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Imagine that several times a year (approximately every 50,000 procedures) there was a cardiac catheterization lab accident in which the medical team (cardiologist, nurse and technician) perished along with their patient. There would be an immediate outcry to make the procedure safer (technology, practices, safeguards) and reduce risk for the patient and providers. Second, all cath lab procedures would undergo intense scrutiny to assure appropriate utilization. Although such a scenario may seem outrageous, it is essentially the same risks that helicopter EMS (HEMS) crews face on a daily basis. In fact, HEMS transport is the only medical procedure that holds a much higher morbidity and mortality for the providers than it does for the patient.

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Despite the rising number of HEMS-related deaths and injuries, only recently has there has been any organized effort to address the problem from the aviation end. Unfortunately, very little has been done to discourage the widespread inappropriate utilization of this procedure. Instead of attempting to limit HEMS usage, many operators continue to focus on increased utilization and expansion—primarily into already saturated markets.

Between 1980 and 2008 there were 264 total HEMS-related fatalities (223 crew members, 34 patients, and 5 other). The year 2008 was the worse year on record with 15 HEMS accidents and 29 fatalities. This resulted in three days of hearings by the National Transportation Safety Board (NTSB). In September of 2009 the NTSB published numerous recommendations aimed at making HEMS safer. Among these recommendations were improved pilot training, additional safety instrumentation and technology on medical helicopters, establishment of national usage guidelines, and annual reporting of the number of hours flown and patients transported. In a significant deviation from any precedent, the NTSB also recommended that the Centers for Medicare and Medicaid Services (CMS) tie HEMS reimbursement to the level of HEMS transport safety provided.

Fleet Expansion
There has been an explosive expansion in the United States HEMS fleet in the last decade. In fact, the fleet has more than tripled to almost 900 helicopters in a little over eight years. Interestingly, there are more medical helicopters in either the Dallas/Fort Worth or Phoenix metropolitan areas than found in all of Canada. In addition, there has also been a transition in HEMS from a hospital-based model to a community-based, for-profit model. The largest area of expansion has been with the interfacility transport of patients—often from one emergency department to another. This uncontrolled, unregulated growth has largely been industry-driven with little scientific support for the practice. A HEMS vendor can essentially place a helicopter base wherever they deem necessary or profitable. Wisconsin, with 65,000 square miles and a population of 5.6 million, has 11 medical helicopters. Most EMS professionals in the state would agree that there is no pressing need for additional helicopters. The state of Missouri, with a very comparable size, population and demographics, has 33 medical helicopters. Why the 300% difference? There are several reasons. Medical necessity is not one of them.
Emergency physicians possess incredible control over the HEMS industry. We are responsible for initiating the majority of the interfacility transfers. We also provide medical control for most HEMS programs and for the ground EMS units that request the helicopters to accident scenes. Thus, we have the ultimate authority as to whether a patent being transferred should go by ground or air. Unfortunately, there has been little education and few guidelines to aid emergency physicians in this decision making process.

In 2009, the American College of Emergency Physicians (ACEP) published a policy statement entitled Appropriate Utilization of Air Medical Transport in the Out-of-Hospital Setting. This policy takes a commonsense and evidence-based approach to out-of-hospital HEMS usage. The policy states: Appropriate reasons to use an air medical helicopter in the out-of-hospital setting include:
(1) Patient has a significant potential to require high-level life support available from an air medical helicopter, which is not available by ground transport.
(2) Patient has a significant potential to require a time-critical intervention and an air medical helicopter will deliver the patient to an appropriate facility faster than ground transport.
(3) Patient is located in a geographically isolated area, which would make ground transport impossible or greatly delayed.
(4) Local EMS resources are exceeded

Limiting Interfacility Transports
In addition to safety concerns, the cost of HEMS transport can be more than ten to fifteen times that of ground transport. It is not uncommon for HEMS transport charges to exceed $15,000 per trip. The ACEP criteria can provide some direction in determining which patients may benefit from interfacility transport by HEMS.

