EMS Now and Tomorrow

The photo shows the back of an ambulance.
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A Brief Look into the Industry and Where It’s Going

Established in the latter half of the 20th century after the famed 1966 white paper titled “Accidental Death and Disability: The Neglected Disease of Modern Society,” modern emergency medical services (EMS) have always been centered around a simple idea: helping sick and injured people within the community. What the above document stated, quite profoundly, was the extremely high mortality and morbidity on the highways of America due to the lack of life-saving prehospital care. From this report, the National Highway Safety Act of 1966 was passed by the U.S. government and established the modern federal EMS agency in the Department of Transportation (DOT) – and eventually the National Highway Traffic Safety Administration (NHTSA).

Both these organizations established and built the modern curriculum, funding, standards and system designs EMS utilizes today.1 Throughout the rest of the century, new sources of funding became available through legislature, education standards developed, and the types of patients grew from acute trauma to medical, and pediatric patients. Today, EMS is increasingly partnering with local hospitals and new research about prehospital care is changing how we practice medicine in the field.

Related

Yet, with all the advancements laid out above, EMS has not changed drastically from the 70s to today. For many, EMS has a very similar process from how it was when it was created. Someone calls 911 for an emergency they feel needs immediate medical care and an ambulance will arrive at that person’s home promptly no matter the date or time. From there, care will be rendered, if appropriate, and EMS will transport them to a tertiary care facility. For many communities, volunteer services are still relied on to respond to calls.

This can further stall the advancement of an agency because of lack of funding and support. One might argue that medical advancements and new technology is different from what it was in the past but the core simplicity of EMS’ job has not changed. New treatments and interventions like point of care ultrasound , tranexamic acid (TXA), rapid sequence intubation (RSI), and mobile stroke units (MSU) are exciting and new to the world of EMS but the reality is that they are often times unrealistic. And yes, things like community paramedicine and “treatment and no transport” protocols are changing this basic notion of “you call, we haul,” but those new forms of EMS and  the futuristic treatments listed above are still widely underfunded, understudied and unavailable in most places.

The goal of this paper is not to point out all that is wrong with EMS and this is not a detailed guide to reinvent the industry. A few articles and topics will be discussed as it pertains to potentially reimagining EMS and will hopefully start a conversation. We should consider all of this research and much more while the industry strives to become better. Current research and ideas may help us figure out what the best course of action could be.

One issue healthcare as a whole, including EMS, struggles with is measuring success. In a paper written by Dr. Munk of University of New Mexico, the idea of value generation is discussed. He believes there is lack of clarity concerning the goals of EMS reform. When EMS leadership looks to the future and want to alter protocols, add new technologies, and develop competencies, the concept of outcome to cost ratios (value generation) can serve as the primary marker of success and development in the future.2 By developing a reliable way to calculate value, advanced procedures and skills every paramedic wants to have added to their scope of practice can be evaluated.

He argues the advanced skills do not increase the value of EMS care and skills for higher acuity patients can be subject to skill degradation since they are used so infrequently. Also, simple changes within the current scope to better improve the patient experience may be just as effective. Better treatment of pain with opiates or providing nausea medication for the sick can be a rather cheap but tremendously beneficial change to EMS if we want to give better patient experiences.

This concept of skill degradation is at the forefront of EMS reform as well. One landmark review of paramedic endotracheal intubations in the field was eye-opening for many providers.3 In the journal article, Wang explains most research studies showed decreased survival rates in patients that were intubated in the field as well more complications within the course of their care. Some may see this data as scary and should be a call to remove endotracheal intubations from the scope of care of ALS providers. While that reaction seems rash, few arguments can be made, and backed up by research, to keep the current practice of out-of-hospital endotracheal intubation. This idea of skill degradation can be applied to most advanced procedures we do.

