Rural Emergency Medical Services (EMS) and Trauma

Emergency medical services (EMS) providers care for individuals who have had a sudden or serious injury, illness, or suffered a major trauma. Access to EMS is critical for rural citizens, but providing services is often challenging in rural areas.

Geography and population served
Rural EMS units typically serve large and sparsely populated areas. The significant distances they must travel mean that it may take EMS personnel longer to arrive at the scene of the emergency, which can have a significant impact on patient outcomes, including survival rates.

Despite sparse rural populations, trauma is certainly a concern in rural areas. Dangerous occupations that are primarily undertaken in rural areas – farming, mining, fishing, and oilfield work – put rural workers at risk and place strains on rural responders. In addition, rural roads and highways are more hazardous. As stated in Rural States Struggle to Reduce Road Death, people drive faster in rural areas, and collisions are more deadly.

EMS Workforce
Most rural communities rely heavily on volunteer emergency medical technicians (EMTs) and paramedics since low volumes make it cost-prohibitive to operate with paid personnel. In a survey of rural EMS directors, 69% responded that recruiting volunteers is a problem, with 55% saying that recruitment and retention problems are getting worse. While EMS call frequency may be low in many rural areas, personnel need to be on-call regularly, participate in often time-consuming patient transfers, and must attend training to keep their skills and certifications up-to-date, all of which can be a burden for people with full-time jobs and family responsibilities.

The difficulties in recruiting volunteers have led some rural EMS systems to employ at least some of their personnel. Since there is often not full-time work for these staff in an emergency capacity, the community paramedic model is growing in popularity as a way to use EMS personnel to provide needed healthcare services in the community. See RHIhub's Community Paramedicine topic guide to learn more about this model.

The 2008 findings brief, Challenges for Rural Emergency Medical Services: Medical Oversight, shows that maintaining adequate medical direction can be difficult for rural EMS, with 19% of rural survey respondents indicating difficulties in recruiting a medical director. Obstacles in obtaining a designated medical director included:

  • Local providers unwilling to perform the duties
  • Inability to pay a medical director
  • No physician, nurse practitioner, or physician assistant in the local area
  • Local providers were not qualified to perform the duties

Finance & Resources
The distances and low population density in rural areas can result in high costs for rural EMS runs. Inadequate reimbursement from third-party payers and small local tax bases add to the problem. According to Rural Volunteer EMS: Reports from the Field, most local EMS services must rely on a mix of funding strategies to keep their units going. Funding sources include billing for services, fundraising events, county/local tax dollars, and one-time state or local grant funds.

Difficult financial constraints for rural EMS often mean that squads must get by with aging or insufficient equipment and infrastructure, including ambulances, medical devices, and communications systems. 

Frequently Asked Questions:

How can a rural EMS unit find funding for major equipment, such as an ambulance?

The following programs can help rural EMS units pay for an ambulance or fire truck for a rural EMS unit:

  • The U.S. Department of Homeland Security's Assistance to Firefighters Grant (AFG) offers funding to rural fire departments and EMS units. Grants may be used for purchasing equipment (including vehicles), providing training, establishing personnel wellness and fitness programs, funding capital projects, and encouraging collaboration efforts. For further information, see Assistance to Firefighters Grant Program.
  • Many municipal and volunteer fire and emergency services departments obtain surplus government property through the Federal Surplus Personal Property Donation Program. To inquire further about this program, contact your State Agency for Surplus Property (SASP).
  • Community Facilities Loan and Grant Program, sponsored by USDA Rural Development, provides funds that may be used to purchase equipment for emergency medical services. Contact your local USDA Rural Development Office for specific information.
  • Savvik Buying Group, a membership network serving the EMS and other public safety organizations. Provides volume discounts for group purchasing. Formerly the North Central EMS Cooperative (NCEMSC).  

How does a rural EMS unit obtain an automated external defibrillator (AED)?

There are several possible funding opportunities to obtain an AED for a rural EMS unit. These include:

The Rural Access to Emergency Devices (RAED) Grant Program, offered by the Federal Office of Rural Health Policy, provides funding to rural communities to purchase automated external defibrillators (AEDs) and to provide training in their use and maintenance. State level funding opportunities may also be available. Contact your state's EMS agency or State Office of Rural Health to inquire.

Additional opportunities may be listed in the funding section of this topic guide.

Are there continuing education programs for EMS personnel?

Where is there a listing of state EMS contacts?

A listing of state EMS contacts is available from the National Association of State EMS Officials.

Can and should a rural hospital be part of the regional and statewide trauma system?

