Abstract
In 2016, the emergency medical services (EMS) community celebrated the 20th anniversary of the Emergency Medical Services: Agenda for the Future document. The authors, convened by the National Highway Traffic and Safety Administration (NHTSA), described the essential attributes and necessary advances required to realize a system in which the nation has “emergency [healthcare] that is reliably accessible, effective, subject to continuous evaluation, and integrated with the remainder of the health system.” 1 This document has guided the evolution of the US system of out-of-hospital emergency care and still informs EMS providers and policymakers today. In 2019, NHTSA published EMS Agenda 2050: A People Centered Vision for the Future of Emergency Medical Services, 2 a sequel document created through grassroots engagement of the EMS community, to articulate a vision for EMS systems over the next several decades. It was written to include a diverse EMS community—both volunteer and paid professionals, in urban and rural settings, working in the private and government sectors, and providing services across a broad range of activities that include 911 call taking and dispatch, emergency medical first response, ground and air ambulance patient management and transport, critical care transport, community paramedicine, and mobile integrated healthcare. The authors describe a people-centered EMS system that equally addresses the needs of patients and their families, the EMS responders that care for them, and the communities they serve. This system is designed around 6 guiding principles that provide the framework for its evolution. The EMS system is to be: (1) inherently safe and effective, (2) reliable and prepared, (3) integrated and seamless, (4) socially equitable, (5) sustainable and efficient, and (6) adaptable and innovative.
One year after the release of EMS Agenda 2050, SARS-CoV-2 began circulating around the globe, resulting in the worst pandemic of our lifetime. This created occupational health and safety risks for responders, extraordinary logistical and operational challenges for response agencies, and affected the health and wellness of responders and community members alike.
The challenges posed by the COVID-19 pandemic served to both accelerate some desirable capabilities and attributes described in the EMS Agenda 2050 vision for the future, while also exposing existing vulnerabilities. The pandemic has been a change agent for innovation and a proving ground for preparedness and resilience, but it has also been a merciless assailant of vulnerable people in our community. The EMS Agenda 2050 vision for a people-centered EMS system and its guiding principles serves as a ready framework to examine the impact of the pandemic on the EMS community and its response.
Inherently Safe and Effective
EMS systems will operate in a fashion that limits injury, infections, illness and stress. The safety of patients, their families, emergency responders and the broader community is of paramount importance. EMS operations and clinical care of patients is guided by the best available evidence. 2
Operating in a fashion that limits infection and illness during a pandemic has been challenging. Early studies reported a 3-fold increased risk of COVID-19 among frontline healthcare personnel compared with the general population. 3 In July 2020, the US Centers for Disease Control and Prevention (CDC) provided guidance for the implementation of a hierarchy of controls for all frontline healthcare providers, including EMS. 4
The CDC guidelines included modifying call-taker procedures at 911 Public Safety Answering Points/Emergency Communication Centers (commonly known as 911 call centers) to help call takers identify people at greater risk of COVID-19 infection, either because of travel, signs or symptoms, or due to known exposure to a COVID-19 positive person (eg, a household contact). The early identification of people at higher risk of COVID-19 infection affords an opportunity for call takers to communicate with first responders, who could then implement transmission-based precautions and other infection prevention measures in advance of making patient contact. It also enables them to send only the necessary resources, in order to keep exposure of the EMS workforce to a minimum and to ensure judicious use of personal protective equipment (PPE).
