HomeMy WebLinkAboutMemorandum Of Understanding with Ada County for Emergency Medical Service Advisory CouncilMEMORANDUM OF UNDERSTANDING
EMERGENCY MEDICAL SERVICES ADVISORY COUNCIL
Emergency Medical Services systems in the United States frequently have no process to design
systems that are patient -centered in their approach to all components of the system.
Furthermore, fragmentation in system components often results in poor communication,
duplication of services, lack of coordination of care, and degrades the potential for the best
patient outcomes.
Through collaboration of all agencies providing Emergency Medical Services (EMS) in Ada
County, it is recognized that the best possible service will be provided to our communities.
The Parties to this Memorandum of Understanding (MOU) desire to establish an EMS system
for the citizens of Ada County based on patient -centered outcomes, utilizing available EMS
system design principles and best practices. 1
The Parties agree that this is a voluntary commitment to collaborate and provide guidance on
the design of a patient -centered system.
Each Party agrees that they will provide a representative to this process, with the intent that
this voluntary effort be inclusive of all EMS providers, EMS stakeholders and the current EMS
Advisory Board within Ada County.
It is the intent of the Parties that this MOU will establish a beneficial approach to patient care,
develop trust between the various EMS agencies, and provide a process for collaboration that
will best meet the needs of the citizens within the EMS system.
1. National EMS Advisory Council Guiding Principles and Core Issues in EMS Design.
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Guiding Principles and Core Issues in EMS System Design
EMS Systems Committee
001 -Systems -007 -Final
National EMS Advisory Council
Committee Reporting Template
FINAL(pending format and grammatical changes)
September 30, 2009
Committee: Systems Committee
Report Number: 001 -Systems -007 -FINAL
Title: Guiding Principles and Core Issues in EMS System Design
Issue Synopsis:
A. Problem statement. EMS systems in the United States frequently have no
process to design systems that are patient -centered in their approach to all
components of the system. Further, fragmentation in system components
degrades the potential for patient -centered outcomes. For these reasons the
suggested problem statement developed by NEMSAC for use by the committee
is:
"System design in emergency medical systems is equally
important in urban, rural and frontier areas, yet most localities fail
to take a patient -centered approach to system design."
B. Resources/references related to the issue
1. National Research Council. 1966. Accidental Death and Disability., The
Neglected Disease of Modern Society. Washington: National Academy of
Sciences.
2. National Highway Traffic Safety Administration. 1996. Emergency Medical
Services Agenda for the Future. Washington, DC: U.S. Department of
Transportation.
3. National Fire Protection Association. 2002. NFPA 450. Guide for EMS
System Design. Quincy, MA
4. Committee on Trauma Research, National Research Council and Institute of
Medicine. 1985. Injury in America: A Continuing Public Health Problem.
National Academy Press: Washington D.C.
5. EMSC National Resource Center, Children's National Medical Center. 2009.
Gap Analysis of EMS Related Research. Report to the Federal Interagency
Committee on EMS. Washington, DC.
6. National Association of State EMS Officials/National Association of EMS
Physicians. 2009. Emergency Medical Services Performance Measures
Project. Recommended Attributes and Indicators for System/Service
Performance. Falls Church, VA
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C. Crosswalk with other standards
1. National Highway Traffic Safety Administration. 1996. Emergency Medical
Services Agenda for the Future. Washington, DC: U.S. Department of
Transportation.
2. National Association of State EMS Officials. 2008. State Emergency Medical
Services Systems. A Model. Falls Church, VA
3. National Highway Traffic Safety Administration. 2001. National EMS
Research Agenda. Washington, DC: U.S. Department of Transportation.
4. The Institute of Medicine of the National Academies. 2006. Emergency
Medical Services: At the Crossroads. Washington, DC
Analysis:
A. History of EMS system structures.
1. EMS System Background
In 1966, the National Academy of Sciences and the National Research Council
published a landmark report on the state of emergency medical services in the United
States. That report, Accidental Death and Disability, the Neglected Disease of Modern
Society, provided the initial framework around which a number of EMS systems were
organized.', Importantly the report also provided the impetus for states and localities to
begin to regulate EMS because prior to 1966 mortuaries operated more than half of the
ambulance services in the United States. The authors of that report stated:
"Adequate ambulance services are as much a municipal responsibility as
fire fighting and police services. If the community does not provide
ambulance services directly, the quality of these services should be
controlled by licensing procedures and by adequate surveillance..."
In essence, this report promulgated and supported the largely local nature of EMS that
still exists today. Several recommendations in the report were focused on the provision
of out of hospital EMS services. The EMS Agenda for the Future' summarized some of
those recommendations, which included:
i. Preparing nationally acceptable training for rescue -squad personnel, police,
firemen, and ambulance attendants;
ii. Adoption at district, county, and municipal levels of ways and means of
providing ambulance services applicable to the conditions of the locality, control
and surveillance of ambulance services, and coordination of ambulance
services with health departments, hospitals, traffic authorities, and
communications services;
iii. Initiation of pilot programs to evaluate automotive and helicopter ambulance
services in sparsely populated areas and in regions where many communities
lack hospital facilities adequate to care for seriously injured persons;
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Of great concern to the authors of the report was that both the public and government
were "insensitive to the magnitude of the problem of accidental death and injury" in the
U.S.; that the standards to which ambulance services were held were diverse and 'often
low"; and that "most ambulances used in this country are unsuitable, have incomplete
... equipment, carry inadequate supplies, and are manned by untrained attendants."
Research compiled since that report makes it clear that EMS systems are much more
than simply ambulance transport services and that problems continue to exist in EMS
system design." Yet, the evidence from that report was so compelling that congress
passed the Highway Safety Act of 1966 that established the first organized EMS
systems in the United States.
