From the State of California Emergency Medical Service Authority (Daniel R. Smiley, Cheryl Starling, Jeff Rubin ), Sacramento, CA, USA; Ukraine Ministry of Health (Anna Loboda), Kiev, Ukraine
Correspondence to Daniel R. Smiley, State of California Emergency Medical Service Authority, Sacramento, CA, USA; Ukraine Ministry of Health, Kiev, Ukraine, USA. E-mail Dan.smiley@emsa.ca.gov
 

Fires, floods, earthquakes and other natural disasters continue to challenge disaster planners. The risk of terrorist attacks with biological, chemical, and nuclear weapons poses new policy and management challenges for governmental agencies that have the responsibility to respond to these threats.¹
Implementing these new priorities will require considerable organizational learning and change.^2-4 But agencies have deeply imbedded professional norms and organizational culture, and they are resistant to change even in times of crisis. Each agency responds with its own routines, and its own distinctive view of “the threat,” which impedes effective collaboration. Within the emergency medical services community, many organizations must be coordinated in order to achieve an effective response to the medical consequences of a disaster event. Additionally, new demands for effective and accountable disaster response are being heard worldwide.^3,4 The media and politicians require the best response possible to ensure the health and safety of the public.
The use of specific benchmarks for medical response can lead to continuous improvement in the overall readiness for EMS and hospital systems as they plan for earthquake response, and other natural or technological disasters involving mass casualties. The use of standard evaluation tools also allows for a comprehensive system formation.

The State of California Emergency Medical Services Authority (EMSA) is charged with providing leadership in developing and implementing EMS systems throughout California and setting standards for the training and scope of practice of various levels of EMS personnel. ⁵ The EMS Authority also has responsibility for promoting disaster medical preparedness throughout the state, and, when required, managing the state's medical response to major disasters. Emergency and disaster medical services in California are rooted in the skills and commitment of the first responders, EMTs, nurses, physicians, and administrators who deliver care to the public and operate the system. In order for high quality services to be delivered with high efficiency, all aspects of EMS systems must work together, mutually reinforcing and supporting each other for the benefit of the patient.^5,6 The California EMS Authority, through standard setting, consensus building, and leadership, plays a central role in improving the quality of emergency medical services available for all Californians.
In California, day-to-day EMS system management is the responsibility of the local and regional EMS agencies. It is principally through these agencies that the EMS Authority works to promote quality EMS services statewide. EMS Authority staff also work closely with many local, state and federal agencies and private enterprises with emergency and/or disaster medical services roles and responsibilities.
The EMS Authority provides statewide coordination and leadership for the planning, development, and implementation of local EMS systems. California has 32 local EMS systems that are providing emergency medical services for California's 58 counties. Seven regional EMS systems comprised of thirty-three counties and twenty-five single county agencies provide the services. Regional systems are usually comprised of small, more rural, less-populated counties and single-county systems generally exist in the larger and more urban counties.

