. Standards3

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

Emergency department

Surgery department

Nursing care

Laboratory/blood bank/

x-ray

Computerized axial

tomography

Trauma nurse coordinator

Treatment protocols

Integrated with EMS

system

Documented institutional

commitment

current JCAH

accreditation

2. Communication

a. Integrated with EMS

system

b. Base station hospital

3. Helicopter landing capability

a. On-site

b. Licensed by regulatory

authority

4. Continuing medical

education

a. Physicians

b. Nurses

c. Prehospital providers

5. Protocols

a. Prehospital bypass/

rerouting, coordinated

with other trauma

hospitals through the

central administrative

agency

b. Treatments3

c. Transfer,3 for all incoming

patients regardless of

origin

6. Prevention/public education

a. Community-based

programs

7. Data collection

a. Adequate personnel

b. Hospital registry

c. System registry

participation

8. Rehabilitation

a. (See Section IV)

9. Medical audit

a. Adequate personnel

b. Quality assurance

Urban

E

E

E

E

E

E

E

E

E

E

E

D

E

E

E

E

E

E

E

E

E

E

E

E

E

E

Rural

E

E

E

E

D

E

E

E

E

E

E

D

D

E

D

D

E

E

E

E

E

E

E

E

E

E

program, including

feedback loop for

demonstrated problems

10. Emergency/disaster

preparedness plan

a. Internal plan

b. Integrated with remainder

of emergency/disaster

preparedness system

B. Specialty Cure Hospitals. Each

system should additionally

identify specialty care hospitals

for the small proportion of

patients requiring such

treatment. Access preferably

entails prehospital transport,

but also includes interhospital

transfer when medically

appropriate. If adequate facilities

do not exist in the area, formal

transfer agreements should be

developed with nearby

resources.

1. standards

a. Pediatric trauma3

b. Bums3

c. Spinal cord traumas

d. Hand trauma/limb

replantation

e. Eye trauma

2. Current JCAH accreditation

3. Communication

a. Integrated with EMS

system

4. Helicopter landing capability

a. On-site

b. Licensed by regulatory

authority

5. Training

a. Physicians

b. Nurses

c. Prehospital providers

6. Protocols

a.

h.

c.

Prehospital bypass/

rerouting, coordinated

with other trauma

hospitals through the

central administrative

agency

Treatment 3

Transfer, 3 for all incoming

patients regardless o f

origin

7. Prevention/public education

a. Community-based

programs

Urban Rural

E E

E E

E E

E

E

E

E

E

E

E

E

D

E

E

E

E

E

E

E

E

E

D

D

D

D

D

E

E

D

E

D

D

D

E

E

E

E
78 ● Rural Emergency Medical Services

IV.

8. Data collection

a. Adequate personnel

b. Hospital registry

c. System registry

participation

9. Rehabilitation

a. (See Section IV)

10. Medical audit

a. Adequate personnel

b. Quality assurance

program, including

feedback loop for

demonstrated problems

11. Emergency/disaster

preparedness plan

a. Internal plan

b. Integrated with remainder

of emergency/disaster

preparedness system

Rehabilitation

Rehabilitation planning, which

should start with emergency

department admission, may

continue after hospital transfer or

discharge. If adequate facilities do

not exist m the area, formal

transfer agreements should be

developed with nearby resources.

A. Special Care Facility

1. Medical direction

2. Adequate staffing

a.

b.

c.

d.

e.

f.

g.

h

Nursing care

Physical therapy

Occupational therapy

Psychosocial/substance

abuse counseling

Family support services

Patient support groups

Orthotic/prosthetic

services

Speech/language/hcarlng

Urban

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

Rural

E

E

E

E

E

E

E

E

E

E

E

E

D

D

D

D

D

D

services

B. Noninstitutional Care

1. Medical direction

2. Adequate staffing

a. Nursing care

b. Physical therapy

c. Occupational therapy

d. Psychosocial/substance

abuse counseling

e. Family support services

f. Patient support groups

g. Orthotlc/prosthetic

services

h. Speech/language/hearing

services

C. Financial Support. Each system

should identify adequate

resources for rehabilitation.

