U.S. Metropolitan Municipalities EMS Medical Directors Consortium ( The “Eagles” Coalition)
INTERNATIONAL RESEARCH PERSPEC TIVES
Study attempts to attach a price tag to aeromedical over-triage
By Sean J. Britton, MPA, NRP
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
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
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. JEMS
Sean J. Britton, MPA, NRP, is an EMS practitioner, educator and administrator. He’s a
paramedic with Superior Ambulance Service
in Binghamton, N.Y., a board member of the
Learn more from Sean Britton at the EMS
Today Conference, Feb. 21–23, in Charlotte, N.C. EMSToday.com