ACCESS TO QUALITY HEALTH SERVICES IN RURAL AREAS - EMERGENCY MEDICAL SERVICES
by Cortney Rawlinson and Paul Crews
One Healthy People 2010 goal is to improve access to comprehensive, high quality health care services.1 According to the Rural Healthy People 2010 (RHP2010) survey, access to quality health services (which includes emergency medical services) was ranked as the top rural health priority. In a preliminary survey of state and national rural experts conducted by RHP2010, emergency medical response was frequently named specifically as a major rural health problem.2
The following Healthy People 20101 objectives are among those addressed in the discussion of emergency medical services:
Emergency medical services is the umbrella term for a continuum of health services including pre-hospital medical services, emergency services provided at the hospital or health center, and the trauma system that often serves as the network of coordinated trauma care.
Due to a variety of factors including availability of professional and paraprofessional service providers, geographic barriers, and resource constraints, there is a wide disparity in emergency medical services between rural and urban areas.3-5 The shortage of qualified medical professionals and other essential personnel, accompanied by a lack of other resources, poses great challenges for the provision of adequate care and treatment to patients following initial stabilization.6
PREVALENCE
Emergency medical services are the vital extension of emergency care from the community to the hospital emergency room. Injuries in rural areas tend to be greater in severity than those in urban areas.4 Only one-third of all motor vehicle accidents occur in rural areas, yet two-thirds of the deaths attributed to these accidents occur on rural roads.7
Volunteers constitute up to 90 percent of emergency medical service teams in rural frontier areas,4 and many of these areas depend on basic emergency medical technicians (EMTs). Therefore, trauma patients in rural areas who have a greater likelihood of needing advanced care are less likely to receive it.
Hospital emergency departments in rural areas encounter many challenges. Chief among these is staffing. Many of the emergency room directors are not specialists in emergency medicine, and for those who are specialized, the low volume of patients creates an environment not conducive to maintaining those skills.4, 8 Providing 24-hour availability of emergency room staff is also a problem; often nurses are relied on until the physician arrives.9 Financial constraints also exist for these facilities serving a small population, making it difficult for them to offer needed trauma services.4
Trauma systems primarily function as a statewide system, pulling together multiple health-care components in an effort to ensure timely response and transport times of injured patients to facilities that, when patients are received, will provide adequate resources and personnel for their treatment.10 Studies have been conducted that support the positive effect of these systems for urban areas, with the effect on rural areas now also being discovered.11
Children account for 25 percent of injury victims, approximately 10 percent of emergency response transports, and one-third of emergency department visits.12, 13 For those from age six through 18 in rural areas, vehicular injury is the most common reason for calls made to EMS.13 One rural study points to motor vehicle crashes along with falls and recreational activities accounting for over one-half of all pediatric injuries.14
The timeliness of
The effectiveness of trauma systems on mortality rates in rural areas has yet to be clearly determined. Many studies compare those patients who were stabilized in an outlying hospital before being transferred to a higher-level facility to those who were directly admitted to the latter facility. One such study found no difference in the mortality rates between those two types of patients. Several other studies show indirect support for the advantages of trauma system implementation.19, 20 There is also evidence supporting negative consequences associated with the transportation of patients to other facilities after stabilization.21
Mortality rates have also been compared between urban pediatric and non-pediatric trauma centers and rural non-pediatric trauma centers. In one study, the centers specifically designed for pediatrics received more pedestrian injuries and falls, while rural non-pediatric centers received more motor vehicle accident passengers. Death rates were the greatest for these rural non-pediatric centers, at 6.2 percent. Both pediatric and non-pediatric centers in urban areas had similar death rates yet were significantly lower than their rural counterparts.12
BARRIERS
Emergency medical services in rural areas face many challenges, making it difficult to provide adequate and timely service to each surrounding area. Providers of these services are often volunteers who have received only the most basic of training.3, 4 These volunteers typically must also report to the unit before actually traveling to the scene, contributing to the response delay.17 Lack of financial resources also factor into a community’s ability to provide adequate and efficient EMS equipment and services.3, 22
Physician recruitment and retention are two major problems rural hospitals face. General and family practitioners are frequently relied upon to provide hospital-based emergency care in rural areas, while many are not adequately trained or certified to do so.6 Many hospitals are contracting out these services to provide emergency coverage, but in doing so, incur great financial burdens.23
Trauma systems experience
many of the same challenges as the rest of
There are a number of
solutions that are feasible to improve
For in-hospital emergency care, telemedicine offers rural facilities the opportunity to take advantage of the skills and knowledge of those in other locations.26 Trauma systems, when implemented in rural areas, should incorporate other services in addition to making tertiary care available at a Level I or II trauma center. Trauma prevention must be promoted; all participants of the referring and accepting institutions should share responsibility for the trauma patients; and referring patterns should be bi-directional, as to allow for those patients who can be appropriately cared for in a smaller hospital, to be “back referred” from the larger facilities.27 Cooperation at each of these levels may help achieve a goal of having the Level I and II centers contribute to the development of the Level III centers.