EMS systems that are structured based on traditional, historical paradigms are
changing rapidly. Many people view EMS as simply ambulance transport or fire
department response to medical events. However, those views are being challenged as
insurance companies demand more accountability for ambulance transport and
emergency treatment, fire departments seek better use of resources, and commercial
ambulance firms are caught between strict local requirements, reduced reimbursement
by federal agencies, and increasing demand for service.
Emergency medical services systems are therefore important considerations for
regulators, physicians, and elected officials. In most areas, a body of elected officials
has overall responsibility for one or more components of the system, such as fire
service first response or transport, or for regulating for-profit ambulance service
contracts. In some cases, multiple local agencies exert some level of control over
components. In many cases, the systems are fragmented—meaning that few systems
have the all-inclusive oversight necessary to manage the interdependence of multiple,
autonomous EMS organizations.
2. Regulation and Oversight
Regulation and oversight are key components of EMS system design because
regulators must be able to ensure accountability and transparency among the providers,
and they must ensure compliance with the guiding principles of the system. Further,
regulators should structure oversight to achieve integration in regulatory systems to
align with regulatory systems across borders to avoid discontinuity in regulations and
regulatory practices. Ultimately, regulators and system administrators must ensure that
regulatory processes do not inadvertently or otherwise affect the ability of vertical or
horizontal supply chain participants. This means that coordination of the regulatory
framework must include considerations of local, county, regional, state, and federal
oversight, and operational integration of all providers in the system including multiple
ground and air resources.
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B. System design.
Current EMS component structures in the United States take many forms. First
response may be provided by public agencies such as fire departments using paid or
volunteer personnel, tribal members, police agencies, helicopter providers, military
personnel, or others; ambulance service may be offered by commercial firms, multi -role
fire departments, volunteer agencies, hospitals, police departments, or municipal third -
service providers. Emergency communications may be provided by highly sophisticated
computerized technology centers, or by more basic centers with basic radio technology
and manual data collection.
EMS is fundamentally a local service. That is why variability exists between EMS
systems across the United States. Each system has evolved according to the local
political, economic, legal, and operating environments. Yet few local governments
understand the complexity of comprehensive EMS structures because EMS systems
are usually poorly defined. One widely accepted EMS system definition is based on
NFPA 450,"' which defines an EMS system as
"A comprehensive, coordinated arrangement of resources and functions
which are organized to respond in a timely, staged manner to medical
emergencies regardless of their cause. "
EMS systems include the primary components of system access and dispatch, first
response, medical care delivery, ambulance transport, and definitive hospital care.
Additional components such as medical oversight, financing, disaster and surge
response, facilities and equipment, and quality improvement processes, are interlocking
components of successful EMS systems.
C. EMS system development.
While a number of authors have identified the outcomes of successful EMS system
design, few have identified how to accomplish those outcomes. The concept of system
design, and the purpose of this document, is to provide tools to develop high quality,
responsive, and responsible EMS systems that meet local needs.
Importantly, the tools are not prescriptive; rather they are established as a set of guiding
principles that are used to describe a number of elements of the EMS system. Local
regulators, physicians, elected officials or others can use the guiding principles to assist
in developing local systems or can evaluate current system designs based on the
guiding principles. Each of the 16 guiding principles provides a method to make
improvements to one of the components of EMS system design.
The Guiding Principles are not designed solely for urban EMS systems. They also offer
opportunities to provide guidance to rural and frontier systems because these principles
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and the activities that surround them are intended to be universal. Although the Guiding
Principles and Core Issues will be, for the most part, the same for urban, suburban,
rural, and frontier EMS systems, specific operational plans for implementing the Guiding
Principles and Core Issues may vary greatly between systems.
The Guiding Principles are collectively intended to provide direction for a community in
EMS system design for current and future needs. The Core Issues, while not all-
inclusive lists, are intended to be issues that EMS systems can prioritize according to
local needs. Together, the Guiding Principles and the Core Issues can be used to
weave the principles of the EMS Agenda for the Future and the Institute of Medicine
Report into operating plans for local agencies. The Guiding Principles and the Core
Issues are intended to be scalable—not only for different sizes and designs of local
systems, but also for regional, state, and multi -state applications.
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Guiding Principles I Core Issues
1. Evidence Based Design
• Each EMS system should recognize that evidence -based medicine is the conscientious, explicit, and
Standards. EMS system
judicious use of current best evidence in making decisions about the care of individual patients. The
design should be based
practice of evidence -based medicine means integrating the best available scientific, medical and
on scientific, medical and
operations research, and that the evidence should meet publication standards inherent in peer -
economic evidence
reviewed journals. The system should make use of each provider's clinical expertise, while
published in peer-
respecting a patient's autonomy.
reviewed literature as well
as evidence provided by
• Each EMS system should clearly define the roles and responsibilities of their medical authority (see
the system's continuous
Guiding Principle #10: Medical Oversight for details) and all medical direction (online and offline)
quality improvement
should reflect the current standard of care based on Evidence Based Medicine (the best evidence in
the literature when it is available or through consensus by specialty when evidence is lacking).
processes.
• Each EMS system should employ a continuous quality improvement (CQI) process. The CQI
process includes monitoring and improving the clinical and operational performance of the system,
and uses statistically valid principles and practices of medical and operational performance
indicators. All organizations in the EMS system that contribute key system components should be
represented in the CQI process if appropriate.
• When multiple cities or communities are served by the EMS system, those EMS systems should
ensure that every community served by the system has a voice in the system design. EMS system
practices must promote effective professional relationships with other components in a community's
healthcare, public safety, and governmental systems.
• Each EMS system should ensure that changes to the standard of care can occur within the
principles of evidence -based medicine. No EMS system or community is so unique to exclude
applicability of the majority of EMS -related peer-reviewed research.
