Emergency Medical Services

Emergency Medical Services Fiscal Year 2010 Report to Congress January 24, 2013 Federal Emergency Management Agency

Message from the Administrator of FEMA January 24, 2013 I am pleased to present the following report, Emergency Medical Services, which has been prepared by the Federal Emergency Management Agency (FEMA). The report has been compiled pursuant to language in House Report 111-157 accompanying the Fiscal Year (FY) 2010 Department of Homeland Security (DHS) Appropriations Act (P.L. 111-83). For FY 2009, and again for FY 2010, the House Appropriations Committee directed FEMA to report on the amount of grant funding received by providers of emergency medical services (EMS), and whether that funding is sufficient for EMS providers to respond to disasters. The committee required FEMA to include an analysis of the current state of disaster preparedness capabilities of EMS providers. This report details EMS grant funding levels, how those grant funds relate to EMS national costs, where in the EMS community grant funds are directed, the preparedness of EMS providers, and where more work in preparedness is needed. The data used in this report came from the Homeland Security Grant Program (HSGP) for FYs 2006 2010 and the Assistance to Firefighters Grant (AFG) for FY 2011; national assessment data from the 2010 and 2011 State Preparedness Reports (SPRs) and the 2011 National EMS Assessment; and numerous open source reports from the U.S. Government Accountability Office (GAO) and other public and private agencies. Pursuant to congressional requirements, this report is being provided to the following Members of Congress: The Honorable John R. Carter Chairman, House Appropriations Subcommittee on Homeland Security The Honorable David E. Price Ranking Member, House Appropriations Subcommittee on Homeland Security The Honorable Mary L. Landrieu Chairman, Senate Appropriations Subcommittee on Homeland Security The Honorable Daniel Coats Ranking Member, Senate Appropriations Subcommittee on Homeland Security i

Inquiries relating to this report may be directed to me at (202) 646-3900 or to the Department s Chief Financial Officer, Peggy Sherry, at (202) 447-5751. Sincerely, W. Craig Fugate Administrator Federal Emergency Management Agency ii

Executive Summary As part of the FY 2009 and FY 2010 appropriations process for DHS, the House Appropriations Committee directed FEMA to report on the current state of disaster preparedness capabilities of EMS providers and grant funding supporting those efforts. To address this requirement, FEMA evaluated grant expenditure data for the HSGP and AFG to determine the amount of funding that grantees have used to support EMS providers. To evaluate current capabilities and remaining gaps, FEMA used data from the 2010 and 2011 SPR surveys, the 2011 National EMS Assessment, and other publicly available sources to evaluate EMS s ability to respond to disasters. This report is organized into two sections: one that examines FEMA grant program funding for the EMS community and another that analyzes EMS disaster preparedness. High-level results from these sections appear as follows. Findings related to grant funding: o From FY 2006 to FY 2010, the HSGP provided an average of $48.7 million each year to EMS providers. In FY 2011, the AFG provided slightly more than $68 million to EMS providers out of a program that totaled $341 million. o On average, grantees directed 2.2 percent of HSGP funds to EMS providers; the majority of HSGP funds were used to purchase equipment. Of the funds used for equipment, approximately 4 percent ($7.2 million) was used to purchase personal protective equipment (PPE). o HSGP and AFG funding represents a small percentage (about 1 percent) of the nationwide cost of EMS services. o Projects that improve the EMS community s ability to work with other disaster response disciplines receive a substantial share of HSGP funds (nearly 60 percent). Findings related to disaster preparedness: o In the 2010 SPR, states report they can satisfy many to most of the SPR s preparedness measures associated with EMS activity. o The 2011 National EMS Assessment indicates that less than a quarter of state EMS offices participates in HSGP activities or receive HSGP funding. o The 2011 National EMS Assessment indicates a quarter or less of local EMS providers participates in HSGP activities and nearly half do not receive HSGP funding. o The 2011 National EMS Assessment indicates that only 14 percent of the states have a requirement for local EMS providers to hold or participate in a mass casualty exercise. o A majority of state EMS offices participate in preparedness efforts, but few receive funding to support these activities. Although the results from the 2010 and 2011 SPRs indicate that EMS providers can satisfy many to most of the SPRs preparedness measures, the 2011 National EMS Assessment identified significant shortfalls in EMS disaster preparedness. These shortfalls exist in EMS provider participation in the HSGP, state and local EMS provider participation in exercises, and the iii

establishment of triage protocols in the EMS community. Even if these shortfalls were addressed, the resource needs of large or simultaneous disasters could prove very difficult to meet. For HSGP projects, continued integration of EMS providers into planning and preparedness initiatives must remain an area of national focus in preparedness assistance programs. iv