Implementing a statewide surveillance system is one potential solution suggested to aid in providing effective and efficient emergency medical services to children. The system would allow the identification of specific injury patterns, allowing the development of prevention programs that focus on those injuries for which a particular area is at a higher risk.28 Education of pre-hospital providers in the specific nature of care required for pediatric patients would also allow those children needing trauma services to receive the appropriate level of care.29, 30
Access to rural emergency medical services encompasses several elements including pre-hospital care, emergency room care, trauma systems, and pediatric care. Through close interaction, these elements constitute emergency medical care as a whole, but they must be analyzed individually for the entire system to be understood. Each component possesses its own unique challenges and issues, and it is only by taking all aspects of the problem into account that progress will be made.
The following models for practice are examples of programs utilized to address this rural health issue.
REFERENCES
1.
2. Gamm, L.; Hutchison, L.; Bellamy, G.; et al. Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health 18(1):9-14, 2002.
3. Stamas, P. Rural EMS: Who
are you and what do you need?
4. Office of Technology
Assessment. Rural emergency medical services-Special report. OTA Publ.
No OTA-H-445.
5. Bray, T.J. Design of the
northern
6. Williams, J.M.; Ehrlich,
P.F.; and
8. Reeder, L. Seeding clouds of change. The drought in rural EMS. Journal of Emergency Medical Services 14(6):42-49, 1989.
9. Spear, S.F. Life-threatening emergencies: Patterns of demand and response of a regional emergency medical services system. American Journal of Preventive Medicine 2(3):163-168, 1986.
10. Mann, N.C; Mullins, R.J.; Hedges, J.R.; et al. Mortality among seriously injured patients treated in remote rural trauma centers before and after implementation of a statewide trauma system. Medical Care 39(7):643-653, 2001.
11. Fassett, S., and Miles, P. Trauma in the rural setting. CRNA: The Clinical Forum for Nurse Anesthetists 8(1):13-21, 1997.
12. Nakayama, D.K.; Copes, W.S.; and Sacco, W. Differences in trauma care among pediatric and nonpediatric trauma centers. Journal of Pediatric Surgery 27(4):427-431, 1992.
13. Seidel, J.S.; Henderson, D.P.; Ward, P.; et al. Pediatric prehospital care in urban and rural areas. Pediatrics 88(4):681-690, 1991.
14. Serleth, H.J.; Cogbill,
T.H.; Perri, C.; et al. Pediatric trauma management in a rural
15. Trevillyan, J.; Abbott,
J.;
16. The
17.
18. Champion, H.R. Reducing highway deaths and disabilities with automatic wireless transmission of serious injury probability ratings from crash recorders to emergency medical services providers, 1999. <http://www.nhtsa.dot.gov/cars/problems/studies/acns/champion.htm>March 2002.
19. West, J.G. Validation of autopsy method for evaluating trauma care. Archives of Surgery 117(8):1033-1035, 1982.
20. West, J.G.; Cales, R.H.; and Gazzaniga, A.B. Impact of regionalization. The Orange County experience. Archives of Surgery 118(6):740-744, 1983.
21. Young, J.S.; Bassam, D.; Cephas, G.A.; et al. Interhospital versus direct scene transfer of major trauma patients in a rural trauma system. American Surgeon 64(1):88-91, 91-82, 1998.
22. Gallehr, J.E., and Vukov, L.F. Defining the benefits of rural emergency medical technician-defibrillation. Annals of Emergency Medicine 22(1):108-112, 1993.
23. Williamson, H.A.; Rosenblatt, R.A.; and Hart, L.G. Physician staffing of small rural hospital emergency departments: Rapid change and escalating cost. Journal of Rural Health 8(3):171-177, 1992.
24. Lerner, E.B.; Billittier, A.J.; Sikora, J.; et al. Use of a geographic information system to determine appropriate means of trauma patient transport. Academic Emergency Medicine 6(11):1127-1133, 1999.
25. Furbee, P.M. GIS
(geographic information systems) in
26. Rogers, F.B.; Ricci, M.; Caputo, M.; et al. The use of telemedicine for real-time video consultation between trauma center and community hospital in a rural setting improves early trauma care: Preliminary results. Journal of Trauma 51(6):1037-1041, 2001.
27. Flowe, K.M.; Cunningham, P.R.; and Foil, M.B. Rural trauma. Systems in evolution. Surgery Annual 27:29-39, 1995.
28. Svenson, J.E.; Spurlock, C.; and Nypaver, M. Factors associated with the higher traumatic death rate among rural children. Annals of Emergency Medicine 27(5):625-632, 1996.
29. Svenson, J.E.; Nypaver, M.; and Calhoun, R. Pediatric prehospital care: Epidemiology of use in a predominantly rural state. Pediatric Emergency Care 12(3):173-179, 1996.
