RURAL AND FRONTIER EMERGENCY MEDICAL SERVICES TOWARD THE YEAR 2000
An Issue Paper Prepared by the National Rural Health Association-May 1997
This issue paper briefly analyzes the current status of emergency medical services (EMS) in rural and frontier areas and recommends improvements to these vital services. The framework for analysis is a recently published national consensus document entitled EMS Agenda for the Future, which was supported by the National Highway and Traffic Safety Administration, Department of Transportation and the Health Resources and Services Administration (HRSA), Department of Health and Human Services, in conjunction with the National Association of EMS Physicians and the National Association of State EMS Directors. Fourteen EMS system attributes are identified in the issue paper, along with where we are, where we want to be and how to get there. The attributes included are as follows.
These attributes are combined and summarized in this issue paper, and the particular challenges and opportunities for rural and frontier EMS assessed. Policy recommendations are then identified for each attribute.
INTRODUCTION
As the effort to control the costs of health care alters the organization and financing of health services, health care providers are struggling to understand the dynamics of the new health marketplace in relationship to their traditional and future roles in the system. This is true for the private medical community, medical schools, community-based health services and the public health sector. Due to the sparsity and vulnerability of rural and frontier health providers, the need for them to understand and proactively engage in these changes is particularly critical. Emergency medical services, or EMS, has become an essential component of the rural health safety net.
Since the late 1960s when civilian EMS was first conceptualized and implemented, it has become institutionalized throughout the United States at the intersection of the public safety and the medical care systems. EMS is particularly critical to rural and frontier residents because they experience disproportionate levels of serious injuries and their distance from traditional health resources increases the morbidity and mortality associated with trauma and medical emergencies.
Today, most citizens expect that they can call 911 and immediately receive life-saving medical advice from trained dispatchers, while paramedics and an ambulance race to their aid. In many areas of the country, including some rural areas, EMS consistently meets these expectations. In other areas, including most rural and frontier communities, these expectations are not met for a variety of reasons identified in this paper. Despite the challenges, the EMS community is actively evolving its future roles with an emerging emphasis on acute-care triage, enhanced integration with primary care, increased participation in public health and prevention activities, and limiting transportation to medical emergencies. However, the challenges of organizing and implementing EMS in rural and frontier areas continue to be significant. Many rural areas struggle with increasing demand and heightened public expectations, organizational instability, under-financing, inadequate access to training and medical direction, a lack of volunteers willing to commit to the considerable demands of emergency response, underdeveloped infrastructure for public access and communications, and much more. In such communities, the uncertainties in today's dynamic health care environment exacerbate concern about the viability and performance of their EMS system.
The NRHA reaffirms its commitment to access to comprehensive health services for all citizens and the critical importance of EMS in rural and frontier areas. It is timely that we once again assess the status of EMS in rural and frontier areas in regard to its unique requirements in both its traditional emergency response roles and its evolving integration with broader community health efforts.
BACKGROUND
In the late 1980s, the NRHA formed a broad-based committee to analyze the status and needs of rural EMS and develop recommendations for public policy. Utilizing the results of a national survey of rural service providers, the NRHA hosted a conference of rural EMS experts, providers, planners and administrators in March 1989. The results and recommendations were published later that summer and combined with a more formal analysis by the federal Office of Technology Assessment to provide a reasonably clear picture of the strengths and weaknesses of rural EMS going into the 1990s.
As a result of the NRHA's efforts, then Rep. Jim Cooper of Tennessee introduced the Rural EMS Improvement Act of 1989 to "establish a program of grants to the states for improving the availability and quality of certain EMS and EMS systems in rural areas." Although this effort failed, some of the concepts and concerns were crafted into the federal Trauma Care Systems Act that passed in 1991 with an appropriation of about $5 million and several specific set-asides for "rural."
Throughout the early 1990s, there have been several rural EMS initiatives funded federally, but mostly for research and demonstration purposes. Except at some state and local levels, there has been no specifically targeted, rural EMS development. It is hoped that this paper will provide the basis and stimulus for much needed rural and frontier EMS development. In 1993 and 1994, the NRHA and the Office of Rural Health Policy (ORHP) convened a work group to produce Health Care in Frontier America: A Time for Change. This report emphasized the necessity of EMS as the essential safety net for frontier communities.