D. Data Collection

1. Adequate personnel

2. Provider registry

3. System registry participation

E. Medical Audit

1. Adequate personnel

2. Coordinate with system

audit

3. Quality assurance program,

including feedback loop for

demonstrated problems

Urban

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

E

Rural

D

E

E

E

D

D

D

D

D

D

D

E

E

E

E

E

E

E

REFERENCES

1 Ins[itutc on Mcdlcmc In\ury In Amertw A Crmtinutrrg Hcal(lt Proh

/cm Washington, DC, National Academy Press, 19H5

2 Nattonal Safety Counctl Accident Fac(s Chicago, NSC, 19HS. p N

3 Amcmcan College of Surgeons HospItol and Prchosptrol Resources Io(

@ulmo/ Core cd r/Je Irr\ured Pa fwn(. ond Appcrrdlces Al Chtciigo, ACS,

Iwo

4 Amcrlcan Aca&my O( Orthopacdlc Surgeons Emergency Core orrd

Trult\pw(uf~(Jf] (d f/Ic Sick orrd Infurcd, cd 4 Chtcago, AAOS, 19S7

$ Am~.rlcan Splna] Inlury Assocla[lon Foundatmn L’uIdc/Incs /or FucI/If),

Cule~or~zdf)(m und .’irorrdurdi ()/ Core !@nn/ Cord /n/ur\, Chicag(], ASIAF,

19U I

Reprinted from April 1987 Annals of Emergency Medicine”
Appendix D

Oregon Trauma Systems Summary and

Hospital Resource Criteria

OREGON TRAUMA SYSTEM SUMMARY

Emergency Medical Services Section

State Health Division

OCTOBER 1989

In 1985 the Oregon Legislature authorized the Oregon State Health Division to

implement a state wide trauma system, The following is a description of our activities,

progress to date, and a brief characterization of the impact these activities are having

on the care of patients with serious traumatic injuries.

The Plan

Approximately 1,300 Oregonians die each year and many more are permanently

disabled by serious injuries. A trauma system reduces death and disability by (1)

identifying the causes of injury and promoting activities to prevent injury from occurring

and (2) assuring that appropriate emergency medical resources are used effectively

and efficiently, The Health Division emphasizes local planning, prevention of injuries

and strengthening of prehospital care in the following ways:

A State Trauma Advisory Board, consisting of the multi-disciplinary

members of the medical team and members of the public, was appointed

to help develop standards and policies for the trauma system and to

serve as a liaison between state and local planners.

Ten trauma areas were established statewide reflecting current patient

referral patterns, resources and geography. In each area an Area

Trauma Advisory Board was appointed to develop the area trauma plan

which coordinates the response, care and transportation of the patient.

There are 157 volunteers on Area Trauma Advisory Boards statewide.

Area Trauma System Plans are in various stages of development and the

Health Division is categorizing or designating trauma hospitals statewide

in accordance with standards modified from the American College of

Surgeons Hospital Resource criteria, Oregon is the first state in the

nation to develop standards which recognize and include rural hospitals,

This assures that patients throughout the state receive care consistent

with national standards. Completion of categorization and designation of

trauma hospitals and adoption of area trauma plans is targeted for

completion by August 1990.

-79 -
80 ● Rural Emergency Medical Services

A statewide information system or “injury registry” will gather data about

causes of injury, the emergency response and the patient outcome. In

addition to evaluating the trauma system for quality assurance, this data

will provide information for prevention of injuries.

The Health Division is implementing an injury prevention program which will use the

injury data to develop and implement prevention strategies which focus on problems

specific to Oregon. This program will provide technical assistance to help local

programs implement effective interventions.

The Health Division has conducted a major pediatric trauma project in an

effort to improve the emergency medical response specifically for

seriously ill and injured children.

Progress to Date

The overriding concern both when this bill was passed and since, has been that the

trauma system must meet the diverse needs of Oregon. To address this concern the

Health Division held informational meetings in 21 cities to obtain input about

emergency medical services problems and to encourage interest in local planning. In

response, 325 emergency providers applied to serve on our advisory board (map

attached).

During the past four years the 157 appointed members of the advisory boards have

been helping to assure that statewide goals, standard and procedures for the trauma

system are appropriate. With the help of the state trauma advisory board, state staff

negotiated compromises among the various recommendations. The results of this

input and discussion have been incorporated in the Trauma System Rules, filed in

February 1987, which establish the minimum standards for area plans covering the

prehospital care interhospital transfer, and quality assurance, as well as the

procedures for hospital categorization and designation.

A Trauma System Resource Guide was developed which describes goals and

guidelines of the trauma system and assists the area trauma advisory boards with their

trauma system planning efforts, Another document, a request-for-proposal, assists

hospitals in developing their trauma services and prepares them for verification

surveys.

Current Activities

Each area trauma advisory board has been writing an area trauma system plan which

is due in three phases. The plan for Area 1 (the seven northwest counties of Oregon)

has been completed and was implemented May 2, 1988. The state board is providing

assistance and review to assure that area plans meet state standards. In the
Appendix D--Oregon Trauma Systems Summary and Hospital Resource Criteria . 81

meantime, the Health Division staff are organizing visits by teams of experts to all

hospitals. This process of categorization and designation assures that patients are

treated in hospitals with a high commitment to trauma care regardless of hospital size

and location.

Within Area #1 (see map attached) two level I trauma hospitals have been designated

in Portland, consistent with the recommendations set forth by the providers in the area

trauma system plan. In the surrounding counties, three level Ill & IV trauma hospitals

were designated, Since the trauma system was implemented in May 1988, the area

board has been working with the Health Division to develop and implement a model

quality assurance program for the continual monitoring and evaluation of the trauma

system.

In Areas #7, #9, and #10 (most of Central and Eastern Oregon) the first part of the

area trauma system plans have been approved and are being implemented, Fifteen

hospitals serving these areas were surveyed in November 1988 by teams of out-ofstate trauma experts and were categorized as trauma hospitals.

The remaining trauma areas (Areas #2, #3, #4, #5, #6 and #8) are in various stages

of trauma system plan development.

The State Trauma Advisory Board is focusing on developing quality assurance

activities, evaluating the rural hospital resource criteria, and continuing to assist Area

Trauma Advisory Boards with trauma plan development.

Impact on Patient Care

In some areas, the trauma planning process has provided a useful forum for amicable

problem solving. The emergency medical service providers are working out problems

and upgrading the quality of care through training and improved coordination. In other

areas, the trauma board is providing the forum for heated but fair resolution of longstanding controversies. The providers are compromising on their preferred

approaches to a trauma system. A few boards are struggling with what often seem to

be insurmountable problems and inadequate resources. Progress is slow in these

areas, In the area that has an implemented system hospitals are reporting excellent

spin-off effects to non-trauma services as a result of developing their trauma service.

Providers report that patients are receiving care that is more consistently in keeping

with the goals for rapid definitive care. In all areas of the state, the development of the

trauma system is being tackled by the appropriate people -- the providers who have to

implement it and the public who will be served by it. We expect to meet a 1990

deadline for a system to improve care for all trauma patients.
82 ● Rural Emergency Medical Services

1

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w

w

w

w

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Appendix D-Oregon Trauma Systems Summary and Hospital Resource Criteria ● 83

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0 0 0

0 0 0

J!

e

u w w

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84 ● Rural Emergency Medical Services

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Appendix D--Oregon Trauma Systems Summary and Hospital Resource Criteria ● 85

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86 ● Rural Emergency Medical Services

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Appendix D-Oregon Trauma Systems Summary and Hospital Resource Criteria • 87

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88 ● Rural Emergency Medical Services

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Appendix E

Trauma Care/EMS Legislation Introduced During

the 101st Congressional Session

S.15—Emergency Medical Services and

Trauma Care Improvement Act of 1989

(C101) 01/25/89

Sen. Cranston (Cosp=23)

Senate Labor and Human Resources

DIGEST AS INTRODUCED:

Emergency Medical Services and Trauma Care Improvement Act of 1989—Amends the Public Health

Service Act to create a new title on trauma care. Directs

the Secretary of Health and Human Services to provide for

the establishment and operation of a National Clearinghouse on Emergency Medical Services and Trauma Care.

Authorizes appropriations for FY 1990 through 1992 or

for the first three fiscal years for which funds are

appropriated. Authorizes the Secretary to make grants and

enter into cooperative agreements and contracts with

respect to emergency medical services and trauma care

systems to: ( 1 ) conduct and support research, training,

evaluations, and demonstration projects; (2) provide

technical assistance to State and local agencies; and (3)

establish guidelines for the development of uniform State

data reporting systems.

Directs the Secretary to make an allotment for each

State for each fiscal year, mandating that at least 35

percent, subject to adjustment, be used for planning,

implementing, monitoring, and evaluating the operation

of county, regional, or State trauma care systems. Sets

forth requirements for such systems. Requires States to

use at least 35 percent of the amount available to them for

a fiscal year to reimburse designated trauma centers for

uncompensated trauma care expenditures. Requires nonFederal matching contributions (in cash or in kind) in a

specified ratio for fiscal years after FY 1990. Requires

each State, for each fiscal year beginning with FY 1990,

to submit the trauma care component of the State

emergency medical services plan (State plan) to the

Secretary. Sets forth requirements for the State plan.

Requires that hospital emergency departments, within

their capability, if an individual appears and requests

examination and treatment: ( 1 ) examine for the existence

of an emergency medical condition or active labor and, if

such a condition or labor exists, treat the individual until

stable, subject to exception; and (2) transfer such individual to other facilities only according to stated criteria.

Requires States to adopt guidelines for the designation of

trauma centers, and for triage, transfer, and transportation

policies, at least as stringent as the applicable guidelines

developed by the American College of Surgeons and by

the American College of Emergency Physicians. Mandates that States: (1) require each trauma center to provide

information to the State central data reporting system

annually; (2) submit, to the Secretary at least annually. the

information it receives from its data reporting and

analysis system; and (3) identify and submit to the

Secretary a list of rural areas lacking certain emergency

medical services. Sets forth restrictions on the use of State

allotments. Requires an annual report from each State to

the Secretary. Sets forth a formula for determination of the

amount of allotments. Provides for: (1) repayment and

offset for failure to use funds as agreed: (2) criminal

penalties for certain false statements; (3) technical assistance and provision of supplies and services by the

Secretary in lieu of grant funds; and (4) a report by the

Secretary to the Congress.

Authorizes appropriations for FY 1990 through 1992.

Directs the Secretary of Health and Human Services to

conduct studies: (1) to determine the adequacy and

appropriateness of the reimbursements provided to trauma

centers under Title X1X (Medicaid) of the Social Security

Act: and (2) of the long-term economic effects of trauma.

Amends the Public Health Service Act to revise the

application procedure for Preventive Health and Health

Services Block Grants to provide the State officer

responsible for the administration of the State highway

safety program an opportunity to participate in the

development of any plan relating to emergency medical

services as such plan relates to high way safety. Allows the

State official responsible for the provision of emergency

medical services the opportunity to participate in the

development of the State highway safety program as such

program relates to emergency medical services.

Amends the Public Health Service Act and the Consolidated Farm and Rural Development Act to allow certain

grant allotments to be used for the purchase of communications equipment. Requires the Federal Communications Commission to: ( 1 ) study the availability of radio

frequency channels for emergency medical services

communications: (2) establish a plan to ensure that the

needs of emergency medical services communications are

provided for in the allocations of frequencies for public

safety; and (3) submit a report to Committees of the

Congress containing such study and plan.

-89-
90 ● Rural Emergency Medical Services —

S. Amdt. No. 378—Amendment to S.15

(C101) 07/20/89

Sen. Cranston (Acosp=9)

Senate Labor and Human Resources

CONG REC S8521

AMENDMENT DIGEST:

SENATE

To provide funding to

services in rural areas.

FROM HOUSE OR

support emergency medical

S.1274-Comprehensive and Uniform

Remedy for the Health Care System Act of

1989 (C1O1) 06/23/89

Sen. Hatch

Senate Labor and Human Resources

DIGEST AS INTRODUCED:

Limited to provisions pertaining to EMS Comprehensive and Uniform Remedy for the Health Care System Act

of 1989—Title V: Improving the Trauma Care System—

Subtitle A: General Federal Emergency Medical Services

Programs-Amends the Public Health Service Act to

create a new title on emergency medical services. Directs

the Secretary of Health and Human Services, by contract,

to provide for the establishment and operation of a

National Clearinghouse on Emergency Medical Services

and Trauma Care. Sets forth the duties of the Clearinghouse. Allows the Clearinghouse to charge fees to defray

and, starting with FY 1991, to cover its costs of operating.

Authorizes appropriations for FY 1990 through 1992 or

for the first through the third fiscal year after FY 1990 for

which funds are appropriated under these provisions.

Directs the Secretary to promulgate regulations that

require States that receive grants under provisions added

by this Act relating to emergency medical services block

grants to provide the Secretary with certain data and

information concerning the use of the grants.

Authorizes the Secretary to make grants for research

and demonstration projects concerning ways to improve

the availability and quality of prehospital emergency

medical services in rural areas by: ( 1 ) developing

innovative uses of communications technologies; (2)

making continuing education more accessible to emergency medical services personnel; (3) developing and

refining training curricula; (4) undertaking outcome

studies; and (5) developing innovative financing mechanisms. Authorizes appropriations for FY 1990 through

1992.

