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I I I I IIIII

Emergency Medical Services System Act of 1973 Following the close of the 92nd Con-

gress, frustration ran high in public and professional circles concerned with the adoption and funding of fed- eral emergency medical services legis- lation. More than one half dozen bills had been introduced before that ses- sion of Congress during 1971-72. Two had passed their respective houses of origin, only to die at the close of ses- sion for lack of time to compromise.

As the 93rd Congress convened in early 1973, that frustration felt by so many concerned for the quality of emergency medical services through- out these United States had dramat- ically heightened Congressional awareness of the need for legislation. Senator Alan Cranston (D-Calif.) and Congressman Paul Rogers (D-Fla.) quickly moved to introduce modified and viable EMS bills, redrafted from their experiences with the previous session.

The rest is pure and simple history. The passage of Senator Cranston's S.504 on May 15, 1973, was soon followed by adoption of Congressman Rogers' H.6458 by the House of Rep- resentatives on May 31, 1973. The sub- sequent amalgamation of the two bills through Conference Committee ac- tion set the stage for what fell only five votes short of being the first success- ful over-ride of a veto by President Nixon. Capitalizing on support for the concept of EMS and a rapidly devel- oping crisis between the President and the Congress, backers of the legisla- tion quickly reintroduced and ob- tained overwhelming Congressional support.

Then, after a short stay in Confer- ence Committee to settle the issue concerning percentage of funding to be allocated for rural EMS, S.2410 was placed before the President supported

by virtually the entire Congress in- cluding such Presidential stalwarts as then-Congressman Gerald Ford (R- Mich.). Thus, the "Emergency Med- ical Services Systems Act of 1973" be- came Public Law 93-154 by President Nixon's signature on November 16, 1973.

Since then, virtually all of the indi- viduals and organizations interested in emergency medical services have look- ed at P.L. 93-154, and its $185 million allocation, as the pot at the end of the rainbow for EMS. The passage of time has softened that excited perspective, to be sure, and there has been a great deal of bitterness and frustration con- cerning management of the Act by the federal bureaucracy. Of special con- cern has been the delay in the devel- opment and publication of regula- tions governing the actual admin- istration of the Act.

The following paragraphs briefly outline the content of P.L. 93-154 and the amount of monies which appear to be available, from where, and for whom.

ALLOCATION OF FUNDS

P.L. 93-154 basically allocates funds into three general areas: 1) planning, implementation and operation of EMS systems at local and regional levels; 2) research and evaluation of EMS methodologies, techniques, devices and delivery systems and 3) training programs in the techniques and meth- ods of providing EMS.

Virtually the entire range of pro- visions under P.L. 93-154 are pred- icated on a "system" concept, fre- quently referred to within the bu- reaucracy as "the 15 points." It is im- portant to recognize the necessity of relating these "15 points" to projects seeking funding through the Act.

THE 15 POINTS

The Law defines an EMS system to include:

1. An adequate number of health professions, allied health profes- sions, and other health personnel with appropriate training and ex- perience.

2. Appropriate training for the per- sonnel (including clinical train- ing) and continuing education pro- grams which:

a) are coordinated with other pro- grams in the system's service area which provide similar training and education;

b) emphasize recrui tment and necessary training of veterans of the Armed Forces with mil- itary training and experience in health care fields and of appro- priate public safety personnel in such areas.

3. Joining the personnel, facilities, and equipment of the system by a central communications system so that requests for emergency health care services will be handled by s facility which:

a) utilizes emergency medical telephonic screening;

b) utilizes or will utilize the uni- versal emergency telephone number 911;

c) will have direct communica- tion connections and intercon- nections with the personnel, facilities, and equipment of the system and with other appro- priate emergency medical ser- vices systems.

4. An adequate number of necessary ground, air, and water vehicles and other transportation facilities

Page 194 Journal of the American College of Emergency Physicians May/June 1974

to meet the individual character- istics of the system's service area:

a) vehicles and facilities which must meet appropriate stand- ards relating to location, de- sign, performance, and equip- ment;

b) operators and other personnel who must meet appropriate training and experience re- quirements for these vehicles and facilities.

5. An adequate number of easily accessible emergency medical ser- vices facilities which are col- lectively capable of providing ser- vices on a continuous basis, which have appropriate standards re- lating to capacity, location, per- sonnel and equipment, and which are coordinated with other health care facilities of the system.

