helicopters in ems

8/7/2019 Helicopters in EMS

1/30

1

HEMS: Luxury or necessity, the cost

NAEMSP Annual Meetingand Scientific AssemblyJanuary 2009 Phoenix, AZ

an consequence o sys em es gn

Thomas Judge / LifeFlight of Maine

Stephen Thomas, MD, FACEP, MPH

University of Oklahoma

Dan Hankins, MD, FACEP

Mayo Clinic

Ira Blumen, MD, FACEP

The University of Chicago

Fixed Wing

Ground CCT


2/30

2


3/30

3

What is clear

Final Report Expert Panel Review of Helicopter

Utilization and Protocols in Maryland Feb. 2009

HEMS is an essential component of a contemporary EMS system.Its use improves outcomes in a high risk population of traumapatients.

Both aviation and critical care medicine are high consequence

endeavors a (high risk, high cost, high benefit). HEMS programsmust operate at the highest levels of safety practically possible.The safety of patients and of crew members must incorporate acomprehensive systems approach to risk management.

The configuration of the HEMS system, including overall missionprofile and the number and location of aircraft should bedetermined primarily on the distribution of the population, injurypatterns, and the geography of the state.


4/30

4

46.7 million Americans

have no access to Level

1 or 2 trauma centers

within 1 hour

Helico ters rovide

access for 81.4 million

Americans who

otherwise would not

have been able to reach

a trauma center within

an hour.

Input 3;

One way drive

Decision

Support Time

Modeling

Constant

average speed

per road

classificationR oa d C la ss Spe ed

R ur al L oc al 2 5

R ural H ig hw ay 5 0

R ural F re ew ay 6 5

U rb an L oc al 2 5

U rb an A rt er ia l 4 0

U rb an F re ew ay 5 5


5/30

5

Input 4;

One way flight

Decision

Support Time

Modeling

CMMC

140 MPH Flight Speed

Improv ingImprov ing

t r iaget r iage


6/30

6

Santa Rosa, FL October 2004

3 Fatal

Federal AviationAdministration 16

International Helicopter Safety Symposium

September 26-29, 2005

16

600

700

800

900

HEMS Crew Fatalities /100,000 PersonnelHEMS Crew Fatalities /100,000 Personnel

Range: 0-806/100,000

29-yr average: 212/100,000

HEMS

0

100

200

300

400

500

8 0 8 1 8 2 8 3 8 4 8 5 8 6 8 7 8 8 8 9 9 0 9 1 9 2 9 3 9 4 9 5 9 6 9 7 9 8 9 9 ' 0 0 ' 01 ' 0 2 ' 03 ' 0 4 ' 05 ' 06 ' 0 7 ' 08

-yr average: ,

164

What is not clear


7/30

7

Emergency Medical Services Intervals and Survival in

Trauma: Assessment of the "Golden Hour" in a NAProspective Cohort. Newgard CD, Schmicker RH, Hedges JR, et. al.

STUDY OBJECTIVE: The first hour after the onset of

out-of-hospital traumatic injury is referred to as the

"golden hour," yet the relationship between time and

ou come rema ns unc ear. e eva ua e e assoc a on

between emergency medical services (EMS) intervals

and mortality among trauma patients with field-based

physiologic abnormality.

CONCLUSION: In this North American sample, there

was no association between EMS intervals and

mortality among injured patients with physiologic

abnormality in the field. Ann Emerg Med Sept. 2009

Scene Tr iage Cr i t er iaScene Tr iage Cr i t er ia

London HEMSFall >2m Ent rap LOC Apne a Burns GSW/Stab Limb threat

Helicopter evacuation of trauma victims in Los Angeles:

does it improve survival? Talying P Teixeira PG, et. al.

BACKGROUND: The purpose of this study was toinvestigate the relationship between the method oftransport after injury and survival among traumapatients admitted to a Level 1 trauma facility in Los

, .

