NAEMSP Annual Meeting and Scientific Assembly

January 2009 Phoenix, AZ

HEMS: Luxury or necessity, the cost and consequence of system design

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

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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 trauma patients. • Both aviation and critical care medicine are high consequence endeavors a (high risk, high cost, high benefit). HEMS programs must operate at the highest levels of safety practically possible. The safety of patients and of crew members must incorporate a comprehensive systems approach to risk management. • The configuration of the HEMS system, including overall mission profile and the number and location of aircraft should be determined primarily on the distribution of the population, injury patterns, and the geography of the state.

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4 million Americans who otherwise would not have been able to reach a trauma center within an hour. One way drive time to CMMC Constant average speed per road classification Road Class Rural Local Rural Highway Rural Freeway Urban Local Urban Arterial Urban Freeway Speed 25 50 65 25 40 55 4 .” Decision Support Time Modeling Input 3.7 million Americans have no access to Level 1 or 2 trauma centers within 1 hour “Helicopters p p provide access for 81.46.

Decision Support Time Modeling Input 4. One way flight time to/from CMMC •140 MPH Flight Speed Improving triage 5 .

2005 Federal Aviation Administration 16 16 HEMS Crew Fatalities / 100.Santa Rosa.000 Personnel 900 800 700 600 500 400 300 200 100 0 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 '00 '01 '02 '03 '04 '05 '06 '07 '08 Range: 0-806/100.000 10-yr 10 yr average: 113/100.000 HEMS 29-yr average: 212/100. FL October 2004 3 Fatal International Helicopter Safety Symposium September 26-29.000 113/100 000 164 What is not clear 6 .

BACKGROUND: The purpose of this study was to investigate the relationship between the method of transport after injury and survival among trauma patients admitted to a Level 1 trauma facility in Los Angeles. there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field. World J Surgery Nov. California. 2009 Scene Triage Criteria Fall >2m Entrap LOC Apnea Burns GSW/Stab Limb threat London HEMS Helicopter evacuation of trauma victims in Los Angeles: does it improve survival? Talying P Teixeira PG. 2009 7 . et. Prospective Cohort. • STUDY OBJECTIVE: The first hour after the onset of out-of-hospital traumatic injury is referred to as the "golden hour. Angeles California CONCLUSIONS: In a metropolitan Los Angeles trauma system. al. Schmicker RH." yet the relationship between time and outcome remains unclear. et. EMS helicopter transportation of injured patients does not appear to improve overall adjusted survival after injury.Emergency Medical Services Intervals and Survival in Trauma: Assessment of the "Golden Hour" in a NA Newgard CD. There is however a potential benefit for severely injured subgroups of patients due to the shorter prehospital times. Ann Emerg Med Sept. We evaluate the association t i l W l t th i ti between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality. al. • CONCLUSION: In this North American sample. Hedges JR.

  Overall. they declined by almost 52%. from about 42%  to Responsible Air Medical to just below 34%. However. from  2004 to 2007. but there was a  heightened sensitivity to the risks of air transport  as well as increased systemwide education on  trauma transport protocols and concepts of  mechanism of injury. mechanism  flights to Bayfront Medical Center  One EMS System's Approach declined moderately. Ground ??? 8 . Air vs. From January 2001 to  January 2004. total air transports to Bayfront  decreased by about 39%. Fourth Annual AMTC Great Debate The use of auto-launch and early activation by HEMS programs lowers the medical necessity threshold for air medical transport and results in corresponding over-utilization. annual AMTs to Bayfront  Medical Center have dropped from 688 to 234. total air transports dropped sharply. Air  transport criteria didn't change in the four to five  years following the crash.JEMS May 2009 From 2001 to 2007.  From 2001 through 2004. mechanism flights have  Romig LA.9% of all flights to Bayfront. Pi ll C O ll Pinellas County EMS h t EMS has achieved a 66%  hi d 66% drop in air transports from 2001 through 2007. since  Transport 2005. Following an increase in  2004. AnhVu N declined even more significantly ‐‐ to  a mere 6.

