Rethinking Emergency

Medical Services:
Applying Evidence and Data to
Redesign Response Models for a
Resilient and Sustainable Future

Applying Evidence and Data to Redesign Response Models for a Resilient and Sustainable Future 1
Background
The current Emergency Medical Services (EMS) delivery model places
significant emphasis on short response times and advanced life support
(ALS) staffing. However, contemporary evidence-based research has revealed
response times have little to no impact on patient outcomes for the majority of
EMS responses1, and only 6.9% of patients accessing EMS require potentially
lifesaving interventions (PLSI)2.

There is a current EMS staffing crisis facing many communities across the
United States, driven by several interconnected issues, including economic
pressures, competition for employment of EMTs and paramedics in the
overall healthcare system, burnout, and workforce retention. A news media
tracking report from the American Ambulance Association and the Academy
of International Mobile Healthcare Integration reveals that between January BETWEEN JANUARY 2021
2021 and December 2024, 94% of the 2,600 EMS related local and national
news reports highlight staffing, economic and response time challenges by EMS AND DECEMBER 2024, 94%
agencies3.
OF THE 2,600 EMS RELATED

The EMS staffing crisis highlights the need for reasonable, evidence-based LOCAL AND NATIONAL NEWS
and data driven system design and response changes to sustain these
vital services while addressing the root causes of workforce shortages REPORTS HIGHLIGHT STAFFING,
and economic challenges. EMS system leaders should critically evaluate ECONOMIC AND RESPONSE
clinical, operational and financial data, provide essential education for local
stakeholders, including community leaders, about local realities of EMS TIME CHALLENGES BY EMS
response acuities, and engage in informed, collaborative decision-making
AGENCIES.
regarding system redesign to mitigate the staffing and resource challenges
faced at the local level.

Key Challenges
WORKFORCE COMPETITION
Although the number of initially certified clinicians through the National
Registry of EMTs has increased from 74,118 in 2020 to 104,312 in 20234, EMS
agencies across the U.S. report overall applications for EMS field positions has
been decreasing. In a recent survey conducted by the National Association of
Emergency Medical Technicians5, 65% of the respondents indicated a reduction
in applications for field EMS positions, with overall respondents indicating a
13% reduction in applicants. This data may reveal that although the number of
certified clinicians is increasing, fewer people are applying for EMS positions.
This may be due to the inherent risks associated with a career in EMS, combined

Rethinking Emergency Medical Services 2

with generally low wages for EMS workers. Due to the indicated they were likely to leave the EMS profession
ongoing nursing shortage6, hospitals and other settings in within 12 months12.
the healthcare sector often recruit paramedics and EMTs
for positions within facilities. The wage rates these systems
can offer often are much higher than EMS agencies can A RECENT STUDY REVEALED THAT 7.1% OF CURRENT
offer.
EMTS AND 7.9% OF CURRENT PARAMEDICS
ECONOMIC STRAIN
RENEWING THEIR CERTIFICATIONS INDICATED THEY
EMS funding primarily depends on reimbursements for
patient transport, which often fall below the actual cost of WERE LIKELY TO LEAVE THE EMS PROFESSION WITHIN
service. Medicare and Medicaid reimbursements typically
cover only a fraction of the expenses, leaving many 12 MONTHS.
agencies struggling financially. The 2024 Ground Ambulance
Data Collection System report from the Centers for
Medicare and Medicaid Services7 revealed the mean cost of
an EMS response is $1,845 and the mean reimbursement
per response is $975.
Considerations of
Potential Solutions
This economic imbalance contributes to operational
decisions by the leaders of provider agencies to decide MOVING FROM ALL ALS TO
TIERED DEPLOYMENT MODELS
between maintaining and upgrading equipment or paying
their workforce a living wage. It has also led to staff For decades, there has been a long-held belief that most
reductions and closures of ambulance services8. EMS responses are for time-critical emergency medical
conditions. This belief led to many systems relying on ALS
When the cost of delivering the level of EMS that the staffed ambulances, typically staffed with at least one
community expects exceeds the revenue that is generated paramedic and one emergency medical technician (EMT). A
from user fees, local communities are faced with using tax recent news report from New Hampshire reported that a fire
revenue or other public funding methods to cover the gap. department shut down an ambulance due to no paramedic
Increasingly, local communities are also facing economic being available to staff the ambulance, as opposed to
challenges and find it difficult to provide the funding simply staffing the ambulance with EMTs and maintaining
necessary to maintain historical EMS delivery performance. ambulance services for the community13.

HIGH TURNOVER AND BURNOUT However, evidence-based, peer reviewed research depicts
EMS personnel experience intense stress, long hours, and the reality of EMS response volume and patient acuity.
relatively low pay, leading to high turnover rates. Estimates For example, a 2024 study of over 1.7 million EMS patient
of clinician turnover (an indicators of workforce stability) encounters revealed that only 6.9% of EMS responses
vary from 6% to 30% annually in both regional and national resulted in a patient receiving a Potentially Life Saving
samples of EMS clinicians9. Many leave due to burnout or Intervention (PLSI)14. Further, few prehospital interventions
better-paying opportunities in other healthcare fields10,11. required to be administered by paramedic level clinicians
A recent study revealed that 7.1% of current EMTs and have been shown to have a significant impact on survival15.
7.9% of current paramedics renewing their certifications

Applying Evidence and Data to Redesign Response Models for a Resilient and Sustainable Future 3
Many EMS systems have transitioned from an all-ALS Given the infrequency of patients requiring critical ALS
deployment model to a tiered deployment model, using intervention, another challenge with all ALS staffing is the
both ALS and Basic Life Support (BLS) ambulances in reduction in opportunities for ALS clinicians to perform ALS
EMS response plans. A study in 2015 found that the skills on actual patients.
most common procedures performed by paramedics were
prophylactic intravenous access and 12-lead monitoring in Several evidence-based, peer reviewed studies have
otherwise alert and stable patients, which suggests these revealed an inverse relationship between the number of
patients would not have had adverse outcomes if these ALS paramedics in an EMS system and paramedic performance
interventions had not been performed16. on critical interventions. Essentially finding that paramedics
perform better clinically when they are highly utilized for
Using an effective, accredited emergency medical dispatch critical patients20,21,22.
(EMD) system can determine the level of clinical capability
necessary for an EMS response. A study evaluating the An additional study found that cardiac arrest patients
clinical efficacy of the Medical Priority Dispatch System treated with BLS care had higher survival rates at discharge
(MPDS®) found that when an ALS upgrade was requested and 90-day post discharge than cardiac arrest patients
on a call identified as eligible for a BLS response, upon treated with ALS care (9% vs. 13%)23.
exclusion of the prophylactic intravenous access, only
0.5% of BLS responses were true ALS upgrades. Advanced EMS Community risk reduction programs like fall protection,
resuscitative therapy was only provided to 27 of 14,100, or nurse/paramedic triage lines, community paramedicine/
0.2% of patients, in the tiered response model17. mobile integrated health, and treatment in place are ways
to reduce the need for an EMS response, thus alleviating
Similar research demonstrates that EMS response times using 9-1-1 ambulances to respond and transport patients
greater than 5 minutes18 have little to no impact on patient unnecessarily, keeping them available in the system for
outcomes for most EMS responses, and the responses in high-acuity 911 responses.
which the patient’s outcome may be favorably impacted
represent about 5% of EMS responses19. The 2024 High Performance EMS System Benchmark
Survey conducted by the Academy for International Mobile
Healthcare Integration (AIMHI) reveals that 100% of the
SEVERAL EVIDENCE-BASED, PEER REVIEWED high-performance EMS systems have transitioned from
an all-ALS ambulance deployment to a tiered deployment
STUDIES HAVE REVEALED AN INVERSE model24.

RELATIONSHIP BETWEEN THE NUMBER OF

Most EMS responses can be effectively managed using
PARAMEDICS IN AN EMS SYSTEM AND PARAMEDIC BLS care. Due to the prevalence of EMTs vs. paramedics
in the available workforce, ambulance staffing could be
PERFORMANCE ON CRITICAL INTERVENTIONS. greatly enhanced, alleviating critical ambulance shortages
ESSENTIALLY FINDING THAT PARAMEDICS for EMS response and reducing the workload of ambulance
clinicians.
PERFORM BETTER CLINICALLY WHEN THEY ARE

HIGHLY UTILIZED FOR CRITICAL PATIENTS.

