Military Prehospital Care and Emergency Medical Service Systems

This Policy Resource and Education Paper is an explication of the Policy Statement Military Emergency Medical Services Systems.

October, 2009

Preamble

This policy resource and education paper (PREP) addresses the out-of-hospital care and emergency medical services (EMS) provided by the United States military services. Its intent is to address the EMS systems for those living, working, or visiting on US military installations, and those EMS services regularly offered by the military to the community at large. This document outlines the essential components of the out-of-hospital and EMS systems that should be available on all military installations whether the system is operated by the uniformed services, other government agencies, or contractually by outside agencies. It applies to all elements of the EMS system including all forms of transportation, out-of hospital emergency medical care, and communications. It is not intended to address the wartime or operational medical system.

System Organization

EMS System Defined An EMS system consists of those organizations, agencies, individuals, facilities, and equipment whose participation is required to ensure the timely and medically appropriate response to each request for out-of-hospital care and medical transportation.

Standards of Service Military installation out-of-hospital services and EMS should, in all cases, meet or exceed the prevailing community standard for all aspects of EMS and out-of-hospital care.

Lead Agency Each military installation should identify a lead agency for administration and management of the EMS system. A lead agency is the entity responsible for coordinating and administrating all aspects of the installation's EMS activities. The lead agency should be responsible for ensuring compliance with all applicable federal, state and local requirements and should facilitate cooperation and mutual support between the military and civilian EMS organizations.

Medical Direction All military EMS systems must have a medical director with responsibilities and authority as outlined by state or national guidelines. The medical director will be a licensed physician who has experience or training in out-of-hospital care and EMS, and who has completed a local, state, or nationally-recognized course in EMS medical direction.

Ambulance Service Emergency vehicles, ambulances, aircraft, and equipment must meet all applicable state and federal guidelines and community standards, at a minimum, with adjustments as necessary based on technological advances and local operational requirements. All emergency vehicle operators must be trained in accordance with US Department of Transportation (DOT)-recommended guidelines or equivalent. The recognized entry level for EMS providers is Emergency Medical Technician - Basic (EMT-B). All personnel with patient care responsibilities must meet this minimum standard regardless of installation location. Community standards may dictate higher levels of training. Personnel involved with specialty transports should receive additional courses of instruction commensurate with their responsibilities and in accordance with nationally recognized professional organizations' recommendations. Air ambulances should meet or exceed accepted community standards for emergency air medical services. Personnel who support unique operations (e.g., hazmat, tactical EMS) should receive additional, mission-specific training. All EMS personnel must be certified by the appropriate state or national (NREMT) organization and maintain certification through approved continuing education and other requirements as determined by the medical director in consultation with the lead agency.

First Response A key component of EMS is first response. Public safety agencies (e.g., fire and police services) should participate as integral members of the EMS system. Public safety agencies affiliated with the EMS system should ensure the availability of adequate equipment, communications, and trained personnel to provide safe extrication and first responder medical response, including automated external defibrillation, within the area of responsibility, while awaiting further EMS support. Specialized rescue teams (e.g., hazmat, confined space, or urban search and rescue teams) should be identified and affiliated with the system, if not integral to the system.

Communications EMS communications must ensure patient access, dispatch, on-line medical control, and interagency links. Direct telephone access (9-1-1) is a national goal and should be provided for all callers on the military installation. Communications personnel should be Emergency Medical Dispatcher (EMD) certified, or the equivalent, and should have the capability and training to provide caller interrogation, priority dispatch, triage instructions, and pre-arrival medical instructions.

Operational Policies

The lead agency for EMS should develop operational policies in accordance with national, state, and local requirements. These should address both clinical situations, through clinical protocols and standing orders, and administrative requirements. Scope of services and responsibilities of affiliated agencies should be well defined. All EMS systems, whether civilian or military, must cooperate and exchange resources in order to provide optimal service at all times. Optimal care of the patient must not be limited by installation boundaries. Therefore, the military EMS system must be fully integrated into the regional EMS system.

Human Resources and Education

Adequate staffing must be provided to meet anticipated demand and national and community standards for system performance. Personnel assigned to EMS duty should have EMS as a primary duty. The recognized entry level for EMS personnel is the US DOT EMT-B. All persons with patient care responsibilities, must, at minimum, meet this level of training. Community standards, however, may dictate a higher level of training. EMS personnel must be certified by the appropriate state or national (NREMT) organization, and maintain certification through approved continuing education and other requirements.

Transportation

Emergency vehicles, ambulances, aircraft, and equipment must meet all applicable state and federal guidelines, and, in all cases, meet the community standard as a minimum. All interfacility patient transfers must meet applicable guidelines as defined by COBRA/EMTALA, The Joint Commission, state, and federal regulations. Patient transfers by the military EMS system are under the direction of the military EMS medical director, with consultation as appropriate.

Facilities

Military medical treatment facilities that receive ambulance patients should be properly accredited and meet applicable federal, state, and local requirements for receiving patients transported by ambulance.¹ If these facilities cannot provide appropriate levels of care to transported or received patients, interfacility transfers must be arranged to meet applicable guidelines and regulations.

Public Information and Education

A critical component of an optimal EMS system is public education. The military EMS system should educate those living, working, and visiting the installation in matters regarding EMS, including access and availability of EMS, CPR and first aid training, and injury and illness prevention.

Continuous Quality Improvement

The continuous quality improvement process is a fundamental part of any successful EMS program. The full support of the installation, its leaders, and EMS personnel is critical for the quality improvement program to effectively assess and improve the system. All elements of the EMS system, including first responders and communications systems, must be encompassed by this ongoing assessment.

Disaster Management & Mass Casualty/Major Incident Planning

Military out-of-hospital systems should be integrated into the installation's and community's disaster plan. Full participation helps ensure optimal disaster mitigation for all persons affected by the disaster.

REFERENCES

1. American College of Emergency Physicians: Medical Direction of Emergency Medical Services.  Policy Statement. Dallas, 2005.
2. American College of Emergency Physicians: Early Defibrillation Programs. Policy Statement. Dallas, 2006. National Association of EMS Physicians. Position Statement: Emergency Medical Dispatch. November 2007.
3. Emergency Cardiac Care Committee and Subcommittees, AHA: Ensuring effectiveness of community-wide emergency cardiac care. JAMA 1992; 268: 2289-2295.
4. Principles of EMS Systems, 3rd Ed., American College of Emergency Physicians, Dallas, 2005.
5. Federal Specifications - Ambulance KKK - A - 1822C Emergency Medical Care Surface Vehicle, Washington, DC, DOT and GSA, 1990.
6. American College of Emergency Physicians: Equipment for Ambulances. Policy Statement. Dallas, 2007.
7. American College of Emergency Physicians: Prehospital Advanced Life Support skills, medications and equipment. Ann Emerg Med 1988; 17: 1109-1111.