INTEGRATION OF HEALTH SERVICES
Description. Integration refers to the horizontal and vertical linkage of health care providers to achieve a higher degree of continuity of services and perhaps greater efficiency. EMS integration can help ensure that out-of-hospital care is incorporated into the management of ill or injured patients. Historically, EMS has been effectively linked with the public safety sector (dispatch, law enforcement and fire service), with nearby EMS providers for mutual aid, with the emergency department of nearby hospitals and, in some areas, with designated trauma centers as part of regionally designed trauma care systems. In the future, successful EMS providers will need to integrate more fully with public health and social service agencies, primary care providers and other health care facilities to ensure that patients are referred or transported to the most appropriate and cost-effective facility. Care should not occur in isolation; rather it should be part of a seamless system that provides patients with well organized and high-quality care.
Rural and Frontier Issues. The successful incorporation of EMS into an overall health care system or network requires the cooperation and availability of each component of the system. This includes access to physicians trained in EMS, health care facility staff, system planners and others. The rural and frontier environment has limited local health care resources, often with personnel that have no training or experience in EMS, a fact that greatly hinders efforts toward effective integration. These same characteristics also make network integration even more critical.
In the traditional EMS system, patients in rural and frontier settings often are transported long distances to health care facilities that are not closely affiliated with local health care resources. In some cases, this is appropriate due to the requirement for sophisticated tertiary care for some emergency patients, particularly for severely injured trauma patients. However, far too often this long distance transportation simply reflects the traditional separation of the EMS service from local primary care providers, public health and social service agencies that might be able to deal effectively with the needs of the patient.
In either case, the ability to provide integrated health services is often impeded by the geographic separation of health system components and the lack of regular communication or organizational networking between them. These problems are compounded by financing mechanisms that have traditionally reimbursed EMS for its transportation role, rather than for its triage, care and referral capacity. On the other hand, rural and frontier areas provide a unique opportunity to demonstrate the capability of the EMS system to fulfill broader public health and primary care outreach roles for traditionally underserved communities.
The successful Red River Expanded EMS Demonstration Project in northern New Mexico, demonstrates that with increased training and medical supervision, expanded public health and primary care protocols for selective rural EMS personnel enhance appropriate access to the overall health care system. In many areas emergency medical technicians (EMTs) are being more fully integrated with primary care providers to supplement evening and weekend coverage by triaging and referring patients back to the local primary care providers. These expanded EMS developments need ongoing evaluation, but are already showing promise in some communities. As these systems develop, opportunities also exist to address the needs of special populations that have sometimes been overlooked, including children, the elderly, minority groups and persons with disabilities.
Integration of Health Services Policy Recommendations. It is essential to the health of rural and frontier communities that the EMS system be integrated into a health care system that is cooperative, shares limited health care resources, provides a broad education to the EMS providers, recognizes innovative methods of health care delivery and is appropriately reimbursed. Specifically, the NRHA recommends that federal legislative efforts enhancing the establishment of rural networks (such as was proposed in the Rural Health Improvement Act of 1996) include EMS and trauma care systems as mandatory components. Also recommended is federal legislative efforts defining or supporting innovative hospital conversions such as the essential access community hospitals and rural primary care hospitals, limited service hospitals or medical assistance facilities recognize the importance of integrating EMS as part of the overall system of care in rural areas. Continued support and study for expanded EMS developments and appropriate reimbursement is a priority to enhance access to health care systems in some rural and frontier areas. EMS workers and EMS systems must be supported to meet the needs of special populations, including children, the elderly, minority groups and persons with disabilities.
