Spaite 1995 Annals of Emergency Medicine

8/14/2019 Spaite 1995 Annals of Emergency Medicine

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U n i f o r m P r eh osp ital D ata E l e m e n ts andDefinit ions: A Report From the U niformPrehospital Emergency Medical Services DataConference

From the Arizona EmergencyMedic ine Research C enter , Univers i tyof Arizona, Tucson*; EM5DataSystems, In c , Phoenix , Arizona~;Department o f Emergency Medic ine,Stanford Univers i tS , EMS Bureau,Montana D epartment o f Heal th andEnv ironmental 5dences , S tate o fMo ntana II,EMSDiv is ion, Nat ionalHighway Traf f ic Safe tyAdminis trat ion~; Div is ion of T raumaand EM S, Heal th Resources an dServ ices Adminis trat ion#; an dUniformed Serv ices Univers ity* *;Nat ional Center o r Injury Prevent ionand C ontrol , Centers or DiseaseControl and P revention"~; and PACEEvaluat ion, SepuIveda Ve terans 'Adminis trat ion M edical Center ,Sepulveda, California.~Rece ived or publ icat ionNovember 9 , 1994 . Accepted or pub-l icat ion November 14, 1994.Funding or th is projec t was suppl iedby NHTSA, contrac t no.DTNH22-92-C-05314, Uni formPrehospi ta l EMS Data Conference .Copyright by the American Col legeof Em ergency Physic ians .

D a n i e l S p a i t e , M D , F A C E P *R o n a l d B e n o i t , B S *D o u g l a s B r o w n , C E P *R i c h a rd C a l e s , M D , F A C E PD r e w D a w s o n llC h u c k G l a s s ~C h r i s t o p h K a u f m a n n , M D , M P H ,

F A C S# * *D a n i e l P o l l o c k , M D #Susan Ryan 11E l i za b e t h M Y a n o , P h D

One of the d is tinct and universa l aspects of em ergency medica lserv ice (EMS) is the bel ie f that before i ts impleme ntat ion ma nypeople were dy ing or be ing k i l led by i l l-equipped, poor ly r a i n e d"hearse dr ivers" and that th is t rag ic s tate of a f fa i rs has beenrect if ied by the a dvances in the prehosp i ta l phase of care.Except for cases of nont raum at ic , out -of -hospi ta l card iac ar restthere i s a lmost no convinc ing sc ient if ic ev idence o prove thatprehospi ta l care has had an impact on m o r b i d i t y o r mo rtal i ty. Atthe very found at ion of th is problem is the lack of a s et o f broad-based, wel l- conceived, accurate, re l iab le, un i form EMS data.Many a t tempt s h ave been made to deve l op a un i fo r m EMS da t aset , but w i thout a na t ional consensus h ese hav e not achievedwide d is t ribut ion. In 19 92, w i th the as s is tance of the Nat ionalHighway Traf f ic S afety Admin is t ra tion, the nat ional consensusprocess began wi th a ser ies of m eet ings involv ing many EMSagencies and organizat ions. This cu lminated in Aug ust 19 94wi th the developm ent of an 81- i tem uni form EMS da ta set . Wedeta i l the pr ior a t tem pts at data set deve lopment and ou t line theprocess leading to the th is un i form, nat ional EMS d ata set .[Spai te D, Ben oi t R, Brown D, Cales R, Dawson D, G lass C,Kaufmann C, Pol lock D, Ryan S, Yano EM : U ni form prehospi ta ldata e lem ents and def in i t ions: A repor t f rom the uni form prehos-p i ta l em ergency medica l serv ices data conference. Ann Em e r gMed A pr il 1995;25:525-534. ]

I N T R O D U C T I O NThe development of modern emergency medical services(EMS) systems has had a profound impact on the expecta-tions of American citizens of immediate access to and con-tinuous availability of emergency medical care outside theconfines of traditional health care facilities. The develop-ment of sophisticated prehospital care systems has alsocreated a unique culture among those who provide thiscare. One of the distinct and nearly universal aspects ofthis culture is the intense belief that in the "old days,"

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p e o p l e d i e d b e c a u s e o f o r w e r e k i l l e d b y i l l- e q u i p p e d ,poo r ly t r a ine d " hea rs e d r ive rs , " a s ta t e o f a f fai r s, mos ta s s u m e , t h a t h a s b e e n r e c t i f ie d b y t h e a d v e n t o f m o d e r nE M S s y s te m s . A d v a n c e s i n p r e h o s p i t a l t r e a t m e n t h a v em a r k e d l y d e c r e a se d t h e m o r b i d i t y a n d m o r t a li t y d u e t os e r io u s i l ln e s s a n d i n j u r y F u r t h e r m o r e , m a n y b e l i ev e t h a tp r o v i d i n g c a r e i n t h e f i el d is m o r e a d v a n t a g e o u s t o t h ep a t i e n t t h a n s u b s e q u e n t i n h o s p i t a l c a r e , e v e n i f i t is o p t i -ma l . T h i s s ens e o f a l i f e s av ing mis s io n ha s cap tu red pub l i ci n t e r e st a n d c o m m a n d e d s o c i e t al r es o u r c e s t h a t c a n o n l yb e m e a s u r e d i n t h e t e n s o f b i l l io n s o f d o l l ar s o v e r t h e p a s tt w o d e c a d e s .

A m a z i n g l y , e x c e p t f o r t h e c a se o f n o n t r a u m a t i c , o u t -o f -hos p i t a l c a rd iac a r re s t i n the u rba n s e t t ing , t he re i sa l m o s t n o c o n v i n c i n g s c i e n ti f ic e v i d e n c e t o p r o v e t h a tp r e h o s p i t a l m e d i c a l c ar e h a s h a d a n i m p a c t o n t h e m o r -b i d i t y o r m o r t a l i t y o f i l ln e s s o r i n j u ~ A t t h e v e r y f o u n d a -t i o n o f t h i s p r o b l e m l ie s t h e l a c k o f a b r o a d - b a s e d , w e l l -c o n c e i v e d , a c c u r a t e , r e l ia b l e c o l l e c t i o n o f u n i f o r m E M Sda ta .

O n e o f t h e m o s t f u n d a m e n t a l o f al l c u r r e n t n e e d s i nE M S is a c c es s t o p r e h o s p i t a l p a t i e n t a n d s y s t e m i n f o r m a -t i o n f r o m t h e w i d e v a r i e t y o f s y s t e m s t h a t e x i s t i n t h i sc o u n t ry . W i t h o u t u n i f o r m E M S d a t a , th e r e i s n o h o p e t h a tt h e m a n y p r e s si n g q u e s t io n s s u r r o u n d i n g o u t c o m e ,i m p a c t , a n d c o s t- e f f ec t iv e n e s s w i l l b e a n s w e r e d . A k h o u g h[ h e m e r e e x i s te n c e o f a n a t i o n a l u n i f o r m d a t a s e t a n d d e f i-n i t i o n s a l o n e i s n o t s u f f ic i e n t t o a n s w e r s u c h q u e s t i o n s ,t h e a b s e n c e o f o n e m a k e s i t i m p o s s i b le .

T H E H I S T O R Y O F E M S D A T A C O L L E C T I O NT o fu l ly apprec ia t e th e p ro b lem s re l a t ed to [he l a ck o fE M S da ta co l l ec t ion , i t i s im por tan t to recogn ize tha t t h i sl a c k is n o t a n e w i s s u e. T h e l a n d m a r k p a p e r " A c c i d e n ta lD e a t h a n d D i s ab i li ty : T h e N e g l e c t e d D i se a se O f M o d e r nS o ci et y," p u b l i s h e d i n 1 9 6 6 b y t h e N a t i o n a l A c a d e m y o fSc iences (NAS) and the Na t iona l Res ea rch Counc i l (NRC) ,f ir s[ n o t e d t h e l a c k o f a d e q u a t e p r e h o s p i t a l d a t aco l l ec t ion :

Data are lacking on which to determine the num ber o f individualswho se lives are lost or injuries are compo unded by misguidedattempts at rescue or first aid, absence of physiciansat the scene ofinjury, unsuitable ambulances with inadequate equipmen t anduntrained attendants, lack of traffic control, or the lack of voicecomm unications facilities.~T h e p a p e r r e c o m m e n d e d t h e d e v e l o p m e n t o f ho s p i ta l -b a s e d t r a u m a r e g is t ri e s [ o c o ll e c t i n f o r m a t i o n f r o m b o t ht h e p r e h o s p i t a l a n d h o s p i t a l s e t ti n g s " as a m e c h a n i s m f o r

t h e c o n t i n u i n g d e s c r i p t i o n o f t h e n a t u r a l h i s t o r y o f t h eva r ious fo rms o f in ju r i e s . "

