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Heart Attack
(Myocardial Infarction)
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9-1-1: Rapid Identification and Treatment of Acute
Myocardial Infarction
NATIONAL INSTITUTES OF HEALTH
National Heart, Lung, and Blood Institute
National Heart Attack
Alert Program (NHAAP)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
National Institutes of Health
National Heart, Lung, and Blood Institute
NIH Publication No. 94-3302
May 1994
FOREWORD
Coronary heart disease (CHD) continues to be the leading
cause of death in the United States despite a remarkable
decline in CHD mortality over the last 30 years. The
National Heart, Lung, and Blood Institute (NHLBI) estimates
that as many as 1.25 million people will experience an acute
myocardial infarction (AMI) in 1993, and nearly 500,000 will
die.
The importance of early treatment has been underscored in
the last decade with the results from clinical trials of
thrombolytic therapy demonstrating mortality reductions with
earlier treatment. Out-of-hospital sudden cardiac death is
an ever-present threat, further highlighting the importance
of early recognition and treatment.
However, a fundamental barrier to timely treatment is
delay--at the level of the patient, the emergency medical
services (EMS) system, and the emergency department. In
June 1991, the NHLBI launched the National Heart Attack
Alert Program (NHAAP) with the goal of reducing AMI
morbidity and mortality, including sudden cardiac death.
The NHAAP Coordinating Committee was formed to help develop,
implement, and evaluate the program. This committee is
composed of representatives of 39 national scientific,
professional, governmental, and voluntary organizations
interested in lowering AMI morbidity and mortality through
professional, patient, and public education.
Initially, the NHAAP is directing educational efforts toward
hospital and prehospital health professionals and high-risk
patients. Eventually, the NHAAP plans to develop public
educational messages about the symptoms and signs of an AMI
and about appropriate actions to take in response to those
symptoms and signs. Although the specific messages have not
been developed for the public education component of the
program, it is anticipated that one of the major messages
will be to dial 9-1-1 in response to the symptoms and signs
of AMI/sudden cardiac death. These educational messages
will be conveyed through various media campaigns, including
print advertisements, posters, billboards, and brochures.
In its adult basic life support protocol, published in 1992,
the American Heart Association has recommended activating
the EMS system by calling the local emergency telephone
number (9-1-1, if available), after determining a victim's
unresponsiveness and prior to initiating the ABC's of
cardiopulmonary resuscitation.
This paper reviews 9-1-1's history, key elements/components,
implementation status, and existing legislation and
standards. It also describes issues and presents
recommendations for ensuring a universally available system.
Finally, it promotes implementation of a universal and
enhanced 9-1-1 system for rapid access to EMS.
Claude Lenfant, M.D.
Director
National Heart, Lung, and Blood Institute
-----------------------------------------------------------
MEMBERS OF THE WRITING GROUP
Contributors
James Atkins, M.D.
Medical Director
Dallas Emergency Medical Services
Professor of Medicine
Department of Internal Medicine
University of Texas Southwestern Medical Center at Dallas
Dallas, Texas
Charles Glass
Highway Safety Program Management Specialist
National Highway Traffic Safety Administration
Department of Transportation
Washington, D.C.
Bruce MacLeod, M.D.
Clinical Assistant Professor of Medicine
University of Pittsburgh
Chairman
Department of Emergency Medicine
Mercy Hospital
Pittsburgh, Pennsylvania
Wallace Madewell
Executive Director
Memphis--Shelby County 9-1-1 Department
Memphis, Tennessee
Bruce Shade
Commissioner
Cleveland Emergency Medical Service
Cleveland, Ohio
Staff
John C. Bradley, M.S.
National Heart Attack Alert Program Support Contract Manager
NHLBI Education Programs Support Contract
R.O.W. Sciences, Inc.
Rockville, Maryland
Mary McDonald Hand, M.S.P.H., R.N.
Coordinator
National Heart Attack Alert Program
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Bethesda, Maryland
Michael Horan, M.D., Sc.M.
