Chapter 1 Introduction to EMS Systems Learning Objectives Define the attributes of emergency medical services (EMS) systems List 14 attributes of a functioning EMS system Differentiate the roles and responsibilities of the emergency first responder from other prehospital care providers 2 Learning Objectives Identify how a patient s race, gender, age, and socioeconomic status can affect a first responder s judgment Discuss the rationale for maintaining a professional appearance when on duty or when responding to calls 3 1
Learning Objectives Identify types of medical oversight and emergency fist responder role in the process Identify a resource for statutes and regulations pertinent to EMS systems in your state 4 Introduction Emergency medical services (EMS) Sophisticated team of emergency care providers Emergency first responder defined as first person to see patient with injury/sudden illness Emergency Medical Services System (EMSS) provides continuation of care from prehospital into hospital environment Provide essential emergency care before advanced medical care providers arrive 5 First step Recognize that an emergency has occurred Activate EMS 6 2
When you arrive at the scene Tell patient you are trained EMS provider Ask patient/bystanders what happened If using assistance from untrained bystanders Communicate instructions clearly Ask assistant to repeat instructions 7 Common role for bystanders Assist by calling for additional emergency care providers Ask for someone who can give detailed, accurate location information 8 After arrival at scene Additional emergency first responders may arrive Firefighters Law enforcement Industrial response team EMTs Paramedics 9 3
10 Emergency medical services Development of civilian EMS Battlefield experiences Soldiers died before getting lifesaving care Early attempts at setting field treatment protocols 11 History of EMS in the United States Ambulances In service in the United States since the mid-1800s Modern EMS Can be traced back to Highway Safety Act of 1966 Academy of Sciences National Research Council 12 4
History of designated emergency phone number (9-1-1) Begins in 1968 American Telephone & Telegraph Company (AT&T) designated 9-1-1 as a national emergency number Today Nearly all Americans live in areas that have 9-1-1 service 13 History of designated emergency phone number (9-1-1) Include personnel trained to give instructions to bystanders to help them provide care while waiting for trained prehospital professionals to arrive at the scene 14 Standardized curricula NHTSA released first national standard curriculum for EMS in 1968 American College of Orthopedic Surgeons released first dedicated prehospital textbook in 1969 Television program put prehospital care in public eye 15 5
Prehospital legislation Enactment of EMSS Act of 1973 Prehospital care got its greatest federal support The law established EMS regions across the United States Provided funding for planning and implementation 16 Prehospital legislation Major components of EMSS Act Establish a lead agency for EMS in the federal government Make grants and contract awards for EMS system development Promulgate the Department of Health, Education and Welfare EMS system requirements Provide extensive technical assistance to support EMS system design and development Provide leadership to interagency committee on EMS 17 14 attributes of a functioning EMS system EMS Agenda for the Future Published by NHTSA in 1996 Revised the original 15 components of the EMS system as published in the 1973 EMSS Act 18 6
14 attributes of a functioning EMS system EMS Agenda for the Future Integration of health services EMS research Legislation and regulation System finance Human resources Medical direction Education systems Public education Prevention Public access Communications systems Clinical care Information systems Evaluation 19 20 Integration of health services Incorporate EMS within healthcare networks structures Be cognizant of special needs of the entire population Incorporate health systems within EMS that address the special needs of all segments of the population 21 7
Integration of health services Expand role of EMS in public health Involve EMS in community health-monitoring activities Integrate EMS with other healthcare provider networks 22 EMS research Allocate federal and state funding for EMS systems research Develop information systems that provide links between: Various public safety services Other healthcare providers 23 EMS research Develop academic institutional commitments to EM-related research Develop involvement/support of EMS research by all those responsible for EMS Structure Processes Outcomes 24 8
EMS research Designate EMS as physician subspecialty and as a subspecialty for other health professions Include research-related objectives in education processes of EMS providers and managers Enhance quality of published EMS research Develop collaboration relationships 25 Legislation and regulation Authorize and sufficiently fund a lead federal agency Enhance abilities of state EMS lead agencies to provide technical assistance Pass and periodically review EMS enabling legislation in all states that Support innovation and integration Establish and sufficiently fund an EMS lead agency 26 Legislation and regulation Establish and fund position of EMS medical director in each state Authorize state and local EMS lead agencies to act on the public s behalf in cases of threats to availability of quality EMS to the entire population Implement laws that provide protection from liability for EMS field and medical direction personnel when dealing with unusual situations 27 9
