1 Utilization of HEMS 1 UTILIZATION OF HEMS Identifying Obstacles to the Utilization of Helicopter Emergency Medical Transport in the Eugene-Springfield Ambulance Service Areas Karen E. Brack Eugene Fire and Emergency Medical Services Department, Eugene, Oregon
2 Utilization of HEMS 2 Abstract In medical transportation services, a fully integrated system should focus on the relationships that capture the most efficacious emergency, non-emergency and critical care ground providers with efficient medical helicopter services. The purpose of this research project was to identify obstacles and potential solutions to resistance to using air medical transport for long-distance transport of critically ill and injured patients in the Eugene-Springfield ambulance service area (ASA). Solutions to the problem of low utilization may ultimately minimize excessive out-of-service times for ground transport ambulances. Descriptive research was used to determine and report the status of HEMS use in the Eugene-Springfield ASAs. An analysis of response and survey data, interviews and a review of pertinent literature were employed to answer the following questions: a) Under what circumstances should helicopter emergency medical services (HEMS) be considered for patient transport? b) What concerns do providers have affecting the decision to activate HEMS? c) What effect does using HEMS have on patient morbidity and mortality? d) To what extent have air ambulances been integrated into existing EMS systems? It is concluded that there are opportunities for additional HEMS utilization resulting in a decrease in out-of-service time for ground transport units by implementing the recommendations: 1. Address concerns of hospital personnel of using HEMS for long distance transfers of critical patients.
3 Utilization of HEMS 3 2. Expand contract with private provider to handle transfers when Life Flight is unable to fly due to weather. 3. Address system capacity issues by transitioning, non-emergent scene calls to the contracted private provider. 4. Finalize agreement with Lane Rural Fire Rescue (LRFR), ASA 8, to assume responsibility for the western rural portions of the City of Eugene s ASA. 5. Begin discussion with ambulance provider from Deschutes County to handle ambulance calls at the eastern rural portions of SFLS s ASA.
4 Utilization of HEMS 4 Utilization of Helicopters CERTIFICATION STATEMENT I hereby certify that the paper constitutes my own product, that where the language of others is set forth, quotation marks so indicated, and that appropriate credit is given where I have used the language, ideas, expression, or writings of another. Signed:
5 Utilization of HEMS 5 Table of Contents Page Abstract 2 Certification Statement 4 Table of Contents 5 List of Figures 6 Introduction 7 Background and Significance 9 Literature Review 12 Procedures 38 Results 40 Discussion 46 Recommendations 52 References 54 Appendices 61
6 Utilization of HEMS 6 List of Figures Page Figure 1: Lane County Ambulance Service Areas 41 Figure 2: Transport Time from Time of Dispatch to Arrival at Hospital for CY Figure 3: Transfers to Portland Area Hospitals 43 Figure 4: Helicopter Transports of Trauma System Entry Patients 44 Figure 5: Top Three Reasons Why HEMS Utilized 46 Figure 6: Reasons Why HEMS Not Utilized 46
7 Utilization of HEMS 7 Introduction In medical transportation services, a fully integrated system focuses on developing relationships that capture the most efficacious emergency, non-emergency and critical care ground providers with efficient medical helicopter services (Zalar, 2004, p. 600). The Federal Emergency Medical Services (EMS) System Act defined an EMS system as a system which provides for the arrangement of personnel, facilities, and equipment for the effective and coordinated delivery in an appropriate geographic area (Pons & Cason, 1997, p.5). Regionalized, coordinated and accountable systems would help to promote cooperation among competing local providers and ensure that patient s receive the right care at the right place at the right time (Institute of Medicine, 2010, p. 1). It s hard to look at the proliferating use of helicopter EMS (HEMS) resources and try to decipher the optimum balance of benefit, risk and safety, and the most likely path to achieving it. Even in urban areas, traffic congestion and overstretched ground resources may sometimes make flight a faster option (Erich, 2008, p. 38). Emergency Medical Services (EMS) ambulance transport services nationwide are struggling to stay in business and existing services are being asked to cover more area with fewer resources. Agencies with dual-trained personnel (firefighter/emergency medical provider), are experiencing an increase in call volume, increased unit-hour utilization, fatigued employees and large populated areas unprotected from fire, hazardous response, rescue and medical transport. An ambulance responding to a rural area on the fringes of their ambulance service area must leave its core service area uncovered for extended periods of time. In other situations, the expectation that an ambulance be called to a hospital to deliver a patient to a distant trauma or specialty care center can also result in the same scenario of leaving a community unprotected for extended periods of time. The use of HEMS would enhance system efficiencies and improve