T he f i r s t f ede ra l l eg i s la t ion to addre s s E M S, the H igh -w a y S a f e t y A c t o f 1 9 6 6 ( m u c h o f w h i c h w a s b a s e d o n t h eN A S / N R C p a p e r ) w a s e s s e n t i a ll y d e v o i d o f l an g u a g ed i r e c t e d a t t h e f o r m a t i o n o f p r e h o s p i t a l d a t a c o l l e c t io ns y s t e m s . H o w e v e r , E M S s y s t e m e v a l u a t i o n g u i d e l in e s ,b a s e d o n d e m o n s t r a t i o n p r oj e c ts , w e r e p u b l i s h e d i n 1 9 7 4b y t h e N a t i o n a l H i g h w a y T ra ff ic S a f e ty A d m i n i s t r a t i o n( N H T S A ) i n t h e H i g h w a y S a fe t y P r o g r a m M a n u a l 1 1 a n dw e r e r e c o m m e n d e d t o t h e G o v e r n o r s' H i g h w a y S a f et yR epre s en ta t ive s fo r u s e in the i r E M S p rogram s . O n theb a s is o f t h e se g u i d e l i n e s a n d d e m o n s t r a t i o n p r o j e c ts i nN e w Y o r k, N H T S A p u b l i s h e d s p e c if i c a m b u l a n c e a n de m e r g e n c y d e p a r t m e n t r e p o rt f o r m s in A p p e n d i x S i n t h eH i g h w a y S a f e t y P r o g r a m M a n u a l 1 1. B u t , a s B o y d p o i n t so u t , " T he s e f u n d s , ex c e p t i n f e w i n s t a n c e s . . , d i d n o ts t i m u l a t e t h e d e v e l o p m e n t o f m e d i c a l l y a c c o u n t a b l e E M Ss ys tem s o f c a re . ' 2

T he f i r st f ede ra l l eg i s l a t ion to s pec i f i c a l ly addre s s da taco l l ec t ion in E M S was the E m ergen cy M ed ica l Se rv ice sSys tem Ac t o f 1973 (E M SSA) . T h i s leg i s l a t ion s t imu la tedc o m p r e h e n s i v e E M S s y st e m s d e v e l o p m e n t t h r o u g h o u t t h en a t i o n a n d s t i p u l a t e d t h a t e v e r y E M S s y s t e m co m p r i s e 1 5m a n d a t o r y sy s t e m c o m p o n e n t s C o m p o n e n t 1 1 w a s" S t a n d a r d R e c o r d K e e p i n g , " w h i c h w a s t o :

. . provide for a standardized patient record keeping systemmeeting appropriate standa rds as established by the Secretary,which reco rds shall cover the treatm ent of the patient from initialentry into the system through his discharge from it, and shall beconsistent with e nsuing patient records used in follow -up careand rehabilitation of the p atientN H T S A a n d t h e D e p a r t m e n t o f H e a l t h a n d H u m a nS e r v ic e s ( D H H ) p r o c e e d e d t o e n c o u r a g e a n d u r g e t h e i rre s pec t ive E M S cons t i tuenc ie s to u s e p re s c r ibed s t anda rdd a t a e l e m e n t s f o r E M S r e p o r t i n g a n d e v a l u a t io n .

E a c h r e g i o n a l s y s te m w a s t o p r o v i d e f o r a c o o r d i n a t e dr e c o r d k e e p i n g s y s t e m i n c l u d i n g l i n k e d p r e h o s p i t a l , h o s -pi ta l , and cr i t ica l care records . To fac i l i ta te pa t ient careeva lua t ion , t he da ta e l emen t s we re a l s o to be cons i s t en tw i t h t h o s e i n p a t i e n t r e c o r d s u s e d i n f o l l o w - u p c a r e a n dr e h a b i li t a ti o n . T h e m i n i m a l p a t i e n t r e c o r d w a s t oc o m p r i s e d i s p a t c h e r r e c o r d s, a m b u l a n c e r e c o r d s ( b o t hbas ic li f e s up po r t an d ad van ced l i fe s up por t [AL S]), anda ll h o s p i t a l r ec o r d s . K e y e l e m e n t s o f a c o o r d i n a t e d E M Srecord we re s pec i f i ed . Howeve r , t he E M S reg ions tha ta p p l i e d f o r o r r e c e iv e d f e d e r a l f u n d s e x p e r i e n c e d m a j o rp r o b l e m s i n i m p l e m e n t i n g t h is c o m p o n e n t . T h e m y r i a dp r o b l e m s e a r n e d t h i s c o m p o n e n t t h e r e p u t a t i o n o f b e i n gt h e m o s t d i f f i c u lt o f al l t h e E M S s y s t e m s c o m p o n e n t s t o

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implemen t ) I ron i ca l l y , de sp i t e t he p roposed complex i tyand s ign if i cance o f "s tanda rd r ecord keep ing , " non e o f theseven fede ra l EMS Dem ons t ra t i on Pro j ect s , wh ichprecede d EMSSA, eva lua ted t he f ea sib il it y o f ca rry ing o u tth i s componen t .

W h i l e d e v e l o p i n g th e S t a n d a r d R e c o r d K e e p i n g c o m -p o n e n t , t h e f ed e r al g o v e r n m e n t c o n t r a c t e d w i t h M a c r oSys t ems , Inc , t o deve lop t he o r ig ina l EMS min imum da t ase t (MDS) . The H ea l th Se rv i ce s Adm in i s t r a t i on (HSA) ,w h i c h w a s r e s p o n s i b l e f o r i m p l e m e n t i n g t h e E M S SA ,de t e rmined i t was no t f ea s ib l e t o impose s t anda rd i zedr e c o r d k e e p i n g f o r m s a n d p r o c e d u r e s o n g r a n tr e c ip i e nt s . < 5 C o n s e q u e n tl y , H S A r e c o m m e n d e d t h a t 2 0da t a e l emen t s se rve a s a min im um da t a se t fo r al l EMSsys t ems . 5 The da t a se t was neve r w ide ly d i s t r i bu t ed o ro f f ic i al ly i ncorp ora t ed i n to EMS da t a co l l ec t i on sys t emsto any s ign i f i can t degree . Fur the rm ore , i t f ai l ed t ore so lve p rob l ems a ssoc i a t ed wi th da t a co l l ec t i on o r ana l -y s is . H o w e v e r , a s y s t e m s e v a l u at i o n w o r k b o o k w a s p u b -l i shed in 1976 to promote eff ic ient da ta col lec t iont echn iques and appropr i a t e eva lua t i on me thods#

In t he 1976 am endm ent s t o EMSSA, Congre ss manda t eda s tudy t o i den t i fy t he ca t egory o f pa t i en ts t o be i nc ludedin a un i fo rm repor t i ng sys t em tha t wo u ld eva lua t e theeffec t iveness of EMS in reducing death and disabi l i tyCongre ss expre ssed t he hope t ha t " t he deve lopmen t o f aun i fo rm repo r t i ng sys t em wo uld d i scourage t he deve lop-me n t o f a mul t i p l i c it y o f incom pa t ib l e r epor t i ng sys t emsthat might prove inadequate for evaluat ing the effec t ive-ness o f EMS sys t ems and re su l t in unneces sa ry dup l i ca -tion of effort ."

In 1977 , t he HSA re spond ed to t he congre ss iona l man-date by ini t ia t ing "program abst rac ts" to evaluate EMSsys t ems . The man da to ry abs t r ac t s spec i fi ed g roups o fpat ients tha t rece ived care in the seven cr i t ica l care areaso f EMS sys t ems (ma jo r t r auma , bu rns , sp ina l co rdin ju r i e s , myoca rd i a l i n fa rc t i on , po i son ings , h igh- r i skobs t e t r i c s /neona t e s , p sych i a t r i c ) wou ld be used a s " t r ac -e rs " f o r o u t c o m e d e t e r m i n a t i o n . T h e o u t c o m e s o f t h es ep a t ie n t s w o u l d s u p p o s e d l y h e l p t h e e v a l u a t io n o f th ee f fec ti veness o f an en t i r e EMS sys t em. In a 1978 s tud ype r fo rmed to va l i da t e t he da t a abs t r ac t i on me thod , i twas de t e rmined t ha t s t a t i s t i c s de sc r ib ing t he i nc idence o fpat ients fa i l ing wi thin the cr i t ica l care ca tegories couldbe r e l i ab ly co l l ec t ed f rom EMS sys t ems , t he reby mee t ingHSA repor t i ng r equ i reme n t s . How eve r , i t was a l so con-c luded tha t HSA had fa i led to c lear ly s ta te the da ta def ini -t i ons and i ns t ruc t ions necessa ry t o co l l ec t appropr i a t eda t a t o eva lua te ou t comes . 7