Surgical airways, medication administration, and even intravenous access all may need to be examined to make sure we are making a difference in patient care. IV initiation on the first attempt in the prehospital setting varies greatly in research studies. In Minville’s study, first attempt IV placement was only 76%.4 In another study, surgical airway skills were examined. With a training program using cadavers, not only were the providers better at establishing an airway but also had less skill degradation after three months.5 A conclusion can be drawn from these studies. The skills that ALS providers covet sometimes are subject to skill degradation and that can lead to poorer outcomes for patients. While some may call for the removal of these skills, better didactic and hands-on training for providers have been proven to make an impact on stopping skill degradation.

Lastly, EMS can be known for high rates of turnover. Constantly terminating and hiring workers can be harmful to an agency in many ways. One study in 2010, looked at the rate of turnover across a wide range of EMS company types and examined the prevalence of turnover as well as the cost associated with it. The longitudinal approach by Dr. Patterson showed a 10.7% (Standard deviation [SD] 10.3) rate of turnover and the median cost calculated for an agency was $71,613.75. The biggest contributors to turnover costs were new hire productivity costs such as training and uniforms and vacancy costs like overtime pay to fill open shifts.6

By just retaining employees, agencies could potentially save a lot of money. How to better retain employees is still not fully understood but one could argue better benefits, pay and workplace culture could all contribute to the retention of employees. For comparison, when looking at turnover and turnover cost in nursing, it appears both values actually appear to be higher. Findings by Jones estimate that at the 4 tertiary care hospitals she looked at, 26.8% of the staff turned over in a year and each nurse that left cost the hospital $10,198 each.7

Emergency medical services are not only changing but are currently at a crossroad. In one direction, a similar image of today’s and yesterday’s EMS can be seen. In the other, is a bright new formation of acute care that patients are happy to receive. While only a few of the many pressing issues of EMS are discussed above, it highlights the wealth of knowledge we already know as well as the potential to learn more. Evidence-based practice is a term popular in today’s medicine. It relies heavily “on the partnership among hard scientific evidence, clinical expertise, and individual patient needs and choices.”8

Should change be quicker as new data shows flaws in our systems or should work be done to improve on what is currently the status quo? These questions will need to be answered and other hard decisions will need to be made by today’s EMS leaders and the next generation of emergency medicine providers.

References

  1. “A Brief History of Emergency Medical Services in the United States.” EMRA, www.emra.org/about-emra/history/ems-history/.
  2. Munk MD. Value generation and health reform in emergency medical services. Prehosp Disaster Med. 2012 Apr;27(2):111-4. doi: 10.1017/S1049023X12000635. Epub 2012 May 17. PMID: 22591776.
  3. Wang HE, Yealy DM. Out-of-hospital endotracheal intubation: where are we? Ann Emerg Med. 2006 Jun;47(6):532-41. doi: 10.1016/j.annemergmed.2006.01.016. Epub 2006 Feb 28. PMID: 16713780.
  4. Minville, V et al. “Prehospital Intravenous Line Placement Assessment in the French Emergency System: a Prospective Study.” European journal of Anesthesiology 23.7 (2006): 594–597. Web.
  5. Luckey-Smith, Kaitlyn, Kevin High, and Elaine Cole. “Effectiveness of Surgical Airway Training Laboratory and Assessment of Skill and Knowledge Fade in Surgical Airway Establishment Among Prehospital Providers. Air Med J. Sep-Oct 2020;39(5):369-373. Web.
  6. Patterson, P. Daniel et al. “The Longitudinal Study of Turnover and the Cost of Turnover in Emergency Medical Services.” Prehospital emergency care 14.2 (2010): 209–221. Web.
  7. Jones, Cheryl Bland. “Staff nurse turnover costs: Part II, Measurements and results.” The Journal of nursing administration 20.5 (1990): 27-32.
  8. McKibbon, K A. “Evidence-based practice.” Bulletin of the Medical Library Association vol. 86,3 (1998): 396-401.
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