Table of Contents Emergency Medical Services I. Legislative Language... 1 II. Background... 2 A. Requirement Overview... 2 B. Grant Support for Building EMS Capability... 2 C. Analysis Methodology... 3 D. Report Structure... 4 III. Grant Funding for the EMS Community... 5 A. Preparedness Grant Funding... 5 B. Comparing Preparedness Grants and National Needs... 7 C. Using Grants to Encourage EMS Integration into Preparedness... 8 IV. Disaster Preparedness Capabilities of EMS Providers... 10 A. National SPR Findings on EMS Preparedness... 10 B. National EMS Assessment Findings on EMS Preparedness... 12 V. Conclusion... 15 VI. Appendices... 17 Appendix A. 2010 SPR Rating Scale... 17 Appendix B. Emergency Triage and Pre-Hospital Treatment Activity Ratings... 18 Appendix C. List of Abbreviations and Acronyms... 21 v

I. Legislative Language This document has been compiled in response to language in House Report 111-157 accompanying the FY 2010 DHS Appropriations Act (P.L. 111-83), which includes the following reporting requirement: The Committee supports the Department s efforts to complete capability assessments for emergency medical service (EMS) providers. However, the Committee remains concerned that current funding levels for the EMS community for training and equipment for disaster preparedness may be insufficient to meet capability requirements. Of particular concern is that EMS providers do not have essential personal protection equipment, such as powered air purifying respirators. FEMA is directed, in conjunction with the Office of Health Affairs, to report to the Committee regarding the current state of disaster preparedness capabilities of EMS providers. This report is due no later than six months after the enactment of this Act and shall include an analysis of the gap between current and target capabilities. FEMA is directed to include language in its grants guidance requiring States to include EMS providers in their Statewide Homeland Security Plans as well as their UASI plans. FEMA shall also make States aware that EMS personal protection equipment is an allowable expense under the State and UASI grant programs. If a State provides no funding to EMS providers, the State should justify its lack of funding by demonstrating that related capabilities have been met or by identifying other pressing priorities. 1

II. Background A. Requirement Overview In FY 2009 and FY 2010, the House Appropriations Committee directed FEMA to report on the current state of EMS provider disaster preparedness and the grant funding supporting it. The House Appropriations Committee was concerned that preparedness funding levels for the EMS community were insufficient and that EMS providers did not have the PPE needed for a disaster. FEMA in coordination with the DHS Office of Health Affairs (OHA), staff from the Federal Interagency Committee for Emergency Medical Services (FICEMS), and the National Highway Traffic Safety Administration (NHTSA) evaluated grant expenditure data from the HSGP and AFG grant programs. The data provided a detailed look at the projects designed and executed by state and local grantees to build EMS capability as well as the allocation of grant funds in the EMS community. The current state of EMS provider disaster preparedness was evaluated on the basis of data obtained from the 2010 and 2011 SPR surveys, the 2011 National EMS Assessment, and other publicly available sources. B. Grant Support for Building EMS Capability The HSGP and AFG are the primary FEMA grant programs that award preparedness funds to build EMS capability. The HSGP delivers funds to state, local, tribal, and territorial jurisdictions to address resource needs to prevent, protect against, mitigate, respond to, and recover from acts of terrorism and other disasters. EMS is one of more than a dozen disciplines that are eligible to and historically have received HSGP funds. HSGP funding data identify projects that support EMS providers by associating those projects with two response disciplines: EMS (fire-based) and EMS (non-fire-based). The funding levels should be viewed as estimated minimum amounts because EMS providers could receive support through funding associated with other disciplines, such as fire. HSGP guidance calls on states to integrate state EMS directors into statewide HSGP governance structures, including Senior Advisory Committees that are required to coordinate grant resources. Program guidance also strongly encourages multidisciplinary involvement in the development and implementation of statewide homeland security strategies. Program guidance from FY 2009 and FY 2010 explicitly required states and urban areas security initiatives (UASIs) to include EMS providers in their strategies. HSGP guidance has also highlighted EMS-related planning costs as allowable (e.g., enhancing state EMS systems, implementing statewide electronic patient care reporting systems) and encouraged grantees to include EMS in multidisciplinary activities related to disaster preparedness. The AFG provides preparedness funds directly to fire departments and non-affiliated EMS organizations to meet firefighting and emergency response needs for critical operational equipment, PPE, emergency vehicles, training, and other resources. AFG guidance defines a 2

