National Association of State Emergency Medical Services Directors
National Association of State Emergency Medical Services Directors
Domestic Terrorism: Issues of Emergency Medical Services (EMS) Preparedness
Purpose:
This resource document addresses key Emergency Medical Services (EMS) issues and components, which are required for the preparation and EMS response to acts of domestic terrorism. This document identifies the critical EMS resources that require immediate fiscal attention nationwide to assure EMS preparedness.
Background
The National Association of Emergency Medical Services Directors (NASEMSD) is an organization of state EMS directors and medical directors from each of the 50 states and the U.S. territories. State EMS directors are responsible for the development, regulation and oversight of EMS and trauma systems at the state and local levels. NASEMSD provides vision and leadership in the development and improvement of EMS systems and in national EMS policy.
Emergency Medical Services are responsible for providing emergency health care response, treatment, and transportation to persons with medical emergencies or injuries. As the intersection of public safety, public health and health care, EMS is the “safety net” when the other services fail. This role requires that EMS provide a public safety role such as the events surrounding September 11th and to provide medical care in its daily integration with the health care system.
There are many lessons to be learned as we continue efforts to assure the ongoing preparedness of the emergency medical services system. This document outlines areas of concern to the EMS community and identifies priority funding and development needs to assure the ongoing viability of the nation’s critical EMS infrastructure. The delivery of EMS takes many forms including private for-profit, private non-profit, hospital based, fire-based, volunteer, paid and other configurations. Some organizations provide emergency medical care and transportation by ambulance, while others provide emergency care at the scene and then transfer the patient care to a ground or air ambulance crew for transportation. Regardless of the specific configuration, delivery of pre hospital EMS is part of an integrated EMS system. While current federal initiatives are beginning to address the needs of some EMS provider organizations, EMS System needs have been largely neglected.
An Emergency Medical Services System that functions well on a day-to-day basis constitutes the very underpinnings of an EMS system that responds in a disaster or major catastrophic event.
Funding
EMS struggles daily to balance the level of care needed within each community with the required resources, personnel, training and education. In fact, according to a Department of Homeland Security report of key state and local preparedness grant programs, EMS providers received approximately four percent of the funding available to first responders, yet EMS personnel represent roughly one-third of traditional first responders, which include law enforcement, fire service and EMS personnel. Equally troubling, despite being designated as a critical area for improvement by the Department of Health and Human Services, EMS received only five percent of the HHS bioterrorism grant funding. Some states allocated no bioterrorism funds to improve the capabilities of the EMS system. Additional funding is essential to provide initial resources and to create an EMS infrastructure that responds well to domestic preparedness events as a part of its day-to-day operations.
Listed below are essential services and equipment for EMS to function adequately in the event of an act of terrorism, mass casualty situations or other catastrophic events.
Education and Training
Background
Nation-wide education programs for domestic preparedness are needed for EMS personnel, administrators, and local medical directors. The Longitudinal EMT Attribute and Demographic Study (LEADS) project, conducted by the National Registry of EMTs, highlights the lack of preparedness training and education among EMS personnel. For example, more than half of EMTs and paramedics received less than one hour of training in biological, chemical and explosive hazards since September 11th. Twenty percent of EMTs and paramedics received no training at all. Funding is needed to provide for standardized course content, travel, personnel cost, and materials for this large-scale effort. This training must include exercises that will identify ongoing training and education preparedness needs.
Resources needed ($28 million)
Funding of $28 million ($500,000 per state and territory) is needed. These funds will support:
· Updating terrorism related content for initial and ongoing EMS personnel training programs consistent with the National EMS Education Agenda for the Future
· Integration of ongoing medically appropriate awareness and recognition level training for EMS personnel including EMS management of nuclear, biological, chemical, radiological and explosive terrorist incidents;
· Exercise support including involvement with appropriate federal and state agencies with EMS expertise. At a minimum include: NHTSA, EMS for Children and Trauma
· Grants to EMS providers to assist with off setting the cost of training of EMT’s.