• Each EMS system should ensure that all organizations and individuals participating in the EMS
system work together to establish that system's EMS standard of care. This process of broad
inclusion, incorporating operational and fiscal impacts ensures that standard of care changes are
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clinically, operationally, and fiscally achievable.
2. Integrated Response
• EMS systems should be designed to eliminate horizontal and vertical fragmentation. The integration
Structure. EMS system
of responders into a single, organized response system reduces the likelihood of error and provides
design recognizes the
a more consistent level of care throughout the system.
unique aspects and
essential contributions of
• Optimal EMS system performance depends upon integrated first response and transport
both first response and
components. EMS systems should recognize that each component provides an essential aspect of
transport components.
the "single patient's" needed care from the EMS system; care can only be reliably achieved when
Component -distinct
these valued. aspects are combined in an efficient, effective manner. The patient should be able to
medical assessments and
appreciate a coordinated response to their perceived emergent health care need(s) with a seamless
treatments are combined
transition of care.
to form the essential
medical care delivered to
• EMS systems should recognize the autonomous responsibilities of each system component
a "single patient" in the
and
account for each component's additional responsibilities. Timely arrival of first response and
EMS system. Therefore,
transport is critical in some cases and overall performance must be delivered from a system
a successful EMS system
infrastructure with sufficient resources to consistently deliver this timely arrival. First response is not
design established around
necessary on all requests for service. Therefore, systems should use evidence -based medical
the "single patient"
interrogation protocols to rapidly identify emergent medical conditions that will benefit from first
depends upon
response. Similarly, patient transport is not always time sensitive, especially when (as determined
coordinated and
by protocol) first response is promptly on the scene. A synergistic approach in which first response
integrated response,
transfers continuing patient care and transport responsibility to the transport component allows for
coordinated medical
optimal resource availability in the system. The transport component should provide ongoing
treatment protocols, and
assessment and treatment according to the patient's response, as well as ambulance transport of
continuing medical
the patient to an appropriate healthcare venue. This duty requires a longer time commitment to
education.
nearly all patients served by the EMS system, and resources should reflect this demand.
• The EMS system should ensure that sufficient EMS professionals exist in the system to care
provide
during times of anticipated peak demands and routine disasters.
• Each EMS system should make sure that all EMS responders use the same medical treatment
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protocols and administrative standards promulgated by the medical authority. Fully integrating these
components, including protocols, compatible medical equipment, integrated continuing medical
education, and a combined re-credentialing process facilitates optimal EMS system performance
and patient outcomes.
3. Team Approach.
• Each EMS system should determine and understand the local team members by identifying all the
Collegial working
stakeholder organizations involved or having an interest in the system, including patient advocates,
relationships and
emergency call takers, emergency responders, mutual aid providers, health care service providers,
collaborative processes
emergency management, relevant health care specialties, social service agencies, health care
among all personnel in
facilities and others.
this EMS system promote
optimal patient care
• Each EMS system should then collaborate with those regional stakeholder organizations in an effort
provided by mutually
utilize rather than re-create regional resources and talents.
respected professionals.
• Each EMS system should establish the roles of participants, including the right to be engaged in the
planning and development of the system and the obligation to provide inputs and assist with
accountability. While some organizations have more involvement and more at stake than others the
team should strive for cooperation and consensus.
• Each EMS system should provide for coordinated medical oversight. While there are likely to be
many organizations playing a role in the emergency care of patients cared for by the EMS system
each having their own medical oversight capability, there should be a commitment to coordinate and
develop a common set of evidence based guidelines, standing orders, and protocols, as well as
common administrative and credentialing procedures.
• Each EMS system should ensure coordinated continuous quality improvement (CQI). While each
organization involved in providing emergency medical services can and should have its own internal
CQI process, there should be a commitment to share data as needed to implement system wide
CQI initiatives.
• Each system should provide for joint operational standard operating uidelines SOGs . In as much
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as multiple components of the EMS system have points of intersecting, coordinated and overlapping
operation, stakeholders in the system should identify those areas of connectivity and strive to
develop common operating guidelines to facilitate seamless transition of information, patient care
activities, logistics and operations.
• Each EMS system should provide mechanisms for joint operational review of Key Performance
Indicators (KPIs); The EMS system, as a unified operation, should employ a set of KPIs that all the
parties agree to in terms of their importance to be measured, monitored and responded to if needed
to improve the performance of the system.
• The system should employ methods to ensure joint strategic planning. The stakeholders should
develop and revise a strategic plan for the system as a whole taking into account current
performance and future system and external trends. Ideally, the primary operational players in the
EMS system should coordinate the timing and process for their own internal strategic planning
process to correspond to the system wide planning.
• The EMS system should provide opportunities for joint training and exercises. The EMS system
should identify common training needs of various players in the system and sponsor training
activities and exercises that bring together staff from the various entities to train and exercise
together. This enables training on common SOG's and other shared learning objectives.
• Each EMS system should provide for joint disaster planning: The EMS system should plan
collaboratively with all the stakeholders in all aspects of disaster management: mitigation,
preparedness, response and recovery. Medical surge is very much a team sport and only through
cooperative efforts can the sum be greater than the parts.
Medical Dispatch
• EMS systems are dependent on appropriate 9-1-1 and emergency dispatch systems. Structures
Prioritization. EMS
should be established for EMS dispatch to rapidly and systematically ascertain what perceived
communications
emergency medical condition is being reported. The most potentially serious and time -sensitive of
optimizes the EMS
these medical conditions merit rapid notification of first response and transport providers. Evidence -
system's patient care
based medical interrogation protocols constitute the foundation for rapidly identifying emergent
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abilities when utilizing
conditions and rapidly dispatching appropriate responders.
evidence -based priority
dispatching. Successful
• EMS dispatch systems should make sure that effective bystander -initiated patient care can be
priority dispatching
achieved via phone directives. Critical interventions such as cardiopulmonary resuscitation (CPR),
initiates patient care and
choking relief, and hemorrhage control can be instituted prior to EMS arrival. Evidence -based pre -
matches necessary
arrival instructions constitute the foundation for rapidly initiating this care.
resource(s) to the patient,
without excessive and
• Emergency response ("lights and sirens" mode) proves an inherent risk to the public and EMS
inappropriate utilization of
professionals. While perceived critical medical conditions warrant this risk, many calls for EMS
first response and
assistance do not. Evidence -based medical interrogations constitute the foundation for
transport components.
differentiating emergency, urgent ("non lights and sirens" mode), and non -emergent responses.
