
No Man is an Island
“No man is an island entire of itself; every man is a piece of the continent, a part of the main; if a clod be washed away by the sea, Europe is the less…any man’s death diminishes me, because I am involved in mankind. And therefore never send to know for whom the bell tolls; it tolls for thee.”
MEDITATION XVII
Devotions upon Emergent Occasions
John Donne
The late great Jim Page famously said: “If you have seen one EMS system, you have seen one EMS system.” When he said it fifty years ago it was true, there were no systems of care, but now nothing is further from the truth. Yet we in EMS are repeating this today and it really is disappointing.
It isn’t true anymore. Systems improve the quality of care and reduce death and disability due to trauma, stroke, STEMI, and for critical ill/injured pediatric patients. Inclusive and collaborative systems of care save lives. Systems of care were essential during the pandemic. Examples abound across the United States, but none better than New York City. They lowered the walls between institutions and during the darkest days of the pandemic. This enabled patients to be moved between healthcare systems regardless of their membership in their system or the insurance they did or did not have.
Yet EMS leaders get this wrong all the time and we hear them repeat the Page mantra ad nauseum. They will espouse the virtues of their specific “based” system of care, and it really makes no difference where it is based – they get it wrong. They consistently confuse system with service delivery model and they are not interchangeable terms.
Why is it important and what is the difference between the system and the service delivery model? When we talk about policy, when we are seeking grants or legislation to support EMS, we are talking about the system. The system is what we are trying to improve, fund and support.
Show of hands:
In your village/town/city, do you call 911 to summon help? When the telecommunicator answers the phone, do they provide some type of pre-arrival instructions on what to do until EMS arrives? Does a first responder show up at your house and provide some type of bleeding control or CPR until the ambulance shows up? Do EMTs and paramedics show up on scene in an ambulance, provide additional life-saving care, continue that care in the ambulance, and then transport you? Do they transport you to a specialty care center, for trauma, STEMI, stroke, or pediatrics? This is the EMS system.
It isn’t any different from town to town, county to county, state to state. The capabilities and capacities may vary. Some communities have not embraced pre-arrival instructions, but at some point they will. In some rural and frontier locations there may be additional hoops to jump through to get to patients in the field in a timely manner or to extract them to the correct facility but by and large this is the system that everyone in EMS knows.
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Who answers that first call to 9-1-1? In San Francisco they have a dedicated 9-1-1 center that handles all calls, and dispatches EMS, police, and fire from one location. In Arizona out on I-10 it is the Arizona Highway Patrol.
Who is the first responder in your town? In Oakland, CA, it is the Oakland Fire Department. In Bloomfield, NJ, it is the Bloomfield Police Department.
Where do the EMTs and paramedics who respond on the ambulance come from? In Dallas, TX, it is the Dallas Fire Department. In Boston, MA, it is Boston EMS, a third service department. In Wellman, IA, it is the Wellman Volunteer Ambulance. In San Mateo County, CA, it is AMR. In Newark, NJ, it is University Hospital.
The service delivery model is different in every community in the United States. The elements of the system are the same, it is only the players who are different.
Now imagine you are policy expert and you are trying to explain to civil service career, appointed, and elected officials what is an EMS system, but at the same time you have physicians and other EMS “leaders” repeating the tired old phrase of “If you have seen one EMS system, you have seen one EMS system.” If we speak to anyone in healthcare or public health they understand what a system is and what it is meant to accomplish.
What service delivery model works best? You tell me. Every entity over a period of time has developed their service delivery model based on the needs of the community, as well as the capabilities and capacities of the organizations who are filling those needs. The keys to a successful EMS system reside in support from career civil servants, elected officials, public safety agencies, public health, hospitals, physicians, EMS chief officers, 911 telecommunicators, EMT’s, paramedics, patients and the public. Without their participation and support, success is impossible to achieve.
The issue we get into is when we try to say that one service delivery model (in the guise of calling it a system) is better than another. Nothing is further from the truth. It distracts from our core mission and makes EMS look fractured. Truth be told there are models of success in every service delivery model, and just as a service delivery model may have success, no service delivery model is exempt from failure. The best services need improvement and the worst services do some things great.