The CDC also provided guidance on:
The importance of source control (ie, application of a mask on the patient, if tolerated, to prevent dispersion of potentially infectious droplets) Limiting the number of personnel making patient contact Applying eye protection in addition to other standard precautions for all responses in communities where the incidence of COVID-19 was high, to afford additional protection in case of caring for patients with asymptomatic COVID-19 infection Gown, gloves, eye protection, and a National Institute for Occupational Safety and Health (NIOSH)-approved, fit-tested N95 respirator when COVID-19 was suspected or confirmed Limiting aerosol-producing procedures when possible and ensuring circulation of fresh air in the ambulance Safe cleaning and disinfection of the ambulance
While it is impossible to be certain about the EMS community's adherence to these recommendations and their effectiveness, a retrospective study done early in the pandemic examined 988 EMS provider encounters with patients who proved COVID-19 positive after arrival at the hospital. 5 According to the study, approximately 67% of responders wore the recommended PPE ensemble for COVID-19 and 29% wore basic gloves and eye protection. The heterogeneity of COVID-19 signs and symptoms, and risk of presymptomatic and asymptomatic cases, increased the difficulty of discerning COVID-19 cases in 911 systems. Even so, a temporal increase in adequate PPE use was observed in the study and was attributed to the iteration of screening procedures by the dispatch center and EMS field responders, which resulted in a reduction in unprotected exposure and need for quarantine. It was also reported that in this cohort, only 3 (0.4%) EMS responders subsequently tested positive for COVID-19 in the following 14-day period. In another retrospective study that examined EMS providers who did and did not have contact with a patient confirmed to have COVID-19 during the infectious period, with 16% of the encounters involving an aerosol-generating procedure, the incidence of COVID-19 infection did not differ among those with and without a COVID-19 patient encounter, further supporting the strength of infection prevention and control measures for EMS personnel. 6
These data help validate the recommended infection prevention and control measures as well as demonstrate the EMS community's ability to effectively apply them to ensure the safety of themselves and their patients. The COVID-19 pandemic also revealed the need for improvements to the evidence base regarding the hierarchy of controls in out-of-hospital settings and exposed other safety and effectiveness vulnerabilities.
Regarding engineering controls, air exchange in the patient compartment of ambulances serves to reduce potentially infectious suspended droplet nuclei that could cause illness when caring for patients with contagious airborne transmissible diseases (eg, measles). These patients require an airborne infection isolation room with 6 to 12 air exchanges per hour when cared for in the hospital. The CDC recommends that patients with COVID-19 be managed in an airborne infection isolation room if possible, when performing aerosol-generating procedures. 7 As defined in the Federal Specification for the Star-of-Life Ambulance, 8 the ambulance air exchange rate requires a complete change of ambient air at least every 2 minutes. This specified air exchange rate requirement was removed in a subsequent change notice. 9 Given the absence of a federal requirement for a specified air exchange rate, and the heterogeneity of the US ambulance fleet, studies should be done to ascertain air exchange rates in contemporary ambulances. Poor understanding of ambulance air exchange rates and persistence of suspended droplet nuclei confounds infection prevention during management and transport of patients and subsequent cleaning and disinfection of the ambulance.
Further, while many of the administrative policies and work practices implemented to prevent exposure of EMS clinicians to potentially infectious body fluids—as described in the Office of the Assistant Secretary for Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) EMS Infectious Disease Playbook 10 —are anchored in the evidence base that supports standard and transmission-based precautions, and are informed by infection prevention practice, many of these recommendations need formal prospective validation in the EMS work environment. Also, while performance characteristics for PPE are well defined in the NFPA 1999, Standard on Protective Clothing and Ensembles for Emergency Medical Operations, 11 EMS personnel are still in need of affordable ensembles that provide the necessary barrier performance and tear resistance while also preventing thermal stress. Human factors studies are needed to better evaluate operational limits for EMS responders in PPE in the out-of-hospital environment, especially for long-distance transports, and to inform “fitness standards” for particular ensembles.
Supply chain interruptions led to difficulties in the ability of many EMS agencies to maintain an adequate inventory of PPE for their workforce. In addition to improving supply chain integrity, strategies for optimizing the supply of PPE for EMS clinicians during shortages requires further investigation. CDC describes strategies for healthcare facilities, 12 but we are lacking validation of extended use and reuse of articles of PPE (eg, facemask, N95 respirator) in the EMS work environment with its attendant variation in ambient temperature and humidity, among other factors. EMS personnel should be provided answers to their questions regarding personal safety when implementing PPE contingency and crisis procedures—such as the use of gloves, gowns, eye protection, face masks, and respirators beyond their designated shelf life or for extended periods and the use of alternative respiratory protection when NIOSH-approved, fit-tested respirators are in short supply.
