Improving Emergency Medical Services

To improve the quality of care patients receive in crisis situations, The Duke Endowment distributed more than $6 million in grants between 2007 and 2012 to help strengthen emergency medical services in North Carolina and South Carolina.


Emergency medical services providers are counted on to save lives. They offer urgent medical care in crisis situations, often while transporting patients to hospitals for definitive care. People experiencing non-life threatening illness or injury also depend on timely and efficient care. In North Carolina and South Carolina, as in the rest of the country, EMS providers are critical for understanding and responding to emergency needs, providing care on the scene and in transit, and facilitating the transfer to definitive care. Providers also play an integral role in disasters, and they serve as on-the-ground resources in identifying public health threats.

Disparities in Level of Emergency Care and Response Times

Each year, 432 EMS agencies in North Carolina respond to more than 1.6 million events, while 265 agencies in South Carolina respond to more than 1.2 million events. Because emergency medical care is provided by a variety of individuals and agencies, both public and private, the level of care can vary greatly, even within communities. Baseline data gathered through the comprehensive EMS information system supported by The Duke Endowment revealed clear disparities in care provided and the importance of improving EMS response times.

For example, in North Carolina in 2007, the difference in response times between the top ten and bottom ten performing counties was 116 percent, correlating to a 27 percent increase in injury fatality rates for the low performers, as well as increased mortality rates for other emergent conditions such as stroke and cardiac arrest. 

Data Challenges

Systematically collecting data about response times and other measures can help establish acceptable performance or safety standards for emergency medical service providers, set benchmarks for improvement, and highlight just how critical timely and efficient medical services are. When The Duke Endowment’s initiative began, data collection among North Carolina providers was inconsistent across the state, and South Carolina did not have a standard, centralized system for recording or comparing EMS event data.

Responses to Specific Conditions

In some situations, a swift and proficient response can mean the difference between life and death. For example, in cardiac arrest, a victim's chances of survival are reduced 7-10 percent for every minute that passes without defibrillation and advanced life support intervention, according to an article from EMS World. Without investment in improved response times and training and equipment for North Carolina and South Carolina EMS providers, chances for survival among cardiac arrest patients in both states would have been diminished.  


To help reduce disparities in care, The Duke Endowment has engaged in three primary strategies targeted at improving EMS response times and related outcomes in North Carolina and South Carolina:

  • Develop standardized data collection systems
  • Promote standards of care with high potential for improving EMS outcomes
  • Support EMS providers with advanced equipment and training

Developing Database Systems

The Duke Endowment’s efforts began with grants of more than $5.5 million between 2004 and 2007 to support four projects in North Carolina and South Carolina aimed at improving EMS data systems. The Endowment awarded $899,250 to the North Carolina Office of Emergency Medical Services to develop a statewide database that includes three components:

  • Pre-Hospital Medical Information System (PreMIS), which provides data entry and reporting capability. PreMIS collects up to 200 data points for each EMS event.
  • Credentialing Information System (CIS), a database used to monitor and provide credentials to EMS personnel, ambulances and agencies.
  • EMS Performance Toolkit Project, custom web-based reports running off the state database. The toolkits analyze individual EMS providers' performance and generate recommendations for improvement.

Because all three of these systems are linked, state EMS offices have the capacity to cross-reference individual provider quality with the credentialing and re-credentialing process. 

In 2007, the Endowment awarded $650,000 to the South Carolina Office of Emergency Medical Services to implement the EMS database system (PreMIS, CIS and EMS toolkits) developed and piloted in North Carolina.

In addition, in 2007 and 2008, the Endowment awarded $2.4 million to help EMS systems in North Carolina develop fully operational Emergency Medical Dispatch systems and standardized policies and procedures across all EMS providers within the system — both characteristics of high-performing EMS systems.

Advancing Standards of Care

Data collected through the statewide EMS systems is organized through six performance improvement “toolkits” specific to core competency areas in response to specific emergent care areas:  response time, trauma, short-term elevation myocardial infarction (STEMI), cardiac arrest, stroke, and pediatric care.

A review of initial data in 2007 showed that improvement of response times for underperforming counties needed to be a top priority in North Carolina. The Endowment awarded $1.6 million to help EMS providers in 26 counties improve their response times.