CONCLUSIONS: In a metropolitan Los Angelestrauma system, EMS helicopter transportation ofinjured patients does not appear to improve overalladjusted survival after injury. There is however apotential benefit for severely injured subgroups of

patients due to the shorter prehospital times.

World J Surgery Nov. 2009


8/30


9/30

9

Air versus ground transport of the major traumapatient: a natural experiment.McVey J, Petrie DA, Tallon JM.

OBJECTIVES: 1) To compare the outcomes of

adult trauma patients transported to a level Itrauma center by helicopter vs. groundambulance. 2) To determine whether using aunique "natural experiment" design to obtaint e groun compar son group w re ucepotential confounders.

CONCLUSIONS: This unique natural experimentled to better matched air vs. ground cohorts forcomparison. As per TRISS analysis, airtransport of the adult major trauma patient isassociated with significantly improved survivalas compared with ground transport. PrehospEmerg Care Jan 2010

CostCost--BenefitBenefitcost per life year savedcost per life year saved

NICU (birth wt. 500-999g)$18,000

Median, 310 medical interventions$19,000

3-vessel CABG for severe angina$23,000

Thrombolysis for acute MI$32,678

Prophylactic AZT post-needlestic$41,000

Level I TC cost per life saved$84,000

Accepted threshold, NEJM 2005$40,000-50,000

HEMS scene trauma, W= 5 $2500

HEMS scene trauma, W= 1 $9700

HEMS use: Massachusetts $2454

HEMS system: U.K. & Norway $10-30,000


10/30

10

How did we get here?

1970s

Translation miltitary to civilian world: MSP /Flight for Life Denver

trauma medevac and the golden hour

Hospital based / cast wide net for emergingtrauma centers

Geography = destiny

Medical distinct from aviation (contract)

Air vs. Ground (no ALS Baxt)

Costs buried (Part A) (Economics = Driver)

1978 Airline Deregulation Act (ADA)

Medical Centerfold


11/30

11

1980s

Rapid growth 70s redux (medical centerfold)

Trauma warsextend the cachement

Care vs. speed ????

Scope of practice / team composition ???

ommun ty ase prov ers (medical + aviation)

1986 Hiawatha Aviation of Rochester v.Minnesota Department of Health

1986 DOT to Arizona: is a helicopter an airtaxi?

Safety problems NTSB 1988

1990s

1990 only year without a death in HEMS

Continued Safety Problems (summit 1992)

Emergence of community based providers

(aviation + medical)

1996 Rocky Mountain Helicopters vs.

Missouri Dept. of Health (CON)

Vermont DON Retro Study DHART (1997)

BBA 1997 National Fee Schedule for

ambulance transport Evidence base? +/-


12/30

12

1990s

1990 AAMS Appropriate Use Guidelines 1991 CAMTS created

1992 NAEMSP Guidelines for Scene

1994 NAEMSP Guidelines for Scene and

Interfacility

1999 ACEP Appropriate Utilization

1999 AAP Pediatric and NICU

1999 ACS Resources for Optimum Care

2000s

2002 NAEMSP Dispatch

2002 ACS Interfacility for rural

2002 ACEP Appropriate Interhospital

2002 AAP Pediatric and Neonatal

Evidence Base (Thomas) compilations) ? +/-

Safety and Risk (Blumen) big problem


13/30

13

2000s

2002 Ambulance fee schedule emplaced. RVUfor transport. Supposed to be cost based

2002 Section 415 (Medicare Drug)

2002 NAEMSP, AMPA, AAMS DispatchGuidelines

Continued safety (FAA, NTSB 2006/09, IHST)

2006 IOM

2007 GAO

2008 Worst safety record

2000s2000s

1997 BBA negotiated rulemaking with final1997 BBA negotiated rulemaking with final

implementation in 2002implementation in 2002

Medicare Fee ScheduleMedicare Fee Schedule Gas PedalGas Pedal

==

helicopterhelicopter

No requirements other than helicopterNo requirements other than helicopter

The primary driver behind the growth fromThe primary driver behind the growth from

350 to >850 helicopters in 9 years350 to >850 helicopters in 9 years

434% increase in Medicare spending in 7 years434% increase in Medicare spending in 7 years


14/30

14

Growth / Demand / Need:Growth / Demand / Need:

60 0

70 0

80 090 0

1000

0

10 0

20 0

30 0

40 0

50 0

80 85 90 95 '00 '03 '04 '05 '06 '07 '08 '09

Total HEMS Aircraft

2000s

Problems with oversight demand vs. need

Problems with integration-- competition

Problems with safety

Problems with appropriate utilization

Problems with quality / variation

Problems with costs

Who is in charge?