First time -sensitive care in higher priority medical conditions. Rapid availability of
response provides
first response can become compromised when first response resources are dispatched to all
requests for EMS service. That is why EMS systems should establish evidence -based medical
interrogation protocols which constitute the foundation for rapidly identifying medical conditions
substantially improved by first response care.
• Each EMS system should provide for appropriate and timely first response care. Timely first
response care depends equally upon the efficient identification of higher priority medical conditions
AND efficient methods of first response notification/dispatch. In some instances, first response self -
dispatch based upon direct observation or monitored radio communications proves the quickest
means for first response utilization.
• Each EMS system should provide appropriate dispatch triage methods. EMS dispatch must be
capable of discerning if medical conditions are markedly worsening while EMS professionals are
responding to the initial call for help. As conditions warrant, EMS dispatch must be capable of
assigning higher priorities to these incidents, notifying currently responding EMS professionals of
change(s) in patient condition, and activating appropriate additional responders to these patients.
• Each EMS system should regularly evaluate and provide for community -appropriate response
times. While response time "standards" may seem well supported, most have been derived without
significant evidence -based medicine. As better EMS science emerges, response time standards
must be periodically re-evaluated and potentially expanded to include other factors. Response time
standards for first response and transport components should factor medical benefit, operational
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safety, and fiscal responsibility concerns.
• Each EMS system should carefully evaluate resource utilization. Sending a first response and/or
ambulance to every EMS request for service may constitute an over -utilization of these resources.
Evidence -based programs exist for alternative response (example: EMS professional(s) in
car/truck/SUV), alternative disposition (examples: medical advice line, social service referral),
and/or alternative destination (examples: walk-in clinics). Over or inappropriate use of resources
means that those critical resources are unavailable for emergent events.
• EMS systems should regularly evaluate medical dispatch. EMS dispatch constitutes an important
part of the EMS system's practice of medicine. Appropriate re-evaluations of EMS dispatch should
utilize evidence -based medicine and medical oversight. Where gaps in evidence exist, industry
"best practices"—medical, operational, and financial—should serve as leading points of discussion
among decision -makers. Dispatch CQI constitutes an integral part of the total EMS system's
improvement efforts.
. Appropriate Resource
• Each EMS system should ensure that an integrated dispatch system exists to provide clear; -
allocation. EMS
consistent, and efficient notification to EMS responders that will eliminate confusion and insure the
communications
delivery of quality patient care.
optimizes the EMS
system's patient care
0 A consolidated dispatch center provides more consistent delivery of information to the EMS
abilities when utilizing
provider and allows compatible staff training and cost utilization.
integrated EMS resource
capabilities to identify and
• Each EMS system should ensure that the technology (CADS, GPS, etc) is available to enhance the
dispatch the closest
dispatch center's ability to send the appropriately equipped and staffed unit to handle the
appropriate responder(s).
requirements of the EMS emergency at hand and to ensure the safety of responders.
• A dispatch center with the capability of connectivity with medical direction and other responding
units (fire, police, rescue, HAZMAT) also enhances the response of other resources that may be
needed to mitigate the incident and protect the patient and responders.
• A dispatch center should have the means of determining the availability of local and regional
resources when local resources are actually or potentially depleted.
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• The EMS system should ensure that the receiving facilities have the ability to report their receiving
status to the dispatch agency. This will allow responders to transport patients to the appropriate
facilities the first time.
6. Coordinated
• EMS systems should ensure that effective continuing education (CE) drives progressive clinical
Competency Assurance.
ability, decision-making, psychomotor skills, competency, and performance.
Effective, coordinated
continuing education (CE)
• EMS systems should base the appropriate number of providers at each level of EMT on the
enables advances in
number of medical responses. Because both critical decision-making and motor skills degrade as
excellent patient care.
patient contacts decrease, a critical component in ensuring competency is determining the
Relevant, engaging CE is
appropriate number of paramedics, EMTs, and other responders in the system.
based upon EMS CQl
findings, updated
• EMS systems should provide effective post -certification continuing education (CE). CE must
guidelines supported by
effectively teach EMS professionals needed clinical improvements identified by CQI and evidence -
evidence based medicine,
based research, often incorporating new medical equipment and/or new medical treatment
patient care capabilities,
protocols.
and treatment protocols.
• EMS systems should align CE methods with the desired effect. Types of training, including
simulation training, should be structured to provide appropriate competency outcomes.
• Expertise from regional resources (e.g. stroke, cardiac and pediatric care centers) should be
accessed to optimize the provider's education, training and experience.
• Systems should provide CE in ways that reflect the way that services are provided in the field.
EMS professionals respond most effectively and efficiently when they train together.
• EMS systems should ensure that eligibility for clinical credentialing by the EMS medical director is
aligned with and depends upon the individual attaining and maintaining appropriate certification
credentials from the state or local credentialing authority.
• System CE should afford every credentialed individual the educational content necessary to fulfill
the baseline requirements for ongoing certification.
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7. Integrated Protocols.