The benefit of HEMS over ground EMS is speed (and in some cases the level of care provided). Some patients require care that cannot be provided by standard ground ambulance crews. However, in many cases, these patients can be safely transported by ground ambulances using critical care paramedic or critical care nursing crews if their condition doesn’t warrant more rapid transportation. A British Columbia study of almost 2,000 interfacility transports of ICU patients found that HEMS transport was not associated with improved overall mortality when compared to ground transport. A University of Wisconsin—Madison study found HEMS interfacility transport faster than ground transport, but suggested that stable patients should go by ground EMS (GEMS) if timely service is available. If the patient does not have a time-sensitive condition, then consideration should be given to using a ground critical care transport service.

Although HEMS transport is always considered more rapid than ground transport, ground transport is typically faster at distances of less than 45 miles. In a California study, researchers found that ground ambulances were always faster at distances of less than 10 miles. At distances greater than 10 miles, HEMS was faster than ground EMS if simultaneously dispatched (which rarely happens). If HEMS was not dispatched simultaneously with ground EMS (the more common scenario), ground EMS was faster at distances of less than 45 miles. An Australasian College of Emergency Physicians policy states that patients less than 30 minutes by road from a hospital do not benefit from HEMS transport. At distances greater than 300 kilometers (or when HEMS flight time exceeds one hour), fixed-wing air transport is preferred. The guidelines in the United Kingdom are similar.

Thus, if the patient is more than 45 miles from the receiving hospital, the question becomes whether or not the patient has a time-sensitive condition. Here the policy is fairly straightforward. Certainly STEMI patients and stroke patients should be transported by HEMS if HEMS transport will deliver them to definitive care within an interventional window when ground EMS may not. In trauma, the role is less clear. In fact, few trauma patients require truly lifesaving surgery. In a 10-year study of all trauma patients brought to a Santa Clara (CA) trauma center, only 1.8% underwent surgery for a life threatening condition. In a 10-year study, researchers in Los Angeles were unable to identify improved survival for trauma patients transported by HEMS (although they felt severely injured patients might benefit from shorter prehospital times).

Despite a lack of evidence demonstrating improved morbidity and mortality with interfacility HEMS transports, it seems intuitive that there is a subset of critically-ill medical/surgical patents where total out of hospital time should be limited. However, additional research is needed to determine which of these patients should go by HEMS and which can safely go by ground EMS.

“Emergency physicians possess incredible control over the HEMS industry. We are responsible for initiating the majority of the interfacility transfers. We also provide medical control for most HEMS programs and for the ground EMS units that request the helicopters to accident scenes. Thus, we have the ultimate authority as to whether a patient being transferred should go by ground or air. Unfortunately, there has been little education and few guidelines to aid emergency physicians in this decision making process.”

Summary
The current prevailing business model for HEMS in the United States is to accept and transport all requests with very little, if any, inquiry as to medical necessity. Such a practice increases risk exposure for both patients and providers. It is not an uncommon scenario for a motor vehicle collision (MVC) patient to undergo a $15,000 helicopter transport followed a $5,000-$7,000 ED trauma work up (primarily based upon the fact that the patient arrived by helicopter) only to be discharged to home hours later. Considering the number of patients who lack any health insurance, this type of treatment can result in financial ruin for some families.
HEMS transport is truly a medical procedure and requires evidence-informed decision-making. With HEMS, the patient’s condition and need for definitive care should be the primary determinant for utilization. While additional research is needed, new strategies can serve as an initial guide for limiting HEMS utilization. One such strategy is detailed in Figure 1 and based upon the ACEP policy discussed earlier. Determining whether a patient has a time-critical condition is often more complex. Figure 2 details the decision scheme for determining whether a patient has a time-critical condition that might benefit from HEMS transport. Regardless, the emergency physician should always err on the side of caution.

Figure 1 (click on image to view high res pdf)
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Figure 2 (click on image to view high res pdf)
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It is imperative that emergency physicians approach HEMS transport with the same caution as they would any potentially hazardous medical procedure. There must be informed consent and the benefits must clearly outweigh the risks. If there is no benefit, any risk is intolerable. If the benefits and risks are equivocal, the significant cost must be considered.

As Emergency Physicians, we hold the reins of the HEMS industry. We can allow it to continue its current unregulated and uncontrolled trajectory or we can initiate a new era of appropriate utilization based on evidence based medicine and solid scientific research. The decision is uniquely ours.