The pandemic has also revealed mental health and wellness challenges in the EMS community. For example, anxiety and concern for personal safety may be heightened when managing patients with a novel disease, and even more so when PPE contingency or crisis procedures as described earlier have been implemented due to supply chain interruptions. First responders in an EMS role are more likely to be exposed to COVID-19 than other first responders. 13 Survey findings published in August 2021 showed that 122 respondents in the EMS community reported “(1) significant policy and guideline alterations have negatively impacted job performance and satisfaction; (2) decreases in agency morale; (3) increased stress; (4) worse mental health when compared with nonpandemic times; and (5) increases in hostility/aggression, loneliness and sadness and weight gain coinciding with decreases in exercise.” 14 Another study demonstrated that among emergency responders surveyed during the COVID-19 pandemic, acute traumatic stress, depression, and anxiety rates are similar to rates in previous disasters (eg, Hurricane Katrina and 9/11). The authors reported that a sizable proportion of frontline responders during the COVID-19 pandemic are at risk for psychiatric morbidity. 10 In addition, a greater proportion of emergency responders reported risky alcohol use, compared with estimates of risky alcohol use among personnel in noncrisis contexts. 15 A survey conducted by the National Association of Emergency Medical Technicians reported that only 59% of survey respondents agreed or strongly agreed that they know where to go for help within their agency if they need it, and only 55% agreed or strongly agreed that their agency considers mental health important. 16 The pandemic is associated with 33% of respondents reporting thoughts about changing careers due to the pandemic. 13 The physical and mental health of the EMS community directly correlates with its resilience in times of crisis. Challenges with job dissatisfaction, burnout, depression, and substance abuse are preexisting challenges only brought into sharper relief by the pandemic.
The EMS community's experience with the COVID-19 pandemic has provided evidence on the effectiveness of infection prevention measures to keep the workforce safe, but it has also revealed the need for improved supply chain integrity and review and validation of safeguards incorporated into its hierarchy of controls for infection prevention. A comprehensive assessment and plan of action regarding the mental health and wellness of this critical workforce is also needed.
Reliable and Prepared
EMS systems are able to provide care that is consistent, compassionate and evidence-based. EMS systems are prepared by being scalable and able to manage day-to-day demand as well as major events. 2
The ability of EMS systems to provide consistent and compassionate care in a scalable fashion has been tested in many communities during the COVID-19 pandemic. For example, when New York City was the global epicenter of the pandemic in March and April 2020, its 911 EMS system experienced its largest surge ever recorded. Call volume increased by 60%, and life-threatening call types increased from 36% to 42% of the total call volume when compared with the previous year. 17 Health systems in New York City rapidly identified and upgraded critical care space to accommodate the surge. NYC Health + Hospitals affiliates alone increased their intensive care unit capacity from 300 to over 1,000 beds. Staffing was supplemented by redeploying staff and mobilizing temporary recruits and volunteers. Admitted high-acuity and critical care patients were managed in emergency departments (EDs) while makeshift tent and telemedicine initiatives were implemented to manage patients who were less acutely ill. Strains on the supply chain threatened access to essential PPE, supplemental oxygen, and ventilators. 18 The EMS system relied on computer-assisted call-taking procedures to efficiently differentiate high- and low-acuity call types and identify responses that required enhanced PPE for the safety of personnel; it also transferred low-acuity calls directly to telehealth services and implemented an on-scene treat-without-transport initiative. 17 In addition, local and out-of-state mutual aid resources were activated to augment response capacity. Preplanned targeted interventions assisted in scaling up the response to meet the demand for services.
The state of Maryland's EMS system also had a surge in demand for services that prompted them to implement a decision support tool early in the pandemic to help identify patients who could potentially conduct self-care at home. Of the patients screened, almost 30% were eligible to remain home and most patients (95%) who were triaged to self-care did not require hospitalization within 24 hours following the EMS encounter. 19 This is another example of how EMS systems can scale safely to meet demands for service in times of crisis.
Underscoring the heterogenous fashion in which a pandemic affects communities across a nation, many EMS agencies in other parts of the country recorded a paradoxical decrease in calls for assistance while calls for assistance in New York City surged. The number of EMS activations nationwide decreased by approximately 34% in 2020 between Week 10 (March 2 to March 8) and Week 17 (April 20 through April 26).20,21 This was accompanied by a 42% decline in ED visits during the same period. 22 While the etiology of these declines warrants more study, the data reflect an underutilization of resources in many parts of the country while others, such as those in New York City, were overwhelmed. It has been reported that surges in hospital COVID-19 caseload are detrimental to COVID-19 survival rates. 23 Load-balancing demands on healthcare systems across communities experiencing greater or lesser demand for healthcare services deserves further study as it could help overwhelmed health systems better manage event-related surges, thereby mitigating hospital congestion and negative downstream operational impacts on 911 EMS systems.
A critical component of being prepared and being able to scale to meet demand during crisis is a healthy workforce. COVID-19 vaccine is the most effective pharmaceutical intervention available to prevent COVID-19-related serious illness, need for hospitalization, and death. Staying up to date with recommended COVID-19 vaccinations is the best protection from these consequences, which has been demonstrated even during periods of high prevalence of the Delta and Omicron variants.24,25 Thus, high vaccination uptake in the EMS community would protect the EMS workforce from the most serious consequences of infection and contribute to its resilience. A high vaccination uptake in the broader community would mean fewer COVID-19-related hospitalizations and deaths and would decrease COVID-19-related demand for EMS and health system resources. As of February 28, 2022, 76% of the US population had received at least 1 dose of vaccine. The vaccine uptake rate is not reported for the EMS community, but anecdotes of vaccine hesitancy are widespread. Before the availability of vaccine, a survey of US firefighters and EMS personnel was conducted. Among respondents, 48% reported high acceptability of the COVID-19 vaccine when it was to become available, whereas 24% were unsure and 28% reported low acceptability. 26 Regional differences in vaccine acceptability were noted. A national effort should be made to partner with experts in behavioral science and health education, to determine what questions need to be answered for people hesitant to receive vaccine and to develop strategies to increase vaccine uptake in this critical workforce.
The pandemic has revealed that preplanned targeted initiatives were critical for EMS systems' ability to provide care that is consistent, compassionate, and scalable in a crisis and during surges in demand for service, as was experienced in New York City when it was the epicenter of the pandemic. It also exposed our vulnerability to public health emergencies, fueled by vaccine hesitancy, and triggers a clarion call to colleagues in the behavioral sciences to help close this gap for EMS systems and the broader community.
Integrated and Seamless
EMS is fully integrated with its healthcare system partners. Communication and coordination across the care continuum are seamless. 2
The efficiency and effectiveness of EMS systems is in great part dependent on the interface between EMS and its health system partners. Improved clinical outcomes are demonstrated when partners develop systems together that address the continuum of patient care (eg, trauma, stroke, ST-segment elevation myocardial infarction, cardiac arrest). System partners must concurrently address operational efficiency, which also benefits patients. With increases in EMS system activations observed, for example, during the Delta variant surge in September 2021, 20 high patient census in hospitals, and staff shortages, the National EMS Information System measured an extended delay in the transfer of patient care from EMS clinicians to ED clinicians. This is measured as the elapsed time from the arrival of a patient by ambulance to the ED, until the care of the patient is transferred and the ambulance is available for the next emergency call. EDs and EMS systems became regularly overwhelmed in many communities, such that available resources were outweighed by growing patient demand for EMS and health system services. This problem is not new, nor is it specific to any particular region of the United States—but it has been aggravated by the COVID-19 pandemic. 27 Emergency department crowding, and specifically the backup of patients already admitted to the hospital and boarding in the ED is a well-known and complex issue with numerous negative consequences. 28 Similarly, delays in the transfer of patient care from EMS clinicians to those in the ED adversely affects patient care, safety, and the availability of ambulances to respond to the next emergency in the community.
EMS and its healthcare system partners have a strong history of collaboration and coordination across the care continuum to improve outcomes in patients who are victims of trauma, stroke, myocardial infarction, and cardiac arrest. These partners must leverage the success of trauma, ST-segment elevation myocardial infarction, and stroke systems of care and address the day-to-day volume of prehospital transports to assist in alleviating congestion in the EDs. They must concurrently agree on solutions about timely transfer of care, which will benefit patients, staff, and the systems the community relies on for a timely emergency response.
Socially Equitable
Access to care, quality of care and outcomes are not determined by age, socioeconomic status, gender, ethnicity, geography, or other social determinants. 2
The pandemic has disproportionately affected people based on race and ethnicity. In the United States, Black, Hispanic, and Native American people are hospitalized over 2.3 times more often, and have a nearly 2-fold higher rate of death attributed to COVID-19 compared with White, non-Hispanic people. 29 The factors contributing to health inequity are multitude, including socioeconomic status, housing, education, and occupation, with minority groups disproportionately represented in the workforce of healthcare, farming, factories, food service, public transportation, and other essential services.
As a safety net for emergency care, EMS is embedded within communities, and thus is well positioned to assist groups that are disproportionately affected by lack of health insurance and lack of access to quality healthcare. Through community education, implementation of preventive strategies, mobile integrated health, and assisting with vaccine administration, EMS is not only able to respond to and address health issues by way of on-scene evaluation and patient transition to healthcare facilities as needed, but also by addressing community needs through public education and implementation of public health interventions.
The COVID-19 pandemic has served to further illuminate health inequities in our community. EMS systems help to overcome inequity by affording a pathway to healthcare access and through provision of services contributing to public health, independent of a person's race, ethnicity, or ability to pay. EMS systems need to be adequately resourced and sustained such that they can continue this vital role in society.
Sustainable and Efficient
EMS systems have the resources needed to provide care in a fiscally responsible, sustainable framework that appropriately compensates the workforce. 2
The COVID-19 pandemic exposed many of the economic and operational challenges that EMS systems face. First, the EMS system has historically been funded primarily through fee-for-service insurance reimbursement. Before the pandemic, Medicare and other payers provided no reimbursement for out-of-hospital care including response, triage, patient assessment, or treatment unless a patient was transported to an ED. 30 Second, the provision of EMS is not an essential service in most states and therefore local jurisdictions are highly variable in the degree to which they fund EMS systems, if at all. 31 Third, a number of federal and state regulatory and technical barriers impede EMS funding for services that most communities would benefit from. For example, the classification of EMS by the Centers for Medicare and Medicaid Services (CMS) as a supplier of a healthcare commodity (eg, transportation), rather than a provider, has resulted in a lack of compensation for many services that EMS providers offer or could offer, whereas the same services provided by another type of allied health professional would qualify for reimbursement. 32
Given these realities, we have seen an accelerating trend in agencies experiencing staffing shortages connected to low industry wages, being unable to maintain basic equipment or performance standards, or going out of business altogether—even before the pandemic.33,34 This lack of a sustainable model left many agencies woefully unprepared for the pandemic, thereby illustrating a fundamental disconnect at the heart of any discussion about how EMS responds to a public health emergency. The fact is that in most cases, EMS is not funded as an essential service, is not compensated or otherwise supported for the cost of readiness or preparedness, and is not compensated to respond to a call from the community or to treat the patient, unless it results in transport to an ED.
By shining a spotlight on the intrinsic flaws of the EMS funding model, COVID-19 created an opportunity for EMS systems and payers to partner in new ways that benefited patients and communities. Early in the pandemic, CMS issued waivers to authorize payment for transport to alternative destinations such as urgent care centers, a long sought-after concession from CMS. 35 More recently, within established constraints, CMS waived the requirement for ambulance services responding to 911 calls to transport a patient to the ED in order to be reimbursed. 36 Retroactively to the beginning of the pandemic, EMS agencies can seek reimbursement for treatment on scene and nontransport based on the needs of the patient.
Meanwhile, the pandemic began just a month after the announcement of the Emergency Triage, Treat and Transport (ET3) initiative from the Center for Medicare and Medicaid Innovation. ET3 is an alternative payment model that provides more options to EMS agencies with Medicare Fee-for-Service beneficiaries. In the traditional payment model, CMS pays EMS only to transport these patients to hospital EDs. ET3 is a 5-year experimental payment model that pays selected participants to transport to an alternative destination (eg, urgent care clinic, community mental health center, primary care office) and facilitates on-scene or telehealth treatment-in-place. 37 Given its impact on EMS systems nationwide, the Center for Medicare and Medicaid Innovation initially delayed implementation. 38 However, after soliciting input from EMS community stakeholders, it recognized that ET3 was very much aligned with a more sustainable and efficient EMS system that better prepared agencies to handle rapid changes in the healthcare system as experienced during the COVID-19 pandemic. 39 Implementation was initiated on January 1, 2021.