15/30

15

Growth

n caefficacy and

appropriateness

Safety

Medical Helicopters TodayMedical Helicopters Today

of helicopters = hospital based of helicopters = hospital based Typically range from 1Typically range from 1--5 helicopters per5 helicopters per

programprogram Vast majority contract with Part 135 operatorsVast majority contract with Part 135 operators

for aviation com onentfor aviation com onent

of helicopters = community based of helicopters = community based Concentration operators, large number ofConcentration operators, large number of

helicopters (e.g. 50helicopters (e.g. 50--300)300)

Some operators only community based, someSome operators only community based, someonly Part 135 vendor contracts for hospital basedonly Part 135 vendor contracts for hospital based

programs, some do bothprograms, some do both Not for Profit, ForNot for Profit, For--profit, Publicprofit, Public

Atlas & Database of Air Medi cal Services

Base Location + 10 min fly circle.Size of 10-min fly circle varies with

cruise speed of specific Rotor Wing model.

95%Complete476 RWBases503 RWAircraft

CenTIR, AAMS, NHTSA, FHWA


16/30


17/30

17


18/30

18

Do the number of helicopters matter?OK ME MA * NAT

# HEMS 18 2 5 17

Pop. Sq. Mi. 49.36 36.03 601.52 74

HEMS / pop. 191,703 637,462 1,587,274 335,425

7 sq. m .

% pop 60 min. TC 36.8 78.9 96.8 84.1

% pop 60 min TC +

HEMS effect

11.6 38.7 31.1 27.7

% pop 60 min TCtotal

48.4 117.6 127.9 111.8

Do the number of helicopters matter?

2008 OK ME MA * NAT

Scene transports 2026 770 1993

Scene trans / pop 5.87 6.03 3.13

Discharge < 24 hrs. 18.2 3.6 5.4

MVC Fatalities per

1000/injuries

14.9 11.7 8.1 12.2

MVC fatalities per 100K

population

21.4 14.2 6.7 14.2

MVC fatalities per 1 million

miles traveled

1.57 1.25 .78 1.41

% reduction in MVC

fatalities 2007 as comparedwith 2002-2006 avg.

+ .06 - 6.1 -8.0 -4.3

What Happens?What Happens?

Increase pressure to flyIncrease pressure to fly

NTSB Testimony: pilots, paramedics, RNs, MDsNTSB Testimony: pilots, paramedics, RNs, MDs

Increased exposure to marginal environmentIncreased exposure to marginal environment

Reduce acuity for flight / medical necessity ?Reduce acuity for flight / medical necessity ?

Increase marketingIncrease marketing golden troutgolden trout

Increase chargesIncrease charges


19/30

19

Newberry, SC July 2004

4 Fatal

55Federal AviationAdministration 55

International Helicopter Safety Symposium

September 26-29, 2005

U.S. HEMS and Fatal AccidentsU.S. HEMS and Fatal Accidents

12

14

16

18

20

NTSBNTSB

IHSTFAA

0

2

4

6

8

72-

79

8 0 8 1 8 2 8 3 8 4 8 5 8 6 8 7 8 8 8 9 9 0 9 1 9 2 9 3 9 4 9 5 9 6 9 7 9 8 9 9 ' 0 0 '0 1 ' 02 ' 0 3 '0 4 ' 05 ' 0 6 '0 7 ' 08 ' 0 9

