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EMS STANDARDS Response Standards The Register took Iowa to task for not establishing response performance standards for EMS. I wouldn't consider that a big deal if EMS were a mandatory service at the county level, so there was active involvement of elected offcials in setting local standards. It is also not a big deal because high-quality scientifc study has demonstrated, time and time again, that ambulance response time does not play a role in patient outcomes, except in a few limited circumstances.2–5 Except in cases involving cardiac arrest, there is little evidence to support or develop meaningful response performance standards. And to the dismay of many, the number that matters in cardiac arrest is 5 minutes or less for CPR-capable responders with defbrillators (who don't have to arrive on ambulances). As a component of total "time to defnitive treatment" intervals, ambulance response performance matters in cases of acute-onset stroke, ST segment-elevation myocardial infarction and serious multisystem trauma. But those incidents, taken together, amount to less than 5% of most EMS systems' call volumes.6 I am fne with the notion that Iowa does not have state-mandated response performance standards. All EMS is local. If EMS were a mandatory service at the county level, then local elected offcials would be required to at least address the issue. If, perhaps, some state funding were provided (or withheld) based on county plans containing certain elements, it would create an incentive for compliance. Why do I keep talking about counties? I'm not fxated on counties—a regional EMS system made up of multiple counties would be even better, particularly in sparsely populated rural areas. Why not towns? Simple: Most communities are not large enough to support substantial EMS organizations with experienced, educated leadership; with career options and mobility for employees; and with resources to do good quality management and staff education. It has been said that EMS agencies in the United States are small, independent, fnancially unstable, clinically unaccountable and damn proud of it! We have thousands of EMS organizations in the USA, the average operating perhaps fve ambulances. Contrast that with the United Kingdom, where there are a dozen or fewer ambulance services for the whole country, or Australia, where there is one ambulance service per state.The Institute of Medicine, in its authori- tative report Emergency Medical Services: At the Crossroads (2006), repeatedly called for the development of systems of emergency care that are regionalized, coordinated and accountable. Despite its strong case, there has been little movement to implement the IOM's recommendations. What is stopping the development of regionalized systems of care? Money? Culture? Fear? In the 1970s this was the thrust of Dr. David Boyd's work with the Department of Health, Education and Welfare (now Health and Human Services) and the EMS Act of 1973. When President Ronald Reagan canned all that, it stopped before it really got started. Since then, there really has been no effort.The latest attempt was the IOM's Crossroads paper, but not much has yet come from that. Dedicated to improving your Inventory, Asset, Purchasing and Fleet Management. Next month we address the issue of personnel background checks, and discuss issues of funding and oversight impacting state EMS offces. REFERENCES & FOOTNOTES 1. For purposes of this article, EMS means not just ambulance service, but the entire system that begins with answering a 9-1-1 call for medical assistance and ends at the hospital, emergency department or with the discharge of the patient without transport. It includes 9-1-1 centers providing call screening and medical prearrival instructions, medical frst response (whether provided by law enforcement, fre or others) and ambulance response, treatment and transportation. 2. Pons PT, et al. Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome? J Emerg Med, 2002; 23: 43–8. 3. Blackwell TH, et al. Response time effectiveness: comparison of response time and survival in an urban emergency medical services system. Acad Emerg Med, 2002; 9: 288–95. 4. Blackwell TH, et al. Lack of association between prehospital response times and patient outcomes. Prehosp Emerg Care, 2009; 13: 444–50. 5. Blanchard IE, et al. Emergency medical services response time and mortality in an urban setting. Prehosp Emerg Care, 2012; 16: 142–51. 6. Myers JB, Slovis CM, Eckstein M, et al.; U.S. Metropolitan Municipalities' EMS Medical Directors. Evidence-based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehosp Emerg Care, 2008 Apr–Jun; 12(2): 141–51. Skip Kirkwood MS, JD, NREMT-P, EFO, CEMSO, is a 40-year veteran EMS provider, educator, consultant and chief offcer. He has served in EMS systems in nine states and in nearly every conceivable EMS system confguration. He has been the chief EMS offcer of a volunteer, not-forproft ambulance service; a fre-based EMS organization, two hospital-operated ambulance services, and a countygovernment operated EMS system. He is a member of the EMS World editorial advisory board. Since 1995, he has taught Emergency Health Service Law and Policy as part of the Master of Science degree program at the University of Maryland Baltimore County. Skip is uniquely positioned to examine these matters of law and policy for the EMS community. 877-217-3707 emsworld@operativeiq.com www.operativeiq.com © 2013 EMS Technology Solutions For More Information Circle 25 on Reader Service Card EMSWORLD.com | JUNE 2013 45