000 Accepted threshold. OBJECTIVES: 1) To compare the outcomes of adult trauma patients transported to a level I trauma center by helicopter vs.000 Median. 500-999g) $18. CONCLUSIONS: This unique natural experiment led to better matched air vs.000 9 . Tallon JM. W = 5 HEMS scene trauma. ground ambulance. NEJM 2005 $40. 310 medical interventions $19.K. ground cohorts for comparison. 2) To determine whether using a unique "natural experiment" design to obtain the th ground comparison group will reduce d i ill d potential confounders.000 Thrombolysis for acute MI $32.Air versus ground transport of the major trauma patient: a natural experiment.000 3-vessel CABG for severe angina $23.000-50. & Norway $10-30.McVey J.000 Level I TC cost per life saved $84. Petrie DA. W = 1 HEMS use: Massachusetts $2500 $9700 $2454 HEMS system: U.000 HEMS scene trauma. Prehosp Emerg Care Jan 2010 CostCost-Benefit cost per life year saved NICU (birth wt.678 Prophylactic AZT post-needlestick $41. air transport of the adult major trauma patient is associated with significantly improved survival as compared with ground transport. As per TRISS analysis.

Ground (no ALS– Baxt) Costs buried (Part A) (Economics = Driver) 1978 Airline Deregulation Act (ADA) Medical Centerfold 10 .How did we get here? 1970’s Translation miltitary to civilian world: MSP / Flight for Life Denver “trauma medevac” and the “golden hour” Hospital based / cast wide net for emerging p g g trauma centers Geography = destiny Medical distinct from aviation (contract) Air vs.

speed ???? Scope of practice / team composition ??? Community based providers (medical + aviation) 1986 Hiawatha Aviation of Rochester v. of Health (CON) Vermont DON Retro Study DHART (1997) BBA 1997 National Fee Schedule for ambulance transport Evidence base? +/- 11 . Missouri Dept.1980’s Rapid growth 70’s redux (medical centerfold) Trauma wars—extend the cachement Care vs. Minnesota Department of Health 1986 DOT to Arizona: is a helicopter an air taxi? Safety problems NTSB 1988 E id b ???? 1990’s 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.

1990’s 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 2000’s 2002 NAEMSP Dispatch 2002 ACS Interfacility for rural 2002 ACEP Appropriate Interhospital 2002 NAEMSP Air Medical Direction 2002 AAP Pediatric and Neonatal Evidence Base (Thomas) compilations) ? +/Safety and Risk (Blumen) “big problem” 12 .

AAMS Dispatch p Guidelines Continued safety (FAA. IHST) 2006 IOM 2007 GAO 2008 Worst safety record 2000’s ► 1997 BBA negotiated rulemaking with final implementation in 2002 ► Medicare Fee Schedule – “Gas Pedal” ► Modeled cost of = hospital twin engine helicopter ► No requirements other than “helicopter” ► The primary driver behind the growth from 350 to >850 helicopters in 9 years ► 434% increase in Medicare spending in 7 years 13 .2000’s 2002 Ambulance fee schedule emplaced. NTSB 2006/09. RVU for transport. AMPA. Supposed to be cost based 2002 Section 415 (Medicare Drug) 2002 NAEMSP.

need Problems with integration-.Growth / Demand / Need: 1000 900 800 700 600 500 400 300 200 100 0 80 85 90 95 '00 '03 '04 '05 '06 '07 '08 '09 Total HEMS Aircraft 2000’s Problems with oversight— demand vs.competition Problems with safety Problems with appropriate utilization Problems with quality / variation Problems with costs Who is in charge? 14 .

Growth Clinical efficacy and appropriateness Safety Medical Helicopters Today ►½ of helicopters = hospital based Typically range from 1-5 helicopters per 1program Vast majority contract with Part 135 operators for aviation component ► ½ of helicopters = community based Concentration operators. For-profit. NHTSA. some only Part 135 vendor contracts for hospital based programs. large number of helicopters (e.g. 50-300) 50► Some operators only community based. FHWA 15 . Size of 10-min fly circle varies with cruise speed of specific Rotor Wing model. AAMS. some do both ► Not for Profit. Public For- Atlas & Database of Air Medical Services Base Location + 10 min fly circle. 95% Complete 476 RW Bases 503 RW Aircraft CenTIR.

2005 272 RW Services 614 RW Bases 753 RW Aircraft http://www.ADAMSairmed.org Center for Transportation Injury Research (CenTIR) Association of Air Medical Services (AAMS) -. 1.Support provided by NHTSA & FHWA 16 .Third Edition National Air Medical Services GIS Database Rotor Wing (RW) Base Locations with 10 Min Fly Circle Corporate Office Oct.