6. Provision for access (including ap- propriate transportation) to spe- cialized critical medical care units in the system's service area, or if there are no such units, or an inad- equate number of them in such areas, provisions for access to such units in neighboring areas if ac- cess to such units is feasible in terms of time and distance.

7. Provision for the effective utiliza- tion of the appropriate personnel, facilities and equipment of each public safety agency providing emergency services in the sys- tem's service area.

8. Organization in a manner that provides persons who reside in the system's service area, and who have no professional training or fi- nancial interest in the provisions of health care, with an adequate opportunity to participate in the making of policy for the system.

9. Provision, without prior inquiry as to ability to pay, for necessary emergency medical services to all patients requiring such services.

10. Provision for transfer of patients to facilities and programs which offer such follow-up care and rehab- ilitation as is necessary to effect the maximum recovery of the pa- tient.

11. A standardized patient record- keeping system meeting appro- priate standards, which records shall cover the treatment of the patient from initial entry into the system through his discharge from it, and shall be consistent with en- suing patient records used in fol- low-up care and rehabilitation of the patient.

12. Programs of public education and information in the system's ser- vice area (taking into account the needs of visitors to, as well as resi- dents of, that area to know or be able to learn immediately the means of obtaining emergency medical services), which pro- grams stress the general dis- semination of information regard- ing appropriate methods of med- ical self-helf and first-aid and re- garding the availability of first-aid training programs in the area.

13. Periodic, comprehensive and inde- pendent review and evaluation of the extent and quality of the emer- gency health care services pro- vided in the system's service area, and submission to HEW of the re- ports of each such review and evaluation.

14. A plan to assure that the system will be capable of providing emer- gency medical services in the sys- tem's service area during mass casualties, natural disasters or na- tional emergencies.

15. Establishment of appropriate ar- rangements with emergency med- ical services systems or similar en- tities serving neighboring areas for the provision of emergency med- ical services on a reciprocal basis where access to such services would be more appropriate and effective in terms of the services available, time and distance.

ADMINISTRATIVE GUIDELINES

It should be quite clear from the range and scope of these "15 points" that relatively few areas in the United States can successfully qualify for funding. Administrative regulations governing guidelines and specifica- tions for each of the points appeared in

the Federal Register, Vol. 39, No. 62 - - Friday, March 29, 1974, (pp. 11759- 11760). These regulations greatly ex- pand on the requirements of each point and should, therefore, be care- fully reviewed.

PROVISIONS OF THE ACT

Planning, Implementation and Operation of EMS Systems

In order to be eligible to receive grant funds in this area of P.L. 93-154, the applicant must be (in order of priority for consideration):

1. A state;

2. A unit of general local govern- ment;

3. A public entity administering a compact or other regional ar- rangement or consortium;

4. Any other public entity and any non-profit private entity.

Applications for grants are to be submitted through the Regional Of- fices of the United States Department of Health, Education, and Welfare. A list of the Regional Offices, respective mailing addresses, and states in the ten regions follows this article.

Briefly, this major portion of the Act provides for:

Section 1202 Grants for feasibility studies and planning, $45,000 maxi- mum grants for 9 month maximum periods, with no matching local funds required.

Section 1203 Grants for establish- ing and initial operation of systems, 50-50 match required by local funds (provision has been made for 75-25 match in cases of "exceptional and demonstrable" need). Second grants made to recipients under this section, incidentally, may not be eligible for more than 25 percent federal funds, re- quiring 75 percent local match (50-50 in cases of exceptional financial need).

Section 1204 Grants for expansion and improvement of existing systems, 50-50 match (again, provision for 75 federal-25 local match has been made for exceptional need situations).

Detailed information on each of these "Section Grants" is obtainable

gay/June 1974 Journal of the American College of Emergency Physicians Page 195

from your DHEW Regional Health Administrator.

Research and Evaluation of EMS Methodologies, Techniques, Devices, and Delivery

Under the provisions of P.L. 93-154, research projects will be funded to ex- plore the development of useful and valid data directed at as.sisting with the designing of community EMS sys- tems, as well as for the development of improved EMS policies. To use the jargon of the bureaucracy, "Projects using experimental or quasi-experi- mental designs are particularly desir- able to improve the validity and gen- eralizability of research results, and in terdisc ipl inary approaches are strongly encouraged."