LEGISLATION AND REGULATION
Description. All states have legislation that provides at least a statutory basis for EMS activities and programs, regulation of EMS personnel and services, scopes of practice, systems design, funding, training and other such issues. However, these laws and regulations vary considerably in comprehensiveness, flexibility, relationship to local government EMS ordinances and resources committed to EMS system planning, implementation and oversight. At the federal level, there are a variety of programs that have some interest, activity or initiatives that relate to different aspects of EMS. Currently, the major federal programs supporting EMS system building at the state and local levels are the Preventive Health and Health Services Block Grant administered by the Centers for Disease Control and Prevention and the EMS for Children Program administered by the Maternal and Child Health Bureau of HRSA. State and federal policy-makers are sometimes reluctant to include rural and frontier providers in developing EMS policy.
Rural and Frontier Issues. This variability in the legal framework for EMS is particularly true and problematic in relationship to rural and frontier EMS that require special support, flexibility, expertise and state-level leadership due to its unique challenges and requirements. Rural EMS still relies on volunteer personnel in most areas. Volunteers can be effective, but only with adequate resources, a clearly delineated context and strong nurturing.
A state and regional EMS infrastructure that both sets expectations and provides assistance to meet those expectations is critical. Similarly, the fine line between a clear regulatory framework that protects the public and the flexibility to pragmatically meet local needs is essential because of the variability of rural and frontier areas.
Rural and frontier areas frequently require proactive assistance to meet, or exemptions from, even minimal standards. A process for openly negotiating these realities is critical for effective public policy. The issue of cross-border relationships is particularly difficult in the nation's vast rural areas where sparse populations and resources require interstate cooperation, rather than rigid, state-by-state regulation.
Legislation and Regulation Policy Recommendations. A federal EMS lead agency should be authorized by law and adequately funded to ensure that federal agencies are well coordinated and focused to assist national, state and local EMS development. The lead agency would provide national leadership and facilitate the development of model systems, innovative demonstration programs, consensus standards, information sharing, and assist states with funding, technical assistance and research. State EMS lead agencies should be clearly authorized by law and adequately funded in each state to ensure that EMS has a sufficient legal basis, authority, resources and leadership to provide adequate training, communications, medical direction, personnel, systems development and integration, vehicles and equipment, data collection, quality improvement and research.
Federal funds for the Preventive Health Services Block Grant, of which almost 10 percent ($11 million to $13 million annually) is used by states to fund EMS efforts, and the EMS for Children Program need to be held at current or higher levels. The Rural Health Outreach Program should continue to support EMS, particularly activities that support EMS training.
EMS lead agencies at all levels should have a legislative mandate, expertise, flexibility and resources to provide needed support and technical assistance to EMS systems in rural and frontier communities. At the state, local and federal level, rural and frontier providers need to be fully represented on boards, committees and other policy bodies.
EMS SYSTEM FINANCING
Description. EMS must have a solid financial foundation to provide its critical safety net services in a consistent and reliable manner. It is recognized that one of the costs of EMS is its commitment to preparedness, or full-time service availability, although costs do vary considerably according to the requirements and expectations of local communities. Primary revenue streams for EMS are fees for service (Medicare, Medicaid, private insurance, private pay and special service contracts), governmental subsidies (local or statewide) and, in some cases, subscription services. Historically, reimbursement for EMS has been tied primarily to the transportation function and not necessarily to the delivery of emergency medical care. Managed care organizations (MCOs) have in some cases sought to limit access to EMS for their beneficiaries by narrowing the definition of "emergency care" to an after-the-fact medical decision, rather than one made by a reasonable or prudent layperson at the time of the event. Some MCOs also have instructed patients to call their primary care physicians prior to calling 911, which may unnecessarily delay needed emergency care.
Rural and Frontier Issues. The financing of rural and frontier EMS is a particular problem because of the relatively low volume of calls in relationship to the essential overhead costs of full-time preparedness. In addition, the traditional reliance on volunteer personnel in many areas, with little or no infrastructure for collecting fees or maintaining the business functions, contributes to the challenge. This traditional lack of a solid business perspective has made it difficult to assess the true cost of providing EMS in rural and frontier areas. In turn, this allows payers to "under-reimburse" and actually pay below cost. Payment for EMS by Medicare fluctuates widely across the country, but rural, and especially frontier areas, receive the lowest reimbursement. Also, there is a reluctance in many volunteer EMS, particularly those combined with fire service, to charge at all, because it is viewed as a public safety service that should be supported entirely by governmental subsidy (taxes) and individual giving. Although this belief is changing, it still is detrimental to securing adequate financing for rural EMS.