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03 3.25 .52 1. OK 2026 5.6.8 11. MD’s ► ► ► ► ► Reduce costs– SE / VFR costs– Increased exposure to marginal environment Reduce acuity for flight / medical necessity ? Increase marketing– “golden trout” marketing– Increase charges 18 . TC % pop 60 min TC + HEMS effect % pop 60 min TC total 18 49.703 3884 36.Do the number of helicopters matter? OK # HEMS Pop. Mi.2 14.1 MA * 1993 3.7 MA * 5 601.7 14.03 637.9 21.425 4514 84. % pop 60 min.78 -8.587. RN’s.9 111.6 11.6 ME 2 36.462 17694 78.1 27.4 117.87 18. Sq.06 ME 770 6.7 .4 1.2 1.57 + .0 NAT 12.41 -4. paramedics.7 48. MVC Fatalities per 1000/injuries MVC fatalities per 100K population MVC fatalities per 1 million miles traveled % reduction in MVC fatalities 2007 as compared with 2002-2006 avg.3 What Happens? ► Increase pressure to fly NTSB Testimony: pilots.2 14. HEMS / pop.13 5.9 38.2 1.4 8.36 191.6 127. mi.8 Do the number of helicopters matter? 2008 Scene transports Scene trans / pop Discharge < 24 hrs. HEMS / sq mi sq.8 31.1 6.1 NAT 17 74 335.274 2639 96.

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 79 Total Accidents Fatal Accidents through December 31. 15. 2008 – AS365N1 – 4 fatal • Aurora. AL – Dec 30. 2007 .4 fatal • Cherokee. AK – Dec. IL – Oct. WI – May 10. 2008 – Bell 407s – 7 fatal • Greensburg. 2007 . • Huntsville. 2008 – Bell 222 – 4 fatal 19 . 2005 Federal Aviation Administration 55 55 U. IN – Sept. TX – June 8. Padre Island. MD – Sept. TX – Feb.S. 5. 2009 Recent Fatal EMS Accidents • Whittier. 2008 – EC135 – 3 fatal . 2008 – Bell 206 – 3 fatal • Forestville. AZ – June 26. HEMS and Fatal Accidents 20 18 16 14 12 10 8 6 4 2 0 FAA NTSB IHST NTSB 72. 2008 – Bell 407 – 4 fatal • Flagstaff.Newberry. 3. 28.Bell 206 – 3 fatal • S. 1. y . 2008 -AS350 – 3 fatal • La Crosse.BK117 . SC July 2004 4 Fatal International Helicopter Safety Symposium September 26-29.

AlainDery M. al. et. Safety Risk Review and Assessment Update FAA HEMS Task Force HAI NTSB Annals of Emergency Medicine—Helicopter Crashes Baker S. NAEMSO. HAI. et.Reports AMS Community and Regulatory NTSB AAMS Conference Summary AAMS Conference Summary Flight Safety Foundation Root Cause Study (AAMS. NEMSPA) NEMSPA Pilot Survey Blumen IJ. Pilot Survey Congressional Research Service FAA Summary of Initiatives 04-07 NTSB Update GAO IOM Emergency Medical Services at the Crossroads-Final AAMS. 2008 Jan 2009 Feb / Sept. Dodd R. al. AMPA State Guideline White Paper AAMS Community Safety Summit HAI / AAMS / FAA / NTSB Flight Safety IRP NTSB GAO 1988 1992 2000 2001 2001 2001 2003 2005/06 Sept 2005 Dec 2005 Jan 2006 April 2006 April 2006 May/Sept 2006 May 2006 March 2007 March 2007 Feb 2007 April 2007 April 2007 July 2008 Nov. Annals Hustwit J. Safety Risk Review and Assessment Blumen IJ. 2009 Dec 2009 Federal Most Wanted Transportation Safety Improvements Improve Safety of Emergency Medical Services Flights 20 . NAEMSP.

3-6. 2009 3Looked at avionics Looked at industry economics ► 21 Recommendations. ► 2008 HEMS on “Most Wanted List” ► Public Hearing on HEMS Feb. Sept.National Transportation Safety Board ► 2006 Study w/ recommendations – few implemented 4 outstanding recommendations. 2009 ► 9 Recommendations. Oct. / Dec. 2009 ► Chairman Hersman – “Follow the money” separation of drivers: Clinical Imperative Aeronautical Reality Finance Fiscal Incentives 21 .