In 1 9 8 1 , s u p p o r t e d b y a g r a n t f r o m t h e N H T S A , t h eH e a l t h O p e r a t i o n s R e s e a r c h G r o u p a t t h e U n i v e r s i t y o fP i t t s b u r g h , t h r o u g h t h e P e n n s y l v a n i a E M S D i v is i o n ,e x a m i n e d t h e f e a s ib i li t y a n d c o m p o n e n t s o f a n A L SM D S f o r th e C o m m o n w e a l t h o f P e n n s y l v a n i a . s T h er e s e a rc h g r o u p u s e d a s t a n d a r d i z e d c o n s e n s u s f o r m a tt o d e v e l o p a n e x t e n s i v e a n d c o m p r e h e n s i v e l is t o f 8 6da t a po in t s fo r i nc lus ion on t he pa t i en t c a re r ecord( P C R ) . D e s p i t e i ts c o m p r e h e n s i v e n a t u r e , t h is M D S w a sn e v e r s i g n i fi c a n tl y u s e d . A N a t i o n a l E M S M a n a g e m e n tI n f o r m a t i o n W o r k s h o p w a s c o n v e n e d i n 1 9 8 3 t o e v a l u -a t e i s s u e s i n E M S m a n a g e m e n t i n f o r m a t i o n s y s t e m s(MIS) . Two o f t he four pap e r se ss ions focu sed on da t an e e d s a n d d a t a s o u r c e s . M o s t o f th e p a p e r s p r e s e n t e dd e s c r i b e d t h e d e v e l o p m e n t o f s t a t e w i d e u n i f o r m E M SPCRs9-1 t and n o t ed t ha t l i nkage wi th h osp i t a l d i scha rgeda t a and po l i ce r ecords wou ld f ac i l i t a t e sys t em eva lua -t i o n . 9 , z l , 1 2

In the la te 198 0s, the Am erican S ocie ty for Testing andMate r ia l s (ASTM) Com mi t t ee F-30 .03 .03 on EMS/MISa t t empted t o deve lop an MD S. Al though seve ra l yea r s o fcomm i t t ee wo rk y i e lded many d ra f t s, t he ASTM consen-sus p rocess d id no t l e ad t o a fi na l, approv ed p rodu c t . In1 9 9 0 , H e d g e s a n d J o y c e p r o p o s e d a n M D S b a s e d o nmu ch o f t he a fo rem en t ioned h i s to ri ca l work . ~3 Desp i t ethe se a t tempt s t o deve lop an MDS, a fo rum w as neve rp rov ided t o a ssu re b road i npu t f rom the enormous cadreof s takeho lde r s . Thu s n one o f the da t a se t s r ece ivedwid espr ead a t tent ion a t the local , s ta te or , regional level .Because i t had become c lear tha t fa i lure to provide ane f fec ti ve p rocess a t t he na t i ona l l eve l wo u ld doo m MDSdev elop me nt to an endless cycle of fa ilure , N HTS Asol ic i ted support f rom other federa l agencies to a id indeve lop ing a consensus fo rum (Tab le 1 ).

THE PURPOSES OF PREHOSPITALD A T A COLLECTIONThe ma in pu rpose s o f p rehosp i t a l da t a co l lec t i on i nc ludethe fo l l owing . (1 ) Da ta co l l ec t ed i n t he f i e ld r ep re sen tt h e l eg a l d o c u m e n t a t i o n o f t h e p a t i e n t e n c o u n t e r .Ind epe nde n t o f a l l o the r i s sues , th i s i n fo rma t ion se rvest h e p r i m a r y p u r p o s e o f b e i n g t h e p r e h o s p i t a l p a t i e n tmed ica l r eco rd . (2 ) In many sys t ems , p rehosp i t a l i n fo r -ma t ion i s necessa ry fo r b i l l i ng o f se rv i ce s p rov ided t othe pa t i en t . Thus t he f i nanc i a l r e sources t o ma in t a in t hesys t em re ly d i rec t l y on t he co l l ec t i on o f th i s i n fo rma t ion .(3 ) The PCR se rves a s t he founda t ion fo r mos t sys t emqua l i t y - improvement p rograms . (4 ) Accura t e p rehosp i t a lda t a co l l ec t i on is fundam enta l t o a ll sys t em eva lua t i ons

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and a l te ra t ions. (5) Research necessary to answer impor-tant quest ions depends on prehospi ta l da ta . This i s espe-c ia lly t rue in a t temp ts to ident i fy cost -effec t iveness andimpac t on pa t i en t ou t come . (6 ) The eva lua ti on o f b roadpub l i c hea l t h i s sues is g rowing inc rea s ing ly dep ende n t onpreho spi ta l da ta . (7) T he abi l i ty to prop er ly a l locate soci -e ta l resources must be t ied to accura te prehospi ta l infor-mat io n an alyzed from local , regional , s tate , and nat ionalperspect ives.

OBSTACLES TO UNIFORM PREHOSPITAL DATACOLLECTION AND USEDesp i t e a widesp read sense am ong EMS pro fe ss iona l s t ha tun i fo rm da t a co l l ec t i on and repor t i ng a re impor t an t t othe fu tu re o f EMS, li tt le p rogre ss h a s been ma de i n t h i sendeavor . The ma in r ea son i s t ha t EMS fund ing , admin-i s t ra t i on , expans ion , sys t em ma in t enance , p ro toco ld e v e l o p m e n t , a n d m e d i c a l d i re c t io n o f t e n r e m a i n u n d e rloca l con t ro l. F ew wou ld a rgue t ha t t h i s shou ld change ,because o f t he d ive r s i t y o f geography , demog raph ic s ,r e s o u rc e s , a n d p a t ie n t p o p u l a t i o n s f o u n d a m o n g E M Ssys t ems . Con sequen t ly , f ew local sys t em adm in i s t r a to r so r med ica l d i rec to r s have a pe r spec t ive o r conce rn bey ondthe p rob l ems and i s sues t ha t t hey f ace i n t he i r own sma l ls u b s y s t e m s . T h u s n e a r l y n o o n e h a s b e e n c o n c e r n e dwi th he lp ing ans wer ques t i on s t ha t are no t o f obv io usloca l impor t ance . In e ssence , e ach sys t em 'owns" i ts ow nda ta (w ha t i s co l l ec ted , ho w i t is co l l ec ted , ho w i t i sused) , and i ts g loba l imp or t ance i s an i s sue o f l i tt l e con-ce rn . Unfor tuna t e ly , many e ssen t i a l ques t i ons can onIyb e a n s w e r e d b y t h e c o m p i l a t i o n a n d s h a r in g o f m e a n i n g -fu l in fo rma t ion f rom m any EMS mic roco sms . 14-~6

Limi t ed r e sources pose a second ba r r i e r t o un i fo rmda ta co l l ec t ion and repor t i ng . T h i s i s t rue on seve ra lf ronts . Fi rst , la rge-sca le col lec t ion, report ing, and aggre-

gat ion of da ta w oul d requi re su bstant ia l f inancial resources.B e c a u se s u c h r e s o u r c e s h a v e n o t b e e n f o r t h c o m i n g f r o mfede ra l o r s t a t e gove rnment s , fund ing wou ld have had t ocome from local and regional ent i t ies . Clear ly , th is hasno t occur red ; n o r w ou l d i t have been p red i c t ed , fo r r ea-sons de ta i led ear lier . Second , even i f adeq uate f inancia lresources w ere available, few local EMS system p erson nelhave t he i n fo rma t ion-managem ent expe r i ence o r expe r t isein deve lopment and implemen ta t i on t o p roduce a sys t emthat i s appropria te and responsive to local and nat ionalneeds . Th i rd , even i n sys t ems whe re appropr i a t e expe r t i seex i s ts , f ew a re a ssoc i a t ed wi th r e sea rch i ns t i t u t i onswhere expe r i ence i n sys t em eva lua t i on , med ica l i n fo r -mat ics, s ta t i s t ica l analysis , and cos t -effec t iveness analysisexists . lZ I t i s not surpr is ing tha t loca l EMS agencies haveseen l i t t l e need t o deve lop soph i s t i c a t ed and expens iveda t a co l l ec t i on p rocesse s t ha t wou ld r ema in v i r t ua l l yu n u s e d .