Total Accidents Fatal Accidents

through December 31, 2009

Recent Fatal EMS AccidentsRecent Fatal EMS Accidents

Whittier, AK Dec. 3, 2007 - BK117 - 4 fatal

Cherokee, AL Dec 30, 2007 - Bell 206 3 fatal

S. Padre Island, TX Feb. 5, 2008 -AS350 3 fatal

La Crosse, WI May 10, 2008 EC135 3 fatal

Huntsville, TX June 8, 2008 Bell 407 4 fatal

Flagstaff, AZ June 26, 2008 Bell 407s 7 fatal

Greensburg, IN Sept. 1, 2008 Bell 206 3 fatal

Forestville, MD Sept. 28, 2008 AS365N1 4 fatal

Aurora, IL Oct. 15, 2008 Bell 222 4 fatal


20/30

20

Reports AMS Community and Regulatory NTSB

AAMS Conference Summary

AAMS Conference Summary

Flight Safety Foundation

Root Cause Study (AAMS, HAI, NEMSPA)

NEMSPA Pilot Survey

Blumen IJ. Safety Risk Review and Assessment

Blumen IJ. Safety Risk Review and Assessment Update

FAA HEMS Task Force

HAI

NTSB

1988

19922000

2001200120012003

2005/06Sept 2005Dec 2005

Jan 2006

Annals of Emergency MedicineHelicopter Crashes

Baker S, Dodd R, et. al. Annals

Hustwit J, AlainDery M, et. al. Pilot Survey

Congressional Research Service

FAA Summary of Initiatives 04-07

NTSB Update

GAO

IOM Emergency Medical Services at the Crossroads-Final

AAMS, NAEMSO, NAEMSP, AMPA State Guideline White Paper

AAMS Community Safety Summit

HAI / AAMS / FAA / NTSB

Flight Safety IRP

NTSB

GAO

April 2006April 2006

May/Sept 2006May 2006March 2007March 2007

Feb 2007April 2007

April 2007July 2008Nov. 2008Jan 2009

Feb / Sept. 2009Dec 2009

Federal Most WantedTransportation SafetyFederal Most WantedTransportation Safety

Improve Safety of EmergencyMedical Services Flights


21/30

21

National Transportation Safety BoardNational Transportation Safety Board

2006 Study w/ recommendations2006 Study w/ recommendations fewfew

implemented 4 outstanding recommendations.implemented 4 outstanding recommendations.

2008 HEMS on Most Wanted List2008 HEMS on Most Wanted List

Public Hearin on HEMS Feb. 3Public Hearin on HEMS Feb. 3--6 20096 2009

Looked at avionicsLooked at avionics

Looked at industry economicsLooked at industry economics

21 Recommendations, Sept. 200921 Recommendations, Sept. 2009

9 Recommendations, Oct. / Dec. 20099 Recommendations, Oct. / Dec. 2009

Chairman HersmanChairman Hersman Follow the moneyFollow the money

separation of drivers:

Clinical Imperative Aeronautical Reality

Finance

Fiscal Incentives


22/30


23/30

23

Correlation of Medical Helicopter

Transports With ConsensusUtilization Guidelines

The Northeast

Evaluation of Transport

Workgroup


24/30

24

Evidence Based Medevac Dispatch

An Extension of the Sacco Triage Method

Goal:Eliminate unnecessary flights without impacting mortality rates.Objective:Screen from medevac consideration patients with high survivalprobability and little or no expected deterioration within 90 minutes

Confidential Unpublished Property of ThinkSharp, Inc. All Rights Reserved.

Results:Eliminates 62% of flights by screening patients with survivalprobabilities of 95% and aboveEliminates 46% of flights by screening patients with survivalprobabilities of 98%.NOTES:Results do not include flights where patients are not admit ted!Results do not include flight reductions from travel time analysi s.