non-affiliated EMS organization as a public or nonprofit EMS organization that provides direct emergency medical services, including emergency medical transport for specific geographic area on a first-due basis, but is not affiliated with a hospital and does not serve a geographic area where EMS is adequately provided by a fire department. Legislation authorizing the AFG requires that EMS providers receive a minimum of 3.5 percent of AFG funds, with a maximum of 2 percent dedicated to non-affiliated EMS agencies. 1 The President s FY 2013 Budget outlined a vision for a new National Preparedness Grant Program (NPGP) designed to develop and sustain core capabilities across the Nation. The vision consolidates many current FEMA grant programs, although AFG would remain as a separate program. Under the NPGP, state EMS directors can identify EMS capability requirements through their jurisdictions threat and hazard identification and risk assessment (THIRA). The THIRA identifies target resource needs based on the greatest risk faced by the jurisdiction. The SPR assesses current capability against these targets and documents any capability gaps that exist. Under NPGP, state administrative agencies (SAAs) will no longer base sub-grant funding on a formula distribution, but will allocate funding on the basis of specific projects intended to fill SPR-identified capability gaps. The new NPGP will help EMS directors to better articulate resource needs and coordinate grant funding. C. Analysis Methodology FEMA analyzed HSGP funding using data from the Grant Programs Directorate s Biannual Strategy Implementation Report (BSIR). HSGP grantees report these data to FEMA twice each year. The data are the grantees best calculation of grant funding distribution. The December 2010 BSIR was the most recent BSIR available for this analysis. The data provided detailed information (e.g., project name, supported discipline, project type, project description) on the funding used by state, local, tribal, and territorial jurisdictions. The supported discipline data element split funding into 15 discipline areas. Funding allocated to the EMS (fire-based) and EMS (non-fire-based) disciplines was identified as EMS preparedness funding. FEMA analyzed AFG funding using data from FEMA s AFG Program Office. Because AFG projects comingle EMS preparedness activities (such as purchasing protective equipment, training, and improving wellness and fitness) with fire department activities, the precise amount of funding that went to EMS was difficult to determine. To separate EMS funding from fire department funding, the AFG Program Office analyzed the FY 2011 call volume of all fire departments in the Nation to identify those fire departments that dispatched 75 or more percent of the time on medical-related emergencies. FEMA, in turn, used funding amounts to those organizations to develop a reasonable estimate of AFG awards supporting EMS nationally. However, this estimate does not guarantee that grantees used these funds only for EMS purposes. This funding along with funding that went to non-affiliated EMS organizations was tallied to determine total EMS preparedness funding. 1 Lennard G. Kruger; Assistance to Firefighters Program: Distribution of Fire Grant Funding; Congressional Research Service Report R32341. April 11, 2012 (http://www.fas.org/sgp/crs/homesec/rl32341.pdf. Accessed January 15, 2013.). 3

FEMA analyzed disaster preparedness using results from the 2010 and 2011 SPRs, the 2011 National EMS Assessment, and other open-source resources. These sources provide differing indications of state and local EMS provider preparedness. FEMA obtained feedback from OHA, FICEMS staff, and NHTSA subject matter experts to help interpret data. D. Report Structure This report is organized into two sections to meet the legislative requirements. The first section outlines EMS funding provided by FEMA through the HSGP from FY 2006 to FY 2010 and the AFG for FY 2011. The second section analyzes the current state of EMS disaster preparedness using results from the 2010 and 2011 SPRs, the 2011 National EMS Assessment, and other opensource resources. 4

III. Grant Funding for the EMS Community Findings on FEMA grant program funding for the EMS community are presented in this section. Details are provided on grant funding levels, how those grant funds relate to EMS national costs, where in the EMS community grant funds are used, and how EMS integrates into preparedness planning. A. Preparedness Grant Funding Finding: From FY 2006 to FY 2010, the HSGP provided an average of $48.7 million each year to EMS providers. The HSGP is one of two primary FEMA grant programs that award preparedness funds to support EMS providers. Figure 1 lists HSGP funding that supported EMS providers. On average, the HSGP provided more than $48 million each year from FY 2006 to FY 2010. In FY 2010, the latest year for which HSGP funding data are available, $47.2 million in HSGP grant funds supported EMS. The data reported by HSGP grantees in the December 2010 BSIR are not fixed or historical, but are a snapshot of the distribution of funding at the time of the report. Distribution data become more accurate as the grant program ages and projects complete. Therefore, reported distribution for FY 2006 is more accurate than FY 2010. Figure 1. HSGP funding for EMS averaged $48.7 million* * Dollar amounts not adjusted for inflation The funding levels in Figure 1 represent an average allocation of 2.2 percent of all HSGP funding. A breakout of the percentage for each year is included in Table 1. State and local grantees allocated the largest percentage of funding (2.8 percent) to EMS in FY 2006 and the 5

smallest percentage (1.9 percent) in FY 2007. This compares with an average allocation of 8.2 percent of HSGP funding for the fire discipline from FY 2006 to FY 2010. Table 1. On average, grantees directed 2.2 percent of HSGP funds to EMS Year EMS Funding Total HSGP Funds Percentage of Total Funds to EMS FY 2006 $55,491,723 $1,986,441,636 2.8% FY 2007 $41,307,441 $2,180,467,665 1.9% FY 2008 $53,044,669 $2,548,511,699 2.1% FY 2009 $46,407,544 $2,228,204,150 2.1% FY 2010 $47,228,219 $2,238,661,092 2.1% The majority of HSGP funds supported equipment acquisition, including purchases of PPE and EMS vehicles. From FY 2006 to FY 2010, HSGP grantees reported directing an average of 74 percent of all EMS funding to equipment. A breakout of the percentage for each year is included in Figure 2. In FY 2010, the latest data available, HSGP grantees reported directing $34.4 million (72.8 percent of all EMS funding) to equipment. The lowest percentage of funding going to equipment in this time period was 70 percent in FY 2009. Figure 2. The majority of HSGP Emergency Triage and Pre-Hospital Treatment funding went to equipment The HSGP funding data used in Figures 1 and 2 and Table 1 did not possess the detail needed to identify which EMS projects supported the acquisition of PPE. To identify protective equipment acquisitions, FEMA analysts used a representative sample of the BSIR, which included project titles, project types, and detailed project descriptions. The sample was composed of projects assigned to the Emergency Triage and Pre-Hospital Treatment target capability. This capability broke out project data by the capability element (planning, organization, equipment, training, and exercise) and into specific equipment subcategories, one of which was PPE. The percentage of 6

