911 and The Area Code From Which You Call: How To Improve The Disparity In California’s Emergency Medical Services.

Jeffrey Covitz


There are 33 separate local emergency medical services (EMS) authority agencies serving the 58 counties in California.1 A local EMS authority (LEMSA) in California governs either EMS providers in a single county or several counties combined. Each LEMSA dictates widely different treatment and transport protocols for its paramedics.2

The medical director for each LEMSA has sole authority to change or maintain a local EMS treatment protocol. The only state-regulated requirement for a protocol is it must fall within the accepted scope of practice for basic life support (BLS), emergency medical technicians (EMTs), or advanced life support (ALS) paramedics, according to Title 22,
§ 100146 of the California Code of Regulations.3 ALS paramedics require a significantly higher level of training and licensure than EMTs.4


1 “Local EMS Agencies,” California Emergency Medical Service (EMS) Authority, accessed August 25, 2018, https://emsa.ca.gov/local-ems-agencies/.

2 Eric C. Silverman et al., “Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-Based Recommendations,” Western Journal of Emergency Medicine 18, no. 3 (April 2017), https://doi.org/10.5811/westjem.2016.12.32066.

3 Pre-hospital Emergency Medical Services, 22 Cal. Code Regs. § 100146 (2016), https://emsa.ca.

4 “Regulations,” California EMS Authority, accessed April 29, 2018, https://emsa.ca.gov/

The preliminary data collected for this thesis substantiates previously published literature that shows a broad disparity in prehospital care and patient outcomes among different LEMSA jurisdictions in California. The literature indicates that this is a national problem and not limited to California. Several possible factors may contribute to the disparity: differences in geography, proximity to specialty hospitals, population size, and socioeconomic differences among each LEMSA area. Although previous research has established the problem of geographic EMS disparities, nothing definitive sufficiently explains its cause. Compounding the problem is a striking lack of performance-measure data for EMS in the United States. The structure of EMS authority, provider standards, and


treatment protocols vary significantly from one U.S. state to another.5 In California, protocols vary significantly from one county to another.

Arguably, the decentralized LEMSA system is the chief culprit in California’s EMS disparities. An analysis of California’s available EMS performance-measure data reveals wide disparities. However, the inequities do not always correlate directly with socioeconomic factors, geographical differences, or population size. Thus far, the only constant across all LEMSAs in California is that they have different treatment protocols and a wide variety of training standards for local EMT and paramedic accreditation. If the LEMSA system is the problem in California, how can the state reorganize EMS to improve patient care and outcomes for all Californians? Is there enough data to compare California’s EMS performance measures to those of states consolidated under one set of prehospital treatment protocols?

The first step to answer the research questions is to compare and contrast known performance measures from several California LEMSA agencies. To narrow the scope of the thesis, the research focused on the following four quantifiable prehospital performance measures:

  1. Percentage of patients meeting trauma triage criteria directly routed to trauma specialty care hospitals;
  2. Percentage of stroke patients directly routed to stroke specialty care hospitals;
  3. Intubation success rates; and

5 Douglas F. Kupas et al., “Characteristics of Statewide Protocols for Emergency Medical Services in the United States,” Prehospital Emergency Care 19, no. 2 (April 2015): 292–301, http://dx.doi.org/

6 A 12-lead electrocardiogram is a machine that traces the heart’s multidimensional electrical activity. When used by paramedics in the field, it can identify the early stages of what is commonly referred to as a heart attack, in medical parlance an ST-elevation myocardial infarction (STEMI), as well as other acute coronary syndromes.

  • 12-lead electrocardiogram acquisition for patients at risk for acute coronary syndromes.6

Although EMS is called to treat and transport dozens of different pathologies, California’s EMS Authority collects the aforementioned performance-measure data.7 The four measures are universal to all EMS systems, rural and urban, and are directly related to EMS actions in the field. Unlike other performance measures, they are not affected by external forces outside the control and quality of a field paramedic’s training.

Because U.S. EMS data are fragmented and incomplete, it is difficult to compare the performance measures of U.S. states that centralize EMS authority with states that decentralize authority, such as California. To make such a comparison, the scope of the research was broadened to examine centralized EMS systems outside the United States that rigorously collect and openly share performance data.


The London Ambulance Service (LAS) is a subdistrict of the United Kingdom’s centralized National Health System (NHS) for emergency medical services. EMS in the United Kingdom has a vertically integrated hierarchy, overseen by the Department of Health, which dictates treatment protocols, transportation guidelines, and dispatch algorithms. There are 11 NHS districts for EMS in the United Kingdom, all operating under the same protocols. In stark contrast to most U.S. EMS systems, the LAS under the NHS collects and openly publishes comprehensive performance-measure data quarterly.