· Grants to EMS providers to assist with training and implementation of NIMS and NRP consistent with PDHS # 8.
Equipment and Supplies
Background
Due to a lack of funding, EMS providers do not have necessary equipment to effectively respond to a terrorist attack or a catastrophic event. EMS personnel without protective equipment are at a high risk of becoming victims themselves and will be unable to transport and care for victims of a biological, chemical, radiological or nuclear attack. EMS units (particularly non-fire based services) frequently do not have the necessary breathing apparatus or personal protective equipment. For example, a 2003 study conducted by the Department of Health and Human Services found that EMS providers lacked the necessary protective equipment to respond to a bioterrorist threat. In fact, in 25 states, 50 percent or less of EMTs and paramedics had adequate equipment to respond to a biological or chemical attack and only one state reported that adequate personal protective equipment would be immediately available on a statewide basis, for all EMS personnel in the event of a biological or chemical attack. A needs assessment must be completed by each state EMS office in order to determine how much funding is needed in order to assure that all EMS providers are protected.
The need to increase DECON capacity is evident given the current threat from anthrax and other chemical agents in addition to other biological and chemical terrorism events. Improved DECON facilities, increased training, and DECON equipment will improve this capacity. This increased capacity should be described as the ability to decontaminate and treat an appropriate number of patients per hour, both the walking and liter victims as defined in the pre hospital and hospital’s role within the state or regional EMS disaster plan.
Resources needed (56 million)
Funding initially of $56 million is needed for this purpose. A needs assessment will be performed by each state office and these funds will then support:
· Grants to EMS providers to purchase and distribute standardized protective equipment;
· Grants to EMS providers to purchase necessary standardized equipment and supplies to treat both adult and pediatric injured victims
· Ongoing training and education of EMS personnel on the proper use of PPE
· Grants to Centers of Excellence for portable DECON units that can be staffed by available EMS personnel;
· Grants to high risk areas for portable DECON units including training and education on setting up and maintaining the units. The Mayor of the city would designate the EMS agency/organization responsible for maintaining and staffing the portable DECON unit;
· Grants to MRC’s and MMRS teams for additional portable DECON units
EMS Systems
Planning, Coordination and infrastructure including hospitals, public health and EMS
Background
To assure an effective response to domestic terrorism, EMS must integrate and collaborate with a variety of organizations and agencies including the public/private sector, various branches of government, and political jurisdictions. Frequently, EMS is a neutral party with a significant pool of workers. EMS must also collaborate with public health departments, law enforcement, fire services, hospitals, and other agencies. This collaboration, so integral to domestic preparedness, cannot happen without sufficient EMS staff to oversee the planning, coordination and mutual aid development. Each state/territory EMS office should oversee the state’s/territory EMS domestic preparedness response and assure, through plans, operational protocols, policies and procedures, that the response is coordinated with other statewide domestic preparedness response activities.
Many of America’s rural and urban hospitals are currently overcrowded and therefore lack response and surge capability in mass casualty situations. Emergency department diversion has been a national issue of public concern, and has worsened over time. In at least one state, a 300% increase in ED diversion hours has been reported in early 2001, and in another state over 30% of the hospitals are diverting patients at any given time. Many cities report ambulances unable to deliver patients to “open” emergency departments. Current hospital disaster plans do not sufficiently address chemical, nuclear, biological, radiological or explosive threats. Hospitals currently lack the capacity to absorb an influx of patients not only from a disaster scene, but from an infectious disease outbreak. Without remedy, the system will fail, ambulances will have no where to take victims and patients will suffer. Alternative treatment centers must be identified; data collected and reporting methods must be established.
In addition, state EMS Offices are typically responsible for the planning and regulation of state trauma systems, which originally were developed in the early 1970’s. Integration of the trauma system with the EMS system and domestic preparedness is a critical link to systematically responding to domestic terrorism and other catastrophic events. Trauma systems in most states are struggling at this time due to increased patient volume, and absence of resources and financing.
