Chapter 13 John P. Serra and Christopher A. Kahn The World Health Organization defines public health as all organized measures used to prevent disease, promote health, and prolong life among the population as a whole. In contrast to this definition, the National Highway Traffic Safety Administration (NHTSA) defines EMS as a response that is activated by an incident causing serious illness or injury, focusing on emergency medical care for the patient(s) [1]. Despite the clear differences in these definitions, EMS and public health share numerous commonalities. Arguably, modern-day EMS was born after the 1966 Institute of Medicine report Accidental Death and Disability: The Neglected Disease of Modern Society [2]. The white paper, as this publication is commonly known, concludes by stating that bolstering the EMS system as a whole would decrease morbidity and mortality, leading to improved public health. Following the publication of the white paper, federal funding flowed into cities, allowing EMS systems to rapidly grow in both form and function in the United States and around the world (see Volume 1, Chapter 1). Thirty years later, in 1996, a refreshed vision for EMS was formulated in the publication by NHTSA and the Health Resources and Services Administration (HRSA) titled The EMS Agenda for the Future [3]. Federal funding supported the creation of this document, with the intent for it to be used by public and private organizations in planning for the future design of the growing EMS system. Within this document were numerous statements encouraging EMS and public health to strengthen their collaborations for the benefit of the community: Emergency Medical Services [EMS] of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in a more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net. In 2000, Dr Mohammad Akhter, then American Public Health Association Executive Director, challenged the National Association of EMS Physicians to work more closely with the public health community. Shortly after that challenge, the EMS and Public Health Roundtable was formed, bringing together leaders and practitioners in prehospital care and public health. The Roundtable provided a forum for prehospital and public health discussion, with the goal of developing guidelines to foster collaboration. During the Roundtable, many examples of prehospital public health efforts were identified, with injury prevention efforts at the forefront. The final meeting of the Roundtable, in August 2001 in Washington, ended with the intention of promoting demonstration EMS and public health projects and developing joint education and training efforts [4]. Public health is composed of many subfields including environmental health, health care policy, occupational medicine, epidemiology, biostatistics, disaster planning, health promotion, and EMS. Two subfields require further elaboration here regarding overlap with EMS: epidemiology and health promotion/needs assessment. Epidemiology is “the study of the occurrence and distribution of health-related states or events in specified populations, including the study of the determinants influencing such states, and the application of this knowledge to control the health problems” [5]. The foundation of epidemiology was constructed by Dr John Snow, a physician in London during the cholera outbreak in the 1850s. By creating a dot map of over 500 cases of cholera by known address, Dr Snow discovered the common source of cholera was water retrieved from the Broad Street pump. Using this information, Snow was able to convince the parish counselors to disable the pump and soon thereafter, the cholera cases in that region subsided. The science of epidemiology rapidly outgrew its origins in disease outbreak monitoring to encompass chronic disease and injury. From ideal response times in emergencies [6,7] to elderly EMS utilization [8–10], epidemiology encompasses the backbone of public health research and thus research in the field of EMS. Health promotion is the process of enabling people to increase control over their health and its determinants, and thereby improve their health. Prior to beginning an intervention in promoting health, the researcher must first identify the deficiencies of health in the study community. Performing a community needs assessment represents one way of identifying health priorities in a community. Just as every individual’s needs vary, those needs within individual communities fluctuate over time. For example, public education on sunscreen is important in all communities, but remains a greater health priority in the southern United States. The reverse may be the case for hypothermia precautions. Preparation of a community needs assessment occurs on the local level. Some of the information typically available in community needs assessments includes employment, emergency department utilization, EMS responses, home ownership, disease incidence, crime, social services, parks and recreation, transportation, etc. For an example of a needs assessment, see the link to Dare County in North Carolina (www.darenc.com/health/docs/CommHlthAsst2013.pdf). In 2011, to highlight the importance of the topic of community needs assessments, the Centers for Disease Control and Prevention (CDC) convened a panel of over 50 subject experts to discuss best practices. Non-profit hospitals have been the greatest supporters of these assessments in the past. The Patient Protection and Affordable Care Act has ensured their support will continue into the future. Non-profit hospitals under section 501(r) of the Internal Revenue Code are required to perform community needs assessments every 3 years to maintain tax-exempt status (www.irs.gov/Charities-&-Non-Profits/Charitable-Organizations/New-Requirements-for-501(c)(3)-Hospitals-Under-the-Affordable-Care-Act). In addition, many community health care centers and non-profit organizations (such as the United Way) also perform community health assessments. This CDC gathering focused on the effect hospitals have on our communities. However, when considering partners for EMS public health initiatives, hospitals remain an important starting point. While the content of community needs assessments varies from state to state and county to county, seeking these documents remains an excellent first step in determining deficits within the community. However, in the report from the CDC conference, Dr Paul Halverson (then with the Arkansas Department of Health) warns that one should consider how interhospital competition negatively interacts with the desire to improve the health of patients and communities. I think it is not a given that hospitals want to come together and share accountability. It’s not necessarily one of the things that comes natural. They are competing for patients. They are competing for physicians. They are competing for scarce resources. And then we ask them to come together and share. It’s not something that they do naturally.[11] When considering priorities in the community, one can also start with the Department of Health and Human Services (DHHS). Since the initial publication of Healthy People 1979, the DHHS has repeatedly set the country’s public health objectives using 10-year benchmarks. The program not only sets the objectives but also challenges communities to collaborate to meet the goals. Healthy People 2020 launched in 2010 with overarching goals to promote high-quality lives and freedom from preventable health states while removing disparities from all groups [12]. An example of a process that communities and individuals have benefited from is injury prevention. The white paper in 1966 focused on these issues. In 1970 Dr William Haddon, Jr. developed the Haddon Matrix (Figure 13.1). This theory was specifically developed for crash data and stated that any crash required three factors: a host (human factors), an agent (vehicle), and environmental factors (often a fourth category of social factors is added). These factors are broken up into precrash, crash, and postcrash categories. While Dr Haddon’s theory was developed for vehicular crash data, it has been used successfully over the years in a multitude of other public health problems. An example of how to apply the Haddon Matrix to public health questions can be reviewed in EMS Provider and Patient Safety During Response and Transport: Proceedings of an Ambulance Safety Conference (http://informahealthcare.com/doi/pdf/10.3109/10903127.2011.626106) [13]. Figure 13.1 Example of Haddon Matrix.
EMS–public health interface
Introduction
Understanding public health
Epidemiology
Health promotion and needs assessment
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