EMS systems research grants are obtainable by public and non-profit private agencies, and through special contracts to private (profit or non- profit) entities or individuals. Appli- cations for such grants will be eval- uated through a "peer review group" mechanism, and must be of the high- est order of sound research design, necessary to answer the complex ques- tions involved with the improvement of emergency medical services.

section 1205 Grants for research in EMS require no matching funds, and will generally be limited to a max- imum of approximately $35,000.

For additional information con- cerning research grants, contact:

Bureau of Health Services Research Attention: EMS Health Resources Administration 5600 Fishers Lane Rockville, Maryland 20852

Training Programs in the Techniques and Methods of Providing EMS

This area of P.L. 93-154 will pro- vide grant funds for assisting eligible educational entities in the establish- ment, improvement or expansion of training programs in the techniques and methods of providing emergency medical services, including the skills required in connection with the provi- sion of ambulance services, and which

will contribute to the establishment, improvement, operation or expansion of emergency medica l services systems. Eligibility as an "educa- tional entity" is defined as:

" . . . a public or non-profit pri- vate school of medicine, osteop- athy or dentistry as defined in Section 724 of the Public Health Services Act, which is accred- ited as provided in Section 775 (b) (2) of the Act, a school of nursing as defined in Section 843 of the Act, or professions as de- fined in Section 795 (1) of the Act, or a public or non-profit pri- vate organization which has education as a major function and which itself delivers emer- gency medical services or has a written agreement with an or- ganization which delivers such services, whereby such organ- ization will provide the setting for clinical experience required for the proposed training." (The Federal Register, Vol. 39, No. 83 - - Monday, April 29, 1974.)

It should be noted that priority of funding for training grants will be giv- en to applications, otherwise eligible, received from recipients of Section 1203 and Section 1204 grant awards. Additional information may be ob- tained from the DHEW Regional Of- rices.

EMS APPROPRIATIONS FOR P.L. 93-154

Even though the Act authorizes $185 million for emergency medical ser- vices, it is probable that less than half of that amount will be appropriated and spent prior to the expiration of funding authority in 1976. For ex- ample, of the $45 million total author- ization for Fiscal Year 1974 (ending June 30), only $26.9 million was ap- propriated. At the time of this writ- ing, not even the first dollar had yet been spent!

Similarly, for Fiscal Year 1975, of $65 million authorized by the Act, DHEW has requested only $26.9 mil- lion of the Congress in its appropria- tion bill. Finally, and interestingly enough, of the $75 million authorized

for Fiscal Year 1976, none is allocated to planning, research or training!

in the following chart, the EMS Act is summarized by category; fiscal year; authorized funding, appropriated funding and requested funding; and projected numbers of projects to be funded. It should be kept in mind that a minimum of 20 percent of all funds appropriated for EMS are mandated for "rural" expenditure, where "rural" has been effectively and cleverly de- fined as population areas under 50,- 000.

EMERGENCY CARE CONFERENCE IN WISCONSIN ANNOUNCED

Emergency Care is the topic of a five day conference to be held August 12- 16, 1974 under the sponsorship of the University of Wisconsin Center for Health Sciences. Lectures by physi- cians as well as work practice demon- strations will describe methods of eval- uating, treating, and transporting emergency patients.

For registration information, write to Vincent Geier, Department of Con- tinuing Medical Education, 610 Wal- nut Street, Madison, Wisconsin 53706.

WEST COAST EM PROGRAM

Harbor General Hospital in Tor. rance, California will be the site of an intensive two-week postgraduate course for physicians in emergency medicine, October 21 to November 1, 1974. The course is entitled, "Emer- gency Department Medicine in Prac. tice."

Information on the course may be obtained by contacting Norman J. Diamond, MD, Harbor General Hos- pital, 1000 West Carson Street, Tor- rance, California 90509; telephone (213) 328-2380, extension 1285.

CHEST PHYSICIANS MOVE OFFICE

The American College of Chest Physicians has moved office facilities to 911 Busse Highway, Park Ridge, Ill. inois 60068. The telephone number at the Park Ridge office is (312) 698-2200.

