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Rural Emergency Medical Services (EMS) and Trauma

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Emergency medical services (EMS) provide emergency medical care to individuals who have had a sudden or serious injury or illness, or who have suffered major trauma. Access to EMS is critical for rural residents but providing EMS in rural areas can be challenging. Responses to mass casualty incidents, such as a crash involving a bus, can deplete EMS resources from multiple jurisdictions.

Rural EMS typically serve a geographically large and sparsely populated area. Due to the nature of rural areas, EMS may be required to travel farther or navigate difficult terrain when responding to a call or transporting a patient to the hospital. Adverse weather conditions, when coupled with longer distances and geographical obstacles, can significantly affect response or transport times.

Trauma care refers to the treatment of serious and life-threatening physical injury. The Patient-Centered Outcomes Research Institute (PCORI) topic brief, Rural Trauma Care, states that rural populations have less access to advanced trauma care. Disparities in Access to Trauma Care in the United States: A Population-Based Analysis, published in 2017 in Injury, found significant disparities in trauma care access for vulnerable populations and identified disparities directly affecting rural residents. The article states that as of 2010, 29.7 million Americans still lack access to a Level I or II trauma center within 60 minutes.

Frequently Asked Questions:

How can a rural EMS agency find funding to purchase major equipment, such as an ambulance?

Multiple programs can assist rural EMS agencies with purchasing or obtaining major equipment:

  • Federal Emergency Management Agency's (FEMA) Assistance to Firefighters Grant (AFG) offers funding to promote the safety of the public, firefighters, and first responders by providing for the needs of fire departments and EMS agencies. In the past, grants have been used to purchase equipment, protective gear, emergency vehicles, training, and other resources necessary to protect emergency personnel. While this fund is targeted to fire department operated EMS agencies, there is 10% set aside of the total funds directed to non-fire, non-hospital, not-for-profit EMS agencies.
  • EMS agencies may be eligible to obtain surplus government property through the Federal Surplus Personal Property Donation Program. Applications for this opportunity are accepted on an ongoing basis. To inquire about this program, contact your State Agency for Surplus Property (SASP) representative.
  • U.S. Department of Agriculture (USDA) Rural Development's Community Facilities Direct Loan and Grant Program offers direct loans and/or grants for essential community facilities in rural areas, which can include equipment for EMS. Applications for this opportunity are accepted on an ongoing basis. To begin the application process, contact your USDA Rural Development State Office.
  • Savvik Buying Group, formerly known as the North Central EMS Corporation, is a cooperative purchasing group requiring membership that serves EMS and other public safety organizations.

Other funding programs and grants can be found on RHIhub's list of funding opportunities related to EMS, which includes federal, state, and private foundation funding opportunities.

How are rural EMS agencies funded?

Rural EMS services often travel longer distances per run due to the larger service areas and lower population density in rural areas, which result in higher average costs per trip for the agency as compared to their urban counterparts that can spend costs over more trips. According to the 2015 WWAMI Rural Health Research Center report, Prehospital Emergency Medical Services Personnel in Rural Areas: Results from a Survey in Nine States, public/government funding was most common for both urban and rural agencies, but urban agencies were funded this way more often. Large rural, small rural, and isolated small rural EMS agencies reported a higher percent of funding from private not-for-profits and public/private partnerships compared to urban EMS agencies. According to Rural Volunteer EMS: Reports from the Field, most rural EMS agencies rely on a variety of funding strategies to provide response services in their communities. Sources of funding and resources can include:

  • Billing
  • Fundraising events
  • County or local tax dollars
  • Donated services or equipment
  • State or local grants
  • Public/private partnerships

Making Informed Decisions about Rural EMS, a 2019 Rural Monitor article, highlights a community in rural Maine that went through the process of Informed Self-Determination to determine the level of EMS response wanted by the community and how those services will be financially supported by the community.

Are there continuing education programs for EMS personnel?

There are many continuing education programs available for EMS personnel. Many rural EMS agencies have internal training officers that coordinate local trainings and use resources from area hospitals, larger ambulance agencies, air ambulance agencies, and area colleges. Online continuing education is available from a variety of internet resources. Some state EMS associations conduct conferences that contain continuing education content. For local or state opportunities near you, contact your state EMS agency and ask to speak with someone about continuing education. Other opportunities for continuing education programs include:

Where can I find a list of state EMS contacts?

NASEMSO maintains a listing of EMS state office contacts.