The f i na l ba r r ie r t o t he deve lopm ent o f un i fo rm da t acol lec t ion and rep ort ing has b een the lack of a lead federa lagency t o d i r ec t a na t iona l consensus p rocess . To removeth is ba r r i e r and t o he lp a ssu re widespread accep t ance,NHTSA bui l t a coal i t ion of federa l agencies and nonfed-era l organiza t ions. With a na t ional , consensus-based uni -form data se t establ i shed, i t i s hoped tha t substant ia leffor ts wi l l be made to deal wi th the other barr iers a t thefederal , state, regional, and local levels.DEVELOPMENT OF THE DATA SET STRAWMANThe U ni fo rm Prehosp i t a l EMS Da ta Confe rence was con-vened i n an e f fo r t t o e s t ab l ish a con sensus-base d na t i ona lEMS da t a set . Dur ing t he deve lop men t p rocess , a tt endeeseva lua t ed cu r ren t p rehosp i t a l da t a e l emen t s , bu i l d ing andref ining def ini t ions as appropria te . The conference estab-l i shed , a s a goal , t he dev e lopm ent o f consensus s t a t emen t s

T a b l e 1 .Sponsoring ederal agencies.N a t io n a l H ig h w a y T ra f f ic S a fe ty A d m in is t ra t i o n , U S D e p a r tme n t o f T ra n s p o rta t io nT h e fo l l o w in g o rg a n iz a tio n s o f th e U S D e p a r tme n t o f H e a l th a n d H u ma n S e rv i c e s :D iv i s io n o f T ra u ma a n d E m e rg e n c y Me d ic a l S y s te ms , H e a l th R e s o u rc e s a n d

S e rv i c e s A d m in is t ra t i o nN a t io n a l C e n te r fo r In ju ry P re v e n t io n a n d C o n t ro l, Oe n te rs fo r D is e a s e C o n t ro lNat ionaF Heart , Lung, and B lood Ins t i tu te , Na t iona l Ins t itu tes o f Hea l thMa te rn a l a n d C h i ld H e a l th B u re a u , H e a l th R e s o u rc e s a n d S e rv i c e s A d m in is tra t io nO f f i c e o f R u ra l H e a l th P o l i c y , H e a l th R e s o u rc e s a n d S e rv i c e s A d m in is t ra t i o nO f f i c e o f C o v e ra g e a n d E l i g ib i l i t y P o l i c y , H e a lth C a re F in a n c e A d m in is t ra t i o nO f f i c e o f S c ie n c e a n d D a ta D e v e lo p me n t , A d m in is t ra t i o n fo r H e a l th C a re P o li c ya n d R e s e a rc hU S F i re A d m in is t ra t i o n , F e d e ra l E me rg e n c y Ma n a g e m e n t A g e n c y

Table 2 .N o@ de rd s t akeholder groups represen ted ~n p lanni ng .A me r i c a n A c a d e m y o f P e d ia t r i csA me r i c a n A m b u la n c e A s s o c ia t io nA me r i c a n C o l le g e o f E m e rg e n c y P h y s ic ia n sA me r i c a n C o l le g e o f S u rg e o n sAmerican Hosp i ta l Assoc ia t ionA me r i c a n S o c ie ty fo r T e s t in g Ma te r ia l sE MS D a ta S y s te ms In c o rp o ra te dN a t io n a l A s s o c ia t i o n o f E MS P h y s ic ia n sN a t io n a l A s s o c ia ti o n o f E MT sN a t io n a l A s s o c ia t i o n o f S ta te E M S D i re c to rsN a t io n a l C o u n c i l o f S ta te E MS T ra in in g C o o rd in a to rsIn ternat iona l A ssoc ia t ion o f F i re Ch ie fs

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E M S D A T ASpai te e t a I

that would lead to the implementation of a widely acceptedand utilized data set to be modified and refined throughresearch.

The national consensus process began in 1992 withthe convening of a series of meetings including manystakeholder organizations (Tables 1 and 2). During thisprocess, a subgroup of the planning committee was giventhe task of developing a "strawman" document to includepotential "core" and "supplemental" data elements anddefinitions. A conceptual change led to the terminology ofunifo rm data set (UDS) instead of minimum data set. Thischange reflected several issues: First, the term "minimum"was a misnomer, given the broad scope of the project andthe predicted final product. With the inclusion of bothcore and supplemental elements, the data set could nolonger be considered minimum. Second, the term "mini-mum" might imply a relatively fixed, if not stagnant,group of elements. It was clearly under stood from the out-set that the consensus group product would only repre-sent a beginning, with the full intent for future evaluation,revision, and improvement . Third, dealing only with theminimum data set would continue to leave the supple-mental elements in the same quagmire of local, regional,and state variation that had typified the previous data set.Finally, compatibility with the monumental work done bythe Utstein Consensus Conference zs for prehospital car-diac arrest data was important, even though some of thesedata elements could not be considered core for many localE M S systems.

CRITERIA FOR INCLUSION OF PREHOSPITALDATA ELEMENTSDuring UDS strawman development, meetings of the dataset development task group provided for extensive discus-sion of each potential data element. The rationale for inclu-sion of a given data element are listed in Table 3. For a dataelement to be regarded as core, it was mandatory that it beconsidered an essential part of the medical record in anylocal EMS system. Many of the core elements had otherrationales for inclusion, but appropriateness for the medicalrecord was a prerequisite. Although one of the intendeduses of the uniform data is evaluation of system-relatedquestions, usefulness for evaluative or epidemiologic pur-poses was not sufficient to qualify a data element as core.The rationale was simple: If data elements were consideredcore despite the fact that their primary usefulness was forresearch or evaluation, the likelihood of their widespreadacceptance would be compromised.

The inclusion of supplemental data elements in theconsensus process was important. Although some mightargue that only core elements should have been included,exclusion of the supplemental elements would have beendetrimental in several ways. First, many of the supple-mental elements are extremely important for EMS systemevaluation and quality improvement at the local, regional,and state levels. However, many of the supplemental ele-ments could not realistically be considered core becauseit would be unfeasible to collect them in all systems. Second,many riMS systems alrea@ collect many of the supplementalelements. Failure to include these as a part of the uniformdata set might discourage systems from continuing tocollect this important information. Third, inclusion of thesupplemental data elements may serve to stimulate futureimprovements in EMS data collection. We hope that manyEMS systems will consider collecting some or all of thesupplemental elements in an effort to provide more detailedand useful information for quality improvement andresearch. Finally, inclusion of the supplemental elementsmay provide valuable insight into future core elements.

THE UNIFORM PREHOSPITAL EMS DATAELEMENT CONFERENCEIn August 1993, the consensus conference convened inArlington, Virginia. A diverse group of participants repre-sented essentially every conceivable organization with aninterest in EMS. The data set st rawman was made avail-able to all conference participants before their arrival. ANational Institutes of Health consensus process was usedto develop the final product. 19 Aided by the Data SetDevelopment Task Group, a panel of 12 expert referees(Table 4) heard testimony during open forums on each ofthe data elements and definitions. Having heard theextensive testimony, the expert panel convened to developthe final data set and definit ions (Appendix). It should benoted that the consensus panel changed the term "core" to~essential" in the final document. According to the con-sensus panel, an essential data element is one that is cru-

T a b l e 3 .Rationale for inclusion in data set.Medical recordSystem evaluat ionQual i ty improvementBil l ingMedico legalResearch

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E M S D A T A5 p a i t e e t a I

c ia l fo r the bas ic ope ra t ion s o f an E MS s e rv ice and tha tcan s e rve a purpos e a t the reg iona l o r na t iona l l eve l. T het e r m " s u p p l e m e n t a l, " w h i c h h a d b e e n u s e d b y t h e d a t a s e td e v e l o p m e n t t a s k g r o u p , w a s c h a n g e d t o " d e s i r a bl e ." T h ep a n e l n o t e d t h a t d e s i r ab l e e l e m e n t s m a y w e l l b e c r i t ic a l tol o c al o p e r a t i o n s b u t m a y n o t b e c o n s i d e r e d c r it i ca l i n a llj u r i s d i c t i o n s o r s i t u at i o n s . O n e s i g n i fi c a n t a d v a n t a g e t oth i s change i s the fac t tha t the t e r ms a re bo th des c r ip t iveand e s s en t i a l ly s e l f -de f in ing .

I t w a s t h e c o n s e n s u s o f t h e p a n e l t h a t t h e se r e c o m m e n -d a t i o n s s h o u l d b e i m p l e m e n t e d a t t h e s ta t e , r e g i o n al , o rl o c al le v e l a s a p p r o p r ia t e . T h e p u r p o s e o f a u n i f o r m d a t as e t a n d d e f i n i t i o n s i s t o p r o v i d e c o m m o n t e r m i n o l o g y a n dd e f i n i t i o n s t o b e u s e d i n t h e e v a l u a t i o n o f E M S . A l t h o u g hthe da ta s e t i s us e fu l in des c r ib ing the p reho s p i t a l a s pec t so f ca r e, i t l a c k s o u t c o m e m e a s u r e s t h a t w o u l d s t r e n g t h e nthe ev a lua t ion p roces s . I t i s to be co ns ide red a f i r s t s t ep inthe p roces s o f E MS s ys tem eva lu a t ion .