•
The system should ensure that medical treatment protocols are developed utilizing evidence- -
Medical treatment and
other protocols are
derived utilizing prevailing
EMS standards of care,
based medicine, acceptable EMS standards of care, and CQI outcomes, and that they consider
system -specific characteristics. These protocols are patient -centric, incorporating the essential
contributions from communications, first response, transport, and healthcare facilities in seamless
treatment plans.
evidence -based medicine,
and system design
•
Medical treatment protocols highlight critical interventions for time -sensitive conditions and reflect
considerations. Medical
treatment protocols are
formatted to recognize the
essential contributions
desirable timeliness of care. Each EMS system should establish methods for consistent
measuring and contributing time -related data from first response, transport, and healthcare facility
components that reflect their respective patient contact spans of time.
from communications, first
response, transport,
healthcare facilities and
•
The system should develop integrated administrative and operating protocols, such as incident
command system, destination decisions, communications and mode of transport.
promote seamless care
delivery. Clinical staffing
must afford the safe
implementation of these
protocols.
•
The EMS system's medical oversight team, led by the medical director(s) should develop medical
treatment protocols supported either by existing evidence based medicine guidelines or
standardized practice and consensus within the specialty. Protocols should focus not only on
meeting patient care needs, but should also include complementary support in continuing
education, equipment and medication specifications, and professional development.
8. Cost Effectiveness. The
•
Each EMS system in each community has a moral and ethical responsibility to ensure that all- -
EMS system recognizes
citizens have access to high quality EMS medical care.
and respects each
community's desire for
•
Each system must ensure fiscal accountability, particularly when multiple agencies are involved.
high-quality emergency
medical services
0
EMS system design, clinical care, and operational decisions should be driven by patient need and
delivered through an
affordable, cost effective
evidence -based medicine and operations. The EMS system's leaders are responsible for making
ethically defensible, scientifically sound, clinically appropriate, and fiscally responsible decisions.
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design. Communications,
first response, and
•
The system should emphasize the "one -team" approach. Incorporating the `one team" philosophy
transport
not only leads to better patient care and a more enjoyable work environment, it also fosters
components/resources
economies of scale. As first response and transport components identify common initial
are integrally linked and
orientation, continuing education, CQI programs, and equipment inventory/maintenance
depend upon the
operations, opportunities exist to make these programs more cost effective by reducing
effectiveness and
duplication of service and/or expanding service without attendant cost.
efficiency of each other.
Additional system
•
EMS readiness costs must be recognized, supported, and funded by the entire beneficiary
resources are added only
population.
when they support the
desired high quality of
•
EMS readiness costs should also include meeting public expectations in times of both
EMS in our communities
unpredictable and preplanned disasters involving considerable staffing, training, and equipment
and do so with reasonable
costs.
costs evaluated through
system -wide impact
analysis.
Medical Oversight.
•
EMS systems should continually consider that all components of EMS medical care constitute the.
Medical care provided
practice of medicine in the out-of-hospital arena as established under state laws and rules.,
by the EMS
professionals in this
•
EMS systems must ensure appropriate medical oversight. Medical oversight physicians provide
system constitutes the
counsel, advice, and direction through approval of medical administrative and treatment protocols
practice of medicine.
as well as through evaluating patient care CQI reports. These functions are vital to each patient
The medical overseers
receiving care in accordance with prevailing professional standards.
and other physicians
must be experienced
•
The EMS system is comprised of one or more medical directors who provide medical
and specialty board
administration and can ensure that skilled personnel have appropriate training, education, clinical
certified as appropriate.
experience, and expertise to provide medically appropriate care to patients on a daily basis under
These physicians
the aegis of the medical authority. . Physician and non -physician members of the medical
commit to providing
oversight team should be educated, trained, certified (when applicable) and experienced in their
objective and
respective areas of supervision.
independent medical
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oversight, without regard
• Non -physician members of the medical oversight team should be
to self -interests and
supported and supervised by
the EMS system's medical director/s.
political pressures.
• The EMS system's medical oversight team led by the medical director/s will be for
responsible
determining provider competence, scope of practice ceiling, credentialing, and level autonomy.
• EMS systems should actively pursue and optimize online and/or offline medical direction
and/or
expertise from willing and able regional resources such as stroke, cardiac and pediatric care
centers, and regional or state EMS medical directors.
• The EMS system's medical oversight team led by the medical director/s should be for
responsible
developing and/or acquiring treatment protocols that meet or exceed the current standard of care
by specialty (supported either by existing EBM guidelines or standardized practice and consensus
within the specialty). Those protocols should be reviewed and updated annually, at a minimum,
and current technology should be optimized to allow for easy access and distribution of those
updates to providers.
• EMS systems and their medical oversight team should ensure that mechanisms are in to
place
guarantee awareness of, competence in, and compliance with medical protocols and updates.
10. Electronic Data Capture.
• Electronic patient records enables 100 percent case review, graphical analysis, and statistical -
Electronic patient records must
analysis; allowing rapid and comprehensive evaluation of clinical and operational patterns. This
be utilized by every provider
capability improves medical treatment protocol compliance and design. EMS systems should
level and integrated into every
therefore ensure that the system has the capability to aggregate, capture, and electronically report
aspect of prehospital care.
on critical patient care issues.
Agencies should adopt
standardized data points and
• Because electronic patient records allow the EMS system to compile a patient care database for
fields (e.g. Utstein Criteria and
needed clinical research, EMS systems should establish electronic database methods to store and
National EMS Information
evaluate data.
System [NEMSIS] that
represent EMS needs and
• The system should provide seamless integration of dispatch, first response, transport, and
standards.
selected health care facility data on each patient by using a shared computer platform. This
September 2009 FINAL 15
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September 2009 FINAL 16
structure ensures that the care provided throughout system is provided at the highest level and
allows for evaluation of practices along the entire continuum of patient care from dispatch to
hospital admission..