Yes. According to Safety in Numbers: Are Major Cities the Safest Places in the United States?, in the Annals of Emergency Medicine, death rates for injury are higher in rural and frontier areas. Therefore, it is important that all rural acute care facilities that receive emergency patients be part of the trauma system. This allows for a more organized response at the local level and ensures that those patients who need interventions and care above the rural facility's capabilities are identified and transferred to a higher level of care in a timely manner.

A 2010 Journal of Trauma Nursing article, Sustaining an Inclusive Trauma System in a Rural State: The Role of Regional Care Systems, Partnerships, and Quality of Care, describes rural health trauma system development, and how partnerships help support this.

Many states have a trauma program manager. In most cases, that person works in the state EMS office, but also could work in the State Office of Rural Health or in a freestanding program. The National Association of State EMS Officials provides a listing of state EMS contacts who can provide information about regional or statewide trauma systems.

How can local EMS agencies be integrated into the local and regional systems of trauma care?

Hospitals often play an important role in engaging local EMS agencies in issues surrounding trauma care. Often the EMS agency's medical director is affiliated with the local facility. This provides a natural bridge between the two agencies on issues of triage protocols, trauma team activation, and quality improvement activities. It is sometimes helpful to engage in a specific community planning process that sets out to use existing EMS resources at the community level. A planning process and associated materials are found in Community-Based Needs Assessment: Assisting Communities in Building a Stronger EMS System.

Are there training programs to help rural hospitals' medical and ancillary staff become better organized and prepared to receive injured patients?

Programs that provide this type of training include:

  • Rural Trauma Team Development Course
    Provides a one-day course, focused on a team approach, for medical personnel who may respond to the initial evaluation and resuscitation of a trauma patient at a rural facility. Intended audiences include nurses, physicians, physician assistants, nurse practitioners, and other hospital personnel who may provide support. Sponsored by the American College of Surgeons.
  • Comprehensive Advanced Life Support (CALS)
    Provides an emergency medical training curriculum for medical teams in rural areas. Focus is on those who provide care in rural emergency departments including physicians, paramedics, nurses, and advanced practitioners.

What are the different levels of trauma care and are these levels mandated by the federal or state governments?

There are no national standards or federal designations for levels of trauma care. According to the American College of Surgeons (ACS),

“the designation of trauma facilities is a geopolitical process by which empowered entities, government or otherwise, are authorized to designate.”

Often it will be the state EMS office that determines what those standards are. Some states use the ACS verification process, which is voluntary, to determine the levels of trauma care for their healthcare facilities.

Although ACS does not designate trauma centers, it will verify that resources listed in the document, Resources for Optimal Care of the Injured Patient, are available.

ACS also provides a searchable state listing of trauma centers that have successfully completed a verification visit.

Are there statistics and data on trauma related deaths and nonfatal injuries treated in emergency departments?

According to a CDC fact sheet, The National Hospital Ambulatory Medical Care Survey: Rural Emergency Departments, there were approximately 10.5 million visits to emergency departments of rural hospitals from 2007-2010. Common reasons for these visits included injuries such as upper extremity lacerations, contusions, open wounds, and fractures. Approximately one-third of all visits were made by people under the age of 25.

In an AHRQ Statistical Brief, Overview of Emergency Department Visits in the United States, 2011, emergency departments in rural areas had a higher rate of visits resulting in discharge, compared with urban areas. Emergency department visits may indicate a lack of readily available primary care for those who cannot obtain care elsewhere.

According to the Insurance Institute for Highway Safety and Highway Loss Data Institute's Urban/Rural Comparison 2013, characteristics of fatal motor vehicle crashes differ between urban and rural areas. Urban areas have higher pedestrian and bicycle deaths, and rural areas have higher passenger vehicle and large truck occupant deaths. The comparison further states that the rate of vehicle accident fatalities in rural areas was 2.6 times higher than the urban rate, for a given distance traveled.

The Centers for Disease Control's (CDC) WISQARS (Web-Based Injury Statistics Query and Reporting System), is an interactive, online database that provides injury, violent death, and cost of injury data statistics. WISQARS uses data from the National Electronic Injury Surveillance System, and includes information about what types of nonfatal injuries are treated in hospital emergency departments. Data on fatal injuries are available by state and county.

The Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS) includes data on rural ED visits. It is available online via HCUPnet. Select from the choices under "Statistics on Emergency Department Use." A series of choices about the types of visits, year, and so on will be asked. Under the "Patient and hospital characteristics" step, select "Location of patient's residence" for rural-specific data:

HCUPnet Screen Shot