M. V. Purvis1, A. R. Beckett1, J. R. Beasley2, H. E. Reed2, A. Haiflich1, Y. Lee1, L. Ding1, S. E. Bowden3, E. A. Panacek3, S. B. Brevard1, J. D. Simmons1 1University Of South Alabama,Department Of Surgery, Division Of Acute Care Surgery And Burns,Mobile, AL, USA 2University Of South Alabama,School Of Medicine,Mobile, AL, USA 3University Of South Alabama,Department Of Emergency Medicine,Mobile, AL, USA
Introduction: In the state of Alabama, utilization of helicopter emergency medical services (HEMS) is based on criteria established by the Alabama Department of Public Health (ADPH) in conjunction with the Alabama Trauma Communications Center (ATCC). These protocols delineate specific anatomic and mechanistic criteria for which consideration should be given for HEMS transport. We hypothesized that a significant number of trauma patients are being over-triaged to HEMS in our region and that many of the criteria the ATCC uses for HEMS triage guidance would have limited predictive value for truly severe injuries.
Methods: We conducted a retrospective review of all adult trauma patients arriving to our level one trauma center by HEMS from January 2015 to April 2017. Interfacility transfers were excluded. Triage decisions were deemed inappropriate (i.e. admission to the ward or discharged home without admission) or appropriate (i.e. admission to the intensive care unit, required emergent operation, or death). Additionally, we analyzed ATCC, HEMS and hospital records of each patient to determine demographics, hospital outcomes, scene details, triage decision criteria, and transport times. Data was analyzed via binary logistic regression to identify predictive factors.
Results: Over 28 months, 381 adult trauma patients arrived to our emergency department by HEMS. Two hundred forty-eight patients (65%) were deemed appropriate while 133 (35%) were considered inappropriate for HEMS transport. Of the 35% of patients grouped inappropriate for HEMS, 8% (30 patients) were discharged home without admission to the hospital. Glasgow Coma Scale (GCS), multiple extremity fractures, age, and gender were significant predictors at the 5% level for appropriate transport by HEMS [Chi-Square=70.372, df=14 and p=0.0001] after controlling for all other variables (GCS Exp(B)=0.714, p=0.0001; multiple extremity fractures Exp(B)=0.211, p=0.050; age Exp(B)=1.019, p=0.028; gender Exp(B)=0.398, p=0.005). The other nine criteria were not found to be significant predictors of appropriate HEMS transport (tachycardia, hypotension, respiratory distress, flail chest, amputation, paralysis, pelvic instability, other patient death in compartment and mechanism). Finally, the insurance demographics of the cohort were similar to that of all trauma patients arriving to our trauma center.
Conclusion: Our findings suggest current ATCC triage criteria for HEMS should be revised to reduce the over-triaging of trauma patients which would avoid unnecessary healthcare expenditure. Based on the average cost of a HEMS transport in our area, approximately 5.4 million dollars was unnecessarily wasted over a 28-month period due to over-triage. Large, adequately-powered, multi-center studies should be prioritized to determine the optimal criteria for selecting HEMS.