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

According to the American Trauma Society, trauma system is defined as:

an organized, coordinated effort in a defined geographical area that delivers the full range of care to all injured patients and is integrated with the local public health system.

Rural hospitals should be part of regional and statewide trauma systems to provide appropriate, collaborative care for their patients.

A 2016 Surgery article, Rural Risk: Geographic Disparities in Trauma Mortality, found that rural residents are more likely to die from a trauma related injury than non-rural residents. This is not a new finding; Safety in Numbers: Are Major Cities the Safest Places in the United States?, in the Annals of Emergency Medicine, states that the risk for injury death increases as rurality increases.

Being part of a trauma system allows rural facilities to respond and treat patients at the local level. It also ensures a pathway for patients, if needed, to interventions and healthcare services outside of the rural facility's capabilities through early recognition and identification that results in transferring the patient to a facility offering a higher level of care.

Many states have a trauma program manager who may be employed by the state EMS office, state office of rural health, or at a freestanding program. For more information on your state or regional trauma systems, contact your state EMS agency.

How can local EMS agencies be integrated into the local and regional trauma system?

Hospitals play a role in engaging the EMS agencies that transport patients to their hospital in discussion, education, and training on trauma care. The medical director for an EMS agency can be affiliated with the local hospital. This situation would provide a natural bridge between the hospital and EMS agency to coordinate, identify, and implement policies and procedures, for example, triage protocols, trauma team activation, or quality improvement and quality assurance reviews. It can be helpful for communities 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 support staff become better organized and prepared to receive injured patients?

Yes, there are a couple of rural specific programs that provide this type of training:

  • Comprehensive Advanced Life Support (CALS)
    CALS provides a training curriculum specifically focused on emergency medical training for physicians, nurses, physician assistants, nurse practitioners, and paramedics in rural areas. CALS allows providers to learn and practice infrequently used skills to save lives.
  • Rural Trauma Team Development Course (RTTDC)
    RTTDC is a one day course that focuses on rural medical personnel responding to an incoming trauma patient. The course emphasizes a team approach when performing initial evaluations and resuscitations on trauma patients at rural facilities. The course is intended to assist nurses, physicians, physician assistants, nurse practitioners, and other hospital personnel who may provide support or care for an injured patient. RTTDC is sponsored by the American College of Surgeons (ACS).

What are the different levels of trauma care? Are these levels mandated by the federal or state government?

Trauma center designations are defined at the state or local level and are usually outlined through a legislative or regulatory authority. There are no federal standard or designation defining a trauma center or the different levels of trauma care. The American Trauma Society (ATS) provides a list of common criteria for each level of trauma care. ATS derived the trauma center level criteria from trauma centers verified by the American College of Surgeons and state trauma designations.

The American College of Surgeons (ACS) states:

The designation of trauma facilities is a geopolitical process by which empowered entities, government or otherwise, are authorized to designate. The ACS does not designate trauma centers; instead, it verifies the presence of the resources listed in Resources for Optimal Care of the Injured Patient.

The process of becoming a verified ACS trauma center is voluntary. Trauma centers can be designated or verified as an adult and/or pediatric trauma center(s). ACS provides a list of verified trauma centers that you can search by institution name, city, state, and country, or by zip code and distance.

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

A 2017 statistical brief, Trends in Emergency Department Visits, 2006-2014, from the Agency for Healthcare Research and Quality (AHRQ) describes 2006 and 2014 emergency department (ED) visit rates as the highest among patients living in micropolitan and noncore areas, 472.7 and 512.5 visits per 1,000 population respectively.

According to a May 2020 report, Traffic Safety Facts, 2018 Data: Rural/Urban Comparison of Traffic Fatalities from the U.S. Department of Transportation, NHTSA, an estimated 19% of the U.S. population live in rural areas but rural deaths accounted for 45% of all traffic fatalities in 2018. Rural Unintentional Injuries: They're Not Accidents – They're Preventable discusses the leading causes of rural unintentional injuries, including rural motor vehicle fatalities, and prevention strategies. An article from the September 2017 Morbidity and Mortality Weekly Report, Rural and Urban Differences in Passenger-Vehicle-Occupant Deaths and Seat Belt Use Among Adults – United States, 2014, found that rurality was associated with:

  • Decreased seat belt use among adults
  • An increase in the proportion of unrestrained passenger-vehicle-occupant deaths
  • An increased age-adjusted passenger-vehicle-occupant death rate

According to National Characteristics of Emergency Medical Services in Frontier and Remote Areas, in Prehospital Emergency Care, approximately 1 in 15 EMS responses in the continental U.S. occur in frontier and remote (FAR) areas and on-scene deaths were more commonly reported in FAR areas than non-FAR areas.