EMS systems have been cobbled together since the 1966 White Paper, but really they are not as integrated into healthcare systems as we would want. Frequently, they are one layer on top of another layer. Over the past 40 years, EMS systems in the United States have evolved both rapidly but disjointedly into a sophisticated, lifesaving, expensive, and expansive conglomeration of public and private entities. These systems are often at odds not only with each other, but with the scientific evidence and public health methodologies and constructs upon which health care systems must be based for best quality outcomes through best efficiencies and proficiencies.
An EMS system is a system that is an integrated, comprehensive public safety and health care system model, that is part of a larger emergency health services system (EHS). The EHS system is a subset of the public health system. (Emergency Medical Services Systems Development. Lessons Learned from the United States of America for Developing Countries, Pan American Health Organization 2003) The distinct difference is an EMS system has developed methods, implemented procedures and process’s that have been established to carry out the core mission of delivering EMS in a community. An EMS system is an organized structure with purpose (to reduce death and disability from traumatic and medical emergencies). It is regarded as a whole structure (and not it’s individual components).
These components are interrelated and interdependent of one another. They continually influence each other to maintain their activity and existence. We engage in this complex endeavor to achieve our goal of reducing death and disability caused by emergencies in our communities.
As a profession, EMS has failed to develop or sustain system design approaches, practices and models that reflect population and evidence-based medicine. We have focused too much on who is going to provide service, rather than how they will provide the service, the quality of the service and care, and what the outcome of their interaction with the system and the service is at the end of the day.
EMS is the only emergency service created by an act of Congress. The Emergency Medical Services Systems Act of 1973 directed the Secretary of Health and Human Services to provide up to $300 million dollars, an incredible sum in 1973, for system development grants and contracts. It also detailed what would be reported back to the Secretary on the effectiveness and efficiency of the system(s). This was accomplished by periodic, comprehensive, and independent review and evaluation of the extent and quality of the emergency medical health care services provided in the systems service area.
Quality assurance in many EMS organizations is often based on meeting internal sequential benchmarks, and performs little to no lateral benchmarking, or identification of patient outcomes. This has resulted in systems being developed based on the erroneous suppositions of their directors that they are providing quality care and not on what the patient community needed or how they benefited from their interaction with the process’s and the system at the end of the day. Our only benchmark in many communities is that we were able to get someone to respond. There are exceptions, Seattle being one, but overall we struggle in this regard.
If you ask anyone, they will say: “Our system is the best.” How is it the best? Patient satisfaction scores? Outcomes? If you ask them what their Utstein rate of cardiac arrest survival to discharge is, with and without bystander CPR, they may not know it. If you ask them what did their service do to influence a reduction in mortality and morbidity for STEMI or trauma patients with an ISS score greater than 15, they definitely wouldn’t. It begs to ask what is our definition that makes us say our systems are a success.
The late Max Weill, MD, founder the Society of Critical Care Medicine, said: “Performing CPR without measuring the effects is like flying an airplane without an altimeter.” I was disheartened to hear that EMS in a region, in particular EMTs and paramedics, didn’t have a seat at the table for quality assurance at hospital level trauma, STEMI, or stroke meetings when these centers focused on performance improvement. How could this be?
Worse, the physician leaders accepted this as fait accompli. If I worked at Ford Motor Company, the line employees lead quality improvement because they have to implement it. To think hospitals and healthcare systems were leading QI activity without EMS at the table is staggering.
We have focused on providing expanded scope activities within our communities, yet we haven’t addressed our core measures of success, never mind that we have never defined success for these new expanded scope activities. Point to the system dashboards that show cardiac arrest survival; reduced mortality and morbidity for major trauma or STEMI. Now do the same for community paramedic? Crisis mobile response? Some organizations have them, but they are few and far between.
Community leaders continue to develop largely unnecessary services and systems against the overwhelming body of scientific research and data, reimbursement requirements, quality expectations and fundamental public health methodologies, planning logic, and need analyses call for. EMS is the only component of the entire emergency public safety response system that is dependent on billing as the primary source of revenue to fund the service. EMS is the only element of the entire American health care system that is being compensated by Medicare, Medicaid, and private payors, including patients who pay out of pocket (self-pay) for medically questionable ALS services.
