Feb 26, 2003 - Disparity in prehospital emergency care services around the world runs the gamut from .... a dispatch system, response, care, and transportation. ..... computer-based records software and to decide on uniform data points from.
Understanding Diversity Among Prehospital Care Delivery Systems Around the World Neal Sikka, MD Department of Emergency Medicine, The George Washington University, 2150 Pennsylvania Ave. NW, Suite 2B, Washington, DC 20037, USA
Gregg Margolis, MS, NREMT-P National Registry of Emergency Medical Technicians, Rocco V. Morando Bldg., 6610 Busch Blvd., Columbus, OH 43229, USA
A major global health problem of the second millennium is the rapid and extensive growth in noncommunicable diseases, including cardiovascular disease and injuries [1]. Heart attack and stroke join road trafc accidents as a major health care burden to all but the poorest of developing countries [1]. Investments in primary health care in developing countries continue to produce advances in global health. However, investments toward the improvement of emergency care fail to keep pace with the impact on health from urbanization, individual mobility, industrialization, and technology that often produce time-sensitive illness and injury. The worldwide definition of emergency care traditionally implies the rapid and appropriate care of victims of traumatic and medical emergencies [2]. Although a comprehensive emergency medical system is traditionally thought of as including all of the health care resources necessary to return an emergency patient to pre-event health (including, in some cases, surgery, in-patient care, intensive care, rehabilitation, etc.), the focus of this article is on the components of the system necessary to get the patient from the point of injury or illness to the hospital or place of definitive care—the phase of care often referred to as ''prehospital care.'' Disparity in prehospital emergency care services around the world runs the gamut from no organized system, to providing transportation only, to providing stabilizing basic care and transport, to extensive use of mobile intensive care units with field physicians. Those who plan, design, and
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manage health care systems around the world struggle to meet their country's unique health care needs, including emergency services. Prehospital systems must exist within a country's cultural, geographic, political, and primary health care infrastructure. In this article we provide an organized approach to analyze the variety of emergency medical services (EMS) systems that have developed around the world. Greater understanding of each dimension of the existing system can lead to strategically chosen initiatives for improvement.
Prehospital care systems Although emergency care represents a relatively small part of any country's health care system, citizens in many modern societies have come to expect, and sometimes demand, that an organized system to manage medical and traumatic emergencies exist in their community. In many cases, the media have created an unrealistically high public expectation that places tremendous pressure on policy makers to invest in the development of a comprehensive emergency medical system. Rampant growth in tourism and international business development has also spurred governmental interest in investing in prehospital systems. Additionally, there is increased awareness by policy makers that the morbidity associated with delayed resuscitation and transport of young, productive trauma victims can have a substantial financial impact on a community, region, or country. The goal of an emergency medical system is to decrease the morbidity and mortality associated with sudden medical and traumatic emergencies. The overwhelming majority of the time, emergencies occur outside of the hospital or health care setting. Therefore, a prehospital emergency medical system must involve an integrated and coordinated chain of resources that (1) notifies authorities when an incident has occurred; (2) dispatches the appropriate resources to the scene of the incident; (3) provides rapid and appropriate care; and (4) transports the patient to a facility that has the appropriate personnel and equipment necessary to manage the patient and to admit, refer, or otherwise dispose the case (Fig. 1). All of this must be done in a timely fashion, 24 hours a day, 7 days a week, 365 days a year. Development and maintenance of emergency medical services requires a considerable investment of resources. As in most other complex service-delivery systems, development of EMS programs requires an organized and well-calculated approach. A needs assessment is a necessary first step toward planning efective initiatives. Many developing countries are undergoing rapid urbanization and industrialization. The shift of people from rural to urban environments leads to increasing traumatic injury, work-related injuries, violence, and motor vehicle crashes [3]. Improvements in primary care and preventive care have shifted the epidemiology of disease from infectious to chronic disease
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Bystander care
Notification dispatch and response
Prehospital care
Transportation
Emergency Department Care
Definitive care (Surgery, Critical Care, etc)
Rehabilitation
Fig. 1. Chain of resources necessary for comprehensive care.