Requires the Federal Communications Commission,

within one year of enactment of this Act, to: (1) complete

a study of the availability of radio channels for emergency

medical services; (2) establish a plan to ensure that the

needs of such services shall be adequately provided for in

the allocation of frequencies; and (3) submit a report

containing the study and the plan to the appropriate

Committees of the Congress,

Subtitle B: Emergency Medical Services Block Grant—

Amends the Public Health Service Act to authorize

appropriations for allotments to States for FY 1990

through 1992. Directs the Secretary, for each such fiscal

year, to: (1) allot to each State an amount under a specified

formula related to the population and land area of the

State; and (2) make payments to each State. Prohibits the

Secretary from making payments unless the State identifies any rural area for which there is no: ( 1 ) emergency

medical services access through a 911 telephone number;

(2) basic life-support system; or (3) advanced life-support

system.

Sets forth application requirements.

Requires that amounts paid to a State under the

allotments be used for: ( 1 ) accident prevention programs;

(2) feasibility studies and planning activities for emergency medical services systems; (3) emergency medical

services; (4) uncompensated trauma care as specified in

this Act; and (5) other activities as determined by the

Secretary.

Allows a State that receives a grant under the allotment

to use not more than 25 percent of the grant to pay the

expenses of certain uncompensated trauma care that has

been provided.

Allows a State to use a limited amount to carry out

emergency medical services activities under these provisions.

Removes provisions of the Public Health Service Act

which allow States to use block grant allotment sums for

feasibility studies and planning for emergency medical

services systems and the establishment, expansion, and

improvement of such systems.

H.R.911—Volunteer Protection Act of 1989

(C101) 02107/89

Rep. Porter (Cosp=200)

DIGEST AS INTRODUCED:

Volunteer Protection Act of 1989—Prescribes circumstances under which volunteers working for nonprofit

organizations or government entities shall be immune

from personal financial liability for acts on behalf of the

organization or entity. Sets forth exceptions to and

conditions on the granting of such immunity that a State

may impose, Requires the Secretary of Health and Human

Services to increase by one percent the fiscal year

allotment which would otherwise be made to a State to
Appendix E—Trauma Care/EMS Legislation Introduced During the 101st Congressional Session ● 91

carry out the Social Services Block Grant Program under

Title XX of the Social Security Act if such State has,

within two years, certified to the Secretary that it has

enacted a State law which provides such immunity.

Provides for the continuation of such increase based on an

annual recertification.

H.R.950—National Rural Health Care Act of

1989 (C101) 02/09/89

Rep. Roybal (Cosp=30)

DIGEST AS INTRODUCED:

Limited to provisions pertaining to EMS—Amends the

Public Health Service Act to authorize the Secretary to

make grants to States which have submitted fiscal year

plans for comprehensive State rural health access planning to assist States in such planning. Authorizes

appropriations for such grant program through FY 1992.

Requires each State to submit a comprehensive rural

emergency medical services plan to the Secretary for each

fiscal year, beginning with FY 1990. Authorizes appropriations through FY 1992 for payments to States, which

vary among States on the basis of the proportion of the

nation’s rural population which reside in each State, to

cover the costs of planning, implementing, and monitoring the operation of trauma care systems in rural areas.

Authorizes the Secretary to make grants to public and

nonprofit entities for planning, constructing, equipping,

supplying, and operating a rural health clinic and training

the personnel at such clinic. Authorizes the Secretary to

make grants to solo and small group medical practices

which provide primary health services to medically

underserved rural populations to assist such practices in

purchasing equipment and supplies and training personnel. Sets forth grant conditions, including the requirement

that such clinics and practices accept as patients Medicare

and Medicaid recipients residing in their service area, and

provide 24-hour-a-day emergency medical services.

Authorizes appropriations through FY 1992.

H.R.1587—Rural Emergency Medical

Services Improvement Act of 1989 (C101)

03/23/89

Rep. Cooper (Cosp=51)

House Energy and Commerce

DIGEST AS INTRODUCED:

Rural Emergency Medical Services Improvement Act

of 1989—Amends the Public Health Service Act to create

a new title on emergency medical services for rural areas.

Directs the Secretary of Health and Human Services to

make an allotment for each State each fiscal year for

improving the availability and quality, in rural areas, of

emergency medical services and emergency medical

services systems provided to victims of emergencies prior

to the arrival of the victims at medical facilities. Requires,

after FY 1990, non-Federal matching contributions in a

specified ratio.