How many times do we bill Medicare for an ALS assessment or a KVO IV line that does not result in ALS treatment? We staff all ALS systems with gear and medications, and even for the most basic patient, they perform an ALS assessment to justify their existence. If I was a doctor or a hospital and I did this, I would be investigated and prosecuted. Yet we do this to generate the revenue we require to stay afloat.
This isn’t how we fund an EMS service or a system of care. Communities need to stand up and pay their fair share, just as they do for police and fire services. We cannot continue to try and sustain our services, our systems on the backs of the socially and economically disadvantaged.
“In the US, if we use the term EMS it commonly means the ambulance service that comes to transport the patient. If we are talking about the EMS System it is the comprehensive integrated public safety and health care system delivery model. It consists of a mechanism for accessing the system, reporting an emergency; prehospital service delivery and transport mechanisms; definitive, specialty, and rehabilitative care facilities; public education, participation, and prevention process’s; educational programming and institutions; integrated medical and administrative direction and oversight organizations and processes; resource allocation and financing structures; coordinating the role of collaborating organizations; etc. The EMS System is part of a larger system, the Emergency Health System…It is important to understand that EMS is an integral subset of the larger EMS System, but by itself is not a system, and only a service delivery mechanism.”1
What should we be doing?
- Define success for systems
- Develop systems of care that are focused on reducing death and disability for medical and traumatic emergencies, identifying those success’s, capturing the metrics, and quantifying the results. We then need to act on the areas that need improvement. We need to repeat this process for as long as we exist.
- Develop contracts that comply with CMS safe-harbors that allow for purchasing of supplies and equipment through hospitals reducing costs and increase access during shortages
- Maintain an EMS presence and participation in hospital/systems for STEMI/stroke/trauma/pediatric QI activities in order to demonstrate our value and improve the system and delivery of our care
- Benchmarks, both lateral and sequential, that demonstrate progress and success
- Compensate our people fairly
- Proper funding of EMS service delivery models and systems of care that are not dependent on billing, when those cost recovery mechanisms negatively impact the socially and economically disadvantaged members of our society, but rather have the very communities who supply the service directly or provide access through the 911 call center to fund their services just as they do the police and fire agencies.
Emergency medical services systems sit at the nexus of integration of the next generation of healthcare systems. EMS has been the first example of an inclusive system of the delivery of care, designed to manage patients in the out of hospital environment, regardless of healthcare provider or ability to pay. The pandemic taught us a hard lesson: That in order to survive, the development of strategic partnerships, leveraging the current capabilities and capacities of systems between insurers, EMS organizations, and healthcare providers, will allow these complex entities to develop high quality, robust, and cost efficient systems of care. It will also increase the resilience of the healthcare system to respond and manage the consequences of catastrophic incidents due to the next pandemic, natural disasters or weapons of ultra – violence.
Marty Linsky, a Harvard professor who wrote “Leadership on the Line,” said we co-create the status quo. We have an opportunity, one where we don’t have to accept the status quo, but take a chance to improve the system. The EMS system isn’t about saving a single life, it is about saving as many lives as possible. We do that through improved systems of care.
References
- “Emergency Medical Services Systems Development. Lessons Learned from the United States of America for Developing Countries : Pan American Health Organization,” December 2003. Pan American Health Organization.
- Berwick D, Fox DM. “Evaluating the Quality of Medical Care:” Donabedian’s Classic Article 50 Years Later. Milbank Q. 2016 Jun;94(2):237-41.
- Emergency Medical Services Systems Act of 1973. https://www.congress.gov/bill/93rd-congress/senate-bill/2410/text
- Moore L, Lavoie A, Bourgeois G, Lapointe J. Donabedian’s structure-process-outcome quality of care model: Validation in an integrated trauma system. J Trauma Acute Care Surg. 2015 Jun;78(6):1168-75.
- HHS/ASPR Project ECHO COVID-19 Clinical Rounds COVID-19 Clinical Grand Rounds https://hsc.unm.edu/echo/partner-portal/echos-initiatives/past-projects/hhs-aspr/