(eg, cardiovascular disease, stroke, diabetes, etc.) and acute trauma [3]. Understanding where a country might lie within this continuum is an important component of the needs assessment. A society that is already shifting to a more urbanized population sufering from noninfectious disease processes will display the need for more advanced emergency care. Evidence exists to support prehospital care interventions to reduce morbidity and mortality in this patient population [4,5]. It is important to understand the current level of infrastructure development and health care availability in a country when considering the development of EMS [6]. An assessment of adequate sanitation systems, potable water, public health education, and existing primary care services must be undertaken. Money may be better spent supporting these critical infrastructure needs before investment in EMS [3]. Adequate and timely surveillance of health care information is an important component of this assessment [7]. Old and incomplete information can lead to a misconception of the state of conditions and the future needs of the system [6,8]. Those faced with the task of developing an emergency medical system are strongly encouraged to keep a ''systems approach'' in mind. The system is only as strong as its weakest link. Ambulance systems developed at great expense may fall short of their potential. Within a country's resources, public education, access, training, equipment, and quality must be maximized. Failure to develop a comprehensive system leads to fragmentation and suboptimal care and to a considerable waste of resources.
Informal systems Many factors contribute to the development of a prehospital care and transportation system. Often, developing countries do not have the finances to invest in expensive prehospital equipment and training. Those resources may be better allocated toward various primary care and preventive measures that can improve the overall health of the citizens. Geography may play a role because urban centers may ofer a large population hub, but it
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may be inefcient and expensive to provide an ambulance service to rural and hard-to-reach communities. These isolated communities may be far from definitive care, and the large investment to transport a patient to the tertiary hospital would provide little survival benefit. The lack of development of hospital-based emergency care can also stifle a country's interest in investing in more sophisticated prehospital care. Finally, politicians often are not interested in improving prehospital care, especially when large, multilateral donor institutions continue to emphasize the necessity of improvement in primary care services. Informal systems are characterized by the absence of a planned response, care, and transport system. Because there is no organized approach to the injured or ill patient, little or no prehospital care takes place. Informal systems range from no prehospital care system to a rudimentary system. When no prehospital care system is in place, patients who become injured or suddenly ill outside of the hospital must rely on family, friends, or strangers to provide transportation to a health care facility. In many countries, rudimentary systems have evolved. They exist when individuals, whose primary role is not emergency care, provide transportation for emergency patients. This is not a formal response system but is often provided by other public servants (often police or fire personnel) in vehicles that were not intended for medical care and transport. In rudimentary systems, the main emphasis is on transportation of emergency patients. In some countries, taxi drivers play a large role in the transportation of medical and traumatic emergencies. Some rudimentary systems have begun to provide basic first aid training to those who provide transportation; however, medical care is typically not their primary role or responsibility [9]. In rudimentary systems, because transportation is generally performed in vehicles not intended for patient care, there is little or no care provided at the scene or en route to the hospital. Policy makers, health care providers, and those with interest in developing international EMS systems may have varying views on the needs of a particular country. An informal system may not be an inadequate system. Consider, for example, the use of bystander, taxi, and police vehicles to transport patients from the scene of an accident to the hospital. This mode of transportation may be the most efcient means of arriving at the hospital in heavily populated and trafc-congested cities such as Kuala Lampur with significantly less cost than a more sophisticated ambulance service [10]. Studies conducted in Northern Iraq, Cambodia, and Ghana showed that, even without a formal EMS system, there was significant improvement after training lay persons in basic trauma care or first aid [9,11]. Opportunities for low-cost interventions in countries with informal prehospital care systems should be sought. Interventions such as the training of bystanders, first responders, and Good Samaritans in first aid and trauma care can be a relatively low cost and efective way to improve prehospital
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care [9,11]. VanRooyen et al [3] proposed building on essential EMS components, such as manpower, training, communications, transportation, facilities, access to care, and coordinated patient record-keeping. As resources become more available, gradual improvements in the systems can occur [3].
