An area is inaccessible to ground traffic.

The use of local ground resources would leave an area temporarily

without adequate resources.

.,..._ Facilities/Critical Care Units

In general, prehospital patients are transported to the closest appropriate medical facility. There are some situations

in which a patient's preference may dictate hospital desti ­

nation. One issue that has emerged as a product of hospital

overcrowding is ambulance diversion, where ambulances

may need to bypass the closest appropriate facility to transport to another center that has capacity. Another factor in

hospital destination is availability of specialty care for

time-critical diagnoses. Examples of field triage and transport for time-critical illnesses include designated "trauma

centers;' facilities with surgical teams and operating rooms

on standby; "stroke centers;' with immediately available

neurology and neurosurgical capabilities; and "cardiac

centers;' with cardiac catheterization laboratories and

therapeutic hypothermia resources readily available for

patients with acute coronary syndromes or cardiac arrest.

Obstetrical, pediatric, and burn centers are recognized in

some regions as specially designated receiving facilities.

.,..._ Public Safety Agencies

Prehospital responses are often coordinated efforts between

police, fire, and EMS personnel. Various paradigms for the

division of labor within a given municipality exist. Some of

the more common EMS structures include fire-based,

third-service, private, and hospital-based. Fire-based

ambulances are staffed and operated by the local fire

department, whereas in third-service systems, EMS are

separate from both police and fire departments. Private

ambulance companies may provide nonurgent transports

CHAPTER 9

or may operate under contract with local governments to

supplement or provide all emergency care for a municipality. Lastly, hospital-based ambulances have crews of

hospital-employed personnel dispatched on ambulances

owned by the hospital.

..... Consumer Participation/Public

Information and Education

An important aspect of most EMS operations is community service, ranging from public relations expositions to

educational initiatives like CPR training. It is also common

for public representatives to participate in the oversight

and decision making that takes place within a public EMS

organization. EMS is often described as existing at the

intersection of public safety and public health; EMS data

and personnel are a critical link in public health infrastructure and preventative interventions.

..... Patient Transfer

One of the primary purposes of EMS is to deliver patients

to the care that they need. In many cases, this involves

transport from the scene of an injury or medical event to a

receiving hospital, but it may also involve the transport of

a patient from one medical facility to another. A key legislative mandate set forth in the Emergency Medical

Treatment and Active Labor Act (EMTALA) is that an

appropriate medical screening exam must be performed to

identify emergent medical conditions that must be stabilized before a patient can be considered for transfer to

another facility. Receiving hospitals must explicitly accept

a transfer before a patient is transported.

..... Coordinated Patient Record Keeping

T�e method of charting varies from one system to another,

W1th many systems now implementing an electronic medical record. A significant barrier to prehospital research is

the tremendous variation that exists in charting methods,