B.                 SUMMARY OF DATA RESULTS


7 California Emergency Medical Service (EMS) Authority, EMS Core Measures Project, Reporting Capability of EMSA and LEMSA Data Systems and Results from Performance Measures Data Year 2015 (Rancho Cordova: California EMS Authority, 2015), 31.

Despite gaps in the data, the thesis draws several conclusions. The regression analysis of California’s core measures report illuminates results that support the hypothesis of this thesis—that the fragmented LEMSA system in California is the root cause of EMS disparity.

1.                  California Core Measure Performance Data, 2015–2016

There is a borderline statistical relationship between median income and patients who were directly routed to stroke specialty hospitals in California only in 2016
(p = 0.052). This is not the case for 2015. It may be assumed that higher data-reporting compliance would show a more significant relationship between median income and stroke routing; however, such a relationship remains speculative. Despite the borderline relationship between stroke care and median income in 2016, there was no statistical relationship between the number of stroke specialty centers and direct-routing. Although the datasets are incomplete, the existing data may suggest that areas with higher incomes get better stroke care in California, regardless of geographic location. This finding does not reject the hypothesis of the thesis; rather, it implies that higher income areas mandate a higher level of stroke care.

There is also a statistical relationship between patients in California who required trauma triage and were directly routed to trauma specialty centers and the number of available trauma centers in a LEMSA jurisdiction in 2016; however, no such relationship is evident for 2015. The 2016 results are not terribly surprising; the more trauma centers available in a geographic area, the more likely EMS transports a patient to one. The lack of a relationship in 2015 is surprising; however, neither result conflicts with the underlying hypothesis.

For all other performance measures examined, there are no statistical relationships among median income, population density, number of specialty hospitals in the LEMSA jurisdiction, or size of a geographic area. The lack of relationships between the variables and the four performance measures supports the hypothesis that the decentralized LEMSA system is the underlying cause of performance disparities. More research is needed to examine all 17 performance measures in California’s core measures report.

2.                  National EMS Information System Datasets

If the administrators of the National EMS Information System (NEMSIS) identified individual states with high compliance for comparison, someone could undertake meaningful research on this topic using NEMSIS statistics. Unfortunately, the current environment prohibits administrators from sharing information from individual states. The inaccessibility of NEMSIS illustrates how vast the EMS data desert is in the United States.

3.                  London Ambulance Service versus California LEMSAs

Despite the limitations of the California data, in almost every comparable measure, the nationally centralized LAS is superior to the decentralized system in California. The
t-tests show statistical significance for two of the four original measures—as well as for two additional measures, cardiac arrest survival and STEMI-center direct-routing. Additionally, LAS reporting is superior compared to individual LEMSAs that report data.

C.                RECOMMENDATIONS

Although further research is required to support the general hypothesis of the thesis, the broad disparities in California’s EMS are obvious, and the current model of EMS authority does not address the problem. Based on the research presented, disparate prehospital care and outcomes may be improved in California with the following proposals.

1.                  Establish Statewide EMS Policies and Treatment Protocols for All Basic Life Support and Advanced Life Support Providers

The guidelines shall be rooted in the latest evidence-based recommendations from the National Association of State EMS Officials. Regional medical directors may then amend state protocols to suit the unique operational requirements of their regions. The state medical director shall impanel a committee to review the state protocols on an annual basis to make updates.

2.                  Eliminate the Local EMS Authority System and Consolidate All LEMSAs into Five Regional Authorities

The regions shall be based on the preexisting boundaries of the California regional trauma committees. Treatment protocols shall be standardized based on the latest evidence-based research and require that providers offer the same level of care, no matter what geographic area they serve.

3.                  Mandate Data Gathering and Reporting by All EMS Agencies

Agencies shall collect and report all 17 performance measures tracked by the annual California Core Measures reports. Additionally, all agencies and cardiac-receiving hospitals shall be required to participate in the Cardiac Arrest Registry to Enhance Survival. The results of each agency’s performance-measure data shall be public and transparent. Moreover, the regional authority and the state shall administer a schedule of consequences for failure to report data.

4.                  Establish a Standard for Continuous Quality Improvement for Every Provider Agency

The state EMS authority shall mandate ratios of continuous quality improvement personnel to field providers in an effort to improve oversight. Establish a universal standard for performance-based accreditation requirements for all paramedics and EMTs in the state. Additionally, all paramedics and EMTs should be mandated to participate in a robust continuing education schedule prescribed by the regional authority.


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