Formal systems Formal systems exist where there are services in place to respond and provide transportation to patients from the field to definitive care. Most formal systems include some type of access number, a call-taking system, a dispatch system, response, care, and transportation. A formal system can be further classified as ''incomplete'' and ''universal.'' A formal system is incomplete if it does not provide access to prehospital emergency medical response to all patients at all times. This is a common situation in developing countries and within countries with developing systems that may not have adequate resources to provide adequate coverage 24 hours a day every day. Economic (eg, ability to pay, insured, etc.) or geographic (EMS is available in some communities/neighborhoods and not others) variables may result in incomplete access. A formal system is considered universal only if it provides access to prehospital emergency medical response to all patients at all times. The system is accessible to anyone in need, regardless of ability to pay or geographic location. There is limited value in developing an EMS system if the public cannot access it. Developing systems must incorporate mechanisms to educate citizens about the services available to them. Educational campaigns that teach citizens about basic life-saving techniques and first aid can help them understand the utility of prehospital care. Visible and active community involvement by EMS personnel can make people feel more comfortable using the services available to them. Other important mechanisms that can help the public embrace EMS services include public service announcements, elementary school educational sessions for children, and the media, with television shows such as ''Emergency,'' ''911,'' and ''Third Watch.'' Citizens must learn to recognize emergencies, such as heart attack and stroke, and be able to initiate an emergency response. Once the emergency is recognized, there needs to be a simple way to access emergency services. Many countries have initiated city-wide, region-wide, and even nationwide access numbers, such as 911 in the United States, which is available to about 90% of the population. In Korea one would call 119 and in China 120, but these access numbers reach a limited part of the urban population [12,13]. Enhancement of the access number with computer-aided dispatch can provide caller location, and welltrained EMDs can provide emergency instruction to the caller until help arrives.
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Personnel The current level of emergency care afects the true benefit of prehospital care system development. If no hospital-based emergency care system exists, then there is little value in rapid transport of patients via an ambulance service [6]. Just as there are various stafng models of providing hospital-based acute care, prehospital care stafng displays similar diversity. EMS systems may staf ambulanceservices with driverswith no training,first aid providers, basic emergency medical technicians (EMTs), paramedics, nurses, or physicians. Physician-based and nonphysician-based are the two primary mechanisms for ambulance stafng. In many countries, including the United States, United Kingdom, Canada, Australia, and Hong Kong, resources are allocated toward training hospital-based physicians to become emergency medicine specialists and nonphysician providers to provide prehospital care [14,15]. First-aid providers, basic EMTs, and paramedics operate as physician surrogates in the field under the auspices of a physician medical director. Typically, they perform their duties based on pre-established protocols and have access to an online medical control physician when they need consultation or must deviate from protocols. Other systems, such as in Singapore and Dubai, rely on nurses to provide similar out-of-hospital care [16]. In resource-poor systems and in cultures where patients do not accept the provision of medical care from nonphysician providers, there may only be a driver with limited first aid skills to transport the patient to the hospital [12]. In some systems, when patients present to the hospital emergency department, they may be tended to by physicians in training, medical ofcers, or on-call physicians with inadequate training [17,18]. Others countries use the ''Franco-German model'' by taking the physician to the patient [4]. In this model, physicians who may have specialized training in emergency medicine or anesthesiology ride in ambulances and provide stabilizing care in the field [6]. However, many countries around the world do not train physicians well in trauma care, and services may be provided by recent medical graduates or interns [8]. In the Franco-German model, the need for well-developed, hospital-based emergency care may be mitigated because the patient can be directly admitted to the hospital specialty service. In a number of countries using this model, the physician can evaluate, treat, and discharge the patient in the field without having to transport the patient to the hospital [19].
Level of service and equipment The level of prehospital service provided depends on many factors, including the training of personnel and adequacy of equipment. Equipment is expensive and requires ongoing maintenance and specific training for appropriate use. An EMS service can be classified by the level of equipment and personnel available to make interventions in the field. The simplest level
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of service can be classified as rudimentary. Vehicles that carry just a bed and oxygen tank may be stafed by drivers with little or no medical training, as in Chennai, India [20]. In Bangkok, Thailand, three diferent volunteer services use pick-up trucks supplied with first aid kits and oxygen to transport patients to hospitals [21]. They scan police radio bands and take direct calls to locate people in need of help [21]. The ''basic'' classification of care describes a higher level of service. Ambulances are the transport vehicles, and a basic ambulance may carry backboards, cervical collars, splints, bandages, and oxygen. The personnel may have some training on the appropriate application of these materials but may not have a formal certificate or licensure. The American and French EMS systems provide a model of the ''advanced'' level of care. The system is organized and has well-equipped ambulances for advanced trauma and cardiac life support that have cardiac monitors, defibrillators, a limited number of resuscitation drugs, and possibly an external pacer and ventilator [22]. Prehospital providers have formal and practical training on the use of all equipment.