LINKAGE OF PREHOSPITAL DATA WITH OTHERINFORMATION SOURCESE v e n i f p r e h o s p i t a l d a t a c o l le c t i o n a n d m a n a g e m e n tw e r e b e i n g p e r f o r m e d p e r f e c t l y o n a n a t i o n a l s c a le , i tw o u l d n o t b e a d e q u a t e , b e c a u s e e v e n w e l l- c o n c e i v e dp r e h o s p i t a l d a t a b a s e s c a r r i e d o u t i n a v a c u u m a r e o f l i m -i t e d u se . S i m p l y s t a t e d , p r e h o s p i t a l i n f o r m a t i o n t h a tr e m a i n s u n l i n k e d w i t h h o s p i t a l a n d a u t o p s y o u t c o m ed a t a h a s l i m i t e d m e a n i n g . I n f a c t , t h e f a i l u r e o f t h i s l in k -a g e is o n e o f t h e m a i n r e a s o n s t h a t s o l it t le e v i d e n c ee x i s ts w i t h r e g a r d t o t h e i m p a c t o f p r e h o s p i t a l c a r e o np a t i e n t o u t c o m e . 2

A l t h o u g h f e w p e o p l e i n v o l v e d i n t h e p r e h o s p i t a l , h o s -p i t a l , and rehab i l i t a t ive a s pec t s o f pa t i en t ca re wo ulda rgue aga ins t the impo r tanc e o f l inkage , the obs tac le s toi n f o r m a t i o n s h a r i n g a re f o r m i d a b l e . I n a d d i t i o n t o t h e

T a b l e 4 .C o m p o s i t io n o f co n fe ren ce co n sen su s p a n e l .

State EMS directorState EMS training co ordinatorAmbulance serv ice manager--pr ivateEMS man ager--publ ic , f i re-basedReg iona l /county EMS managerEMS me dical di rectorEmergency physic ianEmergency nurseTrauma sys tems d i rec to rEpidemiologistEMS researcherPanel chairperson

b a r r i er s o f p a t i e n t c o n f i d e n t i a l i t y a n d a n o n y m i t y o f ag e n -c i es a n d p e r s o n n e l , m o s t E M S a g e n c ie s d o n o t e m p l o yp e r s o n n e l w i t h t h e t e c h n i c a l e x p e r t is e t o p r o p e r l y l i n ks epa ra te da tabas es . T he complex i t i e s and log i s t i c s o fe m e r g e n c y m e d i c a l s y s t e m i n f o r m a t i c s a re c e r t a i n l y n o tt r iv ia l . I t i s hoped tha t the pa ra l l e l work toward a t raumac a r e s y s t e m u n i f o r m d a t a s e t u n d e r t h e a u s p i c e s o f t h eD i v i s io n o f T r a u m a a n d E M S a t t h e H e a l t h R e s o u r c e s a n dS e r v ic e s A d m i n i s t r a t i o n w i l l p r o v i d e t h e o p p o r t u n i t y t od e v e l o p a m o d e l f o r li n k a g e o f p r eh o s p i t a l a n d h o s p i t a li n f o r m a t i o n . O p t im a l l y , f u t u r e c o o p e r a t i o n b e t w e e n f e d -e r a l a n d n o n f e d e r a l a g e n c ie s w i ll p r o v i d e t h e s u p p o r t n e c -e s s a ry t o s u c c e s s f u l l y d e a l w i t h t h i s e n o r m o u s t a sk .

THE FUTURE: IMPLEMENTATION OF THEUNIFORM PREHOSPITAL DATA SETA s s t a t ed p r e v i o u sl y , th e p r o d u c t o f t h e c o n s e n s u s c o n f e r -e n c e s h o u l d o n l y b e c o n s i d e r e d a b e g i n n i n g . A l t h o u g h i ti s h o p e d t h a t t h e s u b s t a n t i a l p r o g r e ss m a d e b y t h e c o n f e r -ence has y ie lded a p rodu c t tha t i s bo th us e fu l an d va luab le ,r e s e a rc h a n d e v a l u a t i o n o f t h e U D S m u s t b e g i n i m m e d i -a te ly P i lo t te s t ing o f the da ta s e t in f ron t i e r , ru ra l , s ubu r -b a n , a n d u r b a n s e t ti n g s w il l b e n e c e s s a r y to d e t e r m i n e t h efeas ib i l ity o f wid es pre ad us e . In ad d i t ion , the p roces s o fa g g r e g a ti n g , a n a l y z i n g , a n d u s i n g i n f o r m a t i o n a t t h ereg iona l , s t a te , and fede ra l leve l s wi l l be ex t rem e ly impor -t a n t . I f q u a l i t y i n f o r m a t i o n i s g a t h e r e d b u t n o t s h a r e d , t h eg l o b a l i m p a c t o f t h is d a t a s e t w i l l b e o n l y m i n i m a l .

I t i s i m p o r t a n t t o n o t e t h a t t h e n a t i o n a l c o n f e r e n c e d i dn o t d e v e l o p c o n s e n s u s o n t h e d a t a i t e m d i c t i o n ar y . F o ri n s t a n c e , th e d a t a e l e m e n t " S i g n s a n d S y m p t o m s P r e se n t "w a s d i s c u s s e d a n d c o n s i d e r e d d u r i n g t h e c o n s e n s u s p r o -ces s. I t d id rece ive a de f in i t io n and a p r io r i ty a s s ignm ento f e ss e n ti a l. H o w e v e r , t h e i t e m s o n t h e d a t a i t e m c o n t e n tl i s t ( i e , abdomina l pa in , back pa in , ch i ldb i r th ) were no tf o r m a l s u b j e c ts o f t h e c o n s e n s u s c o n f e r e n c e . T h e r e fo r et h i s a r ti c le d o e s n o t i n c l u d e t h e e x t e n si v e d a t a d i c t i o n a r yi s su e s , o n l y c u r s o r y c o m m e n t s a n d e x a m p l e s . T h eD i v i s i o n o f E M S a t N H T S A c o n t i n u e s t o w o r k w i t h t h ec o n s e n s u s p a n e l a n d t h e d a t a se t d e v e l o p m e n t t a s k g r o u pto re s o lve thes e rem a in in g i s sues be fo re pub l ic a t ion o f thef i n al fe d e r a l d o c u m e n t . C o p i e s o f t h a t d o c u m e n t w i ll b ea v a il a b le t h r o u g h t h e E M S D i v i si o n o f N H T S A .

F i n al ly , t h e e x i s t e n c e o f a w i d e l y a c c e p t e d u n i f o r m d a t as e t d o e s n o t e n s u r e t h a t a c c u r a t e a n d c o m p l e t e i n f o r m a -t ion w i l l be co l l ec ted in the f i e ld . 21-22 M uch wo rk rem a inst o b e d o n e i n e v a l u a t i n g th e m a n y b a r r i e r s t o t h e p r o c e s so f o b t a i n i n g h i g h - q u a l i t y i n f o r m a t i o n c o l l e c te d i n t h e p r e -hos p i t a l s e t t ing . I f th i s p roces s re s u l t s on ly in the co l l ec -

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t i on and r epo r t i ng o f a la rge am oun t o f bad da t a , i t w i l ls i mp l y l ead t o bad c onc l u s i ons t ha t a r e be l i eved wi t hgreater fervency. I t is the res pons ib i l i ty of EMS profe ssion-a ls a t every l eve l to e nsu re t ha t such a s i t ua t ion does no to c c u r. F u t u r e c o n f e r e n ce s s h o u l d b e c o n v e n e d t o r e v ie wt he exper i ence o f sy s t ems tha t i mp l eme n t t he UDS. Th i sexper i ence , combi ned wi t h r esearch and eva l ua t i on o f t heda t a se t , w i ll f o rm t he bas i s fo r rev i s i on and i m provem en t .I t i s hop ed t ha t t h i s p rocess , a long wi t h i mp roved l i nkageo f i n fo rmat i on , w i ll y ie l d answer s t o t he fundam en t a lques t i ons a bou t t he cos t - e f fec t i veness and o u t com ei mpa c t o f EMS sys tems .