8 Utilization of HEMS 8 care for trauma and critically ill patients; however, with that being said, the current reimbursement model does not promote systemness (2010, Institute of Medicine, p. 71). Medical helicopters can expand the scope of service that local EMS providers can offer their patients. The aging population, closure of rural hospitals & local emergency departments, consolidation of trauma resources and specialty care functions, and the growing need for timely interventions in situations like stroke and cardiac arrest have contributed to the growing need for the use of HEMS (Erich, 2008, p.38). Air medical transport can provide for rapid access to medical care and a higher level of patient care enroute, with a decreased transport time to the receiving facility (Zalar, 2004, p. 603). The problem is a low utilization of air medical patient transport for critically ill and injured patients within the Eugene-Springfield ambulance service area causing excessive out-ofservice time for ground transport ambulances. Currently air medical transport is not being utilized to maximize efficiencies to the overall patient care system. The purpose of the applied research project (ARP) is to identify obstacles and potential solutions to resistance to using air medical transport for long-distance transport of critically ill and injured patients. Descriptive research will be utilized to answer the following questions: (a) under what circumstances should helicopter emergency medical services (HEMS) be considered for patient transport?, (b) what concerns do providers have affecting the decision to activate HEMS?, (c) what effect does using HEMS have on patient morbidity and mortality?, and (d) to what extent have air ambulances been integrated into existing EMS systems?
9 Utilization of HEMS 9 Background and Significance In July 2009 the fire departments from Eugene and Springfield, Oregon started the process to facilitate the merging of two separate fire departments into a single operational function. The ultimate goal of the consolidation of services was to gain operational, financial and administrative efficiencies. In operations, where the rubber meets the road, the job functions are similar and the expectations of service delivery are consistent; the challenge is meeting quality service delivery to a much larger service area with no additional personnel. Both departments provide fire, rescue, emergency advanced life support first response, code enforcement, hazardous materials response, and fire/injury prevention education services to their citizens and visitors. In addition, both departments provide advanced life support ambulance transport services within their fire protection jurisdictions and to an extended geographical ambulance service area (ASA) beyond the boundaries of their respective cities. Prior to 1981 both departments were what one would call traditional fire departments, providing fire protection, fire prevention and medical first response within their city boundaries. A two-tier system was in place whereby the fire departments provided medical first response and a private ambulance service handled all emergency and non-emergency patient transports in both cities and the surrounding area in the county. Abruptly both fire departments were jettisoned into the patient transport business when the private ambulance service, parked the vehicles, locked the doors and walked away. Within the current functionally consolidated environment both EFD and SFLS provide fire, life safety, rescue, emergency medical, fire code enforcement, fire investigation, and public education to their incorporated areas and contract districts. In addition, both departments collectively provide patient care and ambulance transport to citizens and visitors alike in a 2,436
10 Utilization of HEMS 10 square mile area of Lane County, slightly less than 54% of all of Lane County. Of the 352,010 Lane County residents, EFD & SFLS protects approximately two-thirds (67.4%) of the total population (Portland State University, 2010). In 1990 the Oregon Legislature passed a law making each Oregon County responsible for developing a county plan for ambulance and emergency medical service. Oregon Revised Statute (ORS) (formerly ) states that each county shall develop a plan relating to the need for and coordination of ambulance services and establishes one or more ambulance service areas (ASAs) consistent with the plan for efficient and effective provision of ambulance services (ORS , 2003). The legislation ensured that every square inch of Oregon would be covered by a designated ambulance provider within specific service areas assigned in each county. This legislation also prevented ambulance providers from congregating in densely populated metropolitan areas and leaving the vast rural and frontier areas of Oregon unprotected. Since 1990 calls for service for EFD and SFLS have increased by over 250 percent however personnel staffing has increased by only fourteen percent (City of Eugene, 2010). Emergency responses, increased training requirements for fire protection and emergency medical certifications, and complying with federal and state response standards is, at times, causing an untenable situation in managing day-to-day operations. The expanded scope of work is causing an increase in employee fatigue and a limited ability to provide flexibility in daily staffing in order to achieve all of the requirements. In 1981 the National Fire Protection Association (NFPA) required 10 firefighters to handle a single family dwelling structure fire, today that requirement is 15 (NFPA 1710, 2001). In order to respond that number of personnel on scene to combat a structure fire, firefighters from a larger geographical area within the cities must vacate their area of responsibility;
11 Utilization of HEMS 11 adversely impacting response reliability. This requirement further impacts the ability to appropriately respond to other emergency calls within either city, as well as ambulance calls to the rural areas of the designated ASA. A medical call for service to the eastern or western boundaries of the ambulance service area removes an ambulance from service, with two or three personnel, for up to 2 hours 30 minutes to 3 hours. A transfer of a critical patient from local hospitals to a Level I trauma center (only two in Oregon and both are in Portland), or specialty care facility in the Portland area can remove a unit from service for over 6 hours. An explanation of Trauma System Hospital designations can be found in Appendix A. During these extended transports multiple calls for service at the same time continue to impact operations and the ability to respond to emergencies in a timely manner. Helicopter emergency medical services (HEMS) arrived in the Central Willamette Valley in May 2006 when REACH established a base of operations at the Corvallis, OR airport. Typically a HEMS service area is approximately 150 miles in any direction from their base of operation. Eugene-Springfield is within that 150-mile response area and services were available to any area first responder emergency medical provider for scene transports to the local level 2 trauma hospital. Depending on where the incident occurred the patient was either transported to Sacred Heart Hospital in Eugene or returned to Corvallis to Good Samaritan Hospital; both hospitals were designated as level 2 trauma hospitals by the Oregon State Health Division. In 2008 Life Flight, another HEMS service based out of Portland, OR, started a satellite operation from the Eugene airport. Two HEMS operations responding to basically the same service area made for unique situations and dilemmas for on-scene emergency responders. Many first response agencies had already developed a relationship with REACH and therefore called for their activation despite where the need emanated. Activations of HEMS
12 Utilization of HEMS 12 were typically accomplished after the arrival of the first unit on-scene and the lead medical provider determining the critical nature of the patient or patients. On many occasions activation was delayed while awaiting the arrival of a paramedic, responding on a ground ambulance, to verify critical status of patient and need for HEMS transport. Unless the requesting agency indicated which HEMS to activate confusion ensued for dispatch causing further delays in transporting the patient to definitive care. To minimize the confusion and activate HEMS in a timely manner an Auto Launch Policy (Appendix B) was adopted for the Eugene-Springfield ambulance service areas. If dispatch determined, through caller information, that a patient met certain criteria then HEMS would be dispatched at the same time as other responding units; thus saving valuable time and ultimately providing for advanced patient care and expeditious transport to a definitive care facility. Embracing HEMS into the EMS transport system is a benefit to area providers but more importantly benefits critically injured and ill patients through advanced care en-route and rapid transport to a hospital. Enhancing the utilization of helicopters for patient transport in the Eugene-Springfield ambulance service area specifically addresses the risk assessment and intervention components of the Executive Analysis of Community Risk Reduction (EACRR) course curriculum (National Fire Academy [NFA], 2011). Implementation of the recommendations from this research could improve the fire and emergency services capability for response to and recovery from all hazards, a goal of the United States Fire Administration (USFA). Literature Review A top priority of the Metro departments is to develop the means to sustain the ambulance transport system and deploy enough ambulances on the street to keep pace with the workload and call volume. Simply stated, the ambulance transport system is operating at both a financial