Partly due to the public awareness of the ET3 initiative, and partly due to the dramatic uptake in telehealth during the pandemic, many private payers began to recognize the need for detaching payment from transportation. Thus, contracting for services that include 911 alternative destination and treatment-in-place programs, as well as community paramedicine and mobile integrated healthcare programs that offer evaluation and treatment-at-home, picked up considerable momentum among private payers. 40
The COVID-19 pandemic revealed that traditional reimbursement models, which increasingly failed to afford the resources necessary to support a sustainable framework for EMS, are even more inadequate during a public health emergency. Innovative reimbursement strategies were accelerated because of the pandemic. This issue deserves further attention now and after the resolution of the declared public health emergency.
Adaptable and Innovative
EMS systems are continuously evaluated to meet the evolving needs of people and communities. Innovation is encouraged, leading to effective new programs. 2
The community experienced largely adverse impacts as a result of the COVID-19 pandemic, but the pandemic also accelerated technological innovations that were developed and expanded to adapt to the acute healthcare needs of the population. Early in the pandemic there was an immediate need for access to consistent and reliable unscheduled healthcare. The use of audiovisual telehealth encounters is increasingly common for various medical specialties. Until recently, telehealth had a nearly nonexistent presence in acute care medicine. Emergency departments and EMS agencies rarely participated in connected telehealth solutions. The pandemic revealed tremendous potential for this technology to further transform the current EMS delivery model.
Literature to support video telemedicine in EMS is dominated by telestroke and telemental health services. Few studies assessing the safety, performance, and impact of telehealth in other areas of EMS have been performed, and thus telemedicine in EMS was largely nascent during the pandemic. The Federal Interagency Committee on Emergency Medical Services, however, recognized its potential and collaborated with federal agencies and EMS partners to create a resource to guide development of telemedicine solutions for EMS and 911 communications centers. 41 There has been a recent increase in the use of telemedicine networks in EMS systems internationally and these can serve to inform further innovation. Consider the following prepandemic examples:
One regional EMS system in Sweden demonstrated that EMS physicians experienced a positive impact using video-image transmission in addition to traditional voice-only EMS medical control. 42
A retrospective study highlighting the increasing frequency, safety, and reliability of a video telemedicine system revealed noninferiority of tele-EMS compared with an onsite physician. 43
An analysis demonstrated the cost benefit of telehealth in a prehospital environment in Houston, Texas, in which telehealth was used to screen patients before transporting them to the ED. 44 An EMS physician was consulted to evaluate and triage the necessity for patient transport to a hospital ED. The researchers found a 6.7% absolute reduction in medically unnecessary ED visits and a 44-minute reduction in total ambulance “back-in-service” times. Additionally, they extrapolated a $928,000 societal annual cost savings and a $2,468 cost savings per ED visit averted. By providing earlier, advanced remote medical evaluation, unnecessary ED visits were prevented. Where ED visits were still indicated, the EMS physician could promptly provide treatment recommendations and alert receiving facilities of the incoming patient. Similarly, it was determined that the reduction in unnecessary ambulance transports after a telehealth visit with a physician translates to an overall reduction in EMS agency costs.
Researchers describe patient characteristics and results from a cohort of patients in Houston that received a prehospital telehealth consultation from an emergency physician. 45 They enrolled over 15,000 patients over the 3-year study period and identified a multitude of patient characteristics that may not require transport by EMS. Alternative means of transport can be offered to patients, and the reduction of unnecessary ambulance transports translates to an overall reduction in EMS agency costs. Telehealth programs offer a feasible solution to support alternate destination and alternate transport programs.
A National Health Service ambulance trust evaluation in Yorkshire, England, 46 determined the use of video triage for low-acuity calls appeared to be safe, with low rates of re-contact required. There were also high levels of patient and clinician satisfaction compared with standard telephone calls. Several patients in this study (212 out of 1,073 callers) were seen and triaged to a pathway other than a traditional EMS response.
Clinical decision support tools and remotely linked telecommunications technology allow for an earlier comprehensive evaluation at the point of patient contact. Low-acuity patients may be evaluated and released after a telehealth consultation.