• Agencies should adopt standardized data points and fields (e.g. Utstein Criteria). National EMS
Information System (NEMSIS) is the recognized method of ensuring both a standardized data
definition and a uniform architecture. The system should make sure that data points and fields
re resent local EMS system needs and standards.
11. Measuring and
• The system should establish and support a structure that reinforces the development, application,
Reporting on Key
analysis and maintenance of key performance measures EMS systems should make every effort to
developed by EMS systems and national
Performance Indicators.
Key performance indicators
access and utilize current key performance measures
organizations recognized for industry standards and best practice (supported either by existing EBM
(KPIs), such as response time
guidelines or standardized practice and consensus within the specialty).
standards, factor the patient's
perceived condition.
• System overseers must ensure accountability for key performance indicators, including response
Performance indicators in
time and clinical performance in both first response and transport components of this EMS system.
EMS systems are appropriate
for first response, transport,
• The system should create methods to measure performance based on the patient -centric view,
and dispatch agencies. Strict
including outcomes rather than solely response time as performance measures in the EMS system
transport organizations must agree on response and clinical data definitions to
compliance within standards
is expected.
First response and
ensure accurate and aggregated measures of system's performance.
• The system should measure and report response times in fractiles rather than averages, thereby
representing a truer picture of the system's response time reliability. Additionally, response times for
specified area(s) in the service area should be reported to ensure appropriate response time
erformance throughout the entire service area.
12 Structured and
• Each EMS system should ensure that all care provided is subject to review of system access,
Reporting of contact and care must be performed in
Integrated Continuous
treatment and operational compliance. patient
Quality Improvement (CQI).
a manner enabling efficient COI.
As the "singlepatient" paradigm
September 2009 FINAL 16
Guiding Principles and Core Issues in EMS System Design
EMS Systems Committee
001 -Systems -007 -Final
predominates throughout the
• Each EMS system should have structures in place to optimize system performance and improve
EMS system's design of
patient outcomes—both of which are dependent upon the system's ability to conduct integrated CQI
response, medical treatment,
activities.
and continuing medical
education, the EMS system's
• Each EMS system should make sure that operational and medical treatment data are collected,
continuous quality improvement
analyzed, displayed, and acted upon using statistically valid methods. Data definitions must be
should be both vertically and
clear, consistent, and adopted by all system components. Qualitative and quantitative data should
horizontally coordinated and
be organized and displayed in ways that ease interpretation for system decision -makers.
integrated.
• Each EMS system should collaborate and maintain effective working relationships and current data -
sharing agreements with hospitals, trauma committees, and other related health care entities within
their respective region. Expertise from regional tertiary care resources (e.g. stroke, cardiac and
pediatric care centers).should be recruited and utilized for system CQI
• To be effective in establishing an effective CQI process, each EMS system should establish a
Culture of Trust and patient safety. A Culture of Trust helps to ensure that system participants are
able to report potential errors without fear of retribution and medical directors can make system
wide improvements based on those reported errors.
• Each EMS system should use areas for improvement identified through the CQI program to drive
continuing education for EMS providers.
13. Disaster Preparedness
• Each EMS system should design protocols and standards for unusual, high impact events involving
and Surge Response.
all patient populations, including special needs, pediatric and geriatric. Mass casualty incidents
Disaster preparedness and
(MCI) often require EMS professionals to operate differently than day-to-day responses to medical
surge response constitute
illness and/or injury. EMS systems should establish simple, clear MCI response plans to help EMS
essential roles of an EMS
professional to efficiently and effectively contribute to the EMS system's response to unpredictable
system. Effective
disaster events.
preparedness for disaster -
related emergency medical
• EMS professionals can best respond to any given disaster when specifically trained in that type of
needs is dependent upon
disaster. Systems should ensure that realistic drills and focused didactic sessions are delivered on a
September 2009 FINAL 17
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Guiding Principles and Core Issues in EMS System Design
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concise, task -oriented multiple
routine basis to best prepare EMS professionals to care for disaster victims while ensuring personal
casualty response procedures,
safety.
routinely -scheduled realistic
multiple casualty training,
• The well being of EMS professionals responding to disasters, both man-made and natural, is
funding necessary training as
dependent upon ready access to and proper utilization of personal protective equipment. Given the
well as protective and medical
possibilities of intentional chemical, biological, radiological, nuclear, and explosive events, the EMS
equipment, and achieving
system must protectively train, outfit, and equip its most valuable assets — its EMS professionals.
region -wide governmental
operational support. Surge
• This EMS system's Standards of Care may change when facing extreme environmental conditions,
response, similarly, is the
excessive numbers of casualties in relation to available resources, or medical dangers posed to
system's plan and ability to
patients or providers. The EMS Medical Director(s) must work closely with other system leaders to
manage varying levels demand
clearly define acceptable interim standards of care, enabling the greatest possible good to be safely
surge in the system. EMS
delivered to as many casualties as possible.
systems should also be
prepared to rapidly respond to
• EMS systems should establish and implement plans to serve known events with a high likelihood of
an increase in surge .,
EMS need. Mass gatherings, sporting events, and other outdoor entertainment venues provide
opportunities to implement real time plans to serve predictable medical needs.
• No single EMS system can adequately respond alone to all disasters. That Is why regional planning
and operational support is the minimum level of planning and response essential to effective disaster
readiness. Clearly, state and federal planning and operational support is also appropriate in many
circumstances. An integral part of disaster pre -planning is attaining regional government political,
financial, and operational support. The Metropolitan Medical Response System (MMRS) is one
example of an effective multiple agency/multiple government disaster readiness initiative.
• Effective EMS response to disaster is dependent upon effective hospital response to disaster. EMS
system's leaders and its disaster preparedness experts must coordinate efforts with appropriate
hospital-based personnel to promote an effective emergency medical response to disaster,
s eci ically including efficient EMS- emergency department transitions of patient care.