Allows a State to expend payments received for: (1)

recruitment, training, and retention of personnel; (2)

purchase, upgrading, and maintenance of equipment; (3)

planning, coordination, and support of local emergency

medical services and systems; and (4) public education.

Requires that the State plan for emergency services

provide for adequate services in rural areas. Sets forth a

formula for determination of the amount of allotments.

Authorizes appropriations for FY 1990 through 1992.

Authorizes the Secretary to make grants for research into

and demonstration projects concerning ways to improve

the availability and quality of prehospital emergency

medical services in rural areas by using communications

technologies, making continuing education more accessible, improving curricula, undertaking outcome studies,

and developing innovative financing mechanisms.

Authorizes the Secretary to make grants for pilot

projects to develop community-based centers to coordinate and deliver comprehensive occupational health and

safety services to rural communities.

Authorizes appropriations for FY 1990 through 1992

for improving rural prehospital emergency services and

for centers for rural occupational health and safety

services.

H.R.1586—A Bill To Require a Study on

Medicare Reimbursement for Ambulance

Services (C101) 03/23/89

Rep. Cooper (Cosp=48)

DIGEST AS INTRODUCED:

Directs the Secretary of Health and Human Services to

conduct a study into the adequacy and appropriateness of

Medicare (Title XVIII of the Social Security Act)

payments for ambulance services and report the results of

such study to the Congress within one year of this Act’s

enactment.

H.R.1602—Trauma Care Systems Planning

and Development Act of 1989 (C101) 03/23/89

Rep. Bates (Cosp=37)

House Energy and Commerce

DIGEST AS INTRODUCED:

Trauma Care Systems Planning and Development Act

of 1989—Amends the Public Health Service Act to create

a new title on trauma care.
92 ● Rural Emergency Medical Services

Authorizes the Secretary of Health and Human Services to make grants and enter into cooperative agreements

and contracts with respect to trauma care to: (1) conduct

and support research, training, evaluations, and demonstration projects; (2) foster development of trauma care

systems; (3) collect and disseminate information; (4)

provide technical assistance to State and local agencies;

and (5) sponsor workshops and conferences.

Directs the Secretary to establish the Advisory Council

on Trauma Care Systems. Declares that, notwithstanding

provisions of the Federal Advisory Committee Act, the

Council shall continue in existence until otherwise

provided by law,

Directs the Secretary to make an allotment for each

State for each fiscal year for developing, implementing,

and monitoring the modifications to the trauma-care

component of the State plan for the provision of

emergency medical services. Requires non-Federal matching contributions (in cash or in kind) in specified ratios for

fiscal years after the first fiscal year of payments. States

that such component of the State plan will be modified

with regard to: ( 1 ) trauma care regions, centers, and

systems; (2) triage and transport of children; (3) accreditation and evaluation; (4) data reporting and analysis

systems; (5) procedures for paramedical personnel to

assess the severity of injuries; (6) transportation and

transfer policies; (7) public education; (8) coordination

and cooperation; and (9) other matters.

Requires States to adopt guidelines for the designation

of trauma centers, and for triage, transfer, and transportation policies, equivalent to the applicable guidelines

developed by the American College of Surgeons and by

the American College of Emergency Physicians. Authorizes the Secretary, after public notice and an opportunity

for comment, to waive the requirement of adoption of

such guidelines.

Mandates that States: (1) require each trauma center to

provide certain information to the State emergency

medical system annually; (2) submit to the Secretary, at

least annually, the information it receives from its data

reporting and analysis system; and (3) identify and submit

to the Secretary a list of rural areas lacking certain

emergency medical services.

Sets forth restrictions on the use of State allotments.

Requires an annual report from each State to the

Secretary. Sets forth a formula for determination of the

amount of allotments. Provides for: ( 1 ) repayment and

offset for failure to use funds as agreed; (2) criminal

penalties for certain false statements; (3) technical assistance and provision of supplies and services by the

Secretary in lieu of grant funds; and (4) a report by the

Secretary to the Congress.

Authorizes appropriations for FY 1990 through 1992.

Directs the Secretary of Health and Human Services to

conduct studies to: (1) identify programs established by

States in order to reimburse trauma care centers and other

health care providers for the uncompensated provision of

health care; and (2) determine the adequacy and appropriateness of the reimbursements provided to trauma centers

and ambulance service providers under Title XIX (Medicaid) of the Social Security Act.

SOURCE: Congressional Research Service, Bill Digest

Files, SCORPIO, October 1989.
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