Academic journal article Journal of Health and Human Services Administration

Patient Assessment in Emergency Medical Services: Complexity and Uncertainty in Street-Level Patient Processing

Academic journal article Journal of Health and Human Services Administration

Patient Assessment in Emergency Medical Services: Complexity and Uncertainty in Street-Level Patient Processing

Article excerpt


Though still a relatively nascent public function, emergency medical services (EMS) agencies have come to constitute a core local government service. As the initial line of emergency treatment in a larger health care system, EMS providers are tasked with the treatment of patients in urgent, complex, and uncertain situations, and providing transportation to advanced health care facilities. The potentially life-saving interventional and palliative treatments provided by EMS personnel are inarguably a vital social service that, for patients in medically precarious situations, "... may determine the outcome as much as the subsequent hospital-based care" (Institute of Medicine, 2007, p. 1).

The Institute of Medicine of the National Academy of Sciences estimates that approximately 16 million emergency department patients arrive via ambulance every year, an average of more than 30 patients transported every minute (2007, p. xiv). This staggering volume of service is handled by more than 840,000 EMS providers working for local government, nonprofit, or for-profit EMS agencies (American Ambulance Association, 2009). Despite the significant volume of calls for service answered, and the substantial number of individuals engaging in front-line service provision, there is a paucity of research examining the behavior of these individuals from the scholarly field of public administration.

Emergency medical services providers, in their capacity as front-line public servants, can be analytically examined as "street-level bureaucrats" (Lipsky, 1980). Previous empirical research into the behavior of street-level bureaucrats has focused on several distinct occupational areas, including law enforcement, nursing, front-line welfare workers, and teachers (Isett, Morrissey, & Topping, 2006; Lipsky, 1980; Maynard-Moody & Musheno, 2003; Riccucci, 2005; Vinzant & Crothers, 1998). Given the relationship between the fundamental tasks of certain professions and the behavior of individuals fulfilling those roles, it is important to examine EMS providers as separate and distinct from other street-level occupations (Hill & Hupe. 2003, p. 477),

As a profession, EMS has received substantial attention from the fields of clinical medicine, health care economics, operations research, community planning, and other related areas of interest, resulting in a body of empirical evidence on clinical care, provider education, and "systems-level" considerations (National Highway Traffic Safety Administration, 2001). There is, however, there is a lack of research into the behavior of emergency medical services providers at the front lines (Institute of Medicine, 2007). Specifically, there is a lack of understanding of the exercise of discretion and the internal and external sources of influence that act on EMS providers.

This exploratory research begins to narrow this gap in our understanding of EMS by examining the uncertainty and complexity of street-level patient processing. The act of determining the scope and extent of client need--perhaps the most difficult aspect of front-line occupations--is made increasingly complex by the nature of emergency medical service as based in the physiological and psychological needs of patients. Given the intricacy of many of these issues, and their inability to be easily observed, the information gathering process is often clouded or obscured by a variety of sources. And, though EMS provision is rooted in clinical medicine--an area of study not often subject to scrutiny in public administration literature--it serves to illustrate an important example of front-line public policy implementation. As noted previously, EMS has evolved into a core public service over the last several decades (IOM, 2007; NHTSA, 2001). There is an expectation that, in response to both common emergencies and crises and disasters, emergency medical health care will be available to the public regardless of the time of day or type of need. …

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