14, On-going EMS System
• Each EMS system should employ appropriate mechanisms to plan for changes in the practice of -
Planning. EMS strategic
medicine. EMS is a practice of medicine and therefore subject to ever-changing standards of
planning best enables optimal
medical care. Necessary changes to the practice of EMS are part of a larger process of planning for
September 2009 FINAL 18
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001 -Systems -007 -Final
EMS system design and
performance when conducted
system design and function. While medical care specifications are the purview of the EMS medical
authority, the delivery of this medical care depends upon EMS systems
continuously.
ensuring appropriate system
design and productive professional relationships, both of which are fostered through continuous
strategic planning.
• EMS systems should consider their complex roles and how they interface with other healthcare
components. Effectively improving healthcare outcomes for all patient populations, especially given
an ever-growing pediatric and geriatric population with complex emergency medical needs, requires
multi -agency participation, creative solutions, and increased efficiencies to operate within fiscal
constraints. Continuous strategic planning identifies areas of common objectives and the methods to
use the talents of EMTs, first response and transport agencies, and administrative personnel.
Planning that is supported by institutions such as local EMS regulatory agencies and local hospitals,
achieves the best outcomes at reasonable expense.
• Current system design and future recommendations should anticipate the community's EMS needs,
factoring present and needed resources, ultimately fulfilling the commitment to provide optimal EMS
care.
15. Safety of Responders
and Patients. A system -wide
• EMS systems should ensure a Culture of Safety, because EMS providers are often placed ina.
position that could imperil the safety of their themselves
focus on safety should be
patients, and others. Creating this culture
will help providers to understand the importance of maintaining a safe attitude and environment.
woven in to the system design
to ensure that the primary
safety interests of
• The Culture of Safety should strongly influence the processes, training and equipment for EMS
patients,
providers in the system, to maximize provider and patient safety.
citizens, and responders are
protected.
• The EMS system must ensure that providers in the system practice a safe and complete
assessment of the scene and the patient. Environmental awareness is paramount to completing a
proper assessment and treatment of the patient with consideration for patients, providers, and
others at the scene.
• The EMS systems goals must make sure that the practice of safety begins at the outset of the
response and continues throughout the incident --including every stage of the response, treatment,
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September 2009 FINAL 20
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and transport.
• The system should establish standards that consider crew fatigue. Scheduling of EMS personnel
must promote continuous patient safety, optimal clinical care, and appreciable workforce
beneficence. Shift lengths must closely correlate with clinical duty expectations and system
demands to minimize provider fatigue.
• A culture of safety that protects patients and providers must extend to supporting processes and
structures in the system. The culture of safety begins with and includes appropriate selection and
maintenance of equipment (including fleet maintenance processes), and includes operational
rotocols and dispatch standards.
16. Community
• Each EMS system should engage the community by understanding the local team members and all -
Engagement. The necessary
the stakeholder organizations involved or having an interest in the system, including patient
engagement with the
advocates, emergency call takers, emergency responders, mutual aid providers, health care service
community requires that the
providers, emergency management, relevant health care specialties, social service agencies, health
EMS system is designed
care facilities, public health, and others.
appropriately to meet the
community's needs, while at
• Each EMS system has a moral and ethical responsibility to ensure that the community and all
the same time ensuring that
citizens have access to high-quality EMS medical care.
the community has an
adequate voice in EMS
• Each EMS system should educate the community it serves about what the EMS system is, what
system strategy.
appropriate uses for it are, what the community can expect from it and ways that the community may
be active its own health (e.g. injury prevention and community AED/CPR programs). Continuous
communication with the community allows the EMS system managers and the medical community
to identify common objectives and methods to achieve the best medical outcomes at reasonable
expense.
• Each EMS system should engage the community to ensure a community -appropriate balance
between EMS readiness costs, EMS service costs, and the quality of care provided to the entire
beneficiary population.
• EMS systems should engage the community to ensure that the systems have the ability to serve
September 2009 FINAL 20
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Guiding Principles and Core Issues in EMS System Design
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001 -Systems -007 -Final
known events with a high likelihood of EMS need. Mass gatherings, sporting events, and other
outdoor entertainment venues provide opportunities to implement real-time plans to serve
predictable medical needs.
• EMS systems should consider their complex roles and how they interface with the community and
other healthcare components. Effectively improving healthcare outcomes, especially given an over-
growing aging population with complex emergency medical needs, requires multi -agency
participation, creative solutions, and increased efficiencies to operate within fiscal constraints
September 2009 FINAL 21
Guiding Principles and Core Issues in EMS System Design
EMS Systems Committee
001 -Systems -007 -Final
E. Committee conclusion
The committee supports a patient -centered, evidence -based, systems approach
to design of EMS systems. That approach requires that the system stakeholders
establish recommendations for guiding principles, core issues, and operational
plans for use by agencies of the federal government and by system participants
throughout the United States.
Recommended Actions/Strategies:
National EMS Advisory Council
1. Develop methods for agencies to create operational plans to help achieve the
core issues and the guiding principles.
National Highway Traffic Safety Administration
1. Support a federal effort to expand, enhance, and fund EMS research based
on operational, financial, and medical outcomes criteria.
2. Develop and publish key performance indicators (KPls) for EMS systems to
measure and monitor performance. Use NASEMSO Performance Measures
document as basis for performance standards. _-
3. Share committee recommendations with Council on Emergency Medical Care * - ' "'Formatted: Bullets and Numbering
CEMC , Emer enc Care Coordinating Committee ECCC Federal
Emergency Management Agency (FEMA)and Federal Interagency Council
on EMS (FICEMS) so that EMS is not left out of the discussion on health care
reform.
4. Provide the -Guiding Principles information to federal a encies to assist in
funding regionalization demonstration rojects.