Page 196 Journal of the American College of Emergency Physicians May/June 1974

1974-76 PRIORITIES SET AT ACEP WINTER WORKSHOP

The Fifth Winter Workshop of the American College of Emergency Phy- sicians was held March 19-20, 1974 at the Fairmont-Roosevelt Hotel in New

/ Orleans, Louisiana. There were 153 members of the College in attend- ance. They were composed of corn- mittee persons and other members who were interested in providing in- put to ACEP Committees.

Each committee met at least two times with several committees hold- ing additional sessions in order to ac- complish their work. ACEP members were present to attend committee meetings of their choice and gave ACEP leaders an opportunity to hear from the “members back home.”

Each committee provided a written report which was distributed to the Board of Directors in advance of their meeting held later in the week. Copies of the Workshop minutes are avail- able to members from the Head- quarters upon request.

LEARNING SYSTEM DESIGN APPLIED TO EMT TRAINING

Three self-instructional training packages for Emergency Medical Technicians - Ambulance (EMT-A) are being developed and pilot tested by the Tri-County Emergency Medical Services Council in Lansing, Michigan. The project is funded by the Michigan Association for Regional Medical Programs.

A national needs assessment survey had previously identified specific critical skill areas that are inadequate- ly taught in many 81-hour EMT courses. To improve patient care, the

,Jl’ri-County Emergency Medical Ser- vices Council training grant is focusing on three critical skill areas. Project Director David Spilker, MD, stresses that, “Too much of what has been call- ed training doesn’t really produce hands-on competency.”

“The Initial Patient Survey,” “Psychological Intervention,” and “Light Extrication and Use of the Backboard,” were identified as core content areas which were in need of a

formal learning system design. Charles from the costs of distributing the B. Maclean, PhD, Medical Education packages, communities with limited Director on the grant, specified these training budgets will be able to afford criteria for the packages: the relatively low-cost media pack-

1. Provision for a built-in waiver ages. The first two packages will be a-

option to be used by persons able vailable through the Michigan Asso-

to demonstrate mastery of the ciation for Regional Medical Pro-

skill. grams by September of 1974. Included

2. Ability ‘to produce stated in the package will be a practical

behavioral learning gains as waiver option, task description

demonstrated by pilot test data. checklist, self-review questions, self- instructional media modules, practice

3. Language and illustrations simulation kit and user manual. geared to the EMT’s level of un- derstanding and need.

For more information, contact David Spilker, MD, Project Director;

4. Presentation with a minimum of Tri-County Emergency Medical Ser- equipment. vices Council, 241 East Saginaw, East

5. Low production cost permitting Lansing, Michigan 48823.

wide distribution.

6. Adaptability for use with one EMT TRAINING FILMS OFFERED pair, or more, of learners.

A new resource is available to aid in 7. Capability of being used with, or

in place of, physician or other in- teaching the 81-hour EMT-A course. A films series titled “Basic Training

structor contact as necessary. Course for Emergency Medical Tech- 8. Able to be tailored to fit local nicians” has been prepared by the

needs. University of Kentucky Medical Col-

With support from the American lege, with support from the U.S. De-

College of Emergency Physicians, the partment of Transportation.

grant staff has convened three task The series consists of 21 films cov- description workshops of emergency ering the 14 medical/legal lessons in medical technicians, physicians and the basic EMT-A course. Each film nurses who are experts in the core con- follows the present instructor’s lesson tent areas. The consultants helped plan manual. determine for each of the three skill areas “What EMTs should be able to

The films may be purchased as a set

do, ” “How well they should be able to or individually from the Sales Branch,

do it,” and “What is an acceptable National Audiovisual Center (GSA),

demonstration of skill mastery.” Washington, D.C. 20409. The full set of 21 costs $2,084.25. They are not

By separating developmental costs available for rental.

Scientific exhibits for display at the combined ACEP/EDNA Scientific Assembly to be held in Washington, D.C. November 4-5-6 are currently being reviewed by the Scientific Assembly Subcommittee. Individuals or organizations wishing to enter an exhibit should contact Ronald L. Krome, MD, ACEP, 241 E. Saginaw, East Lansing, Michigan 48823, with information about the

~ proposed exhibit.

May/June 1974 Journal of the Amencan College of Emergency Physlclans Page 197