equipment funding within the Emergency Triage and Pre-Hospital Treatment capability allocated to PPE was 4 percent. When this percentage was applied to the data in Figures 1 and 2 and Table 1, the amount of equipment funding dedicated to EMS PPE from FY 2006 to FY 2010 was $7.2 million. Finding: In FY 2011, the AFG provided slightly more than $68 million to EMS providers out of a program that totaled $341 million. EMS providers also receive preparedness funding through the AFG. The AFG provides funds to build EMS capabilities on the basis of four targeted criteria: Prioritizing requests focused on training over those focused on equipment; Giving highest priority to equipment requests that bring an agency into compliance with national, state, or local standards; Placing a high priority on requests that upgrade service at established agencies from Basic to Advanced Life Support (ALS), and on training for EMS providers to deliver ALS services; and Giving funding priority to departments requesting new PPE for the first time and departments replacing or updating obsolete PPE to align with the current standard. An FY 2011 funding level of $68 million represents an allocation of 20 percent of all AFG funding. This value and percentage should be viewed as an estimated upper bound of EMS funding. As stated previously, the value includes state and local grantee allocations to nonaffiliated EMS organizations and fire departments that dispatched 75 or more percent of the time on medical-related emergencies. FEMA used funding amounts to those organizations to develop an estimate of AFG awards supporting EMS nationally, but there is no guarantee that grantees used these funds only for EMS purposes. Because of the difficulty in identifying EMS provider funding in the AFG, only 1 year of data was available for analysis FY 2011. B. Comparing Preparedness Grants and National Needs Finding: HSGP and AFG funding represents a small fraction (about 1 percent) of the nationwide cost of EMS services. Although an exact accounting of funding for EMS is not available, FEMA analysts estimated the nationwide cost of EMS services in 2009 to be slightly more than $11.6 billion. The estimate was based on two reports: one that estimated the average cost to transport a patient 2 and the 2011 National EMS Assessment that estimated the number of EMS transports in 2009. The 2007 GAO report estimated the average ground ambulance transport cost at $415. The 2011 National EMS Assessment estimated the total number of EMS transports in 2009 at slightly more than 28 million. The estimate should be viewed as a lower bound because costs have increased since these reports were published. This cost mostly supports localized, smaller-scale emergencies, such as individual heart attacks and car crashes, rather than responses to disasters. 2 U.S. Government Accountability Office, Ambulance Providers: Costs and Expected Medicare Margins Vary Greatly, GAO-07-383, May 2007 (http://www.gao.gov/new.items/d07383.pdf. Last accessed January 15, 2013.). 7

A comparison of national EMS cost to HSGP and AFG grant funding allocations reveals the fiscal challenge in preparing such a large and distributed system of providers for disasters. The HSGP and AFG grant funds combined (about $117 million) equate to about 1 percent of the estimated annual cost of EMS services across the Nation. C. Using Grants to Encourage EMS Integration into Preparedness Finding: Projects that improve the EMS community s ability to work with other disaster responders receive substantial shares of HSGP funds (nearly 60 percent). The 2012 National Preparedness Report identified the integration of EMS into disaster planning and preparedness initiatives as an area of national focus. Projects that improve the EMS community s ability to work with other disaster responders received a substantial share of HSGP funds from FY 2006 to FY 2010. For example, roughly half of dedicated EMS FY 2010 HSGP funds supported projects that encourage EMS integration into broader disaster preparedness and response activities, including planning efforts and interoperable communications initiatives. The FY 2010 HSGP data provided to FEMA by grantees shed light on the degree to which projects involving the EMS discipline supported broader integration into preparedness efforts. For each project, grantees selected a project type that stated the objective of the investment. Of the 17,206 projects reported in FY 2010, 606 projects, categorized into 30 project types, supported both fire-based and non-fire-based EMS disciplines. Some project types supported specific life-saving activities or the stockpiling of pharmaceuticals, such as: Enhance capabilities to respond to all-hazards events; Enhance capability to restore lifelines post incident; Build/enhance a pharmaceutical stockpile and/or distribution network; and Establish/enhance a sustainable homeland security training program. Other project types supported broader efforts to encourage EMS integration with other response disciplines, such as: Enhance integration of metropolitan area public health/medical and emergency management capabilities; Develop/enhance interoperable communications systems; Establish/enhance mass care shelter and alternative medical facilities operations; and Establish/enhance regional response teams. Table 2 lists the EMS-related project types, the number of projects for each type, and the amount and percentage of funds dedicated to each project type, ordered from highest funding level to lowest. Project types associated with integration efforts are shaded in gray. 8

