Part 3, Chapter 17: Manual Exhibit 3-17-A

Emergency Medical Services

STRUCTURAL MODELS OF EMERGENCY MEDICAL SERVICES. Various models have been proposed and adopted by national medical organizations and by governmental organizations for the structuring, evaluation and coordination of Emergency Medical Services (EMS). The Indian Health Service (IHS) recognizes the value of these structural models and their standards as working guidelines and as representations of the currently accepted consensus on EMS. Selected models and standards are presented here as guides for development, evaluation, and improvement of American Indian/Alaska Native (AI/AN) EMS programs.
COMPONENTS OF AN EMERGENCY MEDICAL SERVICES SYSTEM. Components of an EMS Medical Services System as identified by the Emergency Medical Services Systems Act of 1973, Public Law 93-154. In 1996, the National Highway Transportation Safety Administration (NHTSA) redefined these components as 14 EMS attributes. (See Manual Exhibit 3-17-E.)
1. Manpower. An adequate number of health professionals, allied health professionals, and other health personnel to provide EMS on a 24 hour-a-day basis, seven days a week, within the service area of the system. The major manpower elements to be considered are as follows:
  1. First Responders. Fire, police, Community Health Representatives, others.
  2. Communicators. Emergency Medical Services/Resources Dispatcher.
  3. Emergency Medical Services Technicians.
  4. Registered Nurses. Emergency Department.
  5. Registered Nurses. Critical Care Units.
  6. Physician. Emergency Medicine.
  7. Physician. Specialty (medical, surgical, pediatric, psychiatry)
  8. Emergency Medical Services Systems Medical Director.
  9. Emergency Medical Services Systems Program Coordinator.
2. Training. The provision of appropriate training (including clinical training) and continuing education programs.
3. Communications. Provisions for linking the personnel, facilities, and equipment of the system by a central communications system.
4. Transportation. An adequate number of necessary ground, air, and water vehicles properly equipped to meet the transportation and EMS characteristics of the system areas.
5. Facilities. An adequate number of EMS facilities which are collectively capable of providing service on a continuous basis, which have appropriate standards relating to capacity, location, personnel, and equipment, and which are coordinated with other health care facilities of the system.
6. Critical Care Units. Providing access to specialized critical medical care units including trauma intensive care center/units, burn center units, spinal cord centers, poison control and alcohol detoxification centers, coronary care units, high risk infant units, drug overdose and psychiatric centers, and others as appropriate.
7. Public Safety Agencies. Integration of public safety agencies into standard EMS and disaster operation procedures. This involves the effective utilization of appropriate personnel, facilities, and equipment of such agencies.
8. Community Participation. Community representation in the management and policy formulation of the system.
9. Accessibility to Care. Provision of necessary emergency services to all patients within area without prior inquiry as to the ability of the patient to pay, race, sex, or country of origin as required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §§ 1395dd (1994).
10. Transfer of Patients. Transfer of patients to facilities which offer definitive followup care and rehabilitation as is necessary to effect the maximum recovery of the patient.
11. Standardized Patient Record-keeping. Covers the treatment of the patient from entry into the system through his discharge from it (includes dispatcher records, ambulance records, emergency departments, and critical care).
12. Public Information and Education. Programs of public education and information so that users are aware of how to access and utilize the system properly.
13. Review and Evaluation. Periodic and comprehensive review and evaluation of the extent and quality of the emergency health care services provided by the EMS system.
14. Disaster Linkage. Plan to ensure capability of providing EMS during mass casualties, natural disasters, or national emergencies.
15. Mutual Aid Agreements. Appropriate arrangements with EMS systems serving neighboring areas for reciprocal services.
NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION TECHNICAL ASSISTANCE TEAM STANDARDS. These standards were developed by the NHTSA to assist states with the development of integrated EMS programs and are listed here for reference. The standards are designed for technical evaluation of a state-wide EMS system and are not appropriate for the evaluation of a local or Service Unit EMS program.

