During a meeting with White House National Security staff in November 2011 to discuss a lead federal agency for EMS, the issue of what role the federal government would play in regulating EMS, and what relationship a federal agency would have with the state EMS offices, came up.
Dia Gainor, executive director of the National Association of State EMS Officials (NASEMSO), wanted to make sure White House staff understood just how big and diverse EMS is. “I asked, ‘Do you realize the magnitude of what you’re talking about? We’re referring to nearly 19,500 local EMS agencies. The federal government is never going to reach them directly. That will have to be done in a partnership with the states,’” she says.
That 19,500 number would be included in the National EMS Assessment, the most comprehensive analysis to date of the depth and breadth of the nation’s EMS and 911 systems. The landmark document, released in January by the Federal Interagency Committee on Emergency Medical Services (FICEMS) and funded through the National Highway Traffic Safety Administration (NHTSA), was the culmination of two years of work by researchers from the University of North Carolina and colleagues.
“There are some things that are just so simple it’s amazing we didn’t know them before,” says principal investigator Gregory Mears, M.D., an associate professor of emergency medicine and director of the EMS Performance Improvement Center at UNC Chapel Hill. “How many agencies are in the country? How many vehicles? How many EMS professionals at the EMT or paramedic level? What are the common procedures that are done? How many medical directors are there? What types of EMS agencies exist?”
EMS experts agree the report is a critical document that will be used when discussing everything from workforce planning to the educational needs of the industry; as a starting point in determining the state of volunteerism; to help EMS organizations gauge their potential membership pool; and as a way of helping federal officials understand EMS so they can better direct support.
“Like any mature industry, we should be able to understand and quantify the basic characteristics of EMS, and that usually begins with counts of things, something we didn’t have before,” Gainor says. “In some cases [the Assessment] can be used to exemplify the size and diversity of the EMS system. It can also be used to talk about governance, policy and system improvement.”
Weighing in at a lengthy 550 pages, findings include:
- There are about 826,000 EMTs and paramedics nationwide. “What that tells us is there is a huge workforce out there, and that has implications for recruitment, retention, training and the need for projects to support EMS professionals,” Mears says.
- The workforce is 67 percent male and 33 percent female. It’s also mostly white (75 percent), with about 8 percent African-American, 4 percent Asian and 4 percent Native American. And it’s young—70 percent are aged 20 to 49 years.
- There are 8,500 EMS medical directors, with only eight states requiring continuing education specific to them. “That’s a huge group, and it raises questions of how to train them,” Mears says. “How do you meet their needs as a professional group?” About 80 percent of state medical directors are board-certified in emergency medicine, but other specialties include family and internal medicine, surgery, even obstetrics-gynecology and pediatrics.
- The authority and role of medical directors vary considerably from state to state. Half of all states have a list of medications that have been approved for use by EMS at each EMS professional level. In the other half, medication use is determined by the local EMS medical director.
- About one-quarter of states have a list of approved EMS procedures. Elsewhere, procedures are determined by the local EMS medical director.
- There are 81,295 EMS vehicles and 19,971 EMS agencies. Specialty care transport agencies, including air and ground transport, make up 4 percent of them.
- More than one-half (51 percent) of EMS agencies function at the EMT-basic level, 38 percent at the paramedic level, and 9 percent at the EMT-intermediate level.
- EMS responded to 37 million calls in 2009; 28 million resulted in transports.
Questions answered, questions raised
In doing their research, Mears and his colleagues had to rely on existing data sources. The majority of the information came from a key report—the 2011 EMS Industry Snapshot, an extensive survey of all state and four territorial EMS offices done by NASEMSO, Mears says. Other data sources included the Emergency Medical Services for Children Program 2010–2011 report and the 2007 Indian Health Services Tribal EMS Pediatric Assessment.
What wasn’t as helpful as hoped for was the National EMS Information System’s (NEMSIS’s) national EMS database, Mears says. The goal of NEMSIS is to serve as a national EMS medical record, with information on every EMS response that happens nationwide. Even though all 50 states and six territories have adopted NEMSIS’s definitions as a standard for electronic patient care records with the intention of eventually using that consistency to build a comprehensive national EMS database, only 31 states are providing information to the database, and many that do don’t supply complete information.
“Even though NEMSIS is in place, there is still not a full penetration of NEMSIS in all the states and territories,” Mears says. “What we found was there are only 11 states that collect 100 percent of their EMS information. Until we get more local use and more fully implemented state systems, it makes it very difficult to use the national database to describe EMS, and it indicates we have a lot of work to do to implement the state data systems that feed NEMSIS.”
And though the EMS Assessment certainly offers a wealth of information, it’s also notable for what it couldn’t discern about EMS. For instance, only one state (Idaho) monitors job injuries for EMS workers. Just 18 states monitor on-the-job EMS fatalities, while 11 states monitor EMS vehicle crash data. And only seven states monitor EMS bloodborne pathogen exposure data. “The ability to measure and monitor EMS vehicle crashes and EMS workforce safety is still at a very early infancy,” the report states.
Another question that remains to be answered is the state of volunteerism in EMS. About 77 percent of state officials perceive volunteerism as declining, according to the report, although whether that’s actually happening isn’t entirely clear. In part, that’s because there’s no agreed-on definition of volunteerism. Many agencies consider themselves volunteer if a portion of their staff isn’t compensated, or if the agency doesn’t bill for its services. But it does seem that more EMS agencies are moving away from the volunteer-only model as both EMS and the health care system have grown more complex, according to Mears.
“EMS was built very heavily on a volunteer basis,” he says. “As it’s become more a business operation with billing and reimbursement issues and the complexity of health care and what’s required to take care of patients and the cost of the equipment to do that, it has made it very difficult for volunteer services to exist.”
Another aspect of EMS for which too little is known are 911 call centers, Mears says. Only 15 states are able to track the number of 911 emergency medical calls received statewide, while just 11 are able to track the number of 911 EMS dispatches. In addition, only about one-third of states credential 911 call centers.
“Our dispatch centers are the last frontier for EMS in its development,” Mears says. “We know that for those time-dependent incidents, patient outcomes are dependent upon how well or how efficiently dispatch centers work, and also the medical care and direction dispatchers provide over the phone while EMS is en route. What we’re finding is this is an area that is not well organized and not often regulated by states and there is a lot of work that needs to be done to formalize 911 centers and make sure quality emergency medical dispatch is available to every citizen.”
Gainor praises Mears and his colleagues for their efforts in pulling together the Assessment. She also notes the important role played by the thousands of local EMS agencies that provided information to NASEMSO and NEMSIS. State EMS offices, Gainor says, answered 400 questions about EMS in their state to contribute to the Industry Snapshot, which so much of the Assessment was based on.
“This is a natural complement to what thousands and thousands of local EMS agencies have been working very hard to do, which is to contribute EMS response data using NEMSIS compliant systems to their state, which in turn submits a subset to the national level,” Gainor says. “This is really going to position us to start talking about EMS as a whole industry in very powerful ways in the future.”
To download the 2011 National EMS Assessment, visit ems.gov/news/assessment.html.