Table 2. Project types selected by state and local grantees for the Emergency Triage and Pre-Hospital Treatment capability (Shading indicates project types that emphasize multi-disciplinary integration*) Project Type Projects Funding % of funds Enhance capabilities to respond to all-hazards events 169 $11,519,629 24.4 Enhance integration of metropolitan area public health/medical and emergency management capabilities 59 $8,837,815 18.7 Develop/enhance interoperable communications systems 105 $8,790,729 18.6 Establish/enhance mass care shelter and alternative medical facilities operations 38 $4,537,975 9.6 Establish/enhance regional response teams 68 $3,142,249 6.7 Enhance capability to restore lifelines post incident 4 $1,937,120 4.1 Build/enhance a pharmaceutical stockpile and/or distribution network 10 $1,125,889 2.4 Establish/enhance sustainable homeland security training program 17 $1,046,166 2.2 Other** 136 $6,215,647 13.2 Total 606 $47,153,219*** 100 * There were 321 integration projects at a cost of $27,926,446, nearly 60 percent of all funds. ** Other includes all project types that received less than 2.2 percent of funding. *** Data reported by grantees are not fixed or historical, but are a snapshot of the distribution of funding at the time of the report. As a result, total funding for 2010 in Table 2 varies slightly from total funding in Table 1. For FY 2010, project types that encouraged EMS integration into broader disaster preparedness and response activities, including planning efforts and interoperable communications initiatives, represented an investment of more than $27 million. As detailed in the following case study, integration efforts have improved coordination among response disciplines and enhanced disaster response. Case Study: EMS Response to Joplin Tornado EMS and medical personnel from Joplin and mutual aid agencies established field triage and medical treatment for survivors in the midst of major damage to the city. The tornado severely damaged the St. John s Regional Medical Center, which operates Joplin s EMS. The damage forced medical and EMS personnel to adopt creative, ad hoc solutions to treat hundreds of patients. According to news reports, approximately 200 people received medical treatment in makeshift care centers following the tornado. Some medical personnel parked ambulances in the impact zone and treated the injured rather than attempting to transport them. 9

IV. Disaster Preparedness Capabilities of EMS Providers Findings on the analysis of EMS disaster preparedness are presented in this section. Data for this analysis come from the 2010 and 2011 SPRs, the 2011 National EMS Assessment, and other open-source resources. All states and territories receiving federal preparedness assistance were required to submit an SPR to FEMA, in which they assess their preparedness to prevent, protect against, mitigate, respond to, and recover from acts of terrorism and disasters. With the introduction of Presidential Policy Directive 8 in 2011, FEMA updated the SPR assessment process to shift from target capabilities to core capabilities. In 2010, the assessment involved 37 target capabilities described in the 2007 Target Capabilities List (TCL). In 2011, the assessment involved 31 core capabilities described in the 2011 National Preparedness Goal. The differences between the assessments are explained as follows. A. National SPR Findings on EMS Preparedness Finding: In the 2010 SPR, states reported they can satisfy many to most of the SPR s preparedness measures associated with EMS activity. The 2010 SPR survey asked states to assess their ability to perform 37 capabilities outlined in the TCL, which was the overall framework used in 2010 to assess national preparedness. 3 Of the 37 capabilities, the Emergency Triage and Pre-Hospital Treatment target capability most closely aligned with EMS discipline s role in responding to a disaster. In the 2010 SPR, states rated themselves on a 10-point scale for each activity tied to a particular capability, where 1 indicated that no measures/metrics were satisfied and 10 indicated that all measures/metrics were satisfied. (Appendix A describes the ratings for the entire 10-point scale.) FEMA determined the mean scores for each state to derive national means by capability, allowing for a comparison of assessment results across all 37 capabilities. The Emergency Triage and Pre-Hospital Treatment capability had the ninth-highest score (7.1 out of 10) among the 37 target capabilities. For comparison, Mass Prophylaxis, the highestscoring target capability, had a score of 7.7 out of 10, and Isolation and Quarantine, the lowest scoring, had a score of 5.5. The TCL included eight distinct activities within the Emergency Triage and Pre-Hospital Treatment capability, starting with the activation of EMS resources in response to an incident and continuing through demobilization, as well as steady-state training and exercise actions. Table 3 lists these eight activities and the national mean scores for each from the 2010 SPR. The 3 The target capabilities are described in DHS s September 2007 TCL (https://www.llis.dhs.gov/displaycontent?contentid=26724. Accessed January 15, 2013.). The target capability Emergency Triage and Pre-Hospital Treatment corresponds much more closely to EMS ability to respond to a disaster than the broader Public Health and Medical Services capability, the closest equivalent among the core capabilities defined in the 2011 National Preparedness Goal. 10