Efficacy 22 .

Correlation of Medical Helicopter Transports With Consensus Utilization Guidelines The Northeast Evaluation of Transport Workgroup 23 .

18% 60.Evidence Based Medevac Dispatch An Extension of the Sacco Triage Method Goal: Eliminate unnecessary flights without impacting mortality rates.24% 16.53% 7.58% 92.95% 67.83% 69.68% 87. no deterioration Survival Probability After Applying Injury and Physiological Screens from Medevac Model RPM 0-7 7.50% 89.33% 69.81% 81.54% 55.33% 13.72% 8-14 7.38% 77.56% 55-74 5.96% 93.00% 15-54 4.91% 87.88% 99.33% 62.00% 37.22% 10.50% 53.81% 96.19% 97.88% 99.25% 58.86% 83.85% 97.83% 69.00% 99.33% 62.48% 95.48% 98.24% 16.55% 53.00% 11.96% 92.81% 81.85% 97.50% 53.72% 8-14 7.22% 10.50% 100.43% 29.11% 56.29% 38.39% 0.09% 90. Objective: Screen from medevac consideration patients with high survival probability and little or no expected deterioration within 90 minutes Results: Eliminates 62% of flights by screening patients with survival probabilities of 95% and above Eliminates 46% of flights by screening patients with survival probabilities of 98%.69% 6.74% 86.69% 0 1 2 3 4 5 6 7 8 9 10 11 12 Model excludes 46% from medevac consideration Survival Probability over 98%.53% 69.27% 75+ 1.77% 50.18% 60.33% 13.41% 0.56% 95.70% 81.00% 20.86% 83.69% 0 1 2 3 4 5 6 7 8 9 10 11 12 24 .50% 100.91% 87.48% 98.00% 37.05% 38.77% 50. no deterioration Survival Probability After Applying Injury and Physiological Screens from Medevac Model RPM 0-7 7.62% 47.00% 15-54 4.25% 98.19% 97.25% 58.78% 65.54% 48.87% 75.76% 99. Model excludes 62% from medevac consideration -Survival Probability over 95%.54% 98.13% 20.50% 89.53% 69. Confidential Unpublished Property of ThinkSharp.50% 13.80% 87.21% 98.54% 48. All Rights Reserved.00% 0.70% 81.56% 95.00% 50.65% 99.00% 37.29% 38.05% 95.48% 63.65% 99.27% 75+ 1.50% 13.64% 21.05% 95.22% Total 4.95% 67.00% 37.78% 65.58% 92.96% 93.21% 98.54% 98.05% 38.67% 18.00% 11. NOTES: Results do not include flights where patients are not admitted! Results do not include flight reductions from travel time analysis.46% 41.50% 99.67% 18.39% 0.37% 100.74% 86.25% 58.47% 82.25% 98.22% Total 4.56% 55-74 5.76% 99.38% 77.41% 0.00% 99.59% 55.54% 55.55% 53.00% 0.96% 92.48% 63.43% 29.47% 82.53% 7.59% 55.81% 96.00% 20.62% 47.11% 56.25% 58.64% 21.50% 99.48% 95.87% 75.46% 41.47% 99.47% 99.68% 87.09% 90.00% 50. Inc.13% 20.33% 69.69% 6.37% 100.80% 87.

• One doctor told him that abuse of medical helicopters is a growing problem. according to her hour husband. indicating respiratory. 2009 • Dana Strittmatter was boiling water in her kitchen in July when it spilled on her leg. Percentage of P ti t U i P t f Patients Using H li Helicopters t 35% 30% 25% 20% 15% 10% 5% 0% RPM 10 RPM 11 RPM 12 Age 0-7 Age 8-14 Age 15-54 Age 55-74 Age 75+ Efficacy and costs: Medical helicopter bill is 'a tough pill to swallow‘ Thursday. Its values range from 0. Larry Strittmatter said. 03. • But at the hospital. Dec. She had second-degree burns. The hospital expected her to arrive by ambulance. After paramedics from Benbrook’s Emergency Medical Services arrived. pulse and motor response within normal ranges. 25 . The graph shows that patients aged 75+ receive medevac transport at a much lower percentage than other age groups with similar physiological presentations. Larry. a for-profit company that operates in Dallas-Fort Worth and elsewhere.500. Dallas She was treated and released in an hour. • PHI Air Medical flew her to Parkland Memorial Hospital in Dallas." he said.Medevac clearly shows age bias RPM is a physiological score that correlates highly to survival probability. to 12. they called for a medical helicopter from PHI Air Medical. • The final bill was $17. indicating no physiological response. a doctor and others were angry that she had been transported by helicopter. • "They were shocked when the helicopter pilot radioed in announcing his arrival.