As MCOs cover more rural and frontier populations, it is essential that they fully integrate EMS into their provider networks, not limit access to the 911 emergency response system, and compensate EMS providers at an appropriate level. Rural populations should not suffer due to their distance from after-hours care.
EMS System Financing Policy Recommendations. It is recommended that sufficient financing mechanisms be developed and supported to ensure that a consistent and adequate level of rural and frontier EMS is sustained through a combination of governmental subsidies, contracts and fee generation.
Specifically, the NRHA recommends that EMS must be adequately compensated for preparedness, reducing volume-related incentives and recognizing the unique costs of sustaining an emergency safety net in rural and frontier areas. Compensation for EMS must be based on emergency response, assessment, treatment, triage and disposition that may, or may not, involve traditional transportation. The "prudent layperson" definition of emergency care and the requirement that all MCOs guarantee access to the 911 emergency response system should be mandated (as contained in the American College of Emergency Physicians/Kaiser bill that will be introduced into the 105th Congress, as the successor to H.R. 2100/S. 1233.) Medicare reimbursement for EMS services needs to be adjusted to eliminate imbalances in payments between urban, and rural and frontier services.
EMS EDUCATION
Description. To ensure that the patient care provided by EMS is part of the overall management of the ill or injured patient, innovative approaches to education must be employed. These innovations must address the quality, content and accessibility of the educational programs, both for initial training and for ongoing continuing education of EMS providers.
Rural and Frontier Issues. The implementation and success of EMS education in rural and frontier areas has a variety of challenges that must be addressed to provide quality education. Specifically, it must focus on:
These problems are exacerbated as the educational programs move from the EMT Basic program to advanced life support training.
EMS Education Policy Recommendations. It is essential that educational resources at the federal and state level are readily available and flexible enough to meet the needs of rural and frontier EMS providers. Specifically, this can be accomplished with innovative strategies that include financial subsidies for low-enrollment courses, development of distance learning using telecommunications techniques, provision of incentives for instructors to conduct satellite courses in remote areas, involvement of university medical centers and area health education centers to provide outreach educational programs to rural and frontier areas and flexible scheduling to accommodate the lifestyle realities of rural volunteers.
PUBLIC ACCESS AND COMMUNICATIONS SYSTEMS
Description. The length of time to definitive care is a key patient outcome variable for many critical emergencies. The entire EMS system is initiated by a call for help or assistance. Most people in the United States (about 78 percent) have access to the 911 emergency response call system. Increasingly, this system has been technologically upgraded to include the enhanced 911 capability that automatically displays the name, address and other key information about the caller.
Once the call is received at the dispatch center, the next critical step is the dispatching of appropriate resources and the provision of pre-arrival medical instructions via the telephone (emergency medical dispatch, or EMD). The ability of EMS components to communicate with one another is important as the patient moves toward definitive care. Although these aspects of EMS access and communications have improved enormously in recent years, they still face significant challenges, particularly in rural and frontier areas.
Rural and Frontier Issues. Response times of the EMS system to the scene of emergencies and from the scene to definitive care are almost always longer in rural and frontier areas. On average, response times can be two or three times as long as in urban or suburban areas. This is due to sparse populations, long distances, poor roads, difficult terrains, severe climate conditions, lack of or limited telephone service, inadequate public education, and insufficient infrastructure resources to support advanced emergency call systems or reliable radio communications systems between the field and base hospitals. These are all significant challenges, some of which can be affected with additional funding and technical support, and some that only can be overcome with creative and innovative service delivery and technological approaches.
Public Access and Communications Policy Recommendations. There should be nationwide implementation of the enhanced 911 emergency number, coupled with rural addressing, to ensure that all citizens have better access to EMS and other public safety resources. All emergency personnel answering calls should have training in EMD techniques so that critical first aid and medical advice can be given to callers prior to the arrival of the emergency responders. This component is critical in rural and frontier areas where response times are unavoidably longer.