Rethinking Emergency Medical Services 4

ESTABLISHING EVIDENCE-BASED, CLINICALLY APPROPRIATE
RESPONSE TIME GOALS
A commonly held belief is that there is a correlation between ambulance
response times and patient outcomes. However, there is a direct correlation
between response times and staffing. The shorter the response time goal, the
more resources are needed in order to staff ambulances to be available (i.e.:
not on a response) to meet the community’s response time goals. However,
OTHER CONSIDERATIONS FOR
numerous studies have revealed that patient outcomes cannot be correlated to
REDESIGNING RESPONSE
any response time standard25,26. PLANS COULD INCLUDE

A 2022 joint position statement from fourteen national and international

Dispatch Triage Systems
EMS and patient safety associations encourages EMS systems to reduce
light and siren emergency medical vehicle operation, citing the exceptional
ƒ The use of an accredited
EMS dispatch triage system,
risk associated with his mode of operation and the little clinical benefit of the approved by local medical
reduction in response time27. directors, that prioritizes EMS
responses using quality assured,
evidence-based triage protocols.
A 2008 joint position statement from the U.S. Metropolitan Municipalities’ EMS
Medical Directors28 cites the association of the former [response time] with Call Disposition from the
patient outcomes is not supported explicitly by the medical literature. Communications Center

A meta-analysis conducted on the direction of the National Highway Traffic

ƒ Implementing ‘hear and treat’
dispatch protocols, potentially
Safety Administration (NHTSA)29 of over 200 studies related to the use of light including telemedicine or nurse
and siren responses and response times also revealed that the commonly held triage, to appropriately manage
low-acuity 911 calls without
belief that community expectations regarding light and siren responses may not
necessitating a response from
be true. The report cites a 1988 study of residents in Connecticut which found EMS resources.
that the top two reasons for being uncomfortable in calling EMS were: “Sirens/
Noise” and “Getting a lot of attention”30. The Use of Non-Ambulance
EMS Personnel to Respond to
The 2024 AIMHI EMS System Benchmarking Survey31 revealed that among Low-Acuity 911 Calls Without
high-performance, high-value EMS systems, only 54% of 911 EMS responses the Simultaneous Response of
were responded to using lights and siren, and 43% of the benchmark systems an Ambulance
had increased low-acuity response time goals to over 25 minutes, with two
systems reporting response time goals of 60-minutes and 90-minutes. Another
ƒ EMS response types with low
transport ratios, or that can
two systems had no response time goals for low-acuity 911 responses. These be effectively managed using
systems found that they could reduce response times to critical EMS calls on-scene assessment and
treatment modalities with
by holding responses to low-acuity calls, while at the same time, reducing the
referrals to non-emergency
number of ambulances needed to be staffed to meet the community’s needs department dispositions would
and realistic expectations. reduce the demand on the
ambulance system.

Applying Evidence and Data to Redesign Response Models for a Resilient and Sustainable Future 5
Implementing processes to delay responses to low-acuity scientifically proven EMS system redesign, specifically
calls until there are sufficient available EMS resources in regarding ambulance staffing and reasonable response
the community to ensure a rapid response to high-acuity times, may have a significant impact on EMS system
calls is evidence-based, and a valuable system redesign sustainability in many communities across the country, and
option to improve patient outcomes and reduce the help preserve an over-taxed, stressed EMS workforce.
workload on EMS staff.
EMS system leaders should analyze response data

Conclusions in their local community and critically evaluate the

acuity of patients requesting 911 EMS response in
their communities. Additionally, EMS Systems should
EMS systems across America are facing an unprecedented
perform a community risk assessment to determine the
staffing and economic crisis. Some systems are
best placement and use for paramedics, for example,
failing, while others are facing difficult decisions and
areas where there are prolonged transport times to the
insurmountable hurdles. Many of the reasons for the
emergency department. Based on this evaluation, EMS
staffing and economic crisis are unrealistic public
leaders, including physician medical directors, agency
expectations based on beliefs that are not supported
chiefs, and local elected and appointed officials, should
by contemporary evidence-based research. Significant
consider redesigning response plans to assign the most
community education should be undertaken by local
appropriate EMS response based on the actual acuity
community and EMS system leaders, including physician
level of 911 EMS requests in the local system. Assuring
EMS medical directors, to inform local communities on the
patients with high acuity medical complaints receive
current national research, and actual data from the local
a rapid response, including closest medical response
EMS system types of EMS responses, clinical care provided,
resources with ALS support, and low acuity patients receive
and the potential benefits of an appropriate, data-driven
alternative responses.
redesign of the local EMS response system.
Right-sizing expectations and EMS delivery based on
This White Paper was produced and approved by the Joint

