Emergency Medical Services Response to Motor Vehicle Crashes in Rural Areas (2013)

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SUMMARY EMERGENCY MEDICAL SERVICES RESPONSE TO MOTOR VEHICLE CRASHES IN RURAL AREAS According to national highway safety statistics, a disproportionate number of motor vehicle crashes occur in rural areas. About 40% of vehicle-miles traveled occur on rural roads; how- ever, these rural trips account for 54% of all traffic fatalities. In 2010, a total of 18,026 lives were lost in crashes on rural roadways. Several factors contribute to these higher injury and fatality rates, including that rural crashes are more likely to involve higher vehicle speeds, a lower rate of seat belt use, and less availability of timely emergency medical care. Rural crashes present unique challenges for emergency medical service (EMS) sys- tems. Compared with urban areas, a greