Res­cu­ing pa­tients in ru­ral ar­eas

He­li­copter am­bu­lance ser­vices save lives, but still face cost, safety con­cerns

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Ru­ral health­care providers see ben­e­fits to trans­port­ing some trauma pa­tients to hos­pi­tals by he­li­copter am­bu­lance, but un­cer­tainty re­mains re­gard­ing the safety and ef­fi­cacy of us­ing the costly ser­vices. Bol­ster­ing the case for the use of he­li­copters in emer­gency med­i­cal ser­vices is a re­port that in­di­cates that adult trauma pa­tients trans­ported by he­li­copter have bet­ter odds for sur­vival than sim­i­lar pa­tients trans­ported by ground am­bu­lances.

Also of­fer­ing a po­ten­tial boost to us­ing he­li­copters in EMS, known as HEMS, is an expected set of he­li­copter safety rules from the U.S. Depart­ment of Trans­porta­tion’s Fed­eral Avi­a­tion Ad­min­is­tra­tion that are com­ing largely in re­sponse to a string of nine he­li­copter ac­ci­dents in 2008, six of which pro­duced 24 deaths, ac­cord­ing to the pro­posed rule, which was is­sued in Oc­to­ber 2010.

But since then, the num­ber of he­li­copter am­bu­lance ac­ci­dents has dropped, while ru­ral pa­tients continue to strug­gle with ac­cess to spe­cial­ized trauma care. As a re­sult, more ru­ral com­mu­ni­ties are re­ly­ing on he­li­copters in EMS to trans­port pa­tients, par­tic­u­larly for time-sen­si­tive treat­ments such as a heart at­tack or stroke.

“We know that if we treat those peo­ple within a cer­tain amount of time, we know we can re­verse the dam­age,” says Ti­mothy Pick­er­ing, pres­i­dent of the As­so­ci­a­tion of Air Med­i­cal Ser­vices and di­rec­tor of gov­ern­ment af­fairs for Air Evac Lifeteam, a West Plains, Mo.-based air-am­bu­lance com­pany. Once a cer­tain amount of time has passed, the chances for re­cov­ery for the pa­tient di­min­ish sharply, which is why the in­dus­try has tar­geted such things as the “door-to-bal­loon time” for an­gio­plasty treat­ments.

An at­ten­tion-get­ting study pub­lished in the April 18 is­sue of the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion sup­ports the idea that he­li­copters im­prove pa­tient care. Look­ing at adult trauma pa­tients with a min­i­mum level of in­jury sever­ity, the study’s authors found that pa­tients trans­ported to Level I trauma cen­ters had a 16% greater chance of sur­vival when trans­ported by he­li­copter and for pa­tients trans­ported to Level II trauma cen­ters the sur­vival ad­van­tage was 15% com­par­ing HEMS trans­port to ground trans­port.

The study en­com­passed al­most 62,000 pa­tients trans­ported by he­li­copter and more than 161,000 pa­tients trans­ported by ground, us­ing data from the Amer­i­can Col­lege of Sur­geons Na­tional Trauma Data Bank for 2007-09.

The main out­comes mea­sures were sur­vival to hospi­tal dis­charge and dis­charge dis­po­si­tion.

Pre­vi­ous stud­ies have not all found a pos­i­tive as­so­ci­a­tion with he­li­copter trans­port. “There are a few stud­ies that say he­li­copters don’t help any­body,” says one of the co-authors, Dr. Adil Haider, as­so­ciate pro­fes­sor of surgery, anes­the­si­ol­ogy and crit­i­cal-care medicine; as­so­ciate pro­fes­sor of health pol­icy and man­age­ment; and co-di­rec­tor of the Cen­ter for Sur­gi­cal Tri­als and Out­comes Re­search at Johns Hop­kins Medicine in Bal­ti­more.

The study authors tried to con­trol for vari­ables that po­ten­tially could pro­duce dif­fer­ent re­sults, but in all of the vari­a­tions the data in­di­cated that he­li­copters im­proved out­comes for air-am­bu­lance pa­tients. “That’s why we thought the study was a very im­por­tant one,” Haider says.

One thing that might have af­fected the re­sults in fa­vor of HEMS, and should be in­ves­ti­gated fur­ther, is the fact that air am­bu­lances are staffed gen­er­ally with more-qual­i­fied per­son­nel, he says. A ground am­bu­lance might be staffed with some com­bi­na­tion of emer­gency med­i­cal tech­ni­cians and paramedics, while he­li­copter am­bu­lances usu­ally have at least one reg­is­tered nurse with emer­gency train­ing and may have a doc­tor on board.

The data­base used for the study didn’t in­clude a large num­ber of ru­ral pa­tients, so that is an­other of the ar­eas that fur­ther study would be worth pur­su­ing, Haider says. “My hunch is that it would help in ru­ral sit­u­a­tions,” he says.

It might be pos­si­ble to im­prove even fur­ther the care pro­vided in ru­ral and ur­ban EMS by giv­ing ground-based re­spon­ders bet­ter tech­nol­ogy to help them de­cide whether to call in a he­li­copter, Haider notes. There are cases where he­li­copter-trans­ported pa­tients are sent home the next day, in­di­cat­ing the chop­per wasn’t nec­es­sary, as well as in­stances where fam­i­lies sued over the death of a he­li­copter pa­tient re­sult­ing from an ac­ci­dent, ar­gu­ing that the flight wasn’t nec­es­sary given the level of trauma, he says. Bet­ter de­ci­sion­mak­ing tech­nol­ogy would prob­a­bly make a dif­fer­ence in mak­ing the right call, and could save money, he says.

