Emergency response services, provided through 911 calling and ambulance services, serve as the first line of contact between patients suffering from emergency conditions and the local health care infrastructure. Together with the emergency rooms in hospitals, emergency response services play an important role in the health care outcomes for a number of emergency indications. For example, in the case of out-of-hospital cardiac arrest, the time lapse between collapse and the initiation of CPR and defibrillation is claimed to be an important determinant of the probability of survival.1 As well, the emergency response system plays a critical role in selecting which hospital receives each emergency patient, where hospitals may differ in their quality and in the technologies available for emergency care. The patient benefits from emergency response services thus arise not only from the direct provision of medical and transportation services, but also through the system’s role in allocating patients to the hospital facilities which are most appropriate for their particular medical condition. Furthermore, emergency response systems may have indirect effects on patients through their influence on the choices made by hospitals. Emergency response systems affect the incentives of hospitals to adopt certain technologies, such as gaining “trauma center” certification and introducing capabilities for the provision of cardiac care, since these choices can potentially influence the allocation of emergency patients to hospitals.

There exists wide variation across communities within the United States in terms of the level of care provided through the emergency service system. 911 services are publicly funded, and are almost always operated by local government agencies such as police or fire departments. At one extreme, some communities have invested in “Enhanced 911″ (E911) systems, which link digital information about the source of the call with a detailed address database maintained by the 911 center. The call-takers see each callers’ address and location on a computer screen almost instantaneously when the call is received. Even more advanced alternatives are available, including computer-aided ambulance dispatching. At the other extreme, there are many communities which have not invested even in a “Basic 911” capability. In these environments, individuals attempting to contact the local medical emergency infrastructure must locate and dial a seven-digit number. When the call is received, the call-taker manually searches for and contacts the ambulance which is closest to the emergency and has the appropriate equipment. Likewise, we see substantial heterogeneity in the availability of in-hospital emergency services across communities. Although the American Heart Association has advocated the adoption of Enhanced 911 as the first step in a “chain of survival” for cardiac incidents (Cummins et al, 1991), there has been little systematic evidence presented about the benefits of 911 services. bank loan