ABSTRACT
OBJECTIVE: Helicopter emergency medical services (HEMS) is widely used for prehospital and interfacility transport, but there is a paucity of HEMS outcomes data from studies using randomized controlled trial designs. In the absence of robust randomized controlled trial evidence, judgments regarding HEMS potential benefit must be informed by observational data. Within the study design set of observational analyses, the natural experiment (NE) is notable for its high potential methodologic quality; NE designs are occasionally denoted "quasi-experimental." The aim of this study is to examine all NE outcomes studies in the HEMS literature and to discern what lessons can be learned from these potentially high-quality observational data. METHODS: HEMS NE studies were identified during the development of a new HEMS Outcomes Assessment Research Database (HOARD). HOARD was constructed using a broad-ranging search of published and gray literature resources (eg, PubMed, Embase, and Google Scholar) that used variations of the terms "helicopter EMS," "air ambulance," and "air medical transport." Among the 221 studies ultimately included in HOARD, 16 NE publications describing 13 sets of observational data comprising myriad diagnostic groups were identified. Of these 16 HEMS NEs, 4 HEMS NE studies assessing trauma outcomes were used in a meta-analysis. A meta-analysis was also performed of 4 HEMS NE studies. RESULTS: Although the disparity of studies (in terms of both case mix and end points) precluded the generation of a pooled effect estimate of an adjusted mortality benefit of HEMs versus ground emergency medical services, HEMS was found to be associated with outcomes improvement in 8 of the 13 cohorts. CONCLUSION: The weight of the NE evidence supports a conclusion of some form of HEMS-mediated outcomes improvement in a variety of patient types. Meta-analysis of 4 HEMS NE studies assessing trauma outcomes generated a model with acceptable heterogeneity (I2 = 43%, Q test: P = .16), which significantly (P < .01) favored HEMS use with a pooled HEMS survival odd ratio estimate of 1.66 (95% confidence interval, 1.23-2.22).
Subject(s)
Air Ambulances , Emergency Medical Services , Humans , Aircraft , Outcome Assessment, Health Care , Databases, Factual , Retrospective Studies , Randomized Controlled Trials as Topic , Observational Studies as TopicABSTRACT
INTRODUCTION: In response to the COVID-19 pandemic, emergency medical services (EMS) and hospitals recognized the need for innovative programs addressing 9-1-1 utilization and ambulance transport to provide patient-centered, safe, cost-effective care. The ET3 (Emergency Triage, Treatment, and Transport) model provides flexibility and new payments to ambulance care teams for Medicare beneficiaries for alternate strategies of care. This includes providing treatment in place through telehealth after a 9-1-1 call and ambulance response. Our objective is to evaluate the implementation barriers of a telemedicine service to 9-1-1 responding ambulances providing treatment in place for low-acuity conditions. METHODS: The TeleEMS program was piloted in a large, urban fire-based EMS system with eight ambulances geographically surrounding one hospital. Paramedics received training on the telemedicine software and screening criteria, which were age 1-70 and vital sign parameters. Pregnant, combative, and patients with no clear need for emergency department transport were excluded. Three emergency physicians with additional training in EMS provided the TeleEMS service from 8am to 6 pm on Monday - Friday. The telemedicine software was application-based and provided HIPAA-compliant two-way, real-time audio and video communication through the 4G network on a tablet. The TeleEMS physicians had access to a database of clinics and hospitals that coordinate health care. The TeleEMS physician contacted the patient within 24-72 hours after the encounter for follow-up. RESULTS: The TeleEMS pilot program ran for 12 weeks from April - June 2021. During this time, there were seven completed consults with treatment in place, one completed consult with transport to an emergency department, and five consult attempts that failed due to technological issues with resultant transport. Each of the consults (13/13) met the TeleEMS screening criteria. Post-pilot focus group sessions were held to determine paramedic feedback. Barriers to an EMS telemedicine program include paramedic buy-in, patient expectations for emergency care, technology limitations, and qualified physician resources. CONCLUSIONS: An EMS telemedicine program can be successfully implemented in urban fire-based EMS systems for 9-1-1 responding ambulances. Barriers to implementation should be addressed at the paramedic, patient, technology, and program levels to improve success.