De­ci­sion­mak­ing for ground-based re­spon­ders can be tricky, par­tic­u­larly for ru­ral EMS providers that of­ten rely on vol­un­teers who may not have the same ex­pe­ri­ence or train­ing com­pared with EMS per­son­nel in ur­ban set­tings. Com­pli­cat­ing fac­tors can be the ground vs. air time dif­fer­ence, the weather and the avail­abil­ity of a he­li­copter, says Dr. Jeff Slepin, a re­gional med­i­cal di­rec­tor for EmCare Physi­cian Ser­vices based in Pen­sacola, Fla.

More air-am­bu­lance ser­vices are plac­ing he­li­copters in ru­ral ar­eas as op­posed to re­ly­ing on air­craft based near the trauma cen­ter to re­duce the to­tal time re­quired to get pa­tients to the hospi­tal, in­dus­try ex­perts say.

In­creas­ing ac­cess to trauma care via he­li­copter would be wel­come in ru­ral parts of the coun­try, as those re­gions are hav­ing a tough time re­cruit­ing spe­cial­ists, such as sur­geons (March 26, p. 28). Sec­onds can count in terms of sav­ing lives in EMS, and “I think air trans­port in ru­ral ar­eas be­comes all the more im­por­tant,” says San­dra Pod­ley, CEO at Havasu Re­gional Med­i­cal Cen­ter in Lake Havasu City, Ariz. “I’ve seen air trans­port in ru­ral ar­eas to be key from so many dif­fer­ent an­gles,” she says.

Cal­cu­lat­ing the costs

Un­sur­pris­ingly, the cost of pur­chas­ing and oper­at­ing he­li­copters is a lim­it­ing fac­tor in ru­ral com­mu­ni­ties gain­ing ac­cess to air-am­bu­lance ser­vices. The he­li­copter trauma study points to re­search that shows an an­nual cost of pro­vid­ing he­li­copter trans­porta­tion rang­ing from $115,000 to $4.5 mil­lion.

Re­im­burse­ment for he­li­copters is sim­i­lar to the rest of the in­dus­try in that Med­i­caid pays the least, Medi­care pays more but still at a rate be­low cost, Pick­er­ing says, while pri­vate pay­ers pay the best.

Be­cause of vari­ables such as the dis­tance trav­eled and type of care pro­vided, a range in the amount of re­im­burse­ment typ­i­cally paid to he­li­copter am­bu­lances was un­avail­able from the AAMS, but a pre­sen­ta­tion from a large pub­licly traded med­i­cal he­li­copter trans­port com­pany of­fers some clues.

A June pre­sen­ta­tion from Air Meth­ods Corp., an air-am­bu­lance ser­vice provider based in Den­ver, stated that for ser­vices pro­vided in which the com­pany owns the pro­gram and pro­vides all ser­vices, the com­pany’s net rev­enue per trans­port (af­ter ap­ply­ing a Medi­care/Med­i­caid dis­count and bad-debt ex­pense) was more than $10,000 in the first quar­ter of 2012, a 35% in­crease since Jan­uary 2010. (The other kind of ser­vice Air Meth­ods of­fers is to be em­ployed by a hospi­tal.) Air Meth­ods’ payer mix for owned pro­gram ser­vices was pri­vate in­sur­ance 35%; Medi­care 31%; Med­i­caid 21%; and unin­sured 13%, ac­cord­ing to the re­port.

Look­ing more broadly, the AAMS es­ti­mates that the in­dus­try con­tin­ues to grow and will reach 400,000 pa­tients flown this year af­ter hav­ing flown about 192,000 in 2000, 159,000 in 1990 and 17,500 in 1980.

Some are con­cerned that it was rapid growth that led to the big jump in ac­ci­dents and fa­tal­i­ties seen in re­cent years—in­clud­ing 2008—and prompt­ing the planned tight­en­ing of he­li­copter-am­bu­lance safety rules by the FAA. The agency es­ti­mates there were 135 he­li­copter airam­bu­lance ac­ci­dents and 126 re­sult­ing deaths be­tween 1992 and 2009, ac­cord­ing to the pro­posed new rule re­leased in Oc­to­ber 2010. That year, there were at least eight more ac­ci­dents (Sept. 6, 2010, p. 10).

More re­cently, two ac­ci­dents oc­curred when three were killed—in­clud­ing a heart sur­geon— in De­cem­ber while fly­ing across the north­ern cor­ner of Florida to re­trieve a heart for a transplant, and four were killed—in­clud­ing one pa­tient—in a Mis­souri he­li­copter crash in Au­gust 2011, ac­cord­ing to the As­so­ci­ated Press.

The new safety rules from the FAA should arrive this quar­ter, Pick­er­ing says, but the num­ber of ac­ci­dents has slowed markedly since the deadly year of 2008. In Novem­ber of that year, the FAA put out a notice that made manda­tory changes to air-am­bu­lance flights and pro­vided other rec­om­men­da­tions, in­clud­ing en­cour­ag­ing the use of night-vi­sion gog­gles. Among the changes were re­quire­ments that air am­bu­lance com­ply with cer­tain weather-re­lated lim­i­ta­tions, ac­cord­ing to an FAA fact sheet.

PHOTO COUR­TESY OF MARK MEN­NIE

A re­cent study pub­lished in the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion noted the im­proved sur­vival rates through use of air-am­bu­lance ser­vices.

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