activities are listed from highest to lowest mean score. Assessment results at the activity level generally fell between 6 (i.e., many measures/metrics are satisfied) and 8 (i.e., most measures/metrics are satisfied). In aggregate, scores in this range suggest that states determined that they could perform these activities successfully when required. States had more confidence in their abilities to provide treatment and transport patients. They had less confidence in their abilities to develop and maintain necessary plans, programs, and systems and to triage ill and injured patients. Appendix B provides additional SPR data for the Emergency Triage and Pre- Hospital Treatment target capability. Table 3. Nationwide mean SPR scores for the activities comprising the Emergency Triage and Pre-Hospital Treatment target capability Activity Mean Score Activate Triage and Pre-Hospital Treatment 7.6 Provide Treatment 7.5 Transport Ill and Injured Patients 7.2 Direct Triage and Pre-Hospital Treatment Tactical Operations 7.0 Demobilize Triage and Pre-Hospital Treatment 6.9 Develop and Maintain Training and Exercise Programs 6.5 Triage Ill and Injured Patients 6.4 Develop and Maintain Plans, Procedures, Programs, and Systems 6.4 Finding: The Public Health and Medical Services core capability in the 2011 SPR received the highest national average assessment score, 78 percent. The 2011 SPR survey employed a different assessment approach, using a new set of 31 core capabilities included in the National Preparedness Goal released in September 2011. The 2011 SPR survey asked state, local, tribal, and territorial jurisdictions to self-assess their ability to reach their desired capability levels, rather than TCL-defined levels, in each of the 31 core capabilities. This new capability framework included EMS roles and responsibilities as part of the Public Health and Medical Services core capability. The 2011 SPR survey described that capability as the ability to provide lifesaving medical treatment via EMS and related operations and avoid additional disease and injury by providing targeted public health and medical support and products to all people in need within the affected area. The Public Health and Medical Services core capability received the highest national mean score of 78 percent, meaning that states determined they were more than three-quarters of the way toward achieving their target levels of performance. The mean assessment score nationally across all 31 core capabilities was 62 percent, suggesting that Public Health and Medical Services rated far above the national mean. Definitive assessment of EMS providers is beyond the scope of the 2011 SPR survey because all medical capability assessment was aggregated into the Public Health and Medical Services core capability. 11

B. National EMS Assessment Findings on EMS Preparedness Finding: The 2011 National EMS Assessment identified significant shortfalls in state and local EMS preparedness associated with HSGP participation, exercise participation, and establishment of triage protocols. The 2011 National EMS Assessment, commissioned by the FICEMS and funded through the NHTSA, provided detailed information on EMS emergency preparedness at the state and national levels using multiple data sources. National EMS Assessment results indicated significant capability gaps in EMS disaster preparedness. The differences in findings between the reports can be attributed to the greater breadth of EMS participation in the National EMS Assessment and additional information coming from EMS providers that do not participate in federal grant programs. EMS disaster preparedness indicators showed low levels of participation in FEMA grants-related activity. These indicators included: Less than a quarter of state EMS offices participate in HSGP activities or receive HSGP funding: o 4 percent in leadership o 21 percent in coordination and planning o 21 percent in an operational role o 17 percent receive funding o 64 percent do not participate Approximately a quarter or less of local EMS providers participate in HSGP activities and nearly half do not receive HSGP funding: o 6 percent in leadership o 23 percent in coordination and planning o 26 percent in an operational role o 58 percent receive funding o 32 percent do not participate EMS disaster preparedness indicators related to exercises and triage protocols also showed areas that need improvement. These indicators included: 22 (47 percent) of state EMS offices reported participating in at least one chemical, biological, radiological, nuclear, and explosive (CBRNE) mass casualty exercise in 2010. The majority of exercises were related to biological entities such as pandemic influenza. 7 (14 percent) of the states have a requirement for local EMS agencies to hold or participate in a mass casualty exercise. 34 (68 percent) of the states indicated that either local or statewide EMS protocols including triage have been implemented and are currently in use by local EMS. 12

Finding: Although a majority of state EMS offices participate in preparedness efforts, few receive funding to support these activities. The 2011 National EMS Assessment reported that a majority of state EMS offices participate in national health preparedness efforts. However, a much smaller percentage receives funding to support these preparedness activities. For instance: 81 percent of state EMS offices participate in Emergency Support Function (ESF) #8 (Public Health and Medical Services) preparedness efforts, led by the U.S. Department of Health and Human Service s Assistant Secretary for Preparedness and Response (HHS/ASPR). Only 40 percent of these offices receive funding to support ESF #8 preparedness activities. 87 percent of state EMS offices participate in HHS/ASPR s Hospital Preparedness Program (HPP), which works to improve medical surge capacity and preparedness for public health emergencies. Only 40 percent of these offices receive HPP funding to support these activities. Finding: Recent national EMS assessments found differing indications of state and local EMS provider preparedness. Although recent assessments indicate that EMS providers are increasingly prepared in the areas of planning, organization, equipment, exercises, and providing services to access and functional needs populations, capability shortfalls exist in each area. The following section provides additional detail on these assessments. Planning and organization. Providing EMS is part of the Public Health and Medical Services core capability. Comparing results from the 2006 and 2010 Nationwide Plan Reviews shows large increases in the percentages of states and urban areas with confidence in their plans to provide this capability in an emergency. The percentage of states with confidence in the Health and Medical appendices of their emergency operations plans rose from 25 percent in 2006 to 70 percent in 2010. For urban areas, confidence increased from 18 percent to 73 percent. The 2011 National EMS Assessment reported that states and localities are developing patient triage and tracking systems, but few states have fully deployed them. The assessment s survey of state EMS offices indicated that in 68 percent of the states, state or local EMS protocols that include triage have been implemented and are currently in use by local EMS. Most states have disaster plans that include using mass transportation vehicles such as public or school buses to transport casualties. In more than 75 percent of the states, state and local EMS or emergency management entities can communicate with each other through email, text messaging, or paging when needed for either normal or disaster operations. Equipment. States, counties, and regional EMS councils have deployed a significant amount of regional equipment, including treatment trailers, to support EMS capabilities during a disaster. However, insufficient funding will likely make it difficult for EMS to 13

