Medicine is primarily concerned with preventing and curing disease and relieving suffering. The Emergency Medical Service (EMS) is an important part of the health care system, especially for people who suffer sudden and unexpected emergencies. In most communities, EMS is regarded as a public good. There are myriad approaches to offering EMS: it may be provided by the fire department, by another agency within the local government, by private entities that provide care within a local geographic area, by volunteer organizations, or by any number of other configurations.
Emergency medical service is often regarded as including the full spectrum of emergency care from recognition of the emergency condition, requesting emergency medical aid, provision of prehospital care, through definitive care in the hospital. It may also include medical response to disasters, planning for and providing medical coverage at mass gatherings, and interfacility transfer of patients. However, for the purposes of this document, the examination of EMS is limited to the more traditional, colloquial definition: prehospital emergency care from the time of the request for medical aid until arrival at and transfer of care to the hospital.
EMS care is provided by a variety of personnel, both paid and volunteer, who are trained at various levels of sophistication including first responders, EMT-Basic, EMT-Intermediate, and EMT-Paramedic. Basic level providers, trained in as little as 110 hours, provide services such as first aid, cardiopulmonary resuscitation, and patient stabilization. At the other end of the training spectrum, paramedics, who have acquired up to thousands of hours of training, bring highly sophisticated medical interventions that require critical thinking, such as endotracheal intubation and intravenous medication administration, to patients in the prehospital setting. EMS agencies often employ physicians with the expertise to evaluate new treatments and with the ability to develop and improve protocols based on scientific findings.12
EMS Impact
While precise numbers are not available, EMS treats and transports approximately 25 to 30 million patients per year. As an important point of entry into the healthcare system, EMS is in a unique position to impact those patients. It is logical to assume that prehospital intervention positively affects patient outcome, but this influence is difficult to quantify. For example, early defibrillation to victims of sudden cardiac arrest,13 administration of nitroglycerin to patients with chest pain,14,15 and prehospital administration of fibrinolytic therapy to patients with myocardial infarction16 measurably saves lives. On the other hand, seemingly logical interventions such as the pneumatic anti-shock garment17 and endotracheal intubation of children18 may in fact cause harm. That so few EMS interventions have been subjected to outcome studies illustrates the lack of evidence for most prehospital therapies. More research is necessary to provide the evidence upon which EMS practices can be based.
Misperceptions about EMS on the part of the public abound. In one study, fifteen percent of the patients in a hospital emergency department thought that paramedics were physicians.19 The entertainment media routinely depict cardiopulmonary resuscitation as resulting in good patient outcome, likely leading to unrealistic expectations among the lay public.20 Most members of the public believe that the use of warning lights and sirens saves clinically significant time in ambulance response and transport to the hospital, although several studies have suggested otherwise.21,22 No one has published an evaluation of the public’s perception of the importance of EMS research or the impact of research (or the lack thereof) on EMS practices.
Is EMS Cost-effective?
EMS systems are expensive to operate. The true economic burden of EMS is widely distributed and therefore well hidden from view. In the Medicare program alone, more than $2.5 billion is spent for patient transportation. It is estimated that $5 billion is spent on EMS in the United States each year. More detail on the costs of the EMS system is available in the document describing the Negotiated Rule Making process on EMS reimbursement sponsored by the Health Care Financing Administration on the Internet at www.hcfa.gov/medicare/comstate.htm.23 The incremental costs and benefits of different levels of EMS care are poorly quantified24 and remain the subjects of ongoing studies.25,26
Need for Outcome Measurement
Why are such large sums of money spent on a system with seemingly little evidence of efficacy?27 One reason is that efficacy information is difficult to define and obtain. Part of the problem lies in the uncertainty of how to measure patient outcome. An obvious outcome measure is mortality or lives saved. While seemingly easy to define, there is uncertainty over determining when a “save” occurs. Is it a “save” if a patient requiring CPR is admitted to the intensive care unit but dies after three days? Is it a “save” if that same patient dies in six months but was able to spend five of those months at home with his family?
Mortality is often not a good measure of patient impact because it is an infrequent outcome in many disorders. Evaluation of an infrequent outcome requires either large numbers of patients, long periods of time, or sometimes both. EMS currently lacks the resources for these large research efforts. Disability, relief of suffering, utilization of health services, and costs may be better measures of outcome but are often even more complex to define and obtain. For example, attempting to answer a question such as, “what is the relative benefit of transporting a patient with a femur fracture to the hospital in the back of an ambulance with a leg splint versus by taxicab with no treatment?” can be challenging as one begins to define “benefit.”
Accurately measuring outcome is made more challenging by the fact that the patient is delivered by EMS directly to a more comprehensive part of the health care system. Definitive care is seldom delivered in the field, but significant supportive care may take place there. Attribution of ultimate patient outcome to prehospital events is therefore confounded by the impact of interventions received by the patient later in the continuum of care. Measuring the impact of EMS patient care is further complicated by the concentration of specialized medical services such as major trauma care and tertiary pediatrics in a few experienced hospitals. When treating patients with problems such as major trauma, efficient transport to the optimal facility may be the most important prehospital intervention.28
Organized Research Effort Needed
A well-organized EMS research effort is clearly needed to dramatically increase the evidence upon which prehospital patient care is based. “Public and private organizations responsible for EMS structures, processes and/or outcomes must collaborate to establish a national EMS research agenda. They should determine general research goals and assist with development of research funding sources.”1
The authors of this document discussed the utility of creating a list of specific research topics that would be of value in EMS. However, there are compelling arguments against creating such a list. Individual investigators or research teams rather than committees usually generate the best new ideas. In addition, because of the rapid pace of change in the medical sciences, lists are usually out of date by the time they are published. The writing team agreed that valuable research topics would certainly include the following:
·
Ensuring proper
and effective patient care.
·
Improving the
quality of EMS care and systems.
·
Improving
patient safety by reducing errors.
·
Analysis of the
cost-effectiveness of systems and interventions.
·
Measuring the
direct, indirect, and marginal costs of emergency medical services.
·
Providing
information about the clinical aspects of emergency care, systems configuration
and operation.
·
Encouraging
effective injury prevention strategies and other public health measures.
·
Expanding the
appropriate use of medical informatics in EMS.
·
Developing
valid tools and methods for measuring the quality of EMS care and systems.
·
Learning
effective ways to provide professional education, training, and retraining that
will maximize skill acquisition and retention and improve practice patterns and
patient outcomes.
·
Determining
effective methods of public education that effect positive behavioral changes in
the areas of injury prevention, basic emergency care skills, and the use of EMS
systems.
EMS systems must justify their role in the health care process. They must prove that the care and transportation they provide is necessary and delivered in an effective and economical manner. These mandates can only be achieved by true integration of the research process into the system. Research will lead to the development of more effective treatments, strategies for resource management that benefit the EMS system, and ultimately to improved patient care.