Director
Division of Heart and Vascular Diseases
National Heart, Lung, and Blood Institute
National Institutes of Health
Bethesda, Maryland
Acknowledgments
James Beutelspacher
9-1-1 Project Manager
Department of Administration
St. Paul, Minnesota
Mary A. Boyd
Executive Director
Advisory Commission on State Emergency Communications
Austin, Texas
William Stanton
Executive Director
National Emergency Number Association
Columbus, Ohio
Roanne Rubin Tall*
9-1-1 Coordinator, Seminole County, Florida
New Smyrna Beach, Florida
Carl C. Van Cott
Assistant Chief, Engineering
Office of Emergency Medical Services
North Carolina Department of Human Resources
Raleigh, North Carolina
*Deceased
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NATIONAL HEART ATTACK ALERT PROGRAM COORDINATING COMMITTEE
MEMBER ORGANIZATIONS
Agency for Health Care Policy and Research
American Academy of Family Physicians
American Academy of Insurance Medicine
American Association of Critical Care Nurses
American Association of Occupational Health Nurses
American College of Cardiology
American College of Chest Physicians
American College of Emergency Physicians
American College of Occupational and Environmental Medicine
American College of Physicians
American College of Preventive Medicine
American Heart Association
American Hospital Association
American Medical Association
American Nurses' Association, Inc.
American Pharmaceutical Association
American Public Health Association
American Red Cross
Association of Black Cardiologists
Centers for Disease Control and Prevention
Department of Defense, Health Affairs
Department of Veterans Affairs
Emergency Nurses Association
Federal Emergency Management Agency
Food and Drug Administration
Health Care Financing Administration
Health Resources and Services Administration
International Association of Fire Chiefs
National Association of Emergency Medical Technicians
National Association of EMS Physicians
National Association of State Emergency Medical Services
Directors
National Black Nurses' Association, Inc.
National Center for Health Statistics
National Heart, Lung, and Blood Institute
National Highway Traffic Safety Administration
National Medical Association
NHLBI Ad Hoc Committee on Minority Populations
Society for Academic Emergency Medicine
Society of General Internal Medicine
-----------------------------------------------------------
INTRODUCTION
The cooperative efforts of the Federal Government and the
telephone industry have established 9-1-1 as the national
emergency telephone number to facilitate public access to
emergency response services (police, fire, and medical). To
potentially minimize the time elapsed from the onset of a
cardiac (or other) emergency to the arrival of prehospital
emergency care and then to the delivery of the patient to an
appropriate medical facility, it is necessary to have access
to a pervasive, efficient, and coordinated emergency medical
services (EMS) communications system that includes 9-1-1.
However, the 9-1-1 system function and activities are not as
yet universally available.(1)
The 9-1-1 system enables persons experiencing or witnessing
a medical emergency to access easily and quickly the
emergency response system and, where available, to obtain
emergency medical dispatcher assistance through prearrival
instructions and prompt definitive emergency medical care.
Therefore, ideally, 9-1-1 telephone services should be
available to all people to facilitate access to EMS.
Enhanced 9-1-1, which automatically lists the caller's
location and, through a computer-aided dispatch system, the
identity of the appropriate response agency, adds efficiency
and accuracy to an emergency response system. In the public
safety communications literature, numerous studies have
documented the benefits of using 9-1-1 versus other
emergency telephone numbers. For example, in the Institute
of Electrical and Electronics Engineers (IEEE) publication,
"IEEE Transactions on Vehicular Technology," Ivy(2) reported
the results of three community surveys showing the efficacy
of 9-1-1 services in reducing the uncertainties and delays
that citizens experience in reporting emergencies to the
proper authorities. In the same publication, Reinke(3)
discussed the additional costs and benefits of incorporating
enhanced features into 9-1-1 services.
In the medical literature, Mayron et al.(4) reported an
increase from 63 to 82 percent of people who successfully
activated EMS after the implementation of a 9-1-1 system.
Eisenberg et al.(5) surveyed communities with different
activation systems and found that citizens knew the
emergency activation number only 36 to 47 percent of the
time; in communities with 9-1-1 services, the citizens knew
the emergency activation number 85 percent of the time. It
was also suggested that people in communities adjacent to 9-
1-1 areas called 9-1-1 instead of their seven-digit number
and thus experienced delays in activation of EMS. In many
areas where people dial 9-1-1 when it is not available, they
will get a recording telling them to look up a number in the
directory.(6)
In the United States, partially as a result of the
availability of 9-1-1 services, EMS responses to medical
emergencies are prompt. For example, the national average
elapsed time from the time of injury to hospital arrival for
persons injured in motor vehicle fatality crashes is 33.9
minutes in urban areas and 51.2 minutes in rural areas.(7)
Other factors exist, however, that substantially increase
the delay between the onset of medical emergencies and
hospital arrival. For example, Barsan and associates(8)
reported that hospital arrival (from onset of symptoms) was
fastest for individuals seeking treatment for acute stroke
who used 9-1-1 as their first medical contact (205 minutes)
rather than using their personal physician (603 minutes) or
transporting themselves to the hospital (414 minutes).