In 2009, data from the statewide system showed that survival rates for cardiac arrest varied significantly from one EMS agency to another. Guided by this information, the Endowment awarded $2.15 million to help 40 counties achieve higher standards for cardiac arrest care. In 2012, the Endowment awarded $1 million to the South Carolina Department of EMS to improve cardiac arrest survival rates.

Providing Advanced Equipment

The Endowment’s grants to help North Carolina and South Carolina EMS providers improve cardiac arrest care included the purchase of two specific diagnostic tools: waveform capnography equipment (which measures carbon dioxide levels in respiration) and 12-lead ECG (which measures the heart’s electrical activity).

Providers can now use these tools on the scene of an emergent event and during transport to relay information directly to hospital emergency departments to speed appropriate treatment and improve overall patient transition times to definitive care. The 12-lead ECG also can identify patients who are experiencing a heart attack. In North Carolina, 28 EMS systems were able to employ capnography and 12-lead ECG as a standard of care from 2010 to 2012. The implementation of a similar program began in South Carolina in 2013.

Pursuing New Ideas

In 2013 and 2014, the Endowment is supporting the North Carolina Office of Emergency Medical Services in its efforts to develop a new EMS Self-Tracking and Assessment of Targeted Statistics Program (STATS). Grants totaling $713,315 will allow NCOEMS to implement and test two new innovative tools to assess, track and improve pre-hospital care. One tool will focus on airway performance management and the other on EMS providers, allowing them to benchmark and compare their individual performance with other EMS providers in their state. In addition, grant funds will help NCOEMS update its data system to better match data sets within the 2013 National EMS Data Standards.

Also in 2013 and 2014, the Endowment is providing grants of $281,000 to the New Hanover Regional Medical Center in Wilmington, N.C., and $306,000 to Abbeville County Memorial Hospital in Abbeville, S.C., to implement a community paramedicine program in each location. Community paramedicine combines the emergent care role of EMS personnel with more community outreach efforts focused on prevention and wellness. When deployed successfully, community paramedicine programs can reduce hospital visits among groups that are frequent users of emergency departments (such as the elderly).

This can improve health and reduce costs. A 2010 study published by the RAND Corporation reported that between 14 and 20 percent of emergency department visits were non-emergent with a potential cost nationally of $4.4 billion. In that same year, the Annals of Emergency Medicine reported that frequent users of emergency department services account for four to eight percent of patients and 21-28 percent of all visits. Both New Hanover and Abbeville hope to reduce emergency department visits by 20 percent over two years. 

Participating Sites

North Carolina

  • North Carolina Office of EMS, Raleigh
  • EMS Performance Improvement Center (Department of Emergency Medicine at the University of North Carolina at Chapel Hill), Chapel Hill
  • New Hanover Regional Medical Center (Community Paramedicine Program), Wilmington
  • All EMS systems statewide

South Carolina

  • South Carolina Department of Health and Environmental Control, Division of EMS and Trauma, Columbia
  • Abbeville Area Medical Center (Community Paramedicine Program), Abbeville
  • All EMS systems statewide


Area of Work

  • Quality and safety of health care

Program Area

  • Health Care

Grantmaking Status

The Endowment is continuing to work through current grantees and is not accepting new applications.

Areas of Work

  • Prevention and early intervention for at-risk children

    To equip children and families with skills to ensure that children reach developmental milestones to lead successful lives.

  • Out-of-home care for youth

    To drive child welfare systems toward greater accountability for child well-being.

  • Quality and safety of health care

    Improving the quality and safety of health care delivery

  • Access to health care

    Improving health by increasing access to comprehensive care

  • Prevention

    Expanding programs to promote health and prevent disease

  • Academic excellence

    Enhancing academic excellence through program and campus development

  • Educational access and success

    Increasing educational access and supporting a learning environment that promotes achievement

  • Campus and community engagement

    Promoting a culture of service, collaboration and engagement among schools and communities

  • Rural church development

    Building the infrastructure and capacity of United Methodist churches to enhance ministry and mission

  • Clergy leadership

    Strengthening United Methodist churches by improving the quality and effectiveness of church leadership

  • Congregational outreach

    Engaging United Methodist congregations in programs that serve their communities