Service providers Within formal systems there are multiple service provider models categorized as private/NGO run, government/state run, hospital based, or mixed. In New Delhi, India, the Apollo hospital group supports its own feefor-service ambulance system [23]. In Izmir, Turkey, one ambulance system is stafed by a physician and trained EMTs and is sponsored by the public health department [24]. The prehospital system in Johannesburg, South Africa can be described as a formal, advanced-level, hospital-based system. Ground and air transport air available. Prehospital care providers undergo formal training courses conducted by Johannesburg General Hospital and can complete a National Diploma course in Ambulance and Emergency Care [25]. The Republic of Trinidad and Tobago has a mixed system of ambulance services provided by the Fire Department, Red Cross, and volunteers [26]. Similarly, EMS in the Seychelles Islands exist as mixed systems with varying levels of care. This formal ''incomplete'' system for the Islands provides limited access for most acutely injured patients that must rely on bystanders to transport them to the hospital [27]. However, if a call is made directly to the Victoria Hospital, the hospital-based ambulance equipped with basic life-support equipment may be dispatched. These ambulances are stafed with physicians, nurses, and a driver (Fig. 2) [27].
Country example Emergency medical systems in the United States Prehospital care in the United States augments what is described as a mature system for providing emergency care (Fig. 3) [28]. Some form of
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Informal
Formal
Absence of any system
Incomplete
Rudimentary
Universal
Personnel Driver
Service Providers
Equipment
First Responders
Private/NGO
Rudimentary
Basic EMT
Government
Basic
Paramedic
Hospital Based
Advanced
Nurse
Mixed
Physician
Training
Focus Trauma Acute Medical Emergencies
Absence of any training Non Prehospital Specific
Comprehensive
Fig. 2. Dimensions for analysis of EMS systems.
prehospital care exists in every community in the nation, including urban and rural areas. Prehospital care is typically performed by health care providers with a variety of levels of training, certification, and licensure (including First Responder, EMT-Basic, EMT-Intermediate, and Paramedic). Physicians provide medical direction and support prehospital care providers by participating in continuing education, quality assurance, and direct and indirect medical control. EMS systems exist as public services sponsored by local or state governments or as private companies. Ambulance personnel are made up of dedicated prehospital care providers, some of whom are cross trained to provide other public services, such as fire suppression or law enforcement. Many are paid, and some, especially in rural communities, are volunteers. In the United States, a citizen initiates the EMS system by calling 911. This call is typically routed to a public safety answering point (PSAP) where the call is triaged as a police, fire, EMS, or combination response [29]. PSAP call takers follow protocols to triage each call and pass the information to a dispatcher who interacts with the appropriate responders. Once the call is triaged to EMS, there may be a special EMD who interacts with the caller to gather the critical medical information through an algorithmic set of questions and provides pre-arrival instructions.
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Formal Universal
Personnel
Training
Paramedic based
Prehospital Care Specific
Service Provider
Equipment
Mixed
Advanced
Focus Comprehensive
Fig. 3. Dimensional analysis of EMS in the United States.
In some communities, the type of ambulance response depends on the type of emergency and the level of care the victim may require. Communities in the United States use a single-tiered response, where all responses are at the Advanced Life Support (ALS) level or all at Basic Life Support (BLS) level, or a mixed response to prioritize calls, where a BLS, ALS, or a BLS followed by ALS response protocol is incorporated [30]. First Responders (eg, police or firefighters) are often deployed because they are likely to be the closest providers available and can begin to initiate care while the ambulance is en route. Optimal vehicle distribution and placement is critical to rapid response. Most systems target response times of 4 minutes for BLS units and 6 to 8 minutes for ALS units [31]. Vehicles may be placed strategically throughout a coverage area or housed with other public safety assets. Some systems use sophisticated methods of vehicle placement, using call volume data to place vehicles in areas where they are most likely to be needed during diferent times of the day. Each EMS systems face the challenge of maintaining equipment, personnel, and financing while providing superior EMS services. In an efort to provide high-quality and uniform care, communities throughout the United States have developed a heterogeneous collection of systems. Training For maximum efciency, the training of prehospital care providers should consider the needs of the overall emergency care system. Many
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systems in developing countries survive on minimum training and serve the sole purpose of basic transportation. Informal systems may benefit from low-cost educational interventions for laypersons. In Ghana, the implementation of a 6-hour first aid course for commercial drivers who often transport the ill and injured to the hospitals was undertaken. At 10-month follow-up, improvements in crash-scene management, airway management, bleeding control, and splinting were apparent [9]. In Northern Iraq and Cambodia, health care workers were given 150 hours of intensive in-field trauma care training over a 3-year period. Each health care worker was encouraged to train 50 first-responder laypersons. Along with limited medical equipment and drugs, this low-cost training program led to a significant decrease in trauma mortality [11]. Similar interventions are an important mechanism for improving prehospital care in countries with informal EMS systems. In countries with formal EMS systems, an organized approach to the training and education of prehospital care providers is critical. In Monterrey, Mexico, paramedics were taught Prehospital Trauma Life Support. After the intervention, there was an increase in the number of patients who received c-spine immobilization, airway support, suction, administration of oxygen, and