The United States EMS Act of 1973 (Public Law 93-154) defined an EMS system as “a system which provides for the arrangement of personnel, facilities, and equipment for the effective and coordinated delivery in an appropriate geographic area of health care services under emergency conditions (occurring either as a result of the patient's condition or of natural disasters or similar conditions) and which is administered by a public or nonprofit private entity which has the authority and the resources to provide effective administration of the system.” The target groups for an EMS system include patients suffering from behavioral emergencies, burns, cardiac emergencies, neonatal emergencies, poisonings, spinal cord injuries, and trauma. The delivery of emergency health care requires the participation of numerous independent organizations, including public safety agencies, ambulance services, and hospitals. Despite their autonomy, these organizations have high degrees of functional interdependence as they work to provide care, sometimes simultaneously, to individual patients. Managing interdependence requires planning, standardization, and mutual adjustment. Richard A. Narad, describes the multicratic organization in his Dissertation entitled, “Managing Functional Interdependence between Multiple Autonomous Organizations” (University of Southern California, 1991.) This model serves as the theory base in management and policy considerations for emergency response. The community has five possible approaches to managing the interdependence of its EMS providers.
The first, ignoring it, will result in conflicts, inefficiencies, and, in the end, a lower level of care to the patient. The second approach involves the creation of voluntary networks (for example, EMS councils) to attempt to coordinate system participants. This approach depends on the willingness of participants to cooperate. A third approach, started under the federal EMS initiative, creates an independent agency to develop a system plan and to attempt to convince providers to participate in the plan. Under the fourth approach, this planning agency is granted regulatory powers (such as the franchising of ambulance services and formal designation of specialty hospitals) to assign roles and responsibilities to system participants in order to enforce implementation of the plan. The fifth approach is placing the entire EMS system under a single agency. This method is not fully used even in systems (for example, New York, San Francisco) in which the government owns or manages most of the system's resources.
Under the third and fourth approaches, the job of the lead agency (regardless of its specific regulatory powers) is to plan for the entire EMS system in order to provide the optimal response to the emergency patient. In doing so, it must consider all potential patient needs and all resources required to meet those needs. In many ways, the lead agency must act like the management of a large corporation, coordinating the activities of its various divisions.
Because of the number of autonomous organizations involved in an EMS system, policies should be established at the system level rather than by individual providers. Regionwide policies will standardize the actions of the various organizations so that each knows its role and responsibilities.

Managing an EMS event or a hospital can be challenging in the confusion that often follows a mass trauma event. Based upon data from the CDC (Center of Disease Control), research about mass trauma events shows patterns of hospital use.
It is possible to estimate initial casualty volume and pattern after a mass trauma event. Public health professionals and hospital administrators can use this information to handle resource and staffing issues during a mass trauma event.
Within 90 minutes following an event, 50-80% of the acute casualties will likely arrive at the closest medical facilities. Other hospitals outside the area usually receive few or no casualties. The less injured casualties often leave the scene under their own power and go to the nearest hospital. As a result they are not triaged at the scene by Emergency Medical Services (EMS) and they may arrive to the hospital before the most injured. On average, it takes 3-6 hours for casualties to be treated in the emergency department (ED) before they are admitted to the hospital or released.
Ambulance strike teams must be able to be rapidly mobilized and be self-sufficient for at least 24 hours under a scenario that involves mass casualties. Additional, mobile medical resources should be capable of response and treatment during the first 8 hours of a large event with significant casualties. A hospital must also be able to increase its capacity within a short period of time. When trying to determine how many casualties a hospital can expect after a mass trauma event, it is important to remember that casualties present quickly and that approximately half of all casualties will arrive at the hospital within a 1-hour window. This 1-hour window begins when the first casualty arrives at the hospital. In order to predict the total number of casualties a hospital can expect, double the number of casualties the hospital receives in the first hour.

The current trend is a transformation from “preparedness” to “products”, and “planning” to “operations”. Historically, disaster planning was not based upon specific measurable objectives to achieve a given level of response. California continues to recognize that, in order to provide a state-level disaster medical response system designed to reduce injury and loss of life, multi-organizational coordination must be done. Current emphasize is on the NIMS model in the United States, and the Standardized Emergency Management System (SEMS) in California, using the principles of the Incident Command System, to meet this need as part of the response plan.