Regulation and Policy. To provide a quality, effective system of emergency medical care for adults and children, each EMS system must have in place comprehensive enabling legislation with provision for a lead EMS agency, as well as a funding mechanism, regulations, and operational policies and procedures.
Resource Management. The provision of centralized coordination to identify and categorize the resources necessary for overall system implementation and operation is essential to an effective EMS system. This is required to maintain a coordinated response and appropriate resource utilization throughout the State. It is essential that adult and pediatric victims of medical or traumatic emergencies have equal access to basic emergency care, including the triage and transport of all victims by appropriately certified personnel (at a minimum, trained to the EMT-Basic level in a licensed and equipped ambulance to a facility that is appropriately equipped and staffed, and ready to administer to the needs of the patient).
Human Resources and Training. Emergency Medical Services personnel can perform their mission only if adequately trained and available in sufficient numbers throughout the State. At a minimum, all transporting pre-hospital personnel should be trained to the EMT-Basic level. In addition, each pre-hospital training program should use a standardized curriculum for each level of EMT personnel. In an effective EMS system, training programs are routinely monitored, instructors must meet certain requirements, and the curriculum is standardized throughout the State. In addition, the state agency must provide a comprehensive plan for stable and consistent EMS training programs with effective local and regional support.
Transportation. Safe, reliable ambulance transportation is a critical component of an effective EMS system. Most patients can be effectively transported in a ground ambulance staffed by qualified emergency medical personnel. Other patients with more serious injuries or illnesses, particularly in remote areas, require rapid transportation provided by rotor craft or fixed wing air medical services. Routine, standardized methods for inspection and licensing of all emergency medical transport services is essential to maintain a constant state of readiness throughout the State.
Facilities. It is imperative that the seriously ill patient be delivered in a timely manner to the closest appropriate facility. This determination needs to consider both stabilization and definitive care. This determination should be free of political considerations and requires that the capabilities of the facilities are clearly understood by pre-hospital personnel. Hospital resource capabilities must be known in advance so that appropriate primary and secondary transport decisions can be made.
Communications. An effective communications subsystem is an essential component of an overall EMS system. Beginning with the universal system access number, the communications network should provide for prioritized dispatch, dispatch to ambulance communication, ambulance to ambulance, ambulance to hospital, and hospital-to-hospital communications to ensure adequate EMS system response and coordination.
Public Information and Education. Public awareness and education about the EMS system is essential to a quality system and is often neglected. Public information and education efforts must serve to enhance the public's role in the system, its ability to access the system, and the prevention of injuries. In many areas, EMS personnel provide system access information and present injury prevention programs which ultimately lead to better utilization of EMS resources and improved patient outcome.
Medical Direction. Emergency Medical Service is a medical care system that includes medical practice as delegated by physician to non-physician providers who manage patient care outside the traditional confines of office or hospital. As befits this delegation of authority, it is the physician's obligation to be involved in all aspects of the patient care system. Specific areas of involvement include the following: Planning and protocols; on-line medical direction and consultation; and audit and evaluation of patient care.
Trauma Systems. To provide a quality, effective system of trauma care, each State must have in place a fully functional EMS system. Enabling legislation should exist for the development of the trauma system component of the EMS system: This should include Trauma Center designation, [using American College of Surgeons-Committee on Trauma (ASC-COT) American Pediatric Surgical Association-Committee on Trauma (APSA-COT) and other national standards as guidelines], triage and transfer guidelines of trauma patients, data collection and trauma registry definitions and mechanisms, mandatory autopsies, systems management, and quality assurance for the system's effect on trauma patients. Rehabilitation is an essential component of any statewide trauma system.
Evaluation. A comprehensive evaluation program is needed to effectively plan and implement a state-wide EMS system. Each EMS system must be responsible for evaluating the emergencies which present. The statewide EMS system should be able to state definitively what impact has been made on patients served by the system. Emergency Medical Service system managers must be able to evaluate resource utilization, scope of service, patient outcome, and the effectiveness of operational established standards and objectives, so that improvement in service, particularly direct patient care, can occur. These requirements are part of an ongoing quality assurance (QA) system to review system performance. The evaluation process should be educational and ongoing. Quality Assurance reviews should occur at all phases of EMS system management, so that needed policy changes or treatment protocol revisions can be made.

STAGES OF EMERGENCY MEDICAL SERVICES RESPONSE. Defined by the National Association of State EMS Directors and the National Association of EMS Physicians, October 26,1992.
1. Prevention.
2. Detection.
3. Notification.
4. Dispatch.
5. Pre-arrival.
6. On-scene.
7. Transport and facility notification.
8. Emergency department receiving facility.
9. Interfacility transport.
10. Critical care.
11. Inpatient care.
12. Rehabilitation.
13. Followup.
RESOURCES OF EMERGENCY MEDICAL SERVICES SYSTEMS. Resources of EMS systems as defined by the National Association of State EMS Directors and the National Association of EMS Physicians, October 26, 1992.

Professional, Occupational Lay Disciplines.
1. Pre-hospital emergency medical care personnel.
2. Physicians.
3. Emergency medical dispatchers/public safety dispatchers.
4. Nurses.
5. Directors.
6. Firefighters/police officers/industrial safety personnel.
7. Other allied health care providers.
8. Lay citizens trained in system access, cardiopulmonary resuscitation (CPR), and first aid.
Facilities, Agencies and Organizations
1. Hospitals.
2. Ambulance and first responder services (land, air, and water).
3. Fire departments, rescue squads, and law enforcement agencies.
4. Regional and state EMS planning and coordinating, training, facilitating, and regulating agencies.
5. Educational programs.
6. Local, state, and national EMS professional associations.
7. Federal EMS funding agencies and national EMS voluntary standard-setting organizations.
8. Rehabilitation facilities.
Equipment.
1. Ambulances and rescue vehicles.
2. Medical equipment and supplies.
3. Extrication devices.
4. Communications equipment.
5. Systems access equipment.
6. Protective equipment.
7. Personnel protection equipment.
8. Educational adjuncts.
9. Automated systems.
Funding.
1. Federal agencies.
2. Dedicated revenue sources.
3. Reimbursement mechanisms.
4. Private sector donations.

