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Rural Emergency Medical Services (EMS) and Trauma

Emergency medical services (EMS) providers care for individuals who have had a sudden or serious injury or illness, or who have suffered 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.

Dangerous occupations such as farming, mining, fishing, and oilfield work put rural workers at risk and place strains on rural responders. In addition, rural roads and highways can be more hazardous. As stated in Rural States Struggle to Reduce Road Death, people tend to drive faster in rural areas, and collisions are more likely to be deadly. Though only 20% of the U.S. population lives in rural areas, traffic fatalities in these locations outnumber those in urban areas, according to the March 2016 publication, 2014 Motor Vehicle Crashes: Overview.

EMS Workforce
Most rural communities rely heavily on volunteer emergency medical technicians (EMTs), since low call volume makes it cost-prohibitive to operate with paid personnel. In a survey of rural EMS directors, 69% reported that recruiting volunteers is a problem, and 55% said 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 time-consuming patient transfers, and must attend training sessions to keep their skills and certifications up to date. This can be a burden for people with full-time jobs and family responsibilities.

Difficulties in recruiting volunteers have led some rural EMS systems to offer paid employment to meet at least some of their staffing needs. Since there is often not full-time work for these staff members 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 area
  • Local providers were not qualified to perform the duties

Finance & Resources
The large distances and low population density in rural service 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 in service. Funding sources include billing for services, fundraising events, county/local tax dollars, and one-time state or local grants.

Financial constraints for rural EMS often mean that squads are forced to rely on 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:


Are there continuing education programs for EMS personnel?


Where can I find a list of state EMS contacts?

A list 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 patients who need interventions and care above the rural facility's capabilities are identified and promptly transferred to a facility offering a higher level of care.

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 the ways in which 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. Your state's EMS agency 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 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 such as 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 support staff become better organized and prepared to receive injured patients?

Programs that provide this type of training include:

  • Rural Trauma Team Development Course
    Focuses on a team approach, for medical personnel who may respond to the initial evaluation and resuscitation of trauma patients at rural facilities. Intended audience includes 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 is the state EMS office that determines what those standards will be. Some states use the ACS verification process, which is voluntary, to determine the levels of trauma care for their healthcare facilities.

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

The 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 rural emergency departments?

According to a Centers for Disease Control and Prevention (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.

As reported in an Agency for Healthcare Research and Quality (AHRQ) Statistical Brief, Overview of Emergency Department Visits in the United States, 2011, emergency departments in rural areas had higher rates of visits resulting in discharge, compared with urban areas.

According to the Insurance Institute for Highway Safety's Urban/Rural Comparison 2015, characteristics of fatal motor vehicle crashes differ between urban and rural areas. Urban areas have more motorcycle, pedestrian, and bicyclist deaths, and rural areas have higher rates of passenger vehicle and large truck occupant deaths. In 2014, the most recent year for which data are available, the rate of vehicle accident fatalities in rural areas was 2.4 times higher than the urban rate per mile driven.

The CDC's WISQARS (Web-Based Injury Statistics Query and Reporting System) is an interactive, online database that provides statistics on injury, violent death, and cost of injury. 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. Fatal Injury Reports are available, with breakdowns by metropolitan/nonmetro status, as well as state- and county-level Fatal Injury Mapping.

AHRQ'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 given. Under the “Patient and hospital characteristics” step, select “Location of patient's residence” for rural-specific data:

HCUPnet Screen Shot


Last Reviewed: 12/29/2016