These authors concluded that strategies to increase the use
of 9-1-1 systems may aid in recruiting patients into urgent
treatment protocols for stroke. Of particular concern for
early cardiac care, use of 9-1-1 to access EMS has been
shown to decrease time to reperfusion for individuals with
symptoms and signs of AMI. Patients with symptoms of AMI
who called 9-1-1 in King County, Washington, thereby
accessing the EMS system, received the time-dependent
thrombolytic (clot-dissolving) treatment 1.9 hours earlier
compared with those who transported themselves to the
hospital.(9)
Also, the characteristics of individuals who are likely to
use 9-1-1 for possible acute cardiac problems deserve more
investigation overall. Data from the Myocardial Infarction
Triage and Intervention Project showed that patients with
symptoms and signs of an AMI who called 9-1-1 were more
acutely ill. They had a 50 percent greater mortality than
those presenting directly to the emergency department.(10)
The existence of 9-1-1 telephone access was significantly
associated with survival from out-of-hospital cardiac arrest
(9.18 versus 5.35 percent survival for 9-1-1 versus no 9-1-1
groups, respectively) in a report of 1,753 prehospital
cardiac arrest patients in Iowa. The authors attributed the
association partially to their findings of a significant
association of 9-1-1 with a shorter time interval from
collapse to the 9-1-1 call for help, decreased time to
cardiopulmonary resuscitation, and less time to the first
shock (if in ventricular fibrillation).(11)
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OVERVIEW OF 9-1-1
The idea of a universal emergency telephone number
originated in Europe. The official impetus for the
development of a nationwide emergency telephone number in
the United States was provided in 1967 by recommendations of
the President's Commission on Law Enforcement and the
Administration of Justice.(12) The American Telephone and
Telegraph Company (AT&T) announced in 1968 that 9-1-1 was
available as a single national emergency telephone number
for any public safety agency and community group that
desired to develop a common public number for access to
local emergency services. At that time, the telephone
industry offered their "dial operator" service as a backup
system to the seven-digit emergency-assistance telephone
numbers for police, fire, and medical emergencies. The
availability of 9-1-1 through AT&T meant that emergency call
handling could be shifted from telephone company operators
to public safety agencies. Prior to 9-1-1, seven-digit
emergency numbers proliferated and resulted in confusion for
the public and in delays trying to make emergency contact
with the correct public safety agency.(2) It was not
unusual in many large urban/suburban areas of the United
States to find more than 200 seven-digit telephone numbers
for public safety agencies.(13) Thus 9-1-1 was developed to
increase public access to public safety agencies for police,
fire, and medical emergencies.
Various national professional organizations and task forces
on crime and crime-related activities endorsed the 9-1-1
concept. Local governments began implementing basic 9-1-1
in 1968 with assistance from their telephone companies. The
first area of the country to implement basic 9-1-1 was
Haleyville, Alabama, using an independent telephone company.
New York City was among the cities and towns that first
offered the service in the ensuing 3 years. The first fully
enhanced system was implemented in Orange County, Florida,
in the fall of 1980.(6)
The Federal Communications Commission (FCC) concluded in
1972 that 9-1-1 should be implemented nationwide and that
the Federal Government should provide a greater leadership
role. In 1973, the Office of Telecommunications Policy of
the Executive Office of the President issued Bulletin No.
73-1,(14) which addressed a national policy for the 9-1-1
emergency telephone number. This bulletin states that "it
is the policy of the Federal Government to encourage local
authorities to adopt and establish 9-1-1 emergency telephone
systems in all metropolitan areas and throughout the United
States. Whenever practicable, efforts should be initiated
in both urban and rural areas at the same time."
The concept that 9-1-1 services should be based on
individual community initiatives was widely accepted. By
1977, 600 systems were in existence, and approximately 90
new services were being implemented per year. Although this
level of development was significant, only about 30 percent
of the U.S. population, primarily in urban areas, had access
to 9-1-1 services. Reasons for the slow development of
9-1-1 at the time, as cited by Reinke,(3) were:
* Lack of strong Federal leadership
* No perception of 9-1-1 as a priority public issue
* Lack of targeted funding
* Lack of State action on 9-1-1
* Intra-agency and interagency jurisdictional conflicts
* Telephone industry passivity regarding 9-1-1
implementation
* Fear of high costs for 9-1-1.