System finance Collaborate with other health providers and insurers to enhance patient care efficiency Develop proactive financial relationships between: EMS Other healthcare providers Health care insurers/provider organizations 28 System finance Provide immediate access to EMS for emergency medical conditions Address EMS-relevant issues within governmental healthcare finance policy Commit local, state, and federal attention and funds to continued EMS infrastructure development 29 Human resources Ensure that alterations in expectations of EMS personnel to provided healthcare services are preceded by adequate preparation Adopt principles of National EMS Education and Practice Blueprint 30 10
Human resources Develop a system for reciprocity of EMS provider credentials Develop collaborative relationships between EMS systems and academic institutions Conduct EMS occupational health research Provide a system for critical incident stress management 31 Medical direction Formalize relationships between all EMS systems and medical directors Appropriate sufficient resources from EMS medical direction Require appropriate credentials for all who provide online medical direction Develop EMS as physician and nurse subspecialty certification Appoint all state EMS medical directors 32 Education systems Ensure adequacy of EMS education programs Update education core content objectives frequently so they reflect patient EMS healthcare needs Incorporate research, quality improvement, and management learning objectives in higher-level EMS education 33 11
Education systems Seek accreditation for EMS education programs Commission development of national core content to replace EMS program curricula Conduct EMS education with medical direction Establish innovative and collaborative relationships between EMS education programs and academic institutions 34 Education systems Recognize EMS education as an academic achievement Develop bridging and transition programs Include EMS-related objectives in education of all health professionals 35 Public education Acknowledge public education as a critical activity for EMS Collaborate with other community resources and agencies to determine public education needs Engage in continuous public education programs 36 12
Public education Educate public as consumers Explore new techniques and technologies for implementing public education Evaluate public education initiatives 37 Prevention Collaborate with community agencies and healthcare providers with expertise and interest in illness and injury prevention Support safe communities concept Advocate legislation that potentially prevents injury and illness 38 Prevention Develop and maintain a prevention-oriented atmosphere within EMS systems Include principles of prevention and their role in improving community health as a part of EMS education Improve ability of EMS to document injury and illness circumstances 39 13
Public access Provide emergency telephone service for those who cannot afford routine telephone services Ensure that all calls to public safety answering point (PSAP) are automatically accompanied by unique location identifying information 40 Public access Develop a uniform 9-1-1 service that reroutes calls to appropriate PSAP Evaluate and employ technologies that attenuate potential barriers to EMS access Enhance ability of EMS systems to triage calls and provide resource allocation that is tailored to patients needs Implement 9-1-1 nationwide 41 Communication systems Assess effectiveness of various personnel and resource attributes for EMS dispatching Receive all calls for EMS using personnel with requisite combinations of education, experience, and resources to: Optimally query the caller Make a determination of most appropriate resources to be mobilized Implement an effective course of action 42 14
Communication systems Promulgate and update standards for EMS dispatching Develop cooperative ventures between communications centers and healthcare providers to: Integrate communications processes Enable rapid-related information exchange 43 Communication systems Determine benefits of real-time patient data transfer Appropriate federal, state, and regional funds to further develop and update geographically integrated and functionally based EMS communication networks Collaborate with private interests to effect shared purchasing of communication technology 44 Clinical care Eliminate patient transport as a criterion for compensating EMS systems Establish proactive relationships between EMS and other healthcare providers Commit to a common definition of what constitutes baseline community EMS care 45 15
Clinical care Subject EMS clinical care to ongoing evaluation to determine its impact on patient outcomes Employ new care techniques and technology only after they have been shown to be effective Conduct task analysis to determine appropriate staff configuration during secondary patient transfers 46 Information systems Develop information systems that are able to describe an entire EMS event Adopt uniform data elements and definitions Incorporate them into information systems Develop mechanisms to generate and transmit data that are: Valid Reliable Accurate 47 Information systems Develop integrated information systems with other healthcare providers, public safety agencies, and community resources Provide feedback to those who generate data 48 16
Evaluation Develop valid models for EMS evaluations Evaluate EMS effects for multiple medical conditions Determine EMS effects for multiple outcome categories Determine EMS cost-effectiveness Incorporate consumer input into the evaluation process 49 Trauma systems Caring for a patient with multiple injuries often requires: A variety of healthcare specialists Immediate access to surgical care Because few hospitals provide these resources, trauma systems have been developed Ensure that patients with life-threatening injuries are rapidly transported to the most appropriate hospital/specialized center for life-saving surgical care 50 Trauma systems Level I trauma where highest level of care is available Hospitals giving immediate care to trauma patients in preparation for transfer to higher level of care 51 17