REFERENCES1. Nat ional Academy of Sc iences and the Nat ional Rese archCounc i l : Acc identa l D eath andDisabi l i ty : The Neglected D isease of MO dern Society . Washington, DC. September 1966.2. Boyd DR (ed): A sympo sium on the I l li no is t rauma progra m: A systems approach o the c are ofthe cr i t i ca l ly i n jured. J Trauma1973;13:275,320.3. Boyd DR: The h is tory o f em ergency medica l systems (EMS) n the Uni ted States of America, i nBeyd DR, Edl i ch RF, Sylv ia M (eds), SystemsApproach o EmergencyMed ical Care.N o rw a l k ,Conne ct i cut, Appleton-Century-Cro f t s , 1983.4. Stee le R: Developm ent o f a M in imal Data Set for Emergency Serv ices Pat ient Record Keeping.Macro S ystems, Inc. Prepared o r the Hea l th Serv ices Adm in is t ra t ion, Nat ional Technica lIn format ion Se rv ices (NTIS), Ju ly 1974.8 . B i r ch H : G u i d e l in e s o r P a t i e n t R e co rd K e e p in g S ys t e m s o r E m e rg e n cyMedica l Serv ices.V olI h M o d e l S ys t e m G u i d e l in e s o r P a t ie n t R e co rd K e e p i n g a n d M a n a g e m e n t R e p o r t i n g . M a c roSystems, Inc. Prepare d or the H eal th Serv ices Adm in is t ra t ion, NTIS, Septembe r 1974,6. Evaluat ion workboo k for EMS. US Dep artment o f Hea l th , Educat ion and Wel fare, Publ i c Heal thServ ice, Heal th Serv ices Adm in is t ra t ion, D iv i s ion of E mergency Medica l S erv ices. DHEWPubl i cat ions {HSA ) 76-2021 , Augus t 1976.7. Re l iab i li t y o f accurac y, comp leteness, and com parabi l i t y o f t he emerg ency medica l serv i cessys t e m s d a ta n e e d e d o m e e t re p o r t i n g re q u i re m e n ts o f P u b l i c L a w s 9 3 -1 5 4 a n d 9 4 -5 7 3 . A r t h u rYoun g and Co. F ina l report {draf t ) submi t ted to the Heal th Serv ices Admin is t ra t ion January 19 80.8. Wol fe H, Shuman L , E sposi te G, e t ah DevelopmentefALSMinimum Data SetandBLSAlgorithms.Univers i t y o f P i t t sburgh, August 1981.9 . Jo h n so n S W : D e ve l o p m e n t o f a u n i fo rm a m b u l a n ce ru n re p o r t a n d t h e u se o f n o m i n a l a n d d e l-p h i g ro u p p ro ce ss e ch n i q u e s t o re a ch co n se n su s , n D e t N e f s W C , H a m K S (e d s ) ,Proceedingso fthe NationalEMS Management nformationSystems Workshop.Harr i sburg, Pennsylvania,O c t o b e r 1 9 8 3 .

10. Houston J: Conse nsusdesign and development o f an ef fect i ve, workable ma nagem ent n for-mat ion system or a rura l EMS system : The Da rtmouth system rev is it ed. In Deth le fs WC, Ham KS(eds}, Proceedingsof the Nat ionalEMS Management nformationSystems Workshop.Harr i sburg, Pennsylvania,O c t o b e r 1 9 8 3 .11. Ham KS: Consensusdevelopm ent o r ident i f icat ion o f data e leme nts and impleme ntat ionamon g d iverse reg ional EMS systems, n Deth le fs WC, Ham KS (ads), Proceedingsof theNational EMS Management nformationSystems Workshop.Harr i sburg, Pennsylvania,O c t o b e r1983.12. Larson D: Statewide co l lect ion of EM S-re la ted nformat ion: The Utah vehicu lar trauma study,in Deth le fs WC, Ham KS (eds),Proceedingsof the Nat ionalEMS Management nformationSystems Workshop.Harr i sburg, Pennsylvania,O c t o b e r 1 9 8 3 .1 3 . H e d g e sJR, Joyce SM: M in imum d ata set for EMS repo rt f orm: H is tor i ca l development andfuture impl i cat ions, PrehospDisasterM ad 1 9 9 0 ; 5 : 3 8 3 -3 8 8 .14. Cummins DO: Sect ion Ih Meving toward un i form report ing and terminology. Ann EmergM ed1993;22:33-36.15. Hedges JR: Beyond Utste in : Implementat ion of a mul t i seurce un i form data base or preho spi -ta [ card iac arrest research.Ann EmergMed1993;22:41-46.16. Cumm ins RO: The Utste in s t y le for u n i form report ing of da ta f rom o ut -o f - hospi ta l card iacarrest . Ann EmergM ad 1993;22:37-40.17. Spai te DW, Valenzuela TD, Meis l i n HW : Barr iers o EMS system evaluat ion: Problems associ -a ted w i th f i e ld data co l lect ion. PrehospDisasterM ad 1993;8(suppl ) :S35-S40.18, Cumm ins RO, Chamberla in DA, Abramsen NS, e t a t : Recommended guide l ines for un i formreport ing of data f rom out -o f -ho spi ta l card iac arrest : The Utste in s t y le . Ann EmergM ed1991 29:861-874.1 9 . G u i d e li n e s o r t h e se l e c ti o n a n d m a n a g e m e n t o f co n se n su sdevelopm ent conferences: Of f iceof Medica l Appl i cat ions of Research,Nat ional I nst i t u tes o f Heal th .20. Maid R: The ut i l i zat ion o f publ i c heal th research mode ls n the e valuat ion of EMS systems.San Francisco, Cal i f orn ia , 23rd Annual M eet ing of t he S ociety or Acade mic EmergencyM e d i c i n e , M a y 1 9 9 3 .21. Mosse sso VN: The most neglected o o l i n EM S: The c lock. Ann EmergMed1993;22:1311-1312.22. Spai te DW, Han[on T, Cf iss EA, e t ah Preh ospi ta [d a t a e n t r y co m p l i a n ce b y p a ra m e d i cs a f te rinst i tu t i on o f a comp rehensive EMS data co l lect ion too l . Ann EmergMeg1990;19:1270-1273.T h e a u t h o r s t h a n k t h e m e m b e r s o f th e D a t a C o n f e r e n c e P a n e l: C h a i r m a n , J M i c h a e lD e a n , M D ; J i m D o w s e r ; R i c k B u e ll ; H e r b e r t G a r r is o n , M D ; W B r i g g s H o p s o n , M D ;L e o n a r d I n c h ; C h i e f J a c k K r a k e e l ; R o n a l d M a i D , D O ; P e t e r P e n s , M D , F A C E P ; W a d eS p r u i l l, J r ; P a t r i c ia W a l l e r , P h D ; a n d M a r i e W i l s o n , R N .

R e pr i n t no . 4 7 / 1 /6 2 5 5 8N o r e pr i n ts a v a i l a b l e f r om the a u thor .

A p p e n d i x .Uniform EM S data elements and definitions.D a t a E l e m e n t P r i o r i t y D e f i n i t i o n C o m m e n t

1 . In c i d e n t a d d r e s s E s s e n t i a l A d d r e s s ( o r b e s t a p p r o x i m a t i o n ) w h e r e p a t i e n t w a s f o u n d F r e e t e x to r , if n o p a t i e n t , a d d r e s s t o w h i c h t h e u n i t r e s p o n d e d

2 . I n c i d e n t c i t y E s s e n t i a l C i t y o r t o w n s h i p ( i f a p p l i c a b l e ) w h e r e p a t i e n t w a s f o u n d N u m e r i c e n t r yo r to w h i c h u n i t r e s p o n d e d ( o r b e s t a p p r o x i m a t i o n }

3 . I n c id e n t c o u n t y E s s e n t i a l C o u n t y o r p a r i s h ( i f a p p l i c a b l e } w h e r e p a t i e n t w a s f o u n d N u m e r i c e n t r yo r to w h i c h u n i t r e s p o n d e d ( o r b e s t a p p r o x i m a t i o n )

A P R I L 1 9 9 5 2 5 :4 A N N A L S O F E M E R G E N C Y M E D I C IN E 5 3 1


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E M S D A T AS p a ~ t e e t a Z

A p p e n d i x , continuedData E lement Pr ior ity Def in i t ion Comm ent

4. Inc ident s ta te Essent ia l5 . Locat ion type Essent ia l6 . On s e t d a te D e s i ra b le7 . On s e t t ime D e s i ra b le8 . Date inc ident reported Essent ia l9 . T ime inc ident reported Essent ia l

1 0 . T ime d i s p a tc h n o t i f i e d E s s e n t ia l

1 1 . D a te u n i t n o t i f i e d D e s i ra b le1 2 . T ime u n i t n o t i f i e d E s s e n t ia l1 3 . T ime u n i t re s p o n d s E s s e n t ia l

14 . T ime o f a rr iva l a t scene Essent ia l1 5 . T ime o f a r r i va l a t p a t ie n t D e s i ra b le