Mi per Hel 14. live. NIC AK) 5.304 # Helicopters 4 Pop per Hel 1.407. Mi.that may or may not be true depending on where they live. NVG Note: Medicare Spending on HEMS up 434% in 7 years Is this aviaiton? Is this medicine ? Who is in charge? The Public Assumes… ► All medical helicopters have the same levels of performance and aviation safety technology -they do not. 26 . ► All are well staffed by similarly trained medical crews with the latest medical technology to provide the critical care needed to keep them alive -.493 Avg.084 Sq.604 # Helicopters 17 Pop per Hel: 331. Miles: 58416 (Avg. per Hel 3436 Avg.8m per aircraft 2 Engine IFR. Charges Necessary: $22.Effect of # Helicopters on Charges Area A Area B Sq. guarantee.109 Sq. not.743.0005 HMS Transports Per Population: 2872 Annual Ops Budget: $3. NIC AK) Population: (Avg.there is no such guarantee. Charges Necessary: $5292 Ratio Appropriate Use Population per Appropriate Use: . ► Helicopters transport those in need quickly and efficiently to the closest appropriate hospital at the right time -.

accessibility. but not air ambulances ► States The Airline Deregulation Act (ADA) ► If Medicare = “gas pedal” ADA = “no brakes” ► Preempts state regulation of “prices.” 27 . MO. availability. TN. NC) ► DOT Opinion Letters (TX. acceptability” 24/7 availability/minimum response times Hospital destination criteria Membership programs/marketing State health planning/Certificate f Need St t h lth pl nnin /C rtifi t of N d Geographic service areas/designated base of operations EMS System affiliation/EMS peer review Trauma center affiliation Requirement to serve all patients. routes and services” of air carriers ► Independent air ambulances are air carriers ► Air medical programs utilize ADA via litigation or request DOT opinions to eliminate state rules as prohibited “economic regulation” ► Litigation (MN. regardless of need Any regulation that touches “aviation. HI. non► Nobody regulates economics / integration of HEMS ► Conditions of Medicare participation for many health care providers. NC. TX) ► Confusion and chilling effect on states Dismantled State Laws “Quality.The Problems with Oversight ► Only FAA regulates aviation safety regulate medical care on board the helicopter (not perfectly clear) ► States can’t regulate air medical services Express and field preemption Regulation is mixed from fairly extensive to virtually non-existent. FL.

accessibility and acceptability” prohibited regulation Medical equipment/supplies can go so far as to constitute 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 28 . Hawaii letter “Quality. availability.State Medical Oversight Unclear ► Allowable state laws limited to “care” on board the aircraft Medical equipment and supplies (to limited extent) Qualifications of medical personnel aboard the aircraft Design of medical b ?????? D i f di l bay?????? Configuration of aircraft for critical care?????? Climate control?????? ► BUT.

air air vs. air air vs. disease specific Limited cost benefit studies– (metrics. societal Access / level playing field across geography Alignment. fiscal. no air air vs.Population based studies . additional lives. safety. continuity and integration with EMS and tertiary care resources Acceptable risk benefit ratio – public and clinical transparency Issues: Evidence Base Challenges Limited outcome studies: + Support with accurate patient selection .High Acuity Transport Medicine Medical oversight = risk analysis at multiple levels: clinical. life years) Limited system replacement cost studies– ground 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 / Utilization Review Time / Distance accuracy secondary to care needs Kinematics / vehicle technology 29 .System wide studies vs.

willing is not enough. Institute of Medicine 2007 30 . “Knowing is not enough. 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 The mode of transport is a medical therapy decision. we must apply.” Goethe Epigraph :EMS at the Crossoads. we must do.Issues in Designing System Access and Equity Medical oversight Practice of medicine (non-physicians) Organization of services dynamic environment—(organization across state ( i i lines.

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