Care up in the air

Editor's Note: This is the third installment in a three-part series on medical transportation and EMS. Read the first part, "Trauma in EMS," and the second installment, "Equipping EMS."

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 (Read the March 26, 2012, story, "Looking for an oasis”). 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.

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 air-ambulance 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 (Read the Sept. 6, 2010 story, “Deadly trend”).

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.