In addition, a fear of loss of control on the part of the
departments to be served by 9-1-1 has been cited as another
reason for the slow development of 9-1-1. Only one agency
can receive the initial 9-1-1 call, and in areas where there
is a strong police presence and a strong fire presence, this
may have to be negotiated.(15)
For many years, the Department of Commerce supported an
information center, which is now in the National
Telecommunications and Information Administration (NTIA).
This center monitors progress in 9-1-1 systems development
and provides information about existing systems. In
addition, other Federal departments and agencies offer
technical and financial assistance to State and local
governments for 9-1-1 services. The Department of
Transportation, for example, authorizes technical and
financial support of 9-1-1 system planning and development
using existing Federal highway safety grants programs. More
recently, Federal funding has also become available for
9-1-1 system development to States and local governments
from the U.S. Department of Health and Human Services
through the following grants programs:
-----------------------------------------------------------
Agency
Health Resources and Services Administration (HRSA), Bureau
of Health Resources Development, Division of Trauma and
Emergency Medical Services
Program
Trauma Care Systems Planning and Development Act of 1990
Agency
HRSA Office of Rural Health Policy
Program
Rural Health Outreach Demonstration Grants
Agency
Agency for Health Care Policy and Research (AHCPR)
Program
Health Services Research on Rural Health
-----------------------------------------------------------
Key Elements/Components
The universal emergency telephone number (9-1-1) concept
combines areawide coordination of emergency response
resources and a single telephone number. It provides the
means for reporting emergencies and summoning assistance.
The primary function of 9-1-1 systems is to ensure that the
most appropriate response agency (police, fire, or emergency
medical services) is notified of the emergency with minimum
delay. This function is performed at specialized
communications centers called public safety answering points
(PSAP's). PSAP's conduct the following activities:
* Promptly answer telephone calls directed to the PSAP.
* Interrogate each caller to determine caller time and
identity and the nature, location, and extent
of the emergency. This information must be
elicited verbally in both basic and enhanced 9-1-1
systems. In basic 9-1-1 systems, this function also
involves determining the telephone number from which
the call is being made and the location of the caller.
In enhanced 9-1-1 systems, the process is usually
expedited through computerization.
* Depending upon the nature of the emergency, communicate
the information to the appropriate emergency agency for
its response. Typically, in fully enhanced 9-1-1
systems, the appropriate designated response agency or
unit for a particular type of emergency, for a given
emergency site, is automatically selected from a computer
database. In some enhanced systems, communications links
may be established and emergency information
automatically relayed through a computerized database and
call system.
* Maintain records on all 9-1-1 calls.
The U.S. Department of Transportation encourages States and
political subdivisions to adopt and to implement the
universal emergency telephone number concept (9-1-1) and
single emergency telephone number access.(14)
Implementation Status
The National Emergency Number Association (NENA) estimates
that currently about 75 percent of the U.S. population,
mostly in urban areas, has access to public safety services
through some type of 9-1-1 system.(16) Figure 1 illustrates
the estimated percentage of population with access to 9-1-1
services in each of the States. Many rural households and
roadways fall outside the areas covered by existing 9-1-1
systems. However, they may still have access to public
safety services through seven-digit dialing.
As of June 1993, nearly 195 U.S. cities with a population
over 100,000 have enhanced 9-1-1 service (including four
with enhanced 9-1-1 in the planning stages).(16)
Ideally, enhanced 9-1-1 coverage should be available for 100
percent of the Nation's population in order to ensure rapid
and maximum access to police, fire, and EMS. As already
noted, enhanced 9-1-1 systems can determine the telephone
number and location from which an emergency call is made.
Theoretically this will promote greater access to emergency
services for non-English-speaking callers, as well as for
those who are too upset or sick to communicate the necessary
information. Enhanced 9-1-1 systems also permit automated
use of computerized databases listing designated law
enforcement, fire, and EMS primary and secondary responders
for each location in the 9-1-1 service area. Finally,
enhanced 9-1-1 systems can also selectively route calls,
resulting in fewer jurisdictional disputes among
agencies.(15)
Much work has already been done to develop national
consensus on guidelines for multitiered
(municipal/county/regional/statewide) planning and
implementation for 9-1-1 services. Such guidelines are
contained in the "Standard Guide for Planning and Developing
9-1-1 Enhanced Telephone Systems," F 1381-92.(17) This ASTM
standard guide promotes and facilitates implementation of
State legislation on statewide planning and development of
enhanced 9-1-1 telephone systems. Such legislation has been
enacted and is being implemented in several States--such
as California, Connecticut, Delaware, Maryland, and New
Jersey--and is pending in others.