Model excludes 62% from medevac consideration --

Survival Probability over 95%; no deterioration

Survival Probability After Applying Injury andPhysiological Screens from Medevac Model

RPM 0-7 8-14 15-54 55-74 75+ Total

0 7.87% 7.41% 4.24% 5.22% 1.39% 4.67%

1 75.00% 0.00% 16.13% 10.53% 0.00% 18.00%

2 50.00% 0.00% 20.29% 7.69% 37.50% 20.43%

3 37. 50% 11.11% 38. 55% 6. 25% 13.33% 29. 77%

4 53. 33% 56. 25% 53. 18% 58. 62% 13.64% 50. 59%

5 69. 70% 58. 33% 60. 53% 47. 54% 21.05% 55. 78%

6 81. 58% 62. 50% 69. 81% 48. 48% 38.46% 65. 38%

7 92. 96% 89. 74% 81. 80% 63. 83% 41.54% 77. 86%

8 92. 37% 86. 54% 87. 96% 69. 47% 55.95% 83. 09%

9 100. 00% 98. 50% 93. 19% 82. 05% 67.91% 90. 48%

10 99. 76% 99. 65% 97. 48% 95. 81% 87.68% 95. 85%

11 99. 47% 99. 50% 98. 88% 96. 25% 87.56% 97. 21%

12 99.72% 100 .00% 99.56% 98.27% 95.22% 98.69%

Model excludes 46% from medevac considerationSurvival Probability over 98%; no deterioration

Survival Probability After Applying Injury andPhysiological Screens from Medevac Model

RPM 0-7 8-14 15-54 55-74 75+ Total

0 7.87% 7.41% 4.24% 5.22% 1.39% 4.67%

1 75.00% 0.00% 16.13% 10.53% 0.00% 18.00%

2 50.00% 0.00% 20.29% 7.69% 37.50% 20.43%

3 37. 50% 11.11% 38. 55% 6. 25% 13.33% 29. 77%

4 53. 33% 56. 25% 53. 18% 58. 62% 13.64% 50. 59%

5 69. 70% 58. 33% 60. 53% 47. 54% 21.05% 55. 78%

6 81. 58% 62. 50% 69. 81% 48. 48% 38.46% 65. 38%

7 92. 96% 89. 74% 81. 80% 63. 83% 41.54% 77. 86%

8 92. 37% 86. 54% 87. 96% 69. 47% 55.95% 83. 09%

9 100. 00% 98. 50% 93. 19% 82. 05% 67.91% 90. 48%

10 99. 76% 99. 65% 97. 48% 95. 81% 87.68% 95. 85%

11 99. 47% 99. 50% 98. 88% 96. 25% 87.56% 97. 21%

12 99.72% 100 .00% 99.56% 98.27% 95.22% 98.69%


25/30

25

Medevac clearly shows age bias

RPM is a physiological score that correlates highly to survival probability. Its

values range from 0, indicating no physiological response, to 12, indicating

respiratory, pulse and motor response within normal ranges. The graphshows that patients aged 75+ receive medevac transport at a much lower

percentage than other age groups with similar physiological presentations.

Percentage of Patients Using Helicopters

0%

5%

10%

15%

20%

25%

30%

35%

RPM 10 RPM 11 RPM 12

Age 0-7

Age 8-14

Age 15-54

Age 55-74

Age 75+

Efficacy and costs:Efficacy and costs:

Dana Strittmatter was boiling water in her kitchen in July when itspilled on her leg. After paramedics from Benbrooks EmergencyMedical Services arrived, they called for a medical helicopterfrom PHI Air Medical, a for-profit company that operates inDallas-Fort Worth and elsewhere.

PHI Air Medical flew her to Parkland Memorial Hospital inDallas She was treated and released in an hour accordin to her

Medical helicopter bill is 'a tough pill to

swallow Thursday, Dec. 03, 2009

. ,

husband, Larry. She had second-degree burns. But at the hospital, a doctor and others were angry that she had

been transported by helicopter, Larry Strittmatter said.

One doctor told him that abuse of medical helicopters is agrowing problem. The hospital expected her to arrive byambulance.

"They were shocked when the helicopter pilot radioed inannouncing his arrival," he said.

The final bill was $17,500.


