Developing a foundation for the evaluation of expanded-scope EMS: a window of opportunity that cannot be ignored.

EMS systems are about to undergo a major transformation. Not only will the scope of EMS change, but many experts believe that it will dramatically expand. Some see the "expanded scope" as entailing relatively limited changes, whereas others consider them to be more broad. Although no agreement is evident about the definition for expanded-scope EMS, it is hoped that all EMS professionals can agree that it must be implemented in a manner that can be carefully evaluated to determine its effects on patients and EMS systems. We present a framework for evaluating the effect of expanded-scope EMS in the various types of systems that currently exist. Special consideration must be given to the indirect effects that system changes may have on survival from out-of-hospital cardiac arrest. Numerous issues will affect our ability to properly assess expanded-scope EMS. The basic research models necessary to assess the impact of system change are lacking. Few EMS systems consistently produce significant volumes of good systems research ... that is, there are few "EMS laboratories." Cost-effectiveness and issues surrounding the "societal value" of EMS remain essentially unstudied. Reliable scoring methods, severity scales, and outcome measures are lacking: and, it is ethically and logistically difficult to justify withholding the "standard of care" in an effort to understand the impact of EMS interventions. Despite all of these barriers, it is time to pay the price of doing methodologically sound evaluations that ensure the most optimal societal impact by the EMS systems of the future.