Since September 11th, many EMS services responded to “feared” events of terrorism, such as anthrax letters and chemical events. These events tax the day-to-day EMS system significantly. Protocols, policies and procedures are needed to identify when EMS is truly needed and when these events can be managed with less than normal EMS response. To develop plans and begin to implement solutions, funds need to be available to EMS System for coordinating and participating in the state EMS disaster activities.
Resources needed ($14,000,000)
At least $250,000 per state/territory is needed to provide a dedicated EMS/Domestic preparedness staff person in each state/territory EMS office to establish and coordinate this planning and integration process. These funds would be used to:
· Staff each state/territory EMS office with at least one EMS planning /coordination specialist, whose role would include, at a minimum, coordinating and collaboration of a unified and integrated response for EMS with law enforcement, fire and emergency management. In addition, this person would represent the state EMS office on exercises.
· Assure appropriate EMS involvement in all aspects of state level domestic preparedness planning;
· Train, educate and assure dissemination of planning information and ongoing coordination between state and local EMS systems.
· Develop and implement an annual needs assessment of EMS providers and EMS Systems
· Development and/or implementation of EMS performance standards consistent with HSPD # 8
Medical Direction
Background
Physician emergency medical directors are an essential component of EMS systems. They provide medical leadership, oversight, coordination, access to best practices, and research to assure the best possible EMS medical care for our citizens. EMS medical direction requires political, administrative, and financial support. Critical issues for EMS Medical Direction include: standardized planning and treatment protocols; local, regional, state, and national coordination of medical response; medical oversight of EMS personnel education and training; evaluation of medical/EMS data and assistance with EMS resource allocation; and quality management/quality improvement of the state EMS system. With the integration of EMS, hospitals, and trauma systems medical direction becomes a priority not only at the state level but at the regional level as well.
Despite its criticality for effective state EMS systems, most states have very limited funding to support a state EMS medical director. Even fewer states have funding for a regionalized structure of medical direction.
Resources Needed $14,000,000
Funding of a State EMS Medical Director with the necessary administrative support requires $250,000/state/territory per year. These funds will support:
· An EMS Medical Director for each state and territory;
· Physician oversight for development of EMS protocols and procedures for pre hospital care provided to victims of a terrorist incident including response, triage and transport. These standards will a direct positive impact on the delivery of daily EMS care.
· Physician involvement in the design and daily implementation of a robust Quality Improvement system for victims who receive pre hospital care so that in the event of a terrorist incident the system and the care rendered will be optimal.
· Qualified Physician oversight of EMS training and education related to weapons of mass destruction.
Physicians who are knowledgeable about WMD, Health care and EMS systems are instrumental in the planning and policy process for WMD local and state preparedness.
Data and Information System Surveillance
Background
Complete EMS data is frequently missing at the state, regional and local levels. Data is an important component to a coordinated EMS response and surveillance system. EMS will be the initial contact in the majority, if not all chemical, nuclear, or biological events. EMS data systems can monitor the patient population that EMS serves for signs of biological outbreaks. This data can be compared to the day-to-day normal trends to determine if an outbreak has occurred and where it is located within a community. EMS data is also critical from a resource utilization perspective. The ability to know what resources are available in a timely manner, with respect to equipment, personnel, and expertise is essential. Real-time EMS data must be collected at the local level and provided to the state EMS offices to integrate with local and state public health initiatives.
The National Association of State EMS Directors, with financial support from the National Highway Traffic Safety Administration and Health Resources and Services Administration, has coordinated the development of the National EMS Information System (NEMSIS). NEMSIS is a voluntary and coordinated approach to development and implement a National EMS Information System, including a National EMS Database. The NEMSIS Dataset and Data Dictionary were completed in late 2004. While no states are yet totally compliant with NEMSIS, approximately five (5) states are nearly compliant. Forty-eight states, the District of Columbia and three territories have signed a Memorandum of Agreement supporting NEMSIS.