13 Utilization of HEMS 13 and resource capacity deficit (City of Eugene, 2010, p. 36). Utilizing air transport on a more consistent basis for critically injured or ill patients could free up valuable resources to respond to other emergencies in the city and reduce the number of times emergency calls are transferred to another agency due to lack of available units. Citizens of the Eugene-Springfield area deserve to have a comprehensive and timely response to their emergency whether it is a medical emergency, structure fire or other hazardous response. Identifying (a) under what circumstances should Helicopter Emergency Medical Services (HEMS) be considered for patient transport?, (b) what concerns do providers have affecting the decision to activate HEMS?, (c) what effect does using HEMS have on patient morbidity and mortality?, and (d) to what extent have air ambulances been integrated into existing EMS systems?, and sharing the results of that information with prehospital care providers and hospital staff could enhance the use of HEMS within the emergency medical transport system. Under what circumstances should Helicopter Emergency Medical Services (HEMS) be considered for patient transport? Air medical operations began in the United States in the early 1970s following their use during the Korean War. Their use in remote locations, with limited roadways, and with hostile forces is indisputable. Helicopters transported injured soldiers from the front lines to mobile army surgical hospitals (MASH), where they were stabilized prior to being sent stateside to a medical hospital. Air medical operations for civilian use have followed the military model, emphasizing speed and moving the patient away from the scene to definitive care (Institute of Medicine, 2007, p ). The impetus for the increased use helicopter ambulances in the civilian sector was based on the concept of the golden hour, the period following an injury to the point of resuscitation and definitive care in a hospital (Henry & Stapleton, 2010, p. 643).
14 Utilization of HEMS 14 In 1992 the National Highway Traffic Safety Administration (NHTSA) conducted an assessment of Oregon s emergency medical services and trauma system. One of the findings was inadequate air ambulance coverage in many parts of the state with a recommendation to develop a comprehensive air and ground transportation needs assessment. Fast forward to 2006 in a follow-up assessment by NHTSA which found that major operational changes had occurred related to both air and ground ambulances. As it relates to air ambulance operations: Air ambulance operations would be on a five-year inspection schedule, State is looking at national standards, The Association of Air Medical Responders of Oregon was formed and created a resource guide, Representatives from public and private ambulance service agencies will participate in development of State EMS Plan, and State air ambulance providers are discussing auto-launch policy (State of Oregon, 2006, p ). Nationwide from 1999 through 2008, the number of patients transported by helicopter air ambulance increased from over 200,000 to over 270,000, or by 35 percent, and the number of air ambulances increased from 360 to 677, or by about 88 percent (United States Government Accountability Office [GAO], 2010, p. 6). The GAO also found that the increase in patient transport volume can be attributed to a number of factors: downsizing or closing of community hospitals; the establishment of regional medical facilities, like cardiac and stroke centers; and implementation of the Medicare fee schedule which increased the predictability of Medicare reimbursement (GAO, 2010, p. 9). Amplified HEMS availability allowed for increased access to
15 Utilization of HEMS 15 rural areas of the United States, often freeing up local ground ambulances from traveling long distances with critically ill and injured patients and keeping that ambulance in their community. As early as 1990, in a position paper on the appropriate use of emergency air medical services, the Association of Air Medical Services concluded that Time affects survival. Inefficient transport times expose patients to an environment where the ability to respond to lifethreatening complications is seriously impaired (p.2). Access to HEMS should be determined by the patient s clinical conditions, the need for advanced life support (ALS) or critical care interventions not available from ground providers, the need for rapid transport to the most appropriate hospital or when travel conditions prevent timely transport to the closest appropriate hospital (Judge and McGinnis, 2007, p. 22). In rural areas, systematized and rapid response of pre-hospital HEMS has consistently demonstrated air transport to be lifesaving and cost effective. Better patient outcomes have been attributed to minimizing time to definitive care facilities as well as instituting potentially lifesaving treatments en route (Schuurman, Bell, L Heureux & Hameed, 2009, p.2). The increased utilization of HEMS also creates the possibility that some air transports are unnecessary, that the patient s medical condition is not serious enough to warrant the use of a helicopter. Trauma systems were established to quickly identify the critically injured patient at the scene of injury and to transport them, without delay, to an appropriate definitive care facility. A definitive care facility is one that has sufficient resources, personnel and equipment, to handle comprehensive treatment of a patient. Emergency medical services, both ground and air, are often involved in the transport of trauma patients to hospital care from the scene of injury or during inter-facility transfers and constitute an integral part of any trauma system (Committee on Trauma, 2006).
