Читать книгу Emergency Medical Services - Группа авторов - Страница 29

By 1978, many of the original problems and questions concerning EMS had come into focus. Many of the deficiencies identified in the 1966 NAS‐NRC report had been addressed, and progress was being made in many areas. Economic resources and political support were being contributed by local and state governments, private foundations, non‐profit organizations, and professional groups. However, there was still tremendous geographic variability regarding access to and distribution of services and accessibility, quality, and quantity of EMS resources. Basic questions concerning the effectiveness of the various components, system designs, and relationships still existed, and future funding was uncertain.

In 1978, the NAS‐NRC released Emergency Medical Services at Midpassage, which stated, “EMS in the United States in midpassage [is] urgently in need of midcourse corrections but uncertain as to the best direction and degree.” The report was sharply critical of how the EMS Systems Act had been implemented by DHEW and recommended “research and evaluation directed both to questions of immediate importance to EMS system development and to long‐range questions. Without adequate investment in both types of research, EMS in the United States will be in the same position of uncertainty a generation hence as it is today” [52]. The report documented coordination problems among various governmental agencies, focusing particular concern on the multiple standards promulgated as a condition of funding. Some of the standards were conflicting; often they had never been evaluated [52].

Between 1974 and 1981, there were various sources of federal and private funds, and each grant often came with a new set of requirements. DOT established standards for ambulance design, personnel training, and other transportation elements, and DHEW announced seven critical care areas as the basis for a systems approach and 15 components as modular elements for EMS design. A variety of private organizations also produced standards. With regard to the technique of CPR, the American Red Cross and the AHA established slightly different standards, criteria, and training requirements. By 1978, some states still had not enacted EMS legislation, whereas others had legislated specifically what prehospital clinicians could do, potentially hampering the flexibility needed for successful local development. Lack of national conformity or agreement precluded the development of universally accepted national standards in most areas of EMS.

On 26 October 1978, a memorandum of understanding was signed by DOT and DHEW describing each organization’s responsibilities relating to development of EMS systems. The agreement was an attempt to coordinate government activities and assign national level responsibility for EMS development and direction. DOT, in coordination with DHEW, was to “develop uniform standards and procedures for the transportation phases of emergency care and response.” DHEW was responsible, in coordination with DOT, for developing “medical standards and procedures for initial, supportive, and definitive care phases of EMS systems.” Research and technical assistance were to be performed cooperatively, and both agencies agreed to exchange information and “establish joint working arrangements from time to time” [53].

Because the roots, constituencies, and operating philosophies of DOT and DHEW were markedly different, the 1978 agreement quickly failed. Over the four subsequent years, the lack of coordination continued [54].

In 1980, the EMS directors from each state banded together to form the National Association of State EMS Directors (now NASEMSO). With membership from all 50 states and the territories, it attempted to take a leadership role with regard to national EMS policy, and to collaborate on the development of effective, integrated, community‐based, and consistent EMS systems. Its strategy was to “achieve our mission by the participation of all the states and territories, by being a strong national voice for EMS, an acknowledged key resource for EMS information and policy, and a leader in developing and disseminating evidence‐based decisions and policy” (https://nasemso.org/about/overview).