GARY LUDWIG
Good question! By some estimates there are over 80 different models for delivering emergency medical service care. Try coming up with a definition of an EMS “system” – you would be hard pressed to produce one. EMS system designs vary from state to state and from community to community.
First, contrary to popular belief, an EMS system is just not an ambulance showing up at the scene of an emergency and transporting someone to a hospital. An EMS system entails three, some would argue four, major components. First, the communications center, where each 911 call is screened. Second, the first responders. Third, EMS transport. And fourth, as some would contend, is the hospital. For purposes of this column, I will leave the hospital and communications components out, since you will see there is enough to discuss just with the other two categories.
If you were to take just the two categories of first response and EMS transport, you can come up with over 80 different configurations for EMS care. Eighty different ways? No way! Well, let’s look at different configurations between just first response and transport agencies.
With the first response component, in any given community, you could have: no first response, basic life support (BLS) trained police officers, advanced life support (ALS) trained police officers, BLS engine companies, ALS engine companies, “quick” or “fly” cars with BLS or ALS trained providers, medics on motorcycles, medics on bicycles, plus others – even including a school nurse or a security guard with an AED in a casino who shows up at your side 45 seconds after you’ve collapsed at a slot machine.
With the EMS transport (ambulance) component, in any given community, you could have: fire department BLS transport with cross-trained dual-role firefighters, fire department BLS transport with single-role fire personnel, fire department ALS transport with cross-trained dual-role firefighters, fire department ALS transport with single-role fire personnel, volunteer fire service transport, private for-profit transport, private not-for-profit transport, volunteer squad transport, hospital-based transport, third-service agency transport, police department transport, military transport, helicopter transport, public utility model transport, ambulance district transport, marine (boat) transport, fixed-wing transport, plus others.
Combine any component of the first response category with any component of the EMS transport category and it is easy to see that there are over 80 different configurations for delivering EMS.
Most major cities have the fire department performing first response and EMS transport in different configurations. For example, in New York City, first response BLS is done by firefighters and transport is provided by single-role fire personnel. But in other cities, like Detroit, the fire department does not do first response, but does transport patients to the hospital. In other major cities, like Pittsburgh, Cleveland, Boston and New Orleans, the fire department does first response, but the EMS transport agency is a third service. (A third-service agency usually comes under some other government or quasi-government agency that is not a part of the fire or police department. In many cases, it is its own agency or comes under the health or hospital department of the city.)
In some cities, such as Atlanta and Indianapolis, the fire department does first response and a hospital system owns the EMS transport agency. In other cities, like Kansas City, Tulsa, Reno and Oklahoma City, firefighters do BLS or ALS first response, but transport is handled by a public utility model. (A public utility model is a quasi-government authority with overall responsibility for EMS transport. It owns all the equipment, including ambulances, does the billing, etc., but contracts the human resource component of the system to a private company.)
EMS delivery can take on different versions and looks. Some systems have BLS arriving first with ALS transport arriving several minutes later or you can “front load” the call with ALS first response followed up with a BLS transport ambulance arriving later. A good example of “front loaded” ALS with BLS transport arriving later can be found on the TV show “Emergency!,” which depicted the Los Angeles County Fire Department responding with ALS first response, and then a private BLS, but sometimes ALS transport arriving to transport the patient to the hospital.
In some cities – St. Louis, Los Angeles, Chicago, Houston, Philadelphia, Dallas, Columbus, Seattle, San Francisco, Memphis, Baltimore, Washington, D.C., Nashville, Cincinnati, Tampa, Louisville, Jacksonville, Birmingham, the list goes on and on – the fire service is responsible for first response and transport. In fact, the vast majority of EMS transport in the United States is performed by the fire service.
No matter what the configuration of any system, all EMS delivery should have key major components:
- Management. A management team must be in place to administrate the system. Clear lines of responsibility/authority need to exist and effective communications need to exist. System managers and leaders need to maintain the “system” perspective at the same time they are dealing with more focused issues.
- Human resources. These are the people who actually make the system work on each call. Regardless of system structure, the goal is to recruit, educate and retain EMS personnel in sufficient numbers to provide service throughout the system that meets the performance standards agreed to by the community and the providers. These providers then need to be appropriately dispersed throughout the system and utilized efficiently.
- Communications center. The public should have access to the communications center by using 911. The communications center should have the capability to provide pre-arrival instructions and priority dispatching. Common radio frequencies and equipment need to be in place so that system resources can talk to each other.
- Money. The goal of any EMS system is a careful balance between quality care and response-time standards and operational efficiency. While it would be wonderful to park a paramedic-staffed ambulance on every street corner, it is extraordinarily expensive. Alternatively, it would be inappropriate to have unacceptable levels of mortality and morbidity in the system. A balance that is “right” for the community must be sought out and achieved.
- Medical direction or protocols. Effective EMS systems provide a role for the physician EMS medical director. The physician is involved in many aspects of the operation from establishing the clinical standards of care to the performance improvement process and continuing education.
Other components of an EMS system include customer service feedback, public education, transportation deployment, continuing education and quality improvement.
Obviously, some EMS systems look the same while others vary greatly. No matter how an EMS system is configured, the key is that when a citizen dials 911, he or she can expect to see an emergency vehicle pulling up outside the door.
Related:
How Many Different Ways Can You Perform EMS?