26/30

26

Effect of # Helicopters on Charges

Area A Area BSq. Miles:

58416 (Avg. NIC AK)

Population: (Avg. NIC AK)

5,743,304

R ti A r ri te e# Helicopters 4

# Helicopters 17

Pop per Hel: 331,084

Sq. Mi. per Hel 3436

Avg. Charges Necessary:$22,493

Population per

Appropriate Use: .0005

HMS Transports Per

Population: 2872

Annual Ops Budget:

$3.8m per aircraft

2 Engine IFR, NVG

Pop per Hel 1,407,109

Sq. Mi per Hel 14,604

Avg. Charges Necessary:

$5292

Note: Medicare Spending on HEMS up 434% in 7 years

Is this aviaiton?

Is this medicine ?

Who is in charge?

The Public AssumesThe Public Assumes

All medical helicopters have the same levels ofAll medical helicopters have the same levels ofperformance and aviation safety technologyperformance and aviation safety technology ----they do notthey do not..

All are well staffed by similarly trainedAll are well staffed by similarly trained

technology to provide the critical care neededtechnology to provide the critical care neededto keep them aliveto keep them alive ---- there is no suchthere is no suchguaranteeguarantee..

Helicopters transport those in need quicklyHelicopters transport those in need quicklyand efficiently to the closest appropriateand efficiently to the closest appropriatehospital at the right timehospital at the right time ---- tthat may or mayhat may or maynot be true depending on where they livenot be true depending on where they live..


27/30


28/30

28

State Medical Oversight UnclearState Medical Oversight Unclear

Allowable state laws limited to care on board theAllowable state laws limited to care on board the

aircraftaircraft Medical equipment and supplies (to limited extent)Medical equipment and supplies (to limited extent)

Qualifications of medical personnel aboard theQualifications of medical personnel aboard theaircraftaircraft

Design of medical bay??????Design of medical bay??????

Configuration of aircraft for critical care??????Configuration of aircraft for critical care??????

Climate control??????Climate control??????

BUT, Hawaii letterBUT, Hawaii letter

Quality, availability, accessibility andQuality, availability, accessibility andacceptability prohibited regulationacceptability prohibited regulation

Medical equipment/supplies can go so far as toMedical equipment/supplies can go so far as toconstitute prohibited economic regulationconstitute prohibited economic regulation

Finding

the way forward

High Acuity Transport Medicine

What is your vantage point:

AMS Medical Director

Ground CCT Medical Director

Regional Medical Control

State Medical Director

EM Physician that needs to move patient

EM Physician receiving hospital


29/30

29

High Acuity Transport Medicine

Medical oversight = risk analysis at

multiple levels: clinical, safety, fiscal,societal

Access / level playing field acrossgeograp y

Alignment, continuity and integrationwith EMS and tertiary care resources

Acceptable risk benefit ratio public andclinical transparency

Issues: Evidence Base Challenges

Limited outcome studies: + Support with accurate patient selection - Population based studies - System wide studies vs. disease specific

Limited cost benefit studies(metrics, additional lives, lifeyears)

Limited system replacement cost studies ground vs. air air vs. air air vs. no air air vs. rural / community hospital

Few policy studies unpublished / State of Vermont

Issues: Patient Selection Challenges

Trauma / Medical

Variation in practice Dispatch / Triage Use / Triage

Medical oversight variability

Mode of Transport Decision / UtilizationReview

Time / Distance accuracy secondary to careneeds

Kinematics / vehicle technology


30/30

Issues in Designing System

Access and Equity

Medical oversight Practice of medicine (non-physicians)

Organization of services

ynam c env ronmen (organization across statelines, multi-state providers)

growth (iatrogenic changes in healthcare)

Evidence base for benefits (clinical / costs)

Use criteria

Risk / Safety

Quality management / practice variation

Medical Oversight: transport medicine

is a medical therapy decision.

Knowing is not enough, we mu st apply,willing is not enough, w e must do.Goethe

Epigraph :EMS at the Crossoads.Institute of Medicine 2007

helicopters in ems

Documents