Innovative communications approaches, including satellite, telecommunications, telemedicine and cellular technologies, must be supported nationwide, but particularly in rural areas, to allow for the effective exchange of information from the field to facilities and among facilities. Dispatch centers should be considered as partners in implementing triage systems to direct patients to the appropriate level and source of health care service.
HUMAN RESOURCES
Description. Ensuring an adequate supply of trained and motivated personnel to staff the EMS system is an ongoing challenge that involves public education, recruitment, training, personal support, career ladders, and appropriate awards or recognition for dedicated providers.
Rural and Frontier Issues. As the expectations and demands increase on EMS providers, so does the difficulty in recruiting and retaining them. This is particularly difficult in the many volunteer systems serving rural and frontier areas where compensation and the benefits of employment are not a factor. Since many such areas have an increasingly aging population and, in numerous cases, both parents must work outside the home, the ability to commit time for training and service is becoming increasingly limited. At the same time, many rural and frontier communities cannot, or have not chosen to, support paid positions for EMS. The problem of maintaining adequate staffing is exacerbated by increased risks from dangerous exposures (biological, chemical, interpersonal violence, critical incident stress, etc.); perceptions of increased personal liability; lack of enlightened leadership; inadequate physician participation; limited funding for training, equipment and supplies; and many other such issues. Many of these problems, including low wages, exist in paid rural EMS, often leading to frequent turnover or marginal performance. A particular concern is the current funding crisis in poison control centers that threatens the ability of rural residents to have timely access to poison control information and treatment.
Human Resources Policy Recommendations. State and regional EMS offices should provide leadership and technical assistance to help local communities recruit and retain EMS personnel. Financial support should ensure that volunteers do not have to pay their own expenses to obtain training, supplies or equipment. Leadership training, critical incident stress management services, safety training and other support should be provided to all EMS personnel. Recognition of performance should be accomplished at all levels-local, state and national. EMS workers must be more fully integrated into the delivery system team. Where necessary, federal and state funding strategies should be developed to train and support rural and frontier EMS personnel. Legislation should be developed to enhance and ensure public access to poison control centers.
EMS MEDICAL DIRECTION
Description. Medical direction involves licensed physicians granting authority and accepting responsibility for all aspects of the overall care provided by EMS, with the greatest priority being for ambulance services. It involves participation in all aspects of EMS including training, protocol development, quality assurance, and relationships with the wider medical community to ensure the maintenance of accepted standards of medical practice. Quality medical direction for ambulance services and other components of the system is an essential process to providing optimal care for EMS patients.
Rural and Frontier Issues. Persistent shortages of all health professionals in rural and frontier areas create an additional barrier to EMS medical direction. Where local physicians are present, they often lack the training, interest or incentives-including compensation-to participate actively as EMS medical directors. In some areas, EMS personnel are the only health care providers and must seek medical direction from distant areas. This situation increases the challenge by limiting the opportunities for training, case reviews and personal interaction between EMS medical directors and local EMS providers.
EMS Medical Direction Policy Recommendations. State EMS offices should be encouraged to develop specific outreach efforts for training and supporting rural and frontier physicians to serve as EMS medical directors, including the use of distance learning techniques. Technical assistance and incentives should be provided to physicians in community health centers and other rural practices to undertake such functions. In some remote, isolated areas, non-physician providers should assist in the supervision of EMS personnel under the direction of a physician in a more distant site. State and local EMS systems should be actively encouraged to make maximum use of all licensed and certified health personnel. Funds should be identified locally to pay EMS medical directors for their service.
PUBLIC EDUCATION AND PREVENTION
Description. These two attributes of EMS are interactive and mutually reinforcing. EMS requires a knowledgeable public if the system is to function successfully. This requires a proactive public education effort on behalf of EMS. Such an effort helps in two ways: (1) to help citizens understand how the system works when it is needed, and (2) to garner support for EMS both financially and politically. It also may help recruit new volunteers or other in-kind assistance. In a similar vein, prevention activities provide an opportunity to realize significant reductions in human morbidity and mortality. Engaging in prevention activities is the responsibility of all health care workers-including EMS workers. In fact, EMS personnel bring high credibility, motivation and skills to community prevention campaigns because they are the first called when help is needed.