1 6 . T ime u n i t l e a v e s s c e n e E s s e n t ia l1 7 . T ime o f a r r iv a l a t d e s t in a t i o n E s s e n t ia l

18 . T ime back in serv ice Essent ia l19 . L igh ts and s i rens to scene Essent ia l2 0 . S e rv i c e t y p e E s s e n t ia l21 . Inc ident numb er Essent ia l2 2 . R e s p o n s e u mb e r E s s e n t ia l

23 . PCR num ber Essent ia l2 4 . A g e n c y /u n i t n u mb e r E s s e n t ia l2 5 . V e h ic le t y p e E s s e n t ia l2 6 . F i rs t c re w me m b e r n u mb e r E s s e n t ia l2 7 . S e c o n d c re w me m b e r n u mb e r E s s e n t ia l2 8 . T h i rd c re w me m b e r n u mb e r D e s i ra b le

2 9 . C re w me m b e r l t y p e E s s e n t ia l3 0 . C re w me m b e r 2 t y p e E s s e n t ia l3 1 . C re w me m b e r 3 t y p e D e s i ra b le3 2 . P a t ie n t n a me E s s e n t ia l33 . Pat ien t s tree t address Des irab le34. C i ty o f res idence Des irab le3 5 . C o u n ty o f re s id e n ce D e s i ra b le3 6 . S ta te D e s i ra b le

S ta te , te r r i t o ry , o r p ro v in c e (o r D is t ri c t o f C o lu mb ia ) w h e rep a t ie n t w a s fo u n d o r to w h ic h u n i t re s p o n d e dType o f loca t ion o f inc identD a te o f o n s e t o f s ymp to ms o r i n ju ry d a te

T ime o f o n s e t o f s y mp to ms o r i n ju ry t imeD a te th e c a l l w a s f i r s t re c e iv e d b y a p u b l i c s a fe ty

a n s w e r in g p o in t (P S A P ) o r o th e r d e s ig n a te d e n t i t yT ime c a l l w a s f i r s t re c e ive d b y P S A P o r o th e rd e s ig n a te d e n t i t yT ime o f f i r s t c o n n e c t io n w i th E MS d is p a tch

D a te o n w h ic h re s p o n s e u n i t i s n o t i f i e d b y E MS d is p a tc hT ime a t w h ic h re s p o n s e u n i t i s n o t i f i e d b y E MS d is p a tc hin seconds and c lock synchron iza t ion s trong ly encouraged.T ime a t w h ic h re s p o n s e u n i t b e g in s p h y s ic a l mo t io n

T ime E M S u n i t s to p s p h y s ic a l mo t io n a t s c e n e ( la s t p la c eth a t th e u n i t o r v e h ic le s to p s b e fo re a s s e s s in g p a t ie n t )

T ime a t w h ic h re s p o n s e p e rs o n n e l e s ta b li s h d i re c tc o n ta c t w i th p a t ie n tT ime w h e n re s p o n s e u n i t b e g in s p h y sic a l mo t io n f ro m s c e n eT ime w h e n p a t ie n t a r ri v e s a t d e s tin a t io n o r tra n s fe r p o in t

T ime th a t re s p o n s e u n i t i s b a c k in s e rv ic e a n d a v a i l a b le fo rre s p o n s e

U s e o f l i g h ts a n d s i re n s e n ro u te to s c e n eT y p e o f s e rv i c e re q u e s te dU n iq u e n u mb e r fo r e a c h in c id e n t re p o r te d to d i s p a tc hU n iq u e n u mb e r fo r e a c h in d i v id u a l re s p o n s e b y are s p o n s e u n i t to a n in c id e n tU n iq u e n u mb e r fo r e a c h P C RN u mb e r i d e n t if i e s th e a g e n c y a n d u n i t re s p o n d in g to

an inc identT y p e o f v e h ic le th a t re s p o n d e d to a n in c id e n tP e rs o n n e l c e r t i f i c a t i o n / l i c e n s e n u m b e r fo r f i r s t c re w

m e m b e rP e rs o n n e l c e r t i f i c a t i o n / l i c e n s e n u mb e r fo r s e c o n d c re w

m e m b e rP e rs o n n e l c e r t i f i c a t i o n / l i c e n s e n u mb e r fo r th i rd c re wm e m b e rP e rs o n n e l c e r t i f i c a t i o n / l i c e n s e le v e l o f c re w me mb e rP e rs o n n e l c e r t i f i c a t i o n / l i c e n s e le v e l o f c re w m e mb e rP e rs o n n e l c e r t i f i c a t i o n / l i c e n s e le v e l o f c re w m e mb e rP a t ie n t n a mePat ien t 's s tree t address ( i f app l icab le)P a t ie n t 's c i t y o r to w n s h ip o f re s id e n ce ( i f a p p l i c a b le )C o u n ty o r p a r i s h w h e re p a t ie n t re s id e s ( i f a p p l ic a b le )Sta te , te rr i to ry , o r p rov ince (or D is tr ic t o f Co lumbia)

w h e re p a t ie n t re s id e s

A lp h a n u me r i c e n t ryExam ples : res idence, pub l ic bu i ld ing , fa rmM a y d i f f e r fr o m t h e d a t e o f E M Sre s p o n s e . Ma y b e n u m e r i c a ll y c o d e d .

S ta r t in g p o in t o f th e E M S re s p o n s e . Me a s u re -me n t i n s e c o n d s a n d c lo c k s y n c h ro n iz a tio ns trong ly encouraged.P e rm i ts a s s e ss me n t o f d e la y s b e tw e e n t ime in c i-d e n t re p o r te d a n d th e n o t i f i c a t i o n o f E MS d is -p a tc h . Me a s u re m e n t i n s e c o n d s a n d c lo c k s y -chron iza t ion s trong ly encouraged.Ma y b e n u me r i c a ll y c o d e d .P e rm i ts me a s u re me n t o f re s p o n s ea n d p o s s ib le d e la y s . Me a s u re me n tP e r m i ts m e a s u r em e n t o f i n t e r v a l h e ~ e e n n o t i fi -c a t i o n a n d a c tu a l m o b i l i z a t i o n o f re s p o n s e u n i t.

Me a s u re m e n t i n s e c o n d s a n d c lo c k s y n c h ro n iz a -t i o n s t ro n g ly e n c o u ra g e d .Me a s u re m e n t i n s e c o n d s a n d c lo c k s y n c h ro n iz a -t i o n s t ro n g ly e n c o u ra g e d .Id e n t if i e s e a r l i e s t t ime a t w h ic h E MS c a re c a na c tu a f ly b e g in . M e a s u re me n t in s e c o n d sand c lock synchron iza t ion s trong ly encouraged.

Me a s u re m e n t i n s e c o n d s a n d c lo ck s y n c h ro n iz a -t i o n s t ro n g ly e n c o u ra g e d .M a y r e f l e c t ti m e o f r e n d e z vo u s w i t h a n o t h e r E M S

u n i t . Me a s u re m e n t i n s e c o n d s a n d c lo c k s y n -chron iza t ion s trong ly encouraged.P e rm i ts me a s u re me n t o f to ta l o u t -o f -s e rv ic ein terva l .Y e s , n o , u p g ra d e d , d o w n g ra d e dI te ms s u c h a s s c e n e , i n te r fa c i l i t y , s ta n d b yA lp h a n u me r i c e n t ryE a c h u n i t re sp o n d in g to a s in g le i n c id e n t w o u ldh a v e th e s a me in c id e n t n u m b e r b u t a u n iq u e

re s p o n s e n u mb e r .Usefu l in cons truc t ing agency or un i t -spec i f ic

reports .E x a mp le s : g ro u n d , ro to rc ra f t, f i x e d -w in g , o th e r .Ident i f ies personne l invo lved in response,p a t ie n t c a re , o r b o th .