Challenges to Emergency Medical Services Posed by COVID-19 Pandemic and Recommendations
Abbreviations: CDC, US Centers for Disease Control and Prevention; EMS, emergency medical service; PPE, personal protective equipment.
Another innovative and potentially effective means to prevent EMS transports in an underresourced system impacted by the pandemic is mobile integrated healthcare—the provision of healthcare using patient-centered, mobile resources in the out-of-hospital environment. Mobile integrated healthcare may include provision of on-the-spot evaluation and management to 911 callers instead of traditional resource dispatch; provision of community nurse practitioner-level care tailored toward chronic disease management, preventive care, or postdischarge follow-up; or referral to a broad spectrum of appropriate care including urgent care centers, primary doctors, or scheduled ED EMS transport. 47 Mobile integrated healthcare has been shown to be a solution for patients without time-critical emergencies, which typically require guidance from dispatch about how to perform a lifesaving intervention. In Los Angeles, time-critical emergencies account for less than 2.5% of all 911 EMS incidents. The remainder are low or moderate acuity. 48 Similarly, a review of CMS data from 2005 to 2009 estimated that 13% to 16% of Medicare 911 EMS transports involved conditions that were “nonemergent” while 34.5% of EMS-transported patients who were discharged from the ED could have been managed outside the ED altogether. 49 Healthcare payers and hospital leadership should integrate their services with their local EMS systems in order to understand how these new models of care delivery can positively affect patient flow and overall healthcare expenditures.
The COVID-19 pandemic has strained EMS and health system resources in many communities. It has also served to accelerate adaptability and innovation. Telehealth services, treat-without-transport initiatives, community paramedicine, and mobile integrated healthcare served to meet the demand for healthcare services during the pandemic, and are in need of further feasibility and effectiveness studies postpandemic.
Epilogue
EMS Agenda 2050 and its guiding principles help to inform understanding of EMS systems in terms of the current state, its vulnerabilities, and the obstacles for readiness to perform day-to-day duties and respond effectively to a future, yet unknown crisis. In the Table we outline some of these obstacles and offer recommendations. While the COVID-19 pandemic has been incredibly taxing and difficult for frontline providers and the EMS system, it has also been a change agent for innovation and a clarion call to increase our overall preparedness and resilience.
As it relates to challenging biothreats, the National Emerging Special Pathogens Training and Education Center, funded by the US Department of Health and Human Services ASPR and the CDC, has been working to increase the capability of the United States public health and healthcare systems, including EMS. These efforts focus on strengthening capacity to safely and effectively manage individuals with suspected and confirmed highly hazardous infectious diseases—through education and training initiatives, development of readiness metrics, provision of technical consultation and the coordination of research. More comprehensively, a National Special Pathogens System (NSPS) is envisioned that will sustain a special pathogen healthcare system for rare patient encounters as well as emerging diseases on a larger scale within communities. 50 The NSPS would provide exceptional care for these patients while also achieving organizational mission and sustainability goals. Such a comprehensive healthcare delivery system can only be complete with a robust and resilient EMS enterprise to support it. The NSPS was conceived in part to address gaps recognized in the nation's healthcare system response to the COVID-19 pandemic. It should also be a catalyst for addressing the gaps in EMS preparedness for public health emergencies and a stimulus to further develop adaptive and innovative strategies that will contribute to our EMS system and the community's overall disaster resilience.
Many of these recognized gaps will require concerted effort across the public and private sectors. Efforts to ensure the physical and psychological safety of the EMS workforce is paramount during public health emergencies and daily operations. Supply chain integrity must also be maintained. Recognition of EMS as an essential service is crucial for maintaining its readiness to respond to the next crisis. Finally, critical to the sustainability of EMS is the alignment of EMS agencies and healthcare systems' financial incentives across the patient care continuum, by further detaching payment from transportation while simultaneously making permanent some of the temporary changes that have enabled reimbursement for treatment without transport.
Footnotes
Acknowledgments
The authors thank Dr. Richard Hunt, MD, US Department of Health and Human Services, and Dr. Jon Krohmer, US Department of Transportation, for their national leadership on healthcare preparedness and emergency medical services policy. Their advocacy inspired and indirectly contributed to many of the themes expressed in this article.