meet the Federal Communications Commission s narrow-banding requirement, which became effective on January 3, 2013. This requires EMS units to replace older UHF and VHF radios. Exercises. At the state level, 47 percent of state EMS offices reported participating in at least one CBRNE mass casualty exercise in 2010. The majority of exercises were related to biological events such as pandemic influenza. However, only 14 percent of the states have a requirement for local EMS agencies to hold or participate in a mass casualty exercise. Children and populations with access and functional needs. During disasters, EMS capability to care for children or people with access and functional needs is limited. EMS preparedness initiatives have begun to address these needs, but there are gaps in: o EMS units ability to identify and locate people with functional and access needs within the community; o EMS personnel acquiring and maintaining knowledge about functional and access needs; and o EMS personnel acquiring and maintaining the skills required to care for this population. The National Commission on Children and Disasters reported that just 25 percent of EMS agencies had the supplies and equipment to treat children. 4 A 2007 survey of 75 Indian Health Services EMS agencies, which focused on pediatric care, found that, of the 59 responding agencies, half had mass casualty plans. However, 14 percent reported having insufficient pediatric equipment when responding to a mass casualty incident. 5 Performance measures for the 2010 2011 Emergency Medical Services to Children Program showed that, on average, EMS transport vehicles carried more than 90 percent of the recommended pediatric equipment. However, the program did not achieve its quality indicator to have 90 percent of transport vehicles in each state carry 100 percent of the equipment. Less than 35 percent of the vehicles carried 100 percent of the equipment. 6 4 National Commission on Children and Disasters, 2010 Report to the President and Congress, October 2010 (http://cybercemetery.unt.edu/archive/nccd/20110426214356/http://www.acf.hhs.gov/ohsepr/nccdreport/index.html. Accessed January 15, 2013.) 5 Andrea Lynn Genovesi, MA, Betty Hastings, MSW, and Lenora Olson, PhD; An Assessment of Indian Health Service Affiliated Tribal EMS Agencies in the United States. Poster presented at the American Public Health Association Meeting, Washington, D.C. October 30, 2011. (http://apha.confex.com/apha/139am/webprogram/paper253579.html. Accessed January 15, 2013.) 6 National EMSC Data Analysis Resource Center, 2010 2011 Grant Year, September 8, 2011 (http://www.nedarc.org/performancemeasures/nationaldata/201011grantyear.html. Accessed January 15, 2013.). 14

V. Conclusion Although the results from the 2010 and 2011 SPRs indicate that states and territories can satisfy many to most of the SPRs preparedness measures related to EMS, the 2011 National EMS Assessment of EMS providers indicates that significant shortfalls in EMS disaster preparedness exist. These shortfalls exist in EMS provider participation in the HSGP, state and local EMS provider participation in exercises, and establishment of triage protocols for the EMS community. In 2010, states, on average, ranked EMS provider capability ninth-highest among the 37 target capabilities (on the basis of the Emergency Triage and Pre-Hospital Treatment target capability). Also in 2010, states, on average, assessed eight EMS provider response activities as falling between many measures and metrics are satisfied and most measures and metrics are satisfied. In 2011, the Public Health and Medical Services core capability, which included EMS provider activities, received the highest national average assessment score. However, EMS provider participation in the HSGP is low, with less than a quarter of state EMS offices participating in HSGP activities or receiving HSGP funding. Additionally, a quarter or less of local EMS providers participate in HSGP activities, and nearly half do not receive HSGP funding. Although few state EMS offices receive funding, the majority participate in ESF #8 and HHS/ASPR preparedness efforts. From FY 2006 to FY 2010, state and local grantees allocated 2.2 percent of HSGP funds to EMS providers. Although the majority of funding (74 percent on average) went to equipment, FEMA s analysis estimated 4 percent of that funding, $7.2 million, went to the purchasing of PPE. In FY 2011, the AFG provided slightly more than $68 million to EMS providers out of a program that totaled $341 million. This funding level represents an allocation of 20 percent of all AFG funding, a percentage well above the legislative requirement that EMS receive a minimum of 3.5 percent of AFG funding. The new NPGP will help EMS directors better articulate resource needs and coordinate grant funding through FEMA grant SAAs. The NPGP will allow state EMS directors to identify their target resource needs through a jurisdiction s THIRA. The SPR will use this information to establish a capability gap. Grant funding will support projects on the basis of their ability to address the capability gaps identified in the SPR. The result will be a more transparent, riskbased allocation of grant funding to state and local EMS grantees. EMS capabilities are critical to managing both routine and disaster medical emergencies across the Nation. Although the results from the 2010 and 2011 SPRs indicate that EMS providers can satisfy many to most of the SPRs preparedness measures, the 2011 National EMS Assessment indicates that significant shortfalls in EMS disaster preparedness exist. Even if these shortfalls were addressed, the additional resource needs of a very large disaster or simultaneous disasters 15