FUNCTIONS OF EMERGENCY MEDICAL SERVICES SYSTEMS. Functions of EMS systems as defined by the National Association of State EMS Directors and the National Association of EMS Physicians, October 26, 1992.
1. System Organization and Management.
  1. Authority to direct the development and allocation of system resources.
  2. Authority to develop and implement local, regional, and state infrastructure.
2. Medical Direction.
  1. Direct (on-line) medical direction.
  2. Indirect (off-line) medical direction.
3. Human Resource and Education.
  1. Volunteer and career recruitment for prehospital and hospital disciplines.
  2. Emergency Medical Technician, physician, nursing, medical dispatch, other specialty training, and continuing education programs.
  3. Critical incident stress debriefing and other support services.
4. Communications
  1. System access (detection and recognition by the patient and pre-response element), 911 or other central access.
  2. Dispatch.
  3. Medical direction functions.
  4. Interagency/mutual aid/disaster communications.
5. Transportation.
  1. Emergency ground, air, and water transport.
  2. Non-emergency medically supervised transport.
6. Facilities.
  1. Primary hospital facilities.
  2. Secondary hospital facilities.
  3. Tertiary hospital facilities (includes specialty services).
  4. Triage and transport protocols.
7. Data Collection, Evaluation, and Quality Assurance/Improvement.
  1. Patient run record collection and processing.
  2. Linkages to hospital records for outcome studies.
  3. Linkages to trauma registries.
  4. Linkages to other specialty EMS data systems.
  5. Ongoing review of performance of all system medical. and operational elements.
  6. System improvement mechanisms.
8. Public Information and Education.
  1. Prevention education.
  2. System access information.
  3. Emergency Medical Services System education for system participants, elected officials, and general public.
  4. Citizen CPR and first aid/self-help training.
9. Disaster Medical Services.
  1. Integrated Planning.
  2. Mutual aid and mass casualty incident and incident command system plans and training/exercises.
  3. Disaster medical equipment caches.
  4. Triage systems.
  5. Integration with other emergency management agencies.
10. Research.
  1. Systems.
  2. Interventional.
11. Special-needs Patients.
  1. Designated trauma care systems.
  2. Pediatric care systems.
  3. Poison control systems.
  4. Mental health facilities.
AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA, STANDARDS OF TRAUMA CARE. The American College of Surgeons-Committee on Trauma has developed standards and requirements for four levels of trauma care facilities. The criteria are focused on management of the trauma patient and do not include other types of emergencies. Most IHS emergency departments would meet the criteria for classification as a Level IV trauma facility.
1. Level I facility. A Level I facility is a tertiary care facility that is the regional resource trauma center and is generally a university-based teaching hospital. Level I facilities provide definitive trauma care.
2. Level II facility. A Level II facility has capabilities similar to those of a Level I facility, but generally has less medical and surgical specialties available, and are not required to have a trauma research program. Level II facilities provide initial definitive trauma care.
3. Level III facility. A Level III facility can provide prompt assessment, resuscitation, emergency operations, stabilization, and if necessary, transfer to a facility that can provide definitive trauma care.
4. Level IV facility. A Level IV facility provides advanced trauma life support and arranges timely transport of the trauma patient. Level IV facilities can be hospitals or clinics, generally in remote areas.
JOINT COMMISSION ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS LEVELS OF EMERGENCY SERVICES.

Level I. Comprehensive emergency care 24 hours a day, with at least one physician experienced in emergency care on duty in the emergency care area. There shall be in-hospital physician coverage for at least medical, surgical, orthopedic, obstetrical/gynecological, pediatric, and anesthesiology services by members of the medical staff or by senior-level residents. Other specialty consultation shall be available within approximately 30 minutes. Initial consultation through two-way voice communication is acceptable. The hospital's scope of services shall include in-house capabilities for managing physical and related emotional problems on a definitive basis. The above requirements also apply to a comprehensive Level emergency department/service provided by a hospital offering care only to a limited group of patients, such as pediatric, obstetrical, ophthalmological, and orthopedic.
Level II. Emergency care 24 hours a day, with at least one physician experienced in emergency care on duty in the emergency care area, and with specialty consultation available within approximately 30 minutes by members of the medical staff or by Senior-level residents. Initial communication through two-way voice communication is acceptable. The hospital's scope of services includes in-house capabilities for managing physical and related emotional problems, with provision for patient transfer to another organization when needed.
Level III. Emergency care 24 hours a day, with at least one physician available to the emergency care area within approximately 30 minutes through a medical staff call roster. Initial consultation through two-way voice communication is acceptable. Specialty consultation shall be available by request of the attending medical staff member or by transfer to a designated hospital where definitive care can be provided.
Level IV. Reasonable care in determining whether an emergency exists, renders life-saving first aid, and makes appropriate referral to the nearest organizations that are capable of providing needed services. The mechanism for providing physician coverage at all times shall be determined by the medical staff.