Other Department of Transportation
1 Support a federal effort to expand EMS qrant funding so that EMS agencies - 1 Formatted: Bullets and Numbering j
can im leme it NEMSIS compliant recordinq and reporting.
Federal Interagency Committee on Emergency Medical Services
1. Support a federal effort to expand, enhance, and fund EMS research based
on operational, financial, and medical outcomes criteria.
1. National Research Council. 1966. Accidental Death and Disability: The Neglected Disease of
Modem Society. Washington: National Academy of Sciences.
2. National Highway Traffic Safety Administration. 1996. Emergency Medical Services Agenda
for the Future. Washington, DC: U.S. Department of Transportation.
September 2009 FINAL 22
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001 -Systems -007 -Final
3. National Fire Protection Association. 2002. Guide for EMS System Design. Batterymarch
Park
4. Committee on Trauma Research, National Research Council and Institute of Medicine. 1985.
Injury in America: A Continuing Public Health Problem. National Academy Press: Washington
D.C.
September 2009 FINAL 23
Po Huang, M.D., FACEP
Chairman and President
James R. Davidson, M.D., FACEP
Vice President Clinical Administration/Secretary
Brandon Wilding, M.D., FACEP
Vice President Finance/Treasurer
Thomas P. Peterson, M.B.A., FACMPE
Executive Director
Peter J. Angleton, M.D., FAAFP, FACEP
Hansel Ashby, M.D., FACEP
Randy L. Barnes, M.D.
D. Lee Binnion, M.D., FACEP
Brian Boesiger, M.D., FACEP
Mark Burriesci, M.D.
Matthew B. Campbell, M.D.
Matthew J. Conklin, M.D., FACEP
Benjamin Lee Cornett, M.D.
Address: 2312 N. Cole Rd, Suite B, Boise, ID 83704
May 11, 2010
Mayor Tammy de Weerd
City of Meridian
33 E. Broadway Avenue #300
Meridian, ID 83642
Dear Mayor de Weerd:
IDAHO
EMERGENCY
PHYSICIANS
Phone: (208) 322-1730
Robert L. Davis, M.D.
Jeffrey R. Dingman, M.D.
Eric T. Elliott, M.D.
John P. Epperson, Jr., M.D.
David T. Gough, D.O., FACEP
Heather Hammerstedt, M.D., MPH
Mark A. Henzler, M.D., FACEP
Ryan Heyborne, M.D.
David T. Kim, M.D., FACEP
Frederick J. Klein, M.D., FACEP
Brian W. Moss, M.D.
Michael W. Pool, M.D., FACEP
Jason Quinn, M.D.
Kristen H. Saak, M.D.
Christopher E. Tobe, M.D., FACEP
Jessica Wasielewski, M.D.
Christopher C. Wyatt, M.D., MBA
Fax: (208) 322-1731 Website: www.ie .org
Attached is the Memorandum of Understanding (MOU) developed by all of the Ada County Emergency Medical
Services (EMS) Stakeholders, one of whom was Mark Niemeyer, Chief of Meridian Fire Departmentl. This
group worked diligently to develop the MOU, which was unanimously adopted. A list is attached of the EMS
Stakeholders requested to sign the MOU.
The MOU defines a voluntary commitment to support an Advisory Council inclusive of all EMS providers, to
develop a unified EMS system for Ada County.
We now ask for your signature and the appointment of a representative to the EMS Advisory Council. Should it
be helpful, members of the work group would be happy to meet with you and your EMS constituency to discuss
the MOU.
The agenda for the working group will be based on the National EMS Advisory Council's document, Guiding
PrinciDles and Core Issues in EMS System Design, attached to the MOU.
We thank the EMS Stakeholders for the hard work provided in developing the Memorandum and their precedent
setting support of the concept of a unified EMS system. We look forward to working together for the benefit of
the citizens of Ada County.
Once the MOU is signed, we will call the Advisory Council together, hold organizational elections, and move
forward into discussions leading to actions that all EMS entities can discuss, and if appropriate, approve.
Cordially
Thom s P. Peterson, M.B.A., FACMPE
Executive Director
Cc: Mark Niemeyer, MFD Chief
Enclosure: Memorandum of Understanding — Emergency Medical Services Advisory Council
If
MOU Signatories:
Page One
David H. Beiter
Mayor of Boise
John G. Evans
Mayor of Garden City
Jeff Souza
President — Garden City Council
Pam Beaumont
Member — Garden City Council
Mike Moser
Member — Garden City Council
Elfreda Higgins
Member — Garden City Council
Tammy de Weerd
Mayor of Meridian
Fred Tilman
Chairman — Board of Ada County Emergency Medical Services District
Sharon M. Ullman
Commissioner — Board of Ada County Emergency Medical Services District
Rick Yzaguirre
Commissioner — Board of Ada County Emergency Medical Services District
Michael Huffaker
City of Eagle Council President
J. Scott Dowdy
Mayor of Kuna
Mike Irvan
Chairman — North Ada County Fire & Rescue District
Gary Stillwell
Chairman — Eagle Fire Protection District
Nathan Mitchell
Mayor of Star
Rich Greene
Chairman — Meridian Rural Fire District
MOU Signatories:
a
Page Two
Joe Stear
Chairman — Kuna Rural Fire District
Gunnar Howarth
Chairman —Star Fire Protection District
Judy M. Simmons
Chairperson — Whitney Fire Protection District
Sally Jeffcoat
President & CEO — Saint Alphonsus Regional Medical Center
Pam Bernard
COO—St. Luke's Regional Medical Center
Neeraj Soni, M.D.
President — Emergency Medicine of Idaho
Po Huang, M.D.
President — Idaho Emergency Physicians
Doug Rosin
President — Ada County Fire Chiefs' Association
Tom Peterson
Chair — Ada County Emergency Medical Services Advisory Board