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Figure Missing
Figure 1. Percentage of Population Covered by 9-1-1 in Each
State
Source: Minnesota Department of Administration, 1993.(16)
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Existing State Legislation and Standards
As noted, communities have initiated citizen access to
public safety services via the designated national emergency
telephone number (9-1-1). Because some of these community-
developed systems exclude households located in
unincorporated areas between communities and because of
other inadequacies of individual community initiatives for
9-1-1 systems, many States have developed 9-1-1 legislation.
According to the May 1992 status report of the National
Association of State Nine-One-One Administrators,(18) 9-1-1
legislation now exists in 45 States, an increase from 37
States in 1990. The existing legislation has little
uniformity, however, and there is a need to develop
statewide legislation and standards for 9-1-1 system
funding, management, and operations.
Tables 1, 2, and 3 illustrate the variability in scope,
system characteristics, and management overview prescribed
in existing 9-1-1 legislation. Table 1 shows that 36 States
have legislation that addresses the scope of 9-1-1 on a
statewide basis; 2 States, regionwide; 6 States, countywide;
and 1 State, citywide. Table 2 shows that 12 States have
enhanced 9-1-1 systems prescribed in their existing State 9-
1-1 legislation, 7 have basic 9-1-1 systems prescribed, and
26 have unspecified system characteristics prescribed.
Table 3 depicts the management overview prescribed in the
existing 9-1-1 legislation, specifically showing that 14
States have State boards; 27, district boards; 3, county
boards; and 1, a city board.
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Table 1. Scope Prescribed in Existing 9-1-1 Legislation
Scope Number of States
Statewide 36
Regionwide 2
Countywide 6
Citywide 1
Source: National Association of State Nine-One-One
Administrators (compiled by the Texas Advisory
Commission on State Emergency Communications),
August 1992.(18)
-----------------------------------------------------------
Table 2. System Characteristics Prescribed in Existing
State 9-1-1 Legislation
System Characteristics Number of States
Enhanced 12
Basic 7
Not Specified 26
Source: National Association of State Nine-One-One
Administrators (compiled by the Texas Advisory
Commission on State Emergency Communications),
August 1992.(18)
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Table 3. Management Overview Prescribed in Existing State
9-1-1 Legislation
Management Overview Number of States
State boards 14
District boards 27
County boards 3
City boards 1
Source: National Association of State Nine-One-One
Administrators (compiled by the Texas Advisory
Commission on State Emergency Communications),
August 1992.(18)
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Even more variability exists in 9-1-1 legislation in
provisions for approving system implementation. Some of
this variability may be due only to differences in
legislative language. Approximately 12 different procedures
for approving the implementation of 9-1-1 systems have been
specified by the 45 States. These provisions are
State/county/regional resolution, State/county vote,
legislative action, State/regional ordinance, State board of
supervisors, county plan, county commissioners, public
agency, referendum, board law, and city mandate. In seven
of the States such procedures are not specified.(18)
Variability in many aspects of State 9-1-1 legislation is a
natural byproduct of differences in State constitutions and
in evolving relations between State and local governments
and is not necessarily undesirable. However, some
differences can be classified as apparent oversights that
may need to be changed. For example, 29 States do not
address the characteristics of 9-1-1 systems, and 7 States
do not address procedures for making and approving 9-1-1
system implementation.
Most of the 45 States specify authorized funding mechanisms
(sources, payment/collection processes, and amounts) in
their 9-1-1 legislation and limitations on the uses of such
revenues. Here again, every State is different in some
respect. The most widely used funding mechanism is a
variable fee for 9-1-1 services (usually not to exceed a
specified maximum amount) collected from all telephone
service subscribers. Table 4 shows the various 9-1-1
funding mechanisms and the number of States in which they
are specified in State 9-1-1 legislation.