52 Access to EMS Before 9-1-1 emergency system Each community had its own separate phone numbers for Police Fire Ambulance services Currently many communities have access to basic or enhanced 9-1-1 systems 53 Access to EMS In the basic 9-1-1 system Calls to the emergency number are routed to a central dispatch center Operator must learn exact location of emergency from caller in order to dispatch help 54 18
Access to EMS In the enhanced 9-1-1 system Caller s location is immediately displayed on dispatcher s computer monitor Caller does not need to know or provide that information 55 Access to EMS Modern enhanced 9-1-1 center Can identify location of caller s cell phone Can display only location of telephone, not of emergency A caller using a cell phone should give dispatcher details of emergency location 56 Access to EMS In some emergency situations Patient who calls 9-1-1 might not be able to talk to dispatcher Injury may affect ability to speak May feel threatened by possible attacker present at scene Police may be dispatched first to determine nature of emergency Police may then request additional medical help 57 19
Levels of Training for Prehospital Care Providers In the United States there are four nationally recognized levels of training Emergency medical responder Emergency medical technician (EMT) Advanced emergency medical technician (AEMT) Paramedic 58 Levels of Training for Prehospital Care Providers Emergency medical responder First designated level of professional emergency medical care Firefighter Police officer Neighbor Schoolteacher Industrial first-aid worker that completes a 40-hour training program 59 Levels of Training for Prehospital Care Providers Emergency medical responder Trained for: Assessment of life-threatening conditions in both medical and trauma patients Provision of initial airway care Assistance with breathing Provision of cardiopulmonary resuscitation (CPR) Control of bleeding Stabilization of spinal and extremity injuries Use limited amount of equipment and other skills as determined by local and state regulations 60 20
Levels of Training for Prehospital Care Providers Emergency medical responder Expected to initially control scene and activate EMS Trained to assist other prehospital care providers 61 Levels of Training for Prehospital Care Providers Emergency medical technician (EMT) EMT is progression from skills taught to emergency first responder with additional skills for managing medical and traumatic emergencies 62 Levels of Training for Prehospital Care Providers Emergency medical technician (EMT) Training consists of: A minimum of 120 hours of training may be longer Learn more advanced: Airway skills Management of fractures Administration of medications Transport of patients 63 21
Levels of Training for Prehospital Care Providers Advanced EMT (AEMT) Has skills to establish: Intravenous (IV) lines IV fluids Certain drugs 64 Levels of Training for Prehospital Care Providers Paramedic Provides highest level of prehospital care in the United States Training programs typically consist of 2000 hours or more 65 Levels of Training for Prehospital Care Providers Certification or licensure In states that license or certify emergency fist responders: Process is same as with EMT, AEMT, or paramedic After completion of program that uses education standards and completion of practical examination that follows the curriculum, candidate can apply to take state or national registry examination Certification or licensure is usually issued for a 2- to 4-year period 66 22
Levels of Training for Prehospital Care Providers Americans with Disabilities Act compliance Schools that offer emergency first responder courses will follow The Americans with Disabilities Act State and local rules, regulations, and policies regarding equal access, harassment, and safe educational environments National registry of EMTs makes accommodations for disabled applicants 67 Levels of Training for Prehospital Care Providers Advancement To advance from emergency first responder to emergency medical technician Emergency fist responder should enroll in a recognized EMT program Candidates who successfully complete the program are allowed to sit for the state or national registry examination 68 Developing Future of EMS Federal oversight of EMS is within NHTSA 1996 EMS Agenda for the Future Took what earlier national endeavors had done and expanded methods based on what has been learned in the first 20 years of organized EMS in the United States 69 23
In-Hospital Care Systems Most patients who receive EMS care are transported to emergency departments in local community hospitals 70 In-Hospital Care Systems Specialized emergency centers Have been established around the country Because some kinds of emergencies may require more resources than available in the local emergency department and hospital 71 In-Hospital Care Systems Specialized emergency centers Patient might be transported first to local emergency department where: Staff members start treatment and stabilize the patient Then transport patient to specialized centers 72 24
In-Hospital Care Systems Specialized emergency centers Trauma centers Specialized hospitals committed to maintaining a state of readiness to care for patients with serious multiple injuries Specialized surgeons and nurses must be prepared 24 hours a day to perform complex surgery at only a moment s notice 73 In-Hospital Care Systems Specialized emergency centers Trauma centers These centers have Dedicated intensive care units Computed tomography (CT) scanners Blood banks Specialty physicians Support staff 74 In-Hospital Care Systems Specialized emergency centers Burn centers Provide specialized care for victims of burns Thermal Chemical Electrical Radiation Smoke inhalation injuries 75 25
