States with mandatory statewide ALS protocols as of October 1, 2013. Types of protocols used by each state are indicated by colors (see key). Mandatory A protocols must be used by all EMS providers within the state. Mandatory B protocols are similar but there is a process for services to petition the state to alter some of the protocols. Mandatory C protocols are similar but there is a process for services to petition the state to develop and use their own protocols.
MD DE NJ
Reprinted with Permission: Kupas DF, Schenk E, Sholl JM, Kamin R. Characteristics of statewide protocols for emergency medical services in the United States. Prehospital emergency care 2015;19:292-301.
for innovation, and preliminary indications of improved quality. 85
TENSION BETWEEN AUTONOMY & STANDARDIZATION
There are of course significant tensions between local autonomy and statewide efforts (whether led by State EMS Offices, professional associations, or individuals) to bring standardization. While having uniform protocols and procedures across a state or large region may reduce variation, improve quality, and make it easier for other stakeholders to become familiar with EMS, it might in turn become more difficult to accommodate local innovations including new treatment protocols and new collaborative care models. For example, Texas is probably the only true delegated practice state in which local agency medical directors have a broad range of authority to establish protocols and set policies. 84 As a result, several EMS agencies in that state have become well known in the industry as being centers of innovation. On the other hand, several states (see Figure X ) have established statewide protocols and have experienced significant improvements in the consistency of data reporting, which can be an important ingredient
This tension between local autonomy and statewide or other efforts around standardization are not limited to treatment protocols or adherence to scientific evidence. They are also found in EMS educational standards, policies and procedures, staffing standards, destination policies for specialty care centers, and even regulatory regimes that might differ based on EMS agency type. Often local government has a great deal of autonomy over fire services while the state often is the regulator of hospitals which may have implications for the hospital-based EMS services. 86 STRATEGIES FOR IMPROVEMENT OF REGIONAL COORDINATION
In order to promote greater innovation in EMS, it is ideal that EMS agencies overcome fragmentation
84 W. Ann Maggiore. “Liability for Ems Licensing.” Journal of Emergency Medical Services. Last modified February 2, 2011. http://www.jems.com/articles/2011/02/liability-ems-licensing.html 85 Spaite, Daniel W., Bentley J. Bobrow, Uwe Stolz, Duane Sherrill, Vatsal Chikani, Bruce Barnhart, Michael Sotelo et al. “Evaluation of the impact of implementing the emergency medical services traumatic brain injury guidelines in Arizona: the Excellence in Prehospital Injury Care (EPIC) study methodology.” Academic Emergency Medicine 21, no. 7 (2014): 818-830. 86 “Emergency Medical Services at the Crossroads.” In Future of Emergency Care Series edited by Gail L. Warden. Washington, D.C.: Institute of Medicine, 2007.
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