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Table 4. 9-1-1 Funding Mechanisms
Mechanism Number of States
Variable 9-1-1 fee per subscriber
(to cover costs) collected monthly
by telephone company 16
Fixed 9-1-1 fee per subscriber
collected monthly by telephone company 7
Variable percentage of telephone bill
(to cover costs) collected monthly by
telephone company 5
Fixed percentage of telephone bill
collected monthly by telephone company 7
Bond issue 2
Property tax 2
State application (to cover State and
local administrative costs) 2
Tax/license fee 1
Telephone company revenue from local
directory service charges 1
Not specified 2
Source: National Association of State Nine-One-One
Administrators (compiled by the Texas Advisory
Commission on State Emergency Communications),
August 1992.(18)
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In most States, the existing 9-1-1 legislation permits
rather than mandates 9-1-1 system implementation. However,
State legislative provisions for 9-1-1 are being regularly
changed and updated to address oversights and to ensure:
* Definition of system performance characteristics and
standards of reliability for 9-1-1 systems
* Simplification of procedures for approval of 9-1-1 system
implementation
* Upgrading of State-specified 9-1-1 system characteristics
from basic to enhanced
* Improvement of funding mechanisms
* Quality assurance in 9-1-1 system performance, including
call answering and dispatching
* Improvement of guidelines for appropriate citizen use of
9-1-1.
The definition and planning for beneficial changes in State
9-1-1 legislation and in EMS dispatching are supported by
ASTM standard guides and practices. These changes are
promoted by the National Association of State EMS Directors;
the National Emergency Number Association; the National
Association of State Nine-One-One Administrators; the
National Association of State Telecommunications Directors;
the Associated Public-Safety Communications Officers, Inc.;
and the International Municipal Signal Association.
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ISSUES AND RECOMMENDATIONS FOR IMPLEMENTING
UNIVERSAL/ENHANCED 9-1-1
Important issues to consider in working to achieve
universal/enhanced 9-1-1 include the following:
* 9-1-1 is not universal. Some households do not have
public telephone services because of financial or
logistical reasons, particularly in rural areas. Other
households do have public telephone services but may not
have 9-1-1 services because there has been no local
government initiative to provide such services, it is too
expensive for small local governments, or they live
outside of local government 9-1-1 system service
boundaries.
* Existing 9-1-1 systems may be inefficient and have low
productivity. Efficiency of 9-1-1 services is
potentially increased by upgrading basic 9-1-1 systems to
enhanced 9-1-1 systems. With enhanced 9-1-1, the time
required for processing individual 9-1-1 calls may be
decreased, because identifying the address obviates the
need to spell words and circumvents communication
problems with non-English-speaking callers. This
potentially permits processing a greater number of
cases per unit time and in general furthers the goal of
decreasing the time to obtain appropriate information.
This enables a system to handle the demands of a larger
population and a greater volume of emergency calls during
"busy hours."
* Existing 9-1-1 systems may not be sufficiently
coordinated with EMS dispatch services. One of the
greatest potential benefits of 9-1-1 is emergency medical
dispatch. A well-coordinated dispatch, as a portion of
a 9-1-1 system, may result in fewer instances of
inappropriate response (e.g., response agency or unit,
emergency response vehicle, location).
Coordination of 9-1-1 and dispatch services may be
further enhanced by collocating facilities, by cross-
training personnel, or by completely integrating 9-1-1
and dispatch services. Existing PSAP and dispatch
communications functions may be performed by the same or
by different persons. However, collocating and
integrating these services may generate conflict among
managers of existing facilities and services, even though
consolidation of 9-1-1 can lead to economies of scale,
including cost savings. Ideally, emergency medical
dispatching should be incorporated into fully developed
9-1-1 centers.
A related problem is that private ambulance services may
promote not calling 9-1-1, reflecting variability of
control of these operations and competing services.
* Using 9-1-1 for cardiac emergencies may be perceived as a
minor use of 9-1-1. The estimated composition of 9-1-1
calls is about 85 percent for police response (most of
which are crimes against property), 8 percent for medical
response, and 7 percent for fire response.(19) Less than
2 percent of all 9-1-1 calls involve cardiac emergencies.
Thus a potential perception is that use of 9-1-1 in
response to heart attacks is that minor usage of this
system. However, although cardiac emergencies are a
relatively small percentage of 9-1-1 calls, the potential
for lives saved is great. Changes needed to achieve the
ideal goal of universal/enhanced 9-1-1, including
improved coordination with EMS dispatch services, may
involve relocation and reorganization and thus may be
resisted, as noted.