In-Hospital Care Systems Specialized emergency centers Burn centers There is only one burn center for every six trauma centers in the United States Patient might first be transferred to a trauma center and later to a specialized burn center 76 In-Hospital Care Systems Specialized emergency centers Specialty centers Cater to specific needs with specialized equipment and trained personnel Burn centers Children s hospitals Poison center 77 In-Hospital Care Systems Specialized emergency centers Specialty centers Personnel and databases allow these centers to ensure proper response to patients exposed to poisons Children s medical emergencies are rarely similar to adults Complications of childbirth require specialized care 78 26
In-Hospital Care Systems Specialized emergency centers Poison control center For patients who experience poisoning emergency Centers maintain large databases of information about household and industrial toxins Staff is proficient in toxicology Centers have supportive role and can provide information on a particular poisonous substance 79 Role of First Responder Scene safety Emergency first responders save lives Lifesaving skills that emergency first responders use are often simple and do not require specialized equipment Skills must be used quickly and effectively 80 Role of First Responder Scene safety Emergency first responders programs are designed to teach skills to people who are most likely to reach the scene before an ambulance arrives such as: Police officer Firefighter Teachers Co-workers Factory workers Lifeguards Other members of the community 81 27
Role of First Responder Scene safety Personal safety Must always be a primary responsibility Never jeopardize your own security for that of a patient Be mindful of bystanders and ensure they are safe Always maintain control of the scene until relieved by a more advanced healthcare provider or incident command officer 82 Role of First Responder 83 Role of First Responder Gaining access Emergency first responders must work within the level of their training To ensure the scene is not made more complex by an injury to an emergency first responder 84 28
Role of First Responder Patient care In some situations, patient may not be readily accessible General rule If scene is not safe to enter, wait for scene to be made safe Even if scene is safe, patient may need to be moved before patient assessment can begin 85 Role of First Responder Patient care Once it is safe to approach scene Number of patients should be determined In multiple patient situations Triage or determining severity of patients injuries ensures that neediest patients are cared for first 86 Role of First Responder Patient care Once at patient s side Perform a systematic evaluation for any life-threatening conditions Approaching patient Emergency first responder should determine the mechanism of injury in injured patients or primary complaint of ill patients 87 29
Role of First Responder Patient care In emergency care Patient assessments should always be performed in the same organized manner 88 Role of First Responder Patient care Once you have begun treatment Periodically reevaluate patient to determine if his or her condition is getting better or worse 89 Role of First Responder Patient care When ambulance or more advanced medical care arrives on scene Identify yourself as trained emergency first responder and report Details of the occurrence Your physical assessment Treatment you have given 90 30
Role of First Responder Patient care When ambulance or more advanced medical care arrives on scene They become responsible for care of patient 91 Role of First Responder Patient care When ambulance or more advanced medical care arrives on scene If required to document information in prehospital care record Follow your local or state requirements for documentation 92 Role of First Responder Patient care Personal traits Your responsibilities involve more than just your actions at the emergency scene Personal health and well-being Personal behavior Self-composure Professional appearance Maintain knowledge and skills 93 31
Role of First Responder Patient care Current knowledge of local and national issues 94 Medical Oversight Medical director A physician who develops guidelines and protocols for the emergency treatment of patients Responsible for prehospital medical care delivered by EMS service 95 Medical Oversight Two common types of medical oversight Direct medical control Occurs when prehospital team communicates with physician before providing specific treatment Usually occurs by either radio or telephone 96 32
Medical Oversight Two common types of medical oversight Indirect medical control Involves clear protocols, or standing orders, for treatment of various emergencies Medical director develops protocols and ensures prehospital providers are well trained in them Continuous quality improvement (CQI) program 97 Specific Statutes and Regulations Legal issues affecting EMS include: Good Samaritan laws Consent for treatment Consent for refusal of treatment Abandonment Confidentiality 98 Specific Statutes and Regulations Once you start emergency treatment, you are obligated to continue to give care until you have transferred care to someone of equal or higher training Failure to continue treatment until you are appropriately relieved is called abandonment 99 33
Specific Statutes and Regulations Before giving treatment You need consent from the patient With a minor, consent comes from parent or guardian Verbal consent is acceptable If in life-threatening emergency situations when patient is unconscious or others are unable to give consent consent is said to be implied Competent patients are allowed to refuse help 100 Questions? 101 34