routes, or services [74].
Institute of Medicine Report on the Future of Emergency Care
In the decade from 1993 to 2002, the number of emergency departments and hospital inpatient beds in the United States declined at the same time the number of patients coming to emergency departments increased by 26%. The IOM began a study of hospital‐based emergency care in 2003 that rapidly expanded to address long‐standing and significant issues related to EMS and emergency care for children. EMS systems were viewed as increasingly overburdened and underfunded. The result was a three‐volume IOM report titled The Future of Emergency Care, which was released in 2006 [75]. Key findings of the report included the following: many emergency departments and trauma centers are overcrowded; emergency care is highly fragmented; critical specialists are often unavailable to provide emergency and trauma care; and EMS and emergency departments are not well equipped to handle pediatric care. Key recommendations of the report were to create coordinated, regionalized, and accountable emergency care systems; create a lead (federal) agency for emergency care; end emergency department boarding and diversion; increase funding for emergency care; enhance emergency care research; promote EMS workforce standards; and enhance pediatric presence throughout emergency care.
The IOM report was the first major report on emergency care since the 1966 NAS‐NRC report. One recommendation of particular relevance to EMS physicians was the recommendation to create a subspecialty of EMS. Other recommendations of specific interest to EMS included developing national standards for the categorization of emergency care facilities; developing evidence‐based national model EMS protocols; increasing funding for EMS preparedness; states requiring national accreditation of paramedic education programs and national certification for state licensure; and EMS agencies having pediatric coordinators to ensure appropriate equipment, training, and services for children.
2009–2020: A Period of Incremental Progress
Subspecialty in EMS Medicine
Following decades of efforts and bolstered by a recommendation in the 2006 IOM report The Future of Emergency Care, ABEM successfully petitioned and the American Board of Medical Specialties approved a physician subspecialty in EMS on September 23, 2010. The ABEM website has the following description of the subspecialty:
EMS is a medical subspecialty that involves prehospital emergency patient care, including initial patient stabilization, treatment, and transport in specially equipped ambulances or helicopters to hospitals. The purpose of EMS subspecialty certification is to standardize physician training and qualifications for EMS practice, improve patient safety and enhance the quality of emergency medical care provided to patients in the prehospital environment, and facilitate further integration of prehospital patient treatment into the continuum of patient care [76].
A task force developed and published an article entitled “The core content of EMS medicine” on January 10, 2012. It has since been updated [77]. The first certification examination was administered in October 2013. As of the fall of 2020, 831 physicians have been certified in EMS by ABEM [78].
EMS Clinician Education
In 2009, NHTSA published the National EMS Education Standards. These are consistent with the principles of the 1996 EMS Education Agenda for the Future: A Systems Approach and establish the entry‐level educational competencies for the levels of EMS clinicians outlined in the National EMS Scope of Practice Model [79]. The current model has four levels of clinicians: emergency medical responder, emergency medical technician, advanced emergency medical technician, and paramedic. The EMT‐I that was established in 1999 was eliminated. The National EMS Education Standards replaced the earlier National Standard Curricula, enabling more diverse implementation methods and updates that are more frequent. A revision of the educational standards is expected to be published in 2021.
Community Paramedicine
There has been growing interest in the United States in expanding the role of paramedics to include the management of non‐urgent and urgent low‐acuity illnesses, monitoring patients with chronic illnesses at home, and performing other functions that do not involve the traditional EMS role of treating and transporting patients to emergency departments. While scientific evidence of the safety and effectiveness of such expanded roles is limited, the success of programs in Canada, England, and Australia has drawn the attention of governments and others interested in innovative models of health care delivery and incorporating non‐physician personnel, who are sometimes viewed as underused, into these models [80]. Legislation passed in Minnesota in 2011 (2011 Minn. Laws, Chap. #12) defines community paramedics and establishes a process for educating and certifying them. In 2012, a law was passed to enable reimbursement for community paramedic services under the medical assistance program and to study the cost and quality of the program (2012 Minn. Laws, Chap. #169). Also in 2012, the Maine legislature passed a law to establish pilot community paramedic projects (Chapter 562, Sec. 1 §84). Community paramedic programs also function in many areas of the United States. The National Association of EMTs has established an EMS 3.0 initiative to further promote the potential capabilities of EMS clinicians in providing appropriate care to support the national health care needs [81].
In further recognition of the potential services that EMS systems can appropriately provide, the Centers for Medicare and Medicaid Innovation Center recently initiated an Emergency Triage, Treatment and Transport (ET3) pilot program. Using nearly 200 pilot sites, the program is designed to investigate, over a 5‐year study period, the appropriateness and financial considerations of several models: treat in place (without transport), treat and referral for follow‐up, and transport to alternative destinations (other than an emergency department) [82].
National EMS Culture of Safety Project
EMS is known to be a high‐risk profession; EMS personnel are 2.5 times more likely than the average worker to be killed on the job [83], and their transportation‐related injury rate is five times higher than average [84]. Additionally, there are patient safety concerns as outlined in the 1999 IOM report To Err is Human, as well as concerns about risks to EMS personnel, patients, and the community from ambulance crashes. In 2009, the National EMS Advisory Council recommended that NHTSA create a strategy for building a culture of safety in EMS. With support from the EMSC program at HRSA, NHTSA contracted with ACEP to develop a National EMS Culture of Safety Strategy that was published in October 2013 [85]. This initiative resulted in the formation of the National EMS Safety Council composed of multiple EMS stakeholder organizations to continue to focus on safety considerations for EMS clinicians.
EMS Agenda 2050
Twenty years after the publication of the 1996 Agenda, FICEMS and NEMSAC recommended to NHTSA that it was time to review the status of the recommendations of the 1996 document. Based on those suggestions, the EMS Agenda 2050 team was established. Following community input, regional meetings around the country and discussions, the EMS Agenda 2050 was released in 2019 [86]. This document, projecting the EMS world in 2050, changed the patient‐centered focus of the 1996 document to a people‐centered focus to include not only the patient, but the patient’s family, community, and the EMS clinicians. Acknowledging the difficulty in predicting the clinical and technological capabilities that would be available in 2050, the goals of EMS systems at that time will be based on six guiding principles: adaptable and innovative, inherently safe and effective, integrated and seamless, reliable and prepared, socially equitable, and sustainable and efficient (Figure 1.1). These guiding principles have also been adopted as the tenets of NEMSAC.
Figure 1.1 The six guiding