Recommendations on how to meet the challenges of
implementing universal/enhanced 9-1-1 systems include the
following:
1. The current physical location for every telephone number
must be identified, documented, and updated. Automatic
number identification (ANI) capabilities must be
instituted. In addition, an automatic location
identification (ALI) computer site must be developed and
maintained to identify the location of the telephone
corresponding to each telephone number. Updating the
ALI database to reflect the frequent changes in
telephone subscribers and their locations is a
substantial system maintenance effort that is a joint
responsibility of telephone service providers and
enhanced 9-1-1 system managers. Lack of street numbers
and names in rural areas (where rural route and post
office box numbers are used) poses further barriers to
enhanced 9-1-1.
2. An oversight on Federal Government actions that may
affect 9-1-1 services must be maintained. Changes to
conventional telephone services and cellular radio
telephone systems--for example, creation of new types
of radio telephone systems such as personal
communications systems--may result from changes in
FCC rules, congressional communications bills, and
Federal court orders. Court orders or regulations may
require competitiveness in the communications industry
and permit multiple providers for local telephone
services. Such Federal actions, if taken with an
appropriate concern for maintaining and improving public
access to public safety service, may have a beneficial
effect on the evolution of 9-1-1 systems. If public
safety concerns are ignored in such actions, however,
they may have an adverse effect on the continued
viability of 9-1-1 concepts.
3. Reasonable local guidelines to resolve misuse problems
should be developed. Misuse of 9-1-1 (e.g., prank
calls) may pose problems to 9-1-1 systems.
4. Consideration should be given to reconfiguring
9-1-1 systems on the basis of larger political
jurisdictions. The national 9-1-1 program was
conceived as an initiative to be planned and
implemented through cooperative efforts of local
governments (primarily municipalities) and local
telephone exchanges. Exclusion of 9-1-1 coverage to
households that are outside of municipal boundaries is a
problem. Reconfiguration of 9-1-1 systems on the basis
of larger political jurisdictions (counties, multicounty
regions, or statewide) is a possible solution to avoid
exclusion of rural households. Municipal public safety
officials may object to their 9-1-1 and dispatch
services becoming part of a larger county, regional, or
statewide system because they may perceive a loss of
control and a decrease in responsiveness of public
safety services for their constituents.(15),(17)
5. Strategies to reach households without telephones need
to be developed. One aspect of 9-1-1 as it relates to
access to care for early identification and treatment of
individuals with symptoms and signs of AMI/sudden
cardiac death is that, nationally, not all households
have telephones. Thus, strategies to reach households
without telephones need to be developed. Table 5, which
is based on data from the 1990 U.S. Census Bureau, lists
the 10 States with the highest percentages of households
without telephones.
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Table 5. Percentage of Occupied Housing Units Without
Telephones (Top 10)
State Percent
1. Mississippi 12.6
2. New Mexico 12.4
3. Arkansas 10.9
4. West Virginia 10.3
5. Kentucky 10.2
6. South Carolina 9.1
7. Oklahoma 8.8
8. Alabama 8.7
9. Texas 8.6
10. Arizona 8.5
Source: U.S. Census Bureau, 1990.(20)
-----------------------------------------------------------
6. Each State should have a statewide EMS communications
plan that focuses on public access to EMS and two-way
voice communications. A strategy for implementation of
universal/enhanced 9-1-1 systems is that each State
develop a statewide EMS communications plan that focuses
on public access to EMS and two-way voice
communications. The plan should emphasize statewide
planning and development of enhanced 9-1-1 as described
in the ASTM "Standard Guide for Planning and Developing
9-1-1 Enhanced Telephone Systems," F 1381-92.(17) Use
of this guide will promote uniformity in statewide
planning and implementation of enhanced 9-1-1 systems
so as to provide prompt access to EMS and other public
safety services for the entire population of a State.
The plans should also address extending the coverage and
upgrading the reliability of EMS communications as
described in the ASTM "Standard Guide for Emergency
Medical Services Systems Telecommunications," F 1220-
89(21) and applicable Federal Communication Commission
rules for emergency medical radio services.(22)
7. A national awareness must be promoted concerning the
feasibility and importance of achieving
universal/enhanced 9-1-1. The need for improvement in
9-1-1 and public safety dispatch communications to
achieve objectives for early cardiac care can be a
catalyst for change. National, State, and local
governments and public safety agencies must become
convinced that the benefits of achieving
universal/enhanced 9-1-1 implementation override the
burdens (increased costs, shifts in management
responsibility, and legislative efforts) of needed
changes to create pervasive, efficient, and coordinated
public access and EMS response for cardiac emergencies.