16 Utilization of HEMS 16 In 1985 the Oregon Legislative Assembly authorized the Department of Human Services to develop a comprehensive emergency medical service and trauma system. Oregon Revised Statute (ORS) authorizes the Department of Human Services to: a) develop state and regional standards of care; b) develop a statewide educational curriculum to teach standards of care; c) implement quality improvement programs; d) create a statewide data system for prehospital care; and e) Provide ancillary services to enhance Oregon s emergency medical service system (ORS , 1985). The decision to enter an injured patient into the trauma system can be overwhelming. To aid in this process several triage algorithms have been developed to deal with on-scene trauma transport decisions. Oregon Administrative Rule (OAR) 333 Division 200 establishes the procedures and standards for the development and maintenance of a comprehensive statewide trauma system. Triage and transportation protocols are written assuring that any time patients meet triage criteria as identified in Exhibit 2, presented in Appendix C, they will be transported directly to a Level I or Level II trauma hospital (OAR , 1987). The variables for mandatory entry into the trauma system are: vital signs or physiologic criteria, anatomic criteria, and mechanism of injury. In 1990 the Association of Air Medical Services (AAMS) published a position paper on the appropriate use of emergency air medical services. Six criteria were established to aid prehospital and hospital providers in guiding their decision making process and facilitate the use of a helicopter:
17 Utilization of HEMS 17 1) patient requires critical care life intervention or support at a clinical level that is unavailable from local ground ambulances; 2) patients clinical condition dictates minimal out-of-hospital transport times; 3) potential exists for delays via ground transport; 4) patient cannot be accessed by ground units; 5) patient medical needs require specific treatment not available at local referring facility; 6) transport of the patient by ground ambulance would deplete the local community of its EMS coverage for emergency response (p ). J. Mistovich, K. Karren & K. Keith (2008) and D. Limmer and M. O Keefe (2009) concluded that the following conditions should also be considered in rendering the aid of a helicopter to transport the trauma patient: 1) lengthy extrication of a critically injured patient; 2) lengthy manual transport of the patient out of a remote area to motorized transport; 3) patient needs to be transported to a trauma center or other specialty care facility that is distant from his present location; 4) air transport will clearly save time over ground transport in a time-critical patient; or 5) air transport crew possesses medical skills not available with the ground ambulance (p & p. 931). KE Stewart s research (2010), for his PhD dissertation of the Oklahoma trauma system, found that patients injured in severe motor vehicle crashes including motorcycle crashes or pedestrian incidents had the greatest likelihood of flying versus those patients injured in falls. His research also found that the decision to fly an injured patient was made by a basic or intermediate versus a paramedic (p. 40).
18 Utilization of HEMS 18 Mistovich, Karren & Keith (2008) and Limmer & M. O Keefe (2009) also stated that HEMS should not be limited to those critical patients meeting only trauma criteria. There is a whole host of patients with time critical medical conditions that should be considered for HEMS transport: shock, heart attack, acute stroke, respiratory distress, and severe carbon monoxide poisoning (p & p. 931). What concerns do providers have affecting the decision to activate HEMS? Any EMS incident has associated risks. There is some level of risk related to all aspects of healthcare. In two separate studies between 44,000 and 98,000 Americans die in hospitals each year as a result of medical errors, producing a death rate between 131 and 292 per 100,000 patients. While medical transportation is not a treatment and an accident may not be considered a medical error it is still an adverse event in the healthcare environment (Blumen, 2002, p. 5). The risk of occupational death is excessively high for emergency medical services personnel. Occupational death is estimated to be two and a half times higher for EMS workers compared with other American workers. Seventy-four percent of those fatalities can be attributed to transportation incidents (Maguire, Hunting, Smith, & Levick, 2002). Over a threeyear period ( ), 0.47% of all ground ambulances accidents resulted in a fatal injury, averaging 5.2 fatal injuries per 1,000 accidents (Blumen, 2002, p. 46). Ground Emergency Medical Service (GEMS) vehicular-related injuries and fatalities can be attributed into three categories: the inherent risks of driving/riding in an ambulance, poor ambulance safety standards and design, and increased vulnerability to injury while delivering critical patient care in the back of a moving ambulance (Slattery and Silver, 2009, p. 388). A key decision that EMS personnel make at the scene of injury is the mode of transport, helicopter or ground. EMS personnel consider many factors when deciding how to best transport