30. Hirschfeld, J.A.
Emergency medical services for children in rural and frontier
31. O’Grady, M.J.; Mueller,
C.; and Wilensky, G.R. Essential research issues in rural health: The state
rural health director’s perspective. Policy Analysis Brief, Series W, Vol. 5
No. 1.
32.
<http://www.healthypeople.gov/LHI/>2002.
Chapter Suggested Citation
Rawlinson, C., and Crews, P.
(2003). Access to Quality Health Services in Rural Areas—Emergency Medical
Services. A companion document to Healthy People 2010. Volume 1.
MODELS FOR PRACTICE
FOCUS AREA: ACCESS (EMERGENCY MEDICAL SERVICES)
Program Name: Rural Health Community Systems
Location:
Problem Addressed: Rural Emergency Medical Services Access
Healthy People 2010 Objective: 1-11
Web Address: http://www.steubencony.org/emo/rhcs.html
SNAPSHOT
Rural Health Community
Systems (RHCS) was created in 1997 when the CEOs of Ira Davenport,
As a result of its activities, RHCS was chosen as an example of “best practice” by the National Rural Health Association EMS vision conference.
Blueprint: RHCS was created in 1997 and is an association of
nonprofit and proprietary corporations, public agencies, and individuals
providing health care and related services in central
The network identifies,
addresses, resolves, and monitors activities considered necessary for an
improved
Making a Difference: While RHCS does not report any outcomes measures, they have established community-oriented goals. These include:
Beginnings: In the
early 1990s, a study of primary care needs was done by the Health Systems
Agency, which indicated the need for a closer examination of how emergency
transportation was being handled in
Challenges and Solutions: As do many other community organizations, the network faces challenges with bureaucracy, poor communication, local tradition, and culture. To address these, RHCS reaches its constituents and promotes its activities through the development and implementation of a media day, press releases, newsletters, a website, word of mouth, community/school presentations, and personal contact. To subsidize funding shortfalls, the network depends on its members to provide in-kind services and continuously canvases for additional support through membership connections.
RHCS received the New York State Department of Health Dr. Martin Luther King Healthy Community award. It was also chosen as an example of “best practice” by the National Rural Health Association EMS vision conference.
PROGRAM CONTACT INFORMATION
Elizabeth E. Wattenberg
Rural Health Community Systems
Phone: (585) 593-2178
Fax: (585) 593-3321
MODELS FOR PRACTICE
FOCUS AREA: ACCESS (EMERGENCY MEDICAL SERVICES)
Program
Name: TENKIDS
Location:
Healthy People 2010 Objective: 1-11
Web Address: www.citmt.org
Providing continuing
education opportunities, training, and improved communication are challenges to
the provision of emergency medical services across the nation, but they are
particularly challenging in remote areas. The TENKIDS EMS Computer Network was
established to address this challenge in
Blueprint: A number of organizations contribute to the success
of this network. The Critical Illness and Trauma Foundation (CIT) provides
leadership, oversight, equipment acquisition, and some technical assistance.
The network provides asynchronous learning opportunities via interactive CD-ROM, web-based curricula, and web-cam interaction to responders in the field. The needs of the patient data collection system are met by providing a platform and necessary software. And, finally, an Internet-accessible bulletin board dedicated to Montana EMS issues helps to alleviate many communications challenges.
The backbone of the system is
a multi-media personal computer placed at each ambulance service administrative
office in the state. These individual computers are networked together by the
Internet, and specific software and programs are provided for data collection
and
Making a
Difference: More than 3,000 EMS
providers have participated in some form of training using the TENKIDS
infrastructure. Data collection processes have begun, and dozens of providers
each week utilize the TENKIDS bulletin board system as a routine communications
venue. The TENKIDS network has been featured in the premier
Beginnings: In 1995,
the Office of Rural Health Policy awarded the Critical Illness and Trauma
Foundation with a half million-dollar grant, while the Montana EMS and Injury
Prevention Section also received funding. The problems to be addressed were
identified through focus groups at various EMS conferences and through feedback
provided to the state EMS office and CIT. Working together, project leaders
built the infrastructure of the TENKIDS electronic community, installing
computer hardware and software in every licensed ambulance service in the
state. The
Challenges
and Solutions: High turnover rates
among volunteer
Other than technology updates and the need for ongoing technology training, both of which are supported through external funding resources, the overall maintenance of the system has been relatively inexpensive to maintain. Program staffing is provided via one paid and one donated staff member (each 50 percent time) and six to 10 volunteer staff. National and state publications, feature articles for various levels of media, professional meeting presentations, and “circuit rider” technology training all serve as a means to promote the network and increase awareness of it. The network has also received national recognition through the Peter F. Drucker Foundation for its non-profit leadership and internationally through the Stockholm Challenge for innovative technological applications.
Nels D. Sanddal, MS, REMT-B
Critical Illness and Trauma Foundation
Phone: (406) 585-2659
Fax: (406) 585-2741