Evolution of statewide EMS drug formularies and regulations

Objective. To characterize and follow the variability present in statewide emergency medical services (EMS) medication formularies across the United States over a ten-year period. Methods. Investigators contacted the lead EMS agencies in all 50 states during three years (1992, 1997, and 2002). Using a standardized form, the investigators collected information about each state's prehospital medication policies, including whether a statewide EMS medication formulary existed, the authority of local medical directors to modify it, and what medications it contained. The investigators then sorted states into categories based on the regulatory intent of their EMS medication policies and compared medication listings across years. Results. Responses were obtained from all 50 states (n = 50, 100%) during each of the survey periods. There appeared to be a trend toward stricter state control and toward less variation between statewide formularies. State regulations in seven states stopped allowing local medical directors to retain full control of their systems' formularies, and eight states implemented mandatory statewide formularies. There was a trend toward more consistency between states, with more "most commonly" listed medications (6.9% in 1992 versus 22.1% in 2002) and fewer "least commonly" listed medications (58.3% in 1992 versus 42.3% in 2002). Controversial medications such as neuromuscular blockers and thrombolytics appeared in a small but increasing number of statewide formularies.Conclusions. Considerable variation was found among statewide EMS medication formularies, both in how they were established and in their contents. Although several states continued to rely solely on local medical direction, there seemed to be a trend toward more uniformity and stricter state control over prehospital medication formularies during the study period.