Chapter 5 Douglas F. Kupas, Lee B. Smith, and Dean Cole In 2006, the Institute for Medicine (IOM) described organization of EMS systems across the United States: “In states and regions across the country, there is substantial variation among emergency and trauma care systems. These systems differ along a number of dimensions, such as the level of development of trauma systems, the effectiveness of state EMS offices and regional EMS councils, and the degree of coordination between fire, EMS, hospitals, trauma centers, and emergency management” [1]. Each state and territory within the United States has a state EMS office – a functional entity that regulates various components of the EMS system. Like all other aspects of state government, there is often wide variation in where a state EMS office sits within governmental structure, personnel positions within a state EMS office, and scope of the office’s activity in regulating EMS entities and providing non-regulatory support to the EMS system. Realizing that variations exist, this chapter will describe the general functions of a state EMS office with particular attention to functions that should be understood by local EMS agency medical directors and managers. Variation in the location of state EMS offices within each state’s governmental structure can lead to confusion in terminology. For the purpose of this chapter, the term state EMS office will be used as a broad general term, understanding that a state’s EMS office may be called an office, bureau, department, program, or other terminology. The National Association of State EMS Officials (NASEMSO) is a non-profit organization that is composed of EMS officials from every state and territory within the United States. NASEMSO goals include promotion of the orderly development and coordination of EMS systems across the nation, and the organization is also a forum for exchange of information and discussion of common concerns among state EMS officials. NASEMSO also facilitates interstate cooperation in areas such as patient transfer, communications, and reciprocity of EMS personnel. It has many opportunities for specialized collaboration among states through its councils of medical directors, data managers, trauma managers, pediatric emergency care, and educational and professional standards. The organization also has committees that address specific and unique EMS topics as they occur. Each state and territory has the opportunity to appoint a state medical director to the Medical Directors Council [2]. In response to the 2006 IOM report describing fragmentation in EMS, and with support from the National Highway Traffic Safety Administration (NHTSA) of the US Department of Transportation, NASEMSO coordinated a project that developed a model for state EMS systems. Within this project, NASEMSO organized the model state EMS system into ten subsystems [3]. S There are variations as to the lead agency where EMS resides within each state, and there is significant variation regarding placement of each state EMS office within the structure of its lead agency. NASEMSO’s EMS Systems Model suggests that, ideally, each state EMS office should be located within a lead agency that has a cabinet-level department head who reports directly to and advises the governor. In the vast majority of states, the lead agency for EMS is the Department of Health or a similar department that oversees public health within the state. The second most frequent lead agency for EMS is the Department of Public Safety or similar department that typically oversees law enforcement, fire protection, or emergency management. In other states, the EMS lead agency is a separate EMS authority or commission or within some other department of state government (Figure 5.1). Figure 5.1 Model state EMS system agency. Source: National Association of State EMS Officials. Reproduced with permission of the National Association of State EMS Officials. Whether in the Department of Health or some other agency of state government, the location of EMS within these lead agencies is also important. Departments of Health are frequently broken down into bureaus, which are further divided into divisions, and may be further divided into offices or programs. In addition to a cabinet-level department head, there are four required positions that must exist in an optimally functioning state EMS office. These positions may have official titles that differ but the specific functional roles are as follows. Under these positions that are required for an optimally functioning EMS office are personnel who accomplish regulatory and technical assistance tasks of the office. Regulatory tasks include licensing or certification, inspections, investigations, and discipline. Technical assistance operations may include planning, development, education, and disaster response. The ideal state EMS lead agency facilitates regular independent external assessment of the EMS system, and it develops and updates a comprehensive EMS system plan for the state or territory. State EMS offices generally provide a combination of regulatory and technical assistance functions. EMS agencies and personnel within a state are regulated by a statute, or state law, that permits agencies and personnel to provide EMS to the general public of that state. Rules and regulations of a particular statute provide guidance in regulating and executing the specific law. Although not used liberally, states generally have the ability to waive or exempt an EMS agency or provider from requirements within its rules and regulations; however, requirements of a specific statute must be followed. Waivers of requirements within the rules and regulations are usually permitted only if a waiver will permit an agency or provider to continue to provide EMS when it is in the best interest of the public. Each individual state EMS statute or its attendant regulations may grant a state latitude in developing policies or procedures to assist in regulating EMS entities and to provide regulated entities with information related to their licenses. A policy is a principle or rule to guide decisions and achieve rational outcomes, for which decision makers may be held accountable. A procedure includes actions that are executed in the same manner in order to obtain the same result. A standard operating procedure describes and guides multiple iterations of the same procedure over multiple occasions and locations [6]. It is important that EMS agency medical directors, EMS agency managers, and EMS providers understand the difference between standards and guidelines. Standards are generally requirements that must be met to achieve a designated purpose. These may be mandatory or voluntary but they are generally set by the government or by accrediting organizations. On the other hand, guidelines are generally rules that are set to guide behavior or offer best practice suggestions. They are often advisory and cannot be mandated by a regulatory body. The scope of practice – a description of what a licensed individual legally can and cannot do – is defined and limited by a state’s statute or law. Defining a scope of practice for each level of licensed EMS provider is central to further state regulation of educational programs, medication formularies, required EMS vehicle equipment lists, state-wide protocols, complaint investigations, and reciprocity with other states. NHTSA published the National EMS Scope of Practice Model in 2007 to set consistent criteria for nomenclature and competencies for various levels of EMS providers across the United States [7]. Consistency in the scope of practice of these individuals across states will improve professional mobility of EMS providers and enhance the public’s name recognition and understanding of the providers within the EMS system. Within each state, an individual EMS provider is only permitted to undertake the skills and roles for which the individual has been: While each state sets its standard for EMS education institutes that are acceptable for educating EMS providers, ideally this education takes place in an institution that is accredited by a nationally recognized organization like the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP). Accreditation helps to ensure that EMS providers are educated using well-organized and sound educational curriculum and techniques.
State EMS offices
Introduction
ections of this chapter will examine the subsystems of the model state EMS system in further detail with attention to issues that are of most importance to EMS medical directors.
System leadership, organization, regulation, and policy
System leadership and organization
embership within the group may represent regions within the state or specialty areas of medicine or the health care system.
Regulation and policy
Scope of practice
Trained
Certified as competent
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