Doctor, would you sign this?

It is not an uncommon practice for HEMS crews to ask emergency physicians (EPs) to sign a Certificate of Medical Necessity for helicopter transport. This can occur at either the transferring or receiving facility. As with many things placed before us in the ED, we often sign these without a second thought. However, with increased scrutiny on HEMS costs, utilization, and safety, EPs should avoid reflexively signing these forms. To avoid potential liability, it is essential to first assure that the patient truly has an emergent, time-sensitive condition or requires a level of care clearly unavailable by ground EMS and that HEMS transport is truly necessary. Transferring patients by HEMS because of ED crowding or convenience will be subject to increasing scrutiny. Also, EPs who serve as medical directors of HEMS and ground EMS operations are occasionally asked to retrospectively sign Certificates of Medical Necessity for HEMS transport. These too can be problematic if you were not involved in actual care of the patient in question or do not have first-hand knowledge of the circumstances of the transfer. Remedying the current HEMS crisis starts with EPs carefully reviewing usage and need.
-Bryan Bledsoe, MD   


Dr. Abernethy is a clinical assistant professor of emergency medicine at the University of Wisconsin School of Medicine and Public Health and the chief flight physician for UW Med Flight.
Dr. Bledsoe is a clinical professor of emergency medicine at the University of Nevada School of Medicine.
Dr. Carrison is professor and chair of emergency medicine at the University of Nevada School of Medicine.


References
American College of Emergency Physicians. Appropriate Utilization of Air Medical Transport in the Out-of-Hospital Setting. [Available at: http://www.acep.org/practres.aspx?id=29116]
Belway D, Dodek PM, Keenan SP, Norena M, Wong H. The role of transport intervals in outcomes for critically ill patients who are transferred to referral centers. J Crit Care. 2008;23:287-294.
Svenson JE, O'Connor JE, Lindsay MB. Is air transport faster? A comparison of air versus ground transport times for interfacility transfers in a regional referral system. Air Med J. 2006;25:170-172.
Diaz MA, Hendey GW, Bivins HG. When Is the Helicopter Faster? A Comparison of Helicopter and Ground Ambulance Transport Times. The Journal of Trauma: Injury, Infection, and Critical Care. 2005;58:148.
Australasian College for Emergency Medicine and Australian and New Zealand College of Anaesthetists. Policy on minimum standards for transport of the critically ill. Emerg Med 1993; 5: 245-324.
Black JJ, Ward ME, Lockey DJ. Appropriate use of helicopters to transport trauma patients from incident scene to hospital in the United Kingdom: an algorithm. Emerg Med J. 2004;21:355-361.
 Shatney CH, Homan SJ, Sherck JP, Ho CC. The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system. J Trauma. 2002;53:817-822.
Talving P, Teixeira PG, Barmparas G, et al. Helicopter Evacuation of Trauma Victims in Los Angeles: Does it Improve Survival? World J Surg. 2009;33:2469-2476.
 
 

Comments   

# Rogue Medic 2009-12-30 17:28
Excellent article. This is an important problem that costs too many lives, even in the years with few fatalities.

We need to encourage people to think about the consequences when they decide to fly a patient, or when they allow others to fly a patient, rather than drive the patient to the trauma center.
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# An expected and valid criticismFlyingERDoc83 2009-12-31 07:53
As Dr. Abernethy can attest, it is not the most pleasant sitting around the ops center waiting for something to happen. However, even at a flight program with board-certified EM physicians flying with a Flight Nurse we are often fed incorrect or incomplete clinical information designed to get us to launch first and ask questions later (everything in HEMS is so time-sensitive that delaying a few more minutes to see the faxed EKG can provoke a QA/ QI issue if it is a real STEMI in the retrospectoscop e). By the time we take the risk to fly there only to find the patient pain-free, looking fine, with a normal EKG and a non-STEMI it is often "Well, we got here and we've gotta get back home to base. The patient is going the same place we are and right now we are undoubtedly the most rapid and highly trained transport available. The patient is agreeable to go, so let's bring them along."