This White Paper was produced and approved by the Joint outcomes based on variables such as response times and
Task Force on EMS Response Staffing Configurations. EMS personnel staffing comprising the EMS response. A
compendium of the resources used in the development of
The mission of the Joint Task Force was to develop a this document is included in the References section.
national guidance document on the preferred staffing of
EMS personnel for various types of medical responses, Members of the Task Force on EMS Response Configurations
including interfacility transfers. We envision that this included representatives from:
guidance document will be used by state EMS offices, EMS
agency leaders, EMS medical directors and local community • The Academy of International Mobile Healthcare
leaders when considering revisions to their EMS response Integration
plans to determine the optimal staffing configurations • The International Academies of Emergency Dispatch
that support quality patient care, efficient operations, and • The International Association of Fire Chiefs
practitioner safety. • The International Association of Fire Fighters
• The National Association of Emergency Medical
This is not a government-funded task force, but rather a
Technicians
coalition of EMS industry associations committed to the
transformation of patient-centered EMS delivery based on • The National Association of EMS Physicians
current evidence and science. • The National Association of State EMS Officials
• The National Registry of Emergency Medical Technicians
In the development of this guidance document, participants
used peer-reviewed and published studies on patient
Rethinking Emergency Medical Services 6
References
1
Swor R, Cone D. Emergency medical services advanced life support
18
Price L. Treating the clock and not the patient: ambulance response
response times: Lots of heat, little light. Acad Emerg Med. times and risk. Qual Saf Health Care. 2006;15(2):127–130.
2002;9(4):320–321. https://pubmed.ncbi.nlm.nih.gov/11927458/ https://pubmed.ncbi.nlm.nih.gov/16585114/
2
Jarvis J, Taigman M. Using Red Lights and Sirens for Emergency Swor R, Cone D. Emergency medical services advanced life
19

Ambulance Response: How Often Are Potentially Life-Saving support response times: Lots of heat, little light. Acad Emerg Med.
Interventions Performed? Prehospital Emergency Care, 25(4), 549–555. 2002;9(4):320–321. https://pubmed.ncbi.nlm.nih.gov/11927458/
https://pubmed.ncbi.nlm.nih.gov/32678993/ Dyson K, Bray J. Paramedic Exposure to Out-of-Hospital Cardiac
20

https://aimhi.mobi/news
3 Arrest Resuscitation Is Associated With Patient Survival Circulation:
Cardiovascular Quality and Outcomes Volume 9, Number 2 https://
4
https://www.nremt.org/getmedia/1662a663-231b-4b3d-b711- www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.115.002317
ef5c542144db/NREMT_2023_Annual-Report
21
Vrotsos, K. M., Pirrallo, R. G., Guse, C. E., & Aufderheide, T. P. (2008).
5
https://naemt.org/docs/default-source/ems-data/ems-economic-and- Does the Number of System Paramedics Affect Clinical Benchmark
operational-models-survey-02-20-2023-final.pdf?sfvrsn=1fb9f493_2 Thresholds? Prehospital Emergency Care, 12(3), 302–306. https://www.
6
Tamata AT, Mohammadnezhad M. A systematic review study on the tandfonline.com/doi/full/10.1080/10903120802101355
factors affecting shortage of nursing workforce in the hospitals. Nurs Persse, David E. et al. Cardiac arrest survival as a function of
22
Open. 2023 Mar;10(3):1247-1257. doi: 10.1002/nop2.1434. Epub 2022 ambulance deployment strategy in a large urban emergency medical
Oct 27. PMID: 36303066; PMCID: PMC9912424. services system Resuscitation, Volume 59, Issue 1, 97 – 104 https://
7
https://www.cms.gov/medicare/payment/fee-schedules/ambulance- www.resuscitationjournal.com/article/S0300-9572(03)00178-3/abstract
fee-schedule/medicare-gadcs-resources 23
Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-
8
Zavadsky, M. The EMS Economic and Staffing Crisis Creates an of-hospital cardiac arrest treated by basic vs advanced life support.
Opportunity for Improved System Design: Using data to evaluate your JAMA Intern Med. 2015 Feb;175(2):196-204. https://pmc.ncbi.nlm.nih.
community’s EMS costs, ambulance staffing levels, and response time gov/articles/PMC4314335/
expectations to help prevent your EMS systems from collapsing: Public https://aimhi.mobi/page-18073
24
Management Magazine, Oct. 23; https://icma.org/articles/pm-
magazine/ems-economic-and-staffing-crisis-creates-opportunity- Pons P, Haukoos J, Bludworth W, Cribley T, Pons K, Markovchick
25

improved-system-design V. Paramedic response time: Does it affect patient survival? Acad