intravenous lines for hypotension [32]. There was a significant decrease in the number of deaths that occurred during transport to hospital [32]. Despite this apparently successful intervention and the widespread teaching of Advanced Trauma Life Support or Advanced Cardiac Life Support, there is some evidence that these advanced interventions ofer limited value to patients in urban environments [4]. Many countries have a legislation and licensure/certification system to standardize the levels of training and skill that prehospital personnel can provide. As in the United States, the United Kingdom, and Australia, many countries have multiple levels of training and national certification programs. In countries with rudimentary services, any training is probably better than no training, and certification of personnel may be of little benefit. As the prehospital system formalizes, measuring and certifying the competency of the providers is necessary to ensure quality care and to protect the public. In countries with even more advanced levels of care, prehospital providers have the opportunity to make more significant interventions in the field, which demands a high degree of accountability. Although many successful models exist, one strategy to develop prehospital educational programs is to partner with countries that have existing programs. ''Train the trainer programs'' and pre-established international courses can be efcient ways to educate prehospital providers. These developing systems may benefit from interdisciplinary programs with hospital-based and prehospital providers in the same classes. Some training programs lack the ability to provide adequate practical skills training. New providers need a context in which they can
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apply their fresh knowledge through drills. Prehospital care providers benefit from clinical rotations in a hospital setting. These rotations provide them with the opportunity to practice and refine their emergency triage, assessment, and treatment skills in a supervised setting. These techniques also allow for increased camaraderie between prehospital providers and hospital-based providers. Although it is generally accepted that prehospital-specific training can lead to improved out-of-hospital care, many systems have evolved with no specific prehospital training. Some systems have physicians who have extensive medical training but no training specific to prehospital care. This is the case in Germany, where most EMS physicians are trained in anesthesia, surgery, or internal medicine [33]. These physicians are not required to have special training in advanced cardiac or trauma life support and spend a small part of their practice time in field care [33]. Even the emergency medicine training may not provide some of the skills unique to prehospital care.
Emergency medical system focus Analysis of mature EMS systems has revealed a predictable broadening of focus as the system evolves. Many systems begin with a focus on trauma and rapidly expand to include all emergencies and then strive to incorporate concepts of public health (Fig. 4).
Comprehensive Public Health approach to out-of-hospital community health
Acute Emergencies (medical and Trauma)
Trauma
Fig. 4. The expansion of focus found in maturing EMS systems.
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The modern EMS system envisioned for the United States began as a trauma response system intended to reduce the morbidity and mortality associated with motor vehicle trauma. It became quickly apparent that once the emergency medical system was developed and the public was made aware of its capabilities, it would be used for more than response to traumatic emergencies. The widespread public education about EMS, combined with the rapid evolution of the science of resuscitation medicine (especially cardiopulmonary resuscitation and defibrillation), resulted in a rapid transformation of the American EMS system from a trauma system to a comprehensive prehospital emergency care and transportation system. Trauma represents a minority of the call volume in every EMS system in the United States. This transformation occurs in many countries planning the development of emergency medical systems. Traumatic injuries represent a major public health issue and cannot be ignored; however, the system intended to respond to motor vehicle crashes can also be used to respond to equally critical medical emergencies with little adverse efect on trauma response capabilities and with a comparatively little increase in cost and training. The overwhelming cost of the system is in infrastructure, and the marginal expense of responding to medical and traumatic emergencies is relatively small. The experience of mature EMS systems indicates that once the public becomes familiar with the existence of the system, they expect a response for any emergency, not only traumatic incidences. Once EMS has been successful in building a solid foundation of prehospital response, care, and transportation for patients sufering acute medical and traumatic emergencies, the natural evolution is to expand services into public health activities. As the EMS Agenda for the Future [34] states, ''EMS of the future [in the United States] will be community-based health management . .. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring.'' The challenge is to provide such public health services while still responding to acute traumatic and medical incidences. Numerous developing systems have experienced this expansion of focus, with Australia having been most successful in integrating concepts of public health into prehospital emergency medical services. Health care delivery is a national program in Australia; therefore, prehospital care services can be integrated with primary health care and public health services. Prehospital practitioners are finding new roles that may not be emergent in nature, such as injury prevention and public health surveillance (A.J. Hertelendy, personal communication, May 2004). Countries considering the development of an EMS system are generally encouraged to build a system initially with a focus on acute medical and traumatic emergencies. Once that system has gained experience and maturation, the incorporation of public health concepts is strongly
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encouraged. The application of such concepts, with a modest investment in a mature EMS system, can have a significant efect on unmet community health needs.