How does one justify this? Some times one can't, and I honestly don't know what we do with the bills for the flights where we could justify ground transport (which would take our aircraft out of service for much longer), we could justify critical care personnel (Flight Physician, Flight RN), but we just can't justify the helicopter part of the equation. We fly them since it benefits the program to get the Flight Physician and Flight Nurse back in service more rapidly compared to us hopping in a ground ambulance and the helicopter pilot bringing the aircraft back home alone.

I love flying just as much as the rest of us who do this, but I would definitely rather have patients that truly need my services instead of just being a fancier Part 135 Air Taxi with a lot of medical goodies in the back. If I wanted to be an Air Taxi pilot I would have done that, but I wanted to be a Flight Physician.
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# Acute Care NP, Trauma Nurse Specialist, RN, ParamedicAndrew Bowman 2010-01-02 20:08
As soon as we take away the financial incentive and only fly for the medical need, then we will see a reduction in usage and hopefully, a reduction in fatal crashes. Ground transfer, with an ALS crew, is as effective as HEMS. They should be reimbursed equally.
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# From a Flight Paramedic perspective.... .....Flight Paramedic 2010-01-04 15:59
I agree with many of the points of this well written article. HEMS is obviously over utilized, and an expensive endeavor. There are a couple of discussion points I'd like to bring up regarding the need for clinical expertise during trauma transports.

- I agree that many patients could be transported by a critical care transport crew by ground. The problem with this transport format is that a Certificate of Need process exists for Ground CCT, but does not exist for HEMS operators. Hence, it is difficult to contact a true Ground Critical Care Transport program for a sick ICU patient needing transfer from ED to ICU, ICU/ICU, etc... In my state, there are no specialty adult ground CCT programs, but there are 25 HEMS programs. No Ground CCT programs exist because of the certificate of need process mandated by the state. The CON process for air medical services will not be enacted at the state level. The federal Airline Deregulation Act of 1978 precludes state government from subjecting HEMS providers to obtaining a CON for operation.

- I have been a Flight Paramedic for 7 years, and a Ground Paramedic for 11 years. I have a degree, CCEMTP, FP-C...... all of the education. I can not provide the same level of care on a ground ambulance that I can provide in an air ambulance because of local protocols. In the air, I can manage a ventilator, administer blood products, perform RSI, place Chest Tubes, Deep lines, transport IABP patients, et al....For the most part; my scope of practice is endless. On a ground ambulance, my hands are tied by the local protocol which is written for the lowest common denominator. I can not provide the same care....period. I have saved lives on a helicopter..... not by speed; but by having the ability to perform RSI, placing a chest tube, administering RBC's and early FFP. I can make a difference in a patient's life in a helicopter, but not because of the helicopter, it is because of me. I can't make that same impact in a ground ambulance, because there is no financial benefit to the ground ambulance administrator to expand the local scope of practice/protoc ol, nor for the Physician Medical Director to accept additional levels of liability for advanced procedures, etc....

- There is no doubt that each of the physician's who contributed to this article are respected, and Board Certified. In my state, less than 10% of the physicians who staff ED's are Board Certified in Emergency Medicine. We can't leave the future of HEMS to ED physicians, because in my state, they don't care about the HEMS staff. The major consideration is the liability that they face personally if they don't arrange for transport of a patient that they don't have the capability to manage. This transport can be managed by any means necessary as long as the liability is at the Level I Trauma Center, and not their rural facility.

