Columns, Operations

Study Attempts to Attach a Price Tag to Aeromedical Overtriage

Issue 1 and Volume 43.

HEMS Over-triage

Madiraju SK, Catino J, Kokaram C, et al. In by helicopter out by cab: The financial cost of aeromedical overtriage of trauma patients. J Surg Res. 2017;218:261–270.

The use of helicopters within EMS is a fairly common—and sometimes controversial—practice in the United States. Many researchers have attempted to identify if the clinical benefits of medical helicopters justify the risks and financial costs. This research adds more evidence to the discussion by evaluating aeromedical transport of trauma patients within one urban EMS system.

Methods: This study was a retrospective review of records from the trauma registry at a Level 1 trauma center in Palm Beach County, Fla. The study population was adult patients ( > 18 years old) receiving a trauma alert activation upon arrival to the hospital between 2011 to 2015. Exclusion criteria included nonsurvivable injuries, major burns and those who were dead upon arrival. After exclusion criteria was applied, 4,288 patients were included within the study.

The researchers first divided the study group between patients transported by air vs. ground, then performed statistical analyses to determine if there was a difference in patient characteristics and clinical outcomes between the two groups.

They next performed analyses of the same characteristics and outcomes after grouping the patients based on the triage criteria used by the trauma center. The triage system has three color categories based upon physiological criteria (red), mechanism (blue) and EMS provider judgement (gray).

Within both methods of grouping the patients, the researchers calculated the rates of over-triage, which was defined as patients receiving a trauma alert activation and then either being discharged from the ED to home, admitted to a medical service without having injuries, or admitted to observation for < 48 hours. Lastly, the researchers calculated the financial costs associated with air transport of over-triaged patients.

Results: During the study period, 1,177 (28%) of the patients arrived at the trauma center by helicopter. Compared to patients arriving by ground ambulance, patients arriving by helicopter were more likely to be younger, male, a member of a minority group and uninsured.

When comparing patients transported by air or ground, there wasn’t a difference between the incidence of hypotension or severity of head injury.

The patients transported by air were more likely to need immediate surgery (17.4% vs. 13.2%, p < 0.001) and to be admitted to an ICU (37.5% vs. 33.2%, p = 0.009) than the patients arriving by ground. Arrival to the trauma center by ground vs. air had no statistically significant difference in in-hospital mortality (6.8% vs 6.5%, p = 0.958) or the patient being discharged directly from the ED (19.7% vs 18.3%, p = 0.297).

The red categorized patients were the most likely to die within the hospital or be admitted to the ICU, and the blue categorized patients were more likely than the gray patients to die within the hospital or be admitted to the ICU.

Within each of the three color categories there wasn’t a significant difference in survival when comparing patients transported by air vs. ground. Over-triage was found to be present in 49.7% of the red patients, 53.0% of the blue patients and 72.6% of the gray patients (p < 0.001). The researchers calculated the median annual cost of aeromedical transport for over-triaged patients was $1,316,036.

Discussion: This study is both interesting and well-executed, however we must be cautious before we draw any larger conclusions about the use of helicopters within EMS. This research shows a high financial cost for aeromedical transport and a limited clinical benefit. However, as the authors themselves acknowledged, the limitations of the study include that it only looked at patients arriving at one trauma center, which has high levels of over-triage for patients transported by both ground and air. The authors also noted the study took place within a geographically small area which has robust trauma resources available.

Conclusion: Inappropriate aeromedical transport can have a significant financial impact upon the healthcare system, as was demonstrated within this study. But, areas with different trauma center activation and aeromedical utilization criteria may have found very different results for both clinical outcomes and over-triage rates.

This research clearly demonstrates each trauma system must assess whether its current practices are providing the value intended.