The foundation of medical disaster response is built on a strong “day-to-day” Emergency Medical System (EMS), using the basic components of an EMS System.
One of the primary tasks of both state and regional EMS organizations is development of a system plan. It should set overall goals for an optimal EMS system and should consider the financial, technical, and political constraints that prevent the system from attaining this optimum. Based on these goals and constraints, attainable objectives can be established. The plan should identify the resources that are available and needed to develop the system. It should also establish short- and long-range work plans to achieve the objectives and determine the roles and responsibilities of system participants .
Most EMS system models focus on functional components. The Federal EMS Act identified 15 components that grantees were required to address. Grantees were generally EMS councils and planning organizations. Other developers of EMS system standards also adopted this approach, although using various listings of system components. The federal components were:
1. Manpower
2. Training
3. Communications
4. Transportation
5. Facilities
6. Critical care units
7. Public safety agencies
8. Consumer participation
9. Access to care
10. Patient transfer
11. Coordinated patient recordkeeping
12. Public information and education
13. Review and evaluation
14. Disaster linkage
15. Mutual aid
As with system stages previously noted, listing the components does not identify the individuals or the organizations that are involved. A system design can address the components generically, but an effective plan requires that the roles and responsibilities of specific participating organizations be addressed. California has created EMS system standards and guidelines to assist the EMS planner in developing a comprehensive EMS system.
California has further consolidated the EMS system components into eight main areas: (1) System Organization and Management, (2) Communications and Dispatch, (3) First Responders and Transportation, (4) Manpower and Training, (5) Hospitals and Critical Care areas, (6) Data Collection, Evaluation, and Quality Improvement, (7) Public Information and Education, and (8) Disaster Medical Response. Specific measurable standards for system planning have been developed for each component.
Financing of emergency services is similar to health care financing in general but is complicated by several factors. In the prehospital setting, a mix of health insurance and local tax sources is used to pay for ambulance services. Some communities use a competitive bid process to award an exclusive franchise for ambulance service. This process might include the setting of rates by a government body, a subsidy from local taxes, or other payment systems.
Sufficient funds must be made available to the administration of EMS. These funds can be from the general fund, fees, or grants. For example, in California, the EMSA has a staff of approximately 50 people and a budget of approximately $5 million in order to plan, implement, and evaluate a statewide EMS system. Some states have attached additional fees onto traffic violations or drivers licenses. California has a population of approximately 35 million people (approximately $0.15 per person). Additionally, grants to local EMS agencies, trauma centers, and poison control centers have been available for up to $35 million annually. In addition, 32 local EMS agencies have specific staff members at the local level that provide additional EMS system coordination on a daily basis.
EMS Systems should be regularly evaluated to determine if they are taking a systems approach to readiness. The chart provided in APPENDIX A is summary of benchmarks when examining an EMS System.

Historically, planning and preparedness have lacked specific products and measurable objectives to determine if a jurisdiction was ready to respond. The State of California Emergency Medical Services (EMS) Authority has taken a leadership role in the development and implementation of measurable objectives and implementation of those objectives in the planning process to ensure that California is prepared for a medical response to both natural and technological disasters, as part of the United States Health Resources Services Administration Hospital Terrorism grant. Statistically, California is more likely to encounter a flood or wildfire than an earthquake or a terrorist event. However, with new federal money to prepare for terrorism, emphasis is placed upon this component as well, rather than earthquake or other natural disaster planning specifically.
The recognition that the medical response is time dependent (within 8 hours) has led to specific plans to obtain rapid mobile, medical response within a time-phased deployment. These plans have also included measurable objectives related to EMS and Ambulance Strike Teams, Disaster Medical Assistance Teams, Hospital Surge capacity, communications, lab interconnectivity, training, and exercises. These specific objectives form the benchmark for evaluation of the medical preparedness for EMS and hospitals.
When utilized as a system assessment tool, the specific benchmarks in APPENDIX B for disaster medical response can lead to continuous improvement in the overall readiness for EMS and hospital systems as they plan for earthquake response, and other natural or technological disasters involving mass casualties.

In this period of increased demand for accountability from the media and politicians, the use of a formal method for independent system evaluation and identification of “best practices” is necessary. The transformation from planning to operations using measurable products will serve to enhance disaster readiness. The use of benchmarks in developing a medical response to disaster events may serve as an assessment tool and blueprint for further development of strong EMS systems capable of liquidating the consequences of a significant situation that result in medical casualties.