A g i v e n a g e n c y ma y d e s i re to l i s t th re e o r me rep e rs o n n e l . T h e a b i l i t y to l i s t a t l e a s t tw o i sessent ia l .E x a mp le s : f i r s t re s p o n d e r , e me rg e n c y me d ic a ltechn ic ian bas ic , param edic , nurse

F re e te x tF re e e x t ; p a t i e n t ' s p la c e o f re sid e n c e , i f k n o w nN u me r i c e n t ryN u me r i c e n t ryA lp h a n u me r i c e n t ry

5 3 2 A N N A L S O F E M E R G E N C Y M E D I C I N E 2 5 : 4 A P R I L 1 9 9 5


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E M S D A T A5pa~te et aI

A p p e n d i x , continuedData Element Priority Definit ion Comment37. Z ip code o f r es i dent Essent i a l38 . T e l ephone numbe r Des i rab l e39. Soc i a l Secur i t y numbe r Des i rab l e40. Date of bi r th Essen t ial41 . Age Des i rab l e42. Ge nd er Essent i a l43. Race /ethnici ty Essen t ial

44 . Des t i na t ion / t rans fer red t o Es se nt i a l45 . Des t i na t ion determi nat ion Es se nt i a l46 . L i gh t s , s i r ens used f rom sce ne Essent i a l47 . I nc i dent / pa ti en t d i spos i ti on Es sen t i a l

48 . Ch i e f ompl a i n t Des i rab l e49. Ca use f i n ju r y Essent i a l

50 . P rov i der i mpress i on Essent i a l

51. Preexist ing cond i t ion Essen t ial5 2 . S i g n sand symptoms Essent i a l53. Injury desc r ipt ion Essen t ial54. Injury inten t Des i rable55. Safe t y equ i pment Essent i a l56 . F ac tors f f ec ti ng Des i rab l eEMS de l i very o f care57. A lcoho l /drug use Essen t ial58. T ime of f i rst CPR Des i rable59. Providero f f i rst CPR Des i rable60. T ime CPR discont inue d Desi rab le

61. T i me o f w i t nessed Des i rab l ecard i ac ar res t62 . Wi t ness o f card i ac ar res t Des i rab l e63. T i m eo f f i r s t Des i rab l edef i b r i l l a t o r y shock6 4 . R e t u r no f s p o n - D e s i r a b l etaneous ci rculat ion65. Pu l se a te Essent i a l66. Ini t ial hear t rhythm Desi rab le6 7 . R h y t h mat dest inat ion Desi rab le68. Res pi ratory rate Essen t ial

Z i p code o f pa t i en t 's r es i dencePat i en t 's m ai n te l ephone nu mberPat i en t 's Soc i a l Secur i ty num berPat ient 's date of bi r thPat i en t' s ag e or b es t approx i mat i onGende r o f pa t ien tPat ient 's ethnic or igin

Hea l t h care f ac i l i ty o r p reho sp i ta l un i t / home tha trece i ved pat i en t f rom EMS responde r prov id i ng recordReason a tr anspor t de s t ina t i on w as se l ec tedUse o f l i gh t s , s i r ens , o r bo th f rom the sceneResu l t o f EMS response

S ta tement o f p rob l em by pa t ien t o r o ther personExterna l cause of injury

P rev i der 's c li n ica l i mpress i on tha t l ed t o t he ma nagem entg i ven t o t he pat i en t ( t r ea tments , m ed i ca t ions , p rocedures)P reex i s t ing med i ca l cond i t ions known t o t he prov i derS i gns and symptoms repor t ed t o or observed by prov i derOl inical descr ipt ion o f injury type and bod y si teIntent of indiv idual inf l ict ing injurySafe t y equ i pment i n use by pa t i en t a t t i me o f i n ju r ySpec i a l c i rcumstances a f fec t i ng EMS response or de l i veryo f careSuspec ted a l coho l o r d rug use by pa t i en tBes t es t imate o f t i me o f f i r s t CPRPerson wh o per f o rmed f i r s t CPR on pa t i en tT i me a t wh i ch medi ca l cont ro l o r respond i ng EMSuni t terminated resusci tat ion ef for ts in the f ieldBes t es t imate o f t i me o f w it nessed card i ac ar res t( i f known and a pp l i cab le)Person wh o w i t nessed t he card i ac ar res tT ime of f i rst def ibr i l latory shockWhe ther a p a l pab l e pu l se or b lood pressure wasrestored af ter cardiac arrest and resusci tat ion in the f ield.Pat i en t 's pa l pa ted or a uscu l t a ted pu l se ra te , expressed i nnumb er per m i nuteIni t ial moni tored hear t rhythm as interpreted byEMS personne lMoni t o red card i ac rhy thm on ar r i va l a t des t i na t ionUnass i s t ed pat i en t r esp i ra tory ra te , expressed as numb er permi nute

Num er i c en t ry ; count y can be d er i ved f rom z i pcode.Num er i c en t ryNum er i c en t r y , n ine d i g i t sNum er i c en t ryNum er i c en t r y , th ree -d i g i t f ie l dMal e , f emal e , unknownAmer ican Indian/Alaska Nat ive; Asian/Paci f icis lander ; black non-Hispanic, blackH i span i c , wh i t e no n-H i span i c , wh i t e H i span i c ,u n k n o w nExam ples: hosp i tal (speci fy) , med ical of f ice,morgue, a i rpor t , o t her EMS respond erExamp l es : pa t i en t cho i ce , c l oses t f ac i l i t y , man -aged care , spec i a l t y r esource centerYes , no , upgraded, downgradedExamp l es : cance l ed , pa t i en t r e fusa l, no t r e a t -ment requ i red , t r ea ted and t rans fer red t o o therEMS prov i der , t r ea ted a nd t ranspor t edF r e e e x tI tems shou l d be cons i s t en t w i t h E -codes nICD-9. A l t hough su ch deta i l may n ot be appro-pr i a te , t he data i t ems shou l d be compat i b l ew i t h and co l l aps ib l e t o t he E -code cause o finjury l ist.Pr imary, s ingle mo st per t inent c l inical asse ss-ment . Exam pl es : abdom i na l pa in , a i rwa yobst ruct ion, al lergic react ionExamp l es : as thma, d i abetes , chron i c ob s t ruc ti vepu l monary d i seaseExampl es : back pa i n , b l oody s too l s , headach e.Shou l d be compat i b l e w i t h ICD-9 codes .List of al l injur ies s ustained b y injury type(amputa t i on , b l un t , gunshot ) and body s i t eI n ten t iona l , un i n ten t i ona l , unknow n, no tappl icableExamp l es : none used , shou l der be l t on l y , ch i l dsafety seat , helmet , eye protect ionExamp l es : adverse weather , veh i c le prob l ems,l anguage bar r i e r , hazardous env i ronment ,combat i ve pa t i en tYes , no , unknown, n o t app l i cab le

Bys tander , EMS respond er , no t app l i cab l e ,u n k n o w n

Bys tander , EMS respond er , no t w i t nessed, no tapp l i cab le , unknow nMeasu rement i n seconds and c lock synchron i za-t i on s t rong l y encouraged

Num er i c , no t ob ta i ned, unknow n, no t app l i cab l eUse cur ren t advanced card i ac l i f e sup por t (ACLS)terms and def ini t ions.Use cur ren t ACLS erms and def i n it ions .

APRIL 199 5 25:4 AN NAL S OF EMERGENCY MEDIC INE 5 3 3


10/10


A p p e n d i x , cont inuedData E lement Pr ior i ty Definit ion C o m m en t69. Resp i ra tory e f f o r t

70. Systol ic blood pressu re71. Diastol ic blood pressu re7 2 . S k i n per fusion

73. G l asgow eye-open i ngc o m p o n e n t7 4 . G l a s g o w v e r b a l c o m p o n e n t E s s e n t i a l7 5 . G l a s g o w m o t o r c o m p o n e n t E s s e n t i a l76 . G l asgow Coma Des i rab l e77. Rev i sed rauma Score Des i rab l e7 8 . P r o c e d u r e r t r e a t m e n t n a m e E s s e n t i a l79 . P roce dure t t empts Des i rab l e80. Med i ca t i on name Essent i a l81. Treatm ent author izat ion Des i rable

Essent i a l f o rchi ldren, de-si rablefor adul tsEssent i a lDesi rableEssent i a l f o rchi ldren, de-si rable for adul tsEssent ial

Pat ient 's respi ratory ef forc

Pat ient 's systol ic blood pressurePat ient 's diastol ic blood pressurePat i en t sk in per f us i on , expressed as normalor decreasedPat i en t 's eye-open i ng component o f t he G l asgow Com a Sca lePat i en t' s verba l compon ent o f t he G l asgow C oma Sca l ePat i en t' s motor com ponent o f t he G l asgow Com a Sca l ePat i en t' s t o t a l G l asgow Coma Sca l e score ( t o ta l )Pat i en t' s Rev i sed T rauma ScoreIdent if ica t i on o f p rocedure a t tempted o f per f o rmed on pa t i en tT ota l num ber o f a t tempts f o r each procedure a t tempted,regard l ess or successMedi ca t i on nameInd i ca tes t he t ype, i f any , o f t r ea tm ent au thor i za ti on

Normal ; i nc reased, no t l abored; i nc reased andl abored or decreased and f a t igued; absent ;no t assessed

Comp at i b le w i t h ICD-9 procedure c l ass if ica t i on(P codes)Examp l es : p ro toco l ( s t and i ng orders ) , on-l ine ( radio/ telephone), on-scene physician,w r i t t en orders , unknown, no t app l i cab le

9 3 4 ANNALS OF EMERGENCY MED IC INE 25:4 APRIL 1995

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