CDC's Web-based Injury Statistics Query and Reporting System (WISQARS) is an interactive, online database that provides fatal and nonfatal injury, violent death, and cost of injury statistics. WISQARS also provides data in the form of Fatal Injury Reports, that can be stratified by urbanization classification, and Fatal Injury Mapping at the state- and county-level.

The Healthcare Cost and Utilization Project (HCUPnet) provides data on rural ED visits. A tutorial is available online.

Who makes up the rural EMS workforce?

A 2015 WWAMI Rural Health Research Center report, Prehospital Emergency Medical Services Personnel in Rural Areas: Results from a Survey in Nine States, discusses how rural EMS agencies rely on volunteers to staff their operations. Volunteers can have lower skill levels and higher vacancy ratios compared to their urban counterparts. These rural EMS services may also have fewer opportunities for skills training and review through regular interactions with a medical director and less access to online medical consultation during emergency calls compared to their urban counterparts.

In a survey of rural EMS directors, 69% reported difficulties recruiting and/or retaining volunteers. Recruitment and Retention in Rural and Urban EMS: Results from a National Survey of Local EMS Directors, in the Journal of Public Health Management and Practice, found that regardless of location, it is difficult to find willing persons to volunteer. Local EMS directors reported that community members didn't have the time or interest in volunteering.

While the frequency of EMS runs can be lower in rural areas, EMS personnel are frequently on-call, participate in inter-facility and nonemergency transfers, and attend training to validate their skills and meet the continuing education requirements to maintain their license or certification, which places a substantial burden on volunteers working full-time jobs with family responsibilities. The National Association of State EMS Officials (NASEMSO) recently released Fatigue in EMS Risk Management Guidelines, a framework and evidence-based guidelines to mitigate fatigue-related accidents and safety concerns in the EMS workforce.

Difficulties in recruiting volunteers have led some rural EMS systems to offer paid employment to meet at least some of their staffing needs. Community paramedicine programs are growing in popularity as a model to provide reimbursable community-based healthcare services. For more information on starting a community paramedicine program or the benefits they can provide to rural communities, see RHIhub's Community Paramedicine topic guide.

The 2008 findings brief, Challenges for Rural Emergency Medical Services: Medical Oversight, from the North Carolina Rural Health Research Program shows that maintaining adequate medical direction can be difficult for rural EMS agencies, with 19% of rural survey respondents reporting difficulties recruiting a medical director. Rural EMS agencies report obstacles to obtaining a medical director that include:

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

What can rural EMS agencies do to recruit volunteers?

Recruiting volunteers to maintain and supplement the existing rural EMS workforce is vital to the provision of EMS in rural communities. NAEMT offers many suggestions to increase public awareness and recruit volunteers:

  • Host an open house
  • Host a public safety or injury prevention event or make it part of a recurring community event
  • Teach CPR
  • Offer ride-along opportunities
  • Use your local media
  • Host a survivor summit
  • Use social media to promote your EMS organization and interact with your community members

Recruitment and Retention: Overcoming the Rural EMS Dilemma describes the challenges in rural EMS recruitment and poses tactics to help organizations and communities in rural areas. At the end of the article is a listing of additional recruitment and retention resources.

Is there training available to teach and train community members or laypersons to assist in a medical emergency?

Yes, there are a few trainings widely available that allow community members, families, businesses, and other lay persons to become better prepared for the unexpected.

Stop the Bleed is a joint initiative between the American College of Surgeons and the Hartford Consensus that strives to provide credible information, resources, and training on bleeding control for the layperson. You can search for a Bleeding Control Basics class by city, state, or zip code. Trauma Training Initiative Teaches Rural Laypeople how to Stop the Bleed is a Rural Monitor article highlighting Stop the Bleed training initiatives in rural communities.

First aid, cardiopulmonary resuscitation (CPR), and automated external defibrillator (AED) trainings are often offered together. The American Red Cross and the American Heart Association maintain a comprehensive list of available courses you can search by training, date, or location. You can also reach out to your local hospital, health and fitness groups, or schools to find training opportunities near you.

Last Reviewed: 6/13/2018