Rural and Frontier Issues. In some ways, the opportunities for public education and prevention activities are greater in rural areas than in larger, more complex urban areas. Well-placed public service messages about when and how to call EMS can more easily reach all homes, workplaces and civic organizations. Since most rural and frontier EMS personnel are known in their communities, word-of-mouth also can be effective. Community-based prevention activities are targeted to issues of genuine local concern based upon immediate problems, i.e., hunting injuries, water safety or farm accidents. The lack of adequate financial and training resources, however, limit these efforts.
Public Education and Prevention Policy Recommendations. Federal and state EMS offices, in partnership with public health agencies, should continue to develop and distribute public information resources to local EMS providers to be tailored for local use. Training in public information strategies and prevention activities should be made available. Prevention should be built into the EMT curricula and become part of the mission of EMS. Payers should reimburse for community-based prevention efforts and look toward personnel as both organizers and field workers in prevention campaigns. EMS personnel should be recognized as appropriate providers of primary care and public health services in remote, isolated areas and should be reimbursed for providing services.
EMS RESEARCH, CLINICAL CARE, INFORMATION SYSTEMS AND EVALUATION
Description. During the last 30 years, EMS has evolved rapidly with little research to guide its evolution. System changes often have been predicated on resource availability, perceived needs, individual personalities and product vendors. Research has lacked funding and been limited by a shortage of academic interest, restrictive informed consent interpretations, and lack of interest and education among EMS personnel. As a result of the lack of data and findings, the clinical aspects of EMS systems vary dramatically between geographic areas. Although there is some commonality in training curricula, there is no common base from which to compare systems from a clinical care perspective regarding citizen access to field response, definitive care and rehabilitation. Quality assurance programs, to the extent that they exist, are generally functional within one component of the system, but rarely include participation by all system stakeholders or different levels of care. Quality assurance and evaluation is generally accomplished without the benefit of integrated data systems that can track patients from incident to definitive care. In spite of recent progress with defining pre-hospital and trauma registry data elements, implementation of standardized information systems remains limited.
Rural and Frontier Issues. The lack of data and research to guide the clinical and operational aspects of EMS as part of overall health care delivery systems for rural and frontier areas cannot be overstated. Limited health resources require that all resources be optimally used. Research must be accomplished to assess the clinical implications of long response and transport times, the use of new drug therapies, the best ways to assess and triage patients to the right level of care on the first attempt, and many other related issues. Integrated information systems are the building blocks for such research, as well as for the day-to-day quality assurance and evaluation of EMS systems. Rural and frontier areas do not have the resources to develop and implement such systems without substantial outside support.
EMS Research, Clinical Care, Information Systems and Evaluation Policy Recommendations. Federal and state EMS offices should develop and implement standardized EMS information systems with common data elements, universal participation, and an ability to track patients from the event to definitive care and rehabilitation as a goal. To achieve this goal, there is a need to subsidize outreach, training and hardware and software acquisition for rural and frontier areas.
A national EMS research agenda, with an emphasis on rural studies geared toward injury prevention and rural and frontier EMS systems development, should be established and funding made available through HRSA in cooperation with the ORHP, the National Institutes of Health, the Centers for Disease Control and Prevention and the Agency for Health Care Policy and Research. One possible avenue to effect this agenda might be to add a rural EMS emphasis to the mission of the existing federally funded fural health research centers, or to fund a new center with this specific focus. Academic departments of emergency medicine should be encouraged and funded to actively engage in the EMS research agenda. Guidance and technical assistance in utilizing information for evaluation and quality assurance of local services and overall systems must be accomplished.
CONCLUSION
In spite of enormous progress in rural and frontier EMS in recent years, many of the traditional challenges continue to exist in far too many areas, especially in frontier communities. Further, there are new challenges brought on by the rapidly evolving changes in the overall health care system that affect, and in some cases directly threaten, the stability and functioning of EMS as a critical safety net in rural and frontier areas.
The National Rural Health Association is committed to supporting these policy recommendations to ensure that rural and frontier EMS not only survives, but thrives, to continue its critical mission into the 21st century.