Emerg Med. 2005;12(7):594–600 https://pubmed.ncbi.nlm.nih.
9
Kurth JD, Powell JR, Gage CB, Fauvel AD, Crowe RP, Cash RE, Panchal gov/15995089/
AR. Evaluating changes in the emergency medical services workforce:
A preliminary multistate study. J Am Coll Emerg Physicians Open. 2023
26
Jarvis J, Johns D, Ratcliff T, et. al. The impact of using time critical
May 25;4(3):e12975. doi: 10.1002/emp2.12975. PMID: 37251350; intervention-based dispatch thresholds on lowering lights and siren
PMCID: PMC10211462. use to EMS 911 incidents. JACEP Open 2024;5:e13232 https://doi.
org/10.1002/emp2.13232
10
https://www.ems1.com/ems-advocacy/pinnacle-2024-quick-take-4-
things-we-must-change-to-achieve-ems-sustainability Kupas DF, Zavadsky M, Burton B, Baird S, Clawson JJ, Decker C,
27

Dworsky PI, Evans B, Finger D, Goodloe JM, LaCroix B, Ludwig GG,

https://stateline.org/2023/02/06/states-strive-to-reverse-shortage-of-
11
McEvoy M, Tan DK, Thornton KL, Smith K, Wilson BR. Joint Statement
paramedics-emts/ on Lights & Siren Vehicle Operations on Emergency Medical Services
https://www.tandfonline.com/doi/full/10.1080/10903127.2024.24360
12 Responses. Prehosp Emerg Care. 2022 May-Jun;26(3):459-461.
47#d1e255 https://pubmed.ncbi.nlm.nih.gov/35475941/
Staffing issues leave Pepperell fire station empty for one night. CBS
13 Evidence-Based Performance Measures for Emergency Medical
28

News November 25, 2024 https://www.cbsnews.com/amp/boston/ Services Systems: A Model for Expanded EMS Benchmarking – A
news/staffing-pepperell-fire-station-empty-one-night/ Statement Developed by the 2007 Consortium of U.S. Metropolitan
EMS Medical Directors. Prehospital Emergency Care 2008;12:141–
Levy MJ, Crowe RP, Abraham H, Bailey A, Blue M, Ekl R, Garfinkel E,
14
151.
Holloman JB, Hutchens J, Jacobsen R, Johnson C, Margolis A, Troncoso https://www.tandfonline.com/doi/abs/10.1080/10903120801903793
R, Williams JG, Myers JB. Dispatch Categories as Indicators of Out-of-
Hospital Time Critical Interventions and Associated Emergency Lights and Siren Use by Emergency Medical Services (EMS): Above
29

Department Outcomes. Prehosp Emerg Care. 2024 Apr 29:1-6. doi: All Do No Harm NHTSA Study & Report by Dr. Doug Kupas https://
10.1080/10903127.2024.2342015. Epub ahead of print. PMID: www.ems.gov/assets/Lights_and_Sirens_Use_by_EMS_May_2017.pdf
38626286. 30
Smackery B, Wilson EM. Emergency medical services and the public:
Stratton SJ. Triage By Emergency Medical Dispatchers. Prehospital
15 a research report on consumer attitudes toward EMS in Connecticut.
and Disaster Medicine. 1992;7(3):263-269. doi:10.1017/ Office of EMS, Connecticut Department of Health Services and Barney
S1049023X00039601 School of Business and Public Administration, University of Hartford.
Jan 1988. [Report]
P A Curka 1, P E Pepe, et. al. Emergency medical services priority
16

dispatch. Ann Emerg Med. 1993 Nov;22(11):1688-95. doi: 10.1016/ https://aimhi.mobi/page-18073

31

s0196-0644(05)81307-1
17
Sporer KA, Youngblood GM, Rodriguez RM. The ability of emergency
medical dispatch codes of medical complaints to predict ALS
prehospital interventions. Prehosp Emerg Care. 2007 Apr-
Jun;11(2):192-8. doi: 10.1080/10903120701205984. PMID: 17454806. Published February 10, 2025

Applying Evidence and Data to Redesign Response Models for a Resilient and Sustainable Future 7