HEMS IS a procedure that is over utilized. Much like the diagnostic cardiac catheterization in a facility with no interventional capability, HEMS is expensive, there is a safety risk, and the patient may be discharged within 24 hours. Due to the fact that there are no liability limits, we have to protect our interests, and refer, refer, refer. Pertaining to HEMS operations, we must look to the federal government to remove HEMS from the Airline Deregulation Act. This will allow individual states to place HEMS operators under the Certificate of Need process.
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# Medical DirectorFlight doc 2010-01-15 00:17
Two driving forces that you will have to deal with.
1. I am afraid if I send them by ground and something happens I will be blamed by family, lawyers, docs etc that I didn't send them by air.
2. I am totally unsure what I have here but think they are sick and need them to go away and if I call the helicopter they will get here bale me out and take them away. If I call the ground unit they may be unsure/unable to transport (or don't want to go on a long trip.
We face a society that thinks all new technology is good and the more tech you use the better the care I got. We have also separated us and (often them) from the bill paying/cost. We don't feel any responsibility to the patient's pocketbook and all feel that this flight will be safe. I have had a well trained doctor try to tell me that we should call another helicopter to transport his father (who had a broken leg) when the local one turned it down for icing. Took a lot of persuading to convince him that taking such a risk (even assuming another aircraft would be so foolish as to fly) was hardly in his dad's best interest. This was an intelligent patient/family and I am at a tertiary facility (long story why he wanted transfer) imagine the difficulty of the doc in a small hospital with a less sophisticated family. (God forbid they also have a "membership")
Great idea and maybe we can all get together and support each other as we try to bring sanity to this.
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# Emergency Physician, Ground and air EMS Medical Director, President of the Association of Air Medical ServicesDaniel G. Hankins, MD, FACEP 2010-01-18 09:03
Emergency physicians can make a big difference in this complex problem. Strong medical oversight is the key to appropriate utilization of air versus ground transports. Physicians who are involved in EMS need to work for appropriate utilization and integration of air and ground services into regional and state EMS systems. One model does not fit all regions, which is why integration is essential The wild cards in all of this are: 1) the need for tort reform and 2) the fact that reimbursement for ground critical care is so abysmal that services cannot survive--so it cannot be done. The whole system (air and ground) needs to shift from being reimbursed only for completion of a patient transport to a structure that is financially supported to maintain the system. (Are police officers paid by the number of arrests or firefighters paid by the number of fires fought?) EMS needs to assume its true place as the third pillar of public safety: supported in such a way as to maintain system availability. Then, there is incentive to transport patients in a way that insures the right patient in the right vehicle with the right crew to the right destination. Physicians must work with all of the involved parties to promote national standards as far as levels of out-of-hospital care equivalency from state to state. The states' need to provide public safety for their citizens has to be balanced against the Federal need to oversee aviation. Helicopters are ambulances, higher and faster than ground ambulances, but ambulances nonetheless. Assurance of quality of care and appropriate utilization of out-of-hospital transport modalities is the purview of physicians and we need to take the lead in assuring that the system works in the best way possible.
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# MDRobert Escarza 2010-01-22 19:10
Could a copy of the CON be added as a PDF on this article?
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# Medical Director of an ER and EMS servicesConcerned EP 2010-01-28 14:28
I've been struggling with this issue for years. Around 1997 a rural helicopter service established a "base" and "relationship" at the largest hospital in our area. Since then they have expanded with at least three more bases while encouraging another service to do the same. Now we have 5 aircraft within 50 miles, and they seem to be flying all the time. These services also somehow convinced county administrators to allow for "early activation" where ANYONE can call a helicopter to a scene before ground crews even had a chance to get there and evaluate the situation. The "membership" thing is a whole problem on it's own. It's almost a circus act with the fire department, ground EMS unit, and police having to be present and assist in the helicopter to land safely.
My EMS crews would almost always pass the patient along to the helicopter crew not because of need, but I think because they just almost would feel obligated, since the crew was already on the ground. I finally put an end to that by reviewing every patient who was flown for necessity. Most of these flights were to a facility 30-40 miles away, with not much traffic, easily covered by a ground unit.
Next comes the competence issue of the local ED docs. There is no doubt we have docs in local/rural ED's who don't belong in the ED with minimal skills of handling true emergencies, whether traumatic or medical. So they panic and want these patients gone as fast as possible. Helicopter is the fastest way. Necessity is not at all called into question. It's easy, quick, and no one asks questions or asks for a reason. It is so bad that even some of our local paramedics refuse to take the patients to certain facilities when they know a certain doc is working.
There must be checks and balances. Helicopters are invaluable in certain situations and certain locations. Significant head injuries, significant medical conditions like aneurysm, and significant traumas do need specialized care, over 2 hours drive by ground, that would be too dangerous for the patient. But I would easily predict that 75% of aircraft transport in this area is unnecessary.
The fact that these companies are driven by financial gains should definitely put them and their promotional practices on the radar of regulatory agencies.
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