19 Utilization of HEMS 19 a patient to definitive care from the scene of an injury. The decision should be aimed at what is best for the patient and most appropriately uses an area s resources. Paramedic Field Care (1997), a paramedic instructional text, stated that along with the patients clinical status, the expertise and equipment that ground services provide, the urgency of transport, the safety of the transport environment, and the cost of transport should also be taken into consideration (Pons & Cason, pgs ). The 2007 Air Medical Task Force representing National Association of Emergency Medical Services (NASEMS) Officials, National Association of Emergency Medical Service (NAEMS) Physicians, and Association of Air Medical Service (AAMS) concurred and stated that air ambulances provide an opportunity for the rapid transport of patients and emergent conditions requiring time-dependent care, however, the significant costs and risks of air transport must be balanced against the benefits in each situation (Judge & McGinnis, p. 21). The first hospital-based use of helicopters for patient transport started in 1972 at Denver s Saint Anthony s Hospital. By 1980, eight years later, some 32 helicopter emergency medical services (HEMS) with 39 helicopters were flying more than 17,000 patients a year. By 1990, this grew to 174 services with 231 helicopters flying nearly 160,000 patients. Ten years later, 231 helicopter services with 400 aircraft were flying over 203,000 patients each year. By 2005, 272 services operating 753 rotor-wings (helicopter) and 150 dedicated fixed wing (airplane) aircraft were handling approximately a half-million transports each year. In 2010, the Atlas & Database of Air Medical Services (ADAMS), database of the Association of Air Medical Services reported 309 services operating 900 helicopters and 311 airplanes (McGinnis & Hutton, 2011, p. 3). From 1972 through September, 2002, HEMS had flown approximately three million hours, transporting some two and three-quarter million patients. In that time, there were 166
20 Utilization of HEMS 20 crashes involving HEMS, with 183 fatalities. While the number of crashes each year has fluctuated, the number per 100,000 patients flown had dropped from in 1980 to 5.5 in The risk to patients, estimated over the years of the study, is reported as a fatality rate of 0.76/100,000 patients (McGinnis & Hutton, 2011, p. 21). On February 29, 1988 the National Transportation Safety Board (NTSB) issued 19 safety recommendations to the Federal Aviation Administration (FAA) after examining 59 EMS accidents between May 1978 and December They concluded that EMS operations needed improvement, including weather forecasting, operations during instrument meteorological conditions, personnel training requirements, design standards, crashworthiness, and EMS operations management (NTSB/SS-88-01). In an article appearing in ROTOR magazine (Fall 2005) since 1991, there have been 127 HEMS accidents, of which 49 were fatal, involving 128 fatalities. Of this total, 109 (85.8 percent) were precipitated by some failure in human factors, which includes not only pilot error, but also improper maintenance or quality assurance, inadequate crew or ground coordination, and perhaps, more subtly, inadequate supervision or management. Ninety-six accidents (76 percent) were a direct result of pilot error. These errors can be broadly categorized as poor pilot technique; lack of situational awareness; loss of control; poor aeronautical decision-making; controlled flight into terrain, water or objects; or perhaps a combination of these. Fifty-nine (46.8 percent) of these pilot-induced accidents were a result of either controlled flight into terrain, water, or obstacles; striking an object with either the main or tail rotor; or a loss-of-control resulting in impact with terrain due to spatial disorientation. Of these, 40 occurred at night, and of these, 23, or over half, involved intentional or inadvertent continued VFR flight into IMC conditions ( Helicopter Association International, pg ).
It is estimated that there are around 400,000 helicopter EMS missions flown each year. There are an additional 100,000 150,000 fixed wing medical flights each year. In 2002, there were roughly 400 dedicated
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