Universal emergency medical system challenges Financing Rising health care expenditures make funding prehospital care systems difcult and poses a larger challenge for the future. Three mechanism of financing exist: (1) government funding, (2) user fees, and (3) third-party funding. Government funding is essentially through taxes. In some countries, citizens' income or property taxes can fund ambulance services. Other countries may generate large amounts of revenue from increased influx of tourism dollars or international private companies. Another option that has been used in the state of Nevada, among others, is the idea of ''sin'' taxes [35]. Taxes are collected on items such as cigarettes, alcohol, and prostitution to pay for services such as emergency care. User fees are the controversial practice of charging patients to ofset the cost of ambulance transport. The first user fees were incorporated by the city of Chicago in 1985 [36]. They were initiated to help capture thirdparty reimbursement from Medicare and HMOs. This allowed the city to reallocate tax dollars to other necessary city services. Where third-party payer systems exist, they often pay for part or all of emergency transportation costs. Other third-party payers include multinational corporations. These large companies may be opening large manufacturing sites in lessdeveloped countries. The companies benefit their employees and cut costs from disability and lost work time by investing in the local emergency care system. Multinational lending institutions may also provide funding sources for health care interventions. By emphasizing that emergency services are essential components of the health care infrastructure of a country, some countries have been able to direct primary care funding toward EMS. Quality assurance Outcomes data are necessary to justify the large resource allocation necessary for long-term existence and growth of prehospital care systems. Good quality assurance systems put in place during the development of an EMS system guide the development and sophistication of the interventions that prehospital providers can perform. Some areas to address are response time intervals, practical skills performance, customer service, equipment maintenance, and continuing education. Protocol adherence and evaluation along with medical control are other necessary components of quality
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assurance. Medical control is often a shared responsibility of multiple hospital-based emergency physicians [37]. It is important that developing systems include a designated and dedicated medical director that provides oversight of the entire system and oversees quality indicators [37]. Research Improving the quality and the quantity of research in the field of prehospital medicine is critical for continued improvement in patient care. In developing countries, research components of EMS systems should be linked with quality improvement eforts. Evaluating prehospital care is challenging primarily because of the lack of standards for record keeping and data collection points. Poor prehospital care records coupled with poor hospital-based medical records systems add to the challenge [37]. Nations early in the process of developing medical records are advised to invest in computer-based records software and to decide on uniform data points from the systems inception. The apparent diversity in prehospital care systems makes it impossible to set international criteria for quality measures and research. Ambulance services exist under the control of various agencies. Training varies significantly among providers, from no training to sophisticated certification programs. Finally, we must respect the privacy of our patients. The issues of informed consent and emergency waivers of informed consent must be overcome before clinical research can be conducted. The experience of countries with formal advanced prehospital care systems should provide guidance to countries developing new systems. This exchange can help the new system avoid the problems that occur with piece-meal development and an inadequate ability to measure the performance of the system. Implementation of an organized and cohesive data collection system will be a forward step toward answering the critical questions of EMS efciency, cost efectiveness, and quality care [38].
Summary Understanding the diversity in EMS systems around the world is a daunting challenge. It is difcult to describe or categorize these complex systems, but examination of whether a country has an informal or formal system is a starting point. Further understanding of access within the system allows additional insight into the care available. Personnel, training, equipment, communication systems, and service provider levels ofer clear information regarding the sophistication of the system. The focus of an EMS system can help gauge its development and role in the community. Clear descriptions of each of these dimensions allows for better communication and understanding of a country's prehospital care system. This dimensional analysis enhances communication regarding the existing system
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and provides an opportunity to understand where improvements and interventions might be efective.
Acknowledgments The authors thank Kristen Hill for her help in preparing the manuscript. They also express their appreciation for contributions made by Attila J. Hertelendy and Walt Alan Stoy.
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