could prove very difficult to meet. For HSGP projects, continued integration of EMS providers into planning and preparedness initiatives must remain an area of national focus in preparedness assistance programs. HSGP grant guidance should continue to call for increased EMS integration into statewide and urban area governance structures. 16

VI. Appendices Appendix A. 2010 SPR Rating Scale States received the information in Table 4 about the meaning of SPR scores 1 10 before they assessed themselves on their ability to perform activities associated with each target capability. Table 4. 10-point rating scale for the 2010 SPR Score 1 2 3 4 5 6 7 8 9 10 Description No measures or metrics are satisfied at the specified level for this activity. This may be because it is not critical to the region, or because insurmountable barriers exist. The activity cannot be performed successfully. Needs within this activity have been recognized and initial efforts have been made to satisfy some measures/metrics at the specified level for this activity, but very few if any have been met. The activity is unlikely to be performed successfully. A few measures/metrics are satisfied at the specified level for this activity, but many gaps remain and it is not yet clear how they will be overcome. This activity is unlikely to be performed successfully. Some measures/metrics are satisfied at the specified level for this activity, and substantial effort remains. Significant barriers remain, and plans are being created to address them. The activity may be performed with partial success if needed. Some measures/metrics are satisfied at the specified level for this activity, and considerable effort remains. Important barriers that could undermine achievement exist, but plans are being created or are in place to resolve them. The activity may be performed with partial success if needed. Many measures/metrics are satisfied at the specified level for this activity, and though much effort remains, a plan is in place to satisfy the rest. Remaining issues are being identified. The activity may be performed successfully if required. Most measures/metrics are satisfied at the specified level for this activity, and though effort remains, a plan is in place to satisfy the rest. Remaining issues have been identified and are being addressed. The activity may be performed successfully if required. Most measures/metrics are satisfied at the specified level for this activity, and though moderate effort remains and a few issues are outstanding, a plan is in place and being followed to address them. It is likely, though not assured, that the activity could be performed adequately if required. Almost all measures/metrics are satisfied at the specified level for this activity, and progress is being made toward satisfying the others with no issues outstanding. It is likely, though not assured, that the activity could be performed adequately if required. All measures/metrics are satisfied at the specified level for this activity. Ideally, activity performance is validated via exercises or experience. 17

Appendix B. Emergency Triage and Pre-Hospital Treatment Activity Ratings For the 2010 SPR, states rated themselves on a 10-point scale for each activity tied to a particular capability, where 1 indicated that no measures/metrics were satisfied and 10 indicated that all measures/metrics were satisfied. Eight activities were associated with the Emergency Triage and Pre-Hospital Treatment capability. The following graphs depict state ratings for each activity. Appendix A describes the entire 10-point scale. 1. Activate Triage and Pre-Hospital Treatment 2. Provide Treatment 18

3. Transport Ill and Injured Patients 4. Direct Triage and Pre-Hospital Treatment Tactical Operations 5. Demobilize Triage and Pre-Hospital Treatment 19

6. Develop and Maintain Training and Exercise Programs 7. Triage Ill and Injured Patients 8. Develop and Maintain Plans, Procedures, Programs, and Systems 20

Appendix C. List of Abbreviations and Acronyms Acronym AFG ALS ASPR BSIR CBRNE DHS EMS ESF FEMA FICEMS FY HHS HPP HSGP NHTSA NPGP OHA PPE SAA SPR TCL THIRA UASI UHF VHF Definition Assistance to Firefighters Grant Advanced Life Support Assistant Secretary for Preparedness and Response Biannual Strategy Implementation Report Chemical, Biological, Radiological, Nuclear, and Explosives Department of Homeland Security Emergency Medical Services Emergency Support Function Federal Emergency Management Agency Federal Interagency Committee for Emergency Medical Services Fiscal Year U.S. Department of Health and Human Services Hospital Preparedness Program Homeland Security Grant Program National Highway Traffic Safety Administration National Preparedness Grant Program Office of Health Affairs Personal Protective Equipment State Administrative Agency State Preparedness Reports Target Capabilities List Threat and Hazard Identification and Risk Assessment Urban Areas Security Initiative Ultra High Frequency Very High Frequency 21