8. Key groups that can help effect change should promote
9-1-1 implementation. Among these key groups are the
National Association of State EMS Directors; the
National Association of State Telecommunications
Directors; the National Association of State Nine-One-
One Administrators; the National Emergency Number
Association; the 9-1-1 Committee of the Associated
Public-Safety Communications Officers, Inc.; and the
International Municipal Signal Association. Such groups
as these can help effect change and should be involved,
as should the National Association of EMS Physicians and
associations of fire chiefs, sheriffs, chiefs of police,
and law enforcement officers. Networking and
establishing better links among EMS groups (including
private ambulance services), professional communications
associations, State regulatory utility commissioners,
law enforcement, and fire systems are important factors
in achieving universal/enhanced 9-1-1.
9. Continued monitoring of the status of 9-1-1 systems
should be supported. The National Association of State
EMS Directors and the National Association of State
Telecommunications Directors have published several
reports on national surveys of 9-1-1 services, and the
9-1-1 Committee of the Association for Public-Safety
Communications Officers, Inc., has developed an
extensive collection of reports on 9-1-1 systems. The
National Association of State Nine-One-One
Administrators, the National Emergency Number
Association, and the International Municipal Signal
Association are excellent survey sources as well.
Research on barriers to 9-1-1 implementation at the
local and State levels, which is concurrent with
monitoring the status of 9-1-1 systems implementation,
should be fostered.
10. The ASTM "Standard Guide for Planning and Developing
9-1-1 Enhanced Telephone Systems," F 1381-92, should be
implemented by States. The ASTM "Standard Guide for
Planning and Developing 9-1-1 Enhanced Telephone
Systems," F 1381-92(17) promotes and facilitates the
enactment and implementation of statewide enhanced 9-1-1
systems. Thus any recommendations for prehospital
early cardiac care should address consideration of the
benefits associated with statewide enhanced 9-1-1
systems, although scientific data are lacking that
demonstrate improved outcomes with statewide 9-1-1
system administration compared with local control.
-----------------------------------------------------------
SUMMARY
Even though cardiac emergencies represent a relatively small
percentage of 9-1-1 calls, they constitute a high-risk group
of users. Ideally, implementation of universal and enhanced
9-1-1 will allow ready access to the EMS system, and will
include emergency medical dispatching services, for
individuals seeking treatment for symptoms and signs of an
AMI, as well as sudden cardiac death. Organizations that
seek to promote universal/enhanced 9-1-1 should work with
groups involved in enhanced 9-1-1 system planning and
development to help achieve that goal as well as promote
continuing collaboration to implement improved emergency
medical dispatching practices.
The presence of universal 9-1-1 does not itself ensure rapid
access to EMS if the patient or bystanders do not employ it
appropriately or are unaware of its existence.(23) However,
a major assumption of this paper is that universal and,
ideally, enhanced 9-1-1 is a fundamental prerequisite to a
seamless access to EMS. The 1992 National Conference on CPR
and Emergency Cardiac Care recommended that for adult sudden
cardiac death victims, the rescuer should phone first to
activate the EMS system before preforming CPR. This is a
shift from its 1986 recommendation that rescuers perform CPR
for 1 minute on adult victims before calling the EMS
system.(24) In terms of patients with heart attacks, once
9-1-1 is in place universally, national public education
campaigns can promote use of 9-1-1 in response to the
symptoms and signs of an AMI in order to facilitate entry
into the EMS system and early identification and treatment
of AMI. Such education will aim to reduce the greatest
source of delay in receiving care for an AMI--that
related to the patient.
-----------------------------------------------------------
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DISCRIMINATION PROHIBITED: Under provisions of applicable
public laws enacted by Congress since 1964, no person shall,
on the grounds of race, color, national origin, handicap, or
age, be excluded from participation in, be denied the
benefits of, or be subjected to discrimination under any
program or activity (or, on the basis of sex, with respect
to any educational program or activity) receiving Federal
financial assistance. In addition, Executive Order 11141
prohibits discrimination on the basis of age by contractors
and subcontractors in the performance of Federal contracts,
and Executive Order 11246 states that no federally funded
contractor may discriminate against any employee or
applicant for employment because of race, color, religion,
sex, or national origin. Programs of the National Heart,
Lung, and Blood Institute are operated in compliance with
these laws and Executive Orders.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
National Institutes of Health
National Heart, Lung, and Blood Institute
NIH Publication No. 94-3302
May 1994
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