The authors report the first national survey of EMS-initiated refusal practices. Few urban EMS systems have implemented this policy to decrease utilization by persons with low-acuity illness or injury. This may be related to the fact that few EMS systems currently have alternatives to emergency ambulance transport.

An academic, business, and community alliance comprising 285 organizations, including 43 national groups represented on a Blue Ribbon Panel organized by the U.S. Secretary of Transportation, targeted Arkansas, Florida, Mississippi, Minnesota, Tennessee, and Wisconsin for high involvement/intervention consisting of community organization and other political action to support passage of primary seat belt laws. State-level alliance activities began in January 2003. All six states enacted a primary seat belt law between 2004 and 2009. From January 2003 to May 2010, passage of primary legislation was 4.5 times as likely (95% CI 1.90, 10.68) in states with high versus low alliance involvement. Positive interaction between high alliance involvement and offers of federal incentives may have occurred as well. This evidence of success suggests that academic-business-community alliances for action to promote evidence-based public health policy may be effective.

Objectives: 1) To describe elements of adult nontraumatic cardiac arrest protocols in those U.S. cities in which resuscitative efforts are being terminated in the out‐of‐hospital setting. 2) To determine the prevalence and methods of on‐scene family grief counseling delivered in this setting. Methods: Emergency medical services (EMS) systems in each of the 200 largest cities in the United States were surveyed by telephone regarding the content of their adult cardiac arrest protocols. Type of arrest (medical vs trauma), final dysrhythmia, termination policies, and presence or absence of a grief counseling protocol were recorded. Results: All of the target population responded to the telephone survey. Most (135; 68%) EMS systems currently have written protocols that allow in‐field termination of resuscitative efforts for adult nontraumatic cardiac arrest patients who remain asystolic. Only 47 (24%) EMS systems allow cessation of efforts for patients without return of spontaneous circulation regardless of the dysrhythmia. Base station contact is required for authorization to end resuscitative efforts in 120/135 (89%) EMS systems. Only 26/135 (19%) EMS systems that cease efforts in the field have written policies concerning on‐scene family grief counseling. This counseling is most likely to be conducted by the out‐of‐hospital providers themselves. Conclusion: Many U.S. urban EMS systems are terminating efforts for selected adult nontraumatic cardiac arrest patients, although few have written policies to address grief intervention for family members at the scene.

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Abstract. Emergency medical services (EMS) occupy a unique position in the continuum of emergency health care delivery. The role of EMS personnel is expanding beyond their traditional identity as outof-hospital care providers, to include participation and active leadership in EMS administration, education, and research. With these roles come new challenges, as well as new responsibilities. This paper was developed by the SAEM EMS Task Force and provides a discussion of these new concepts as well as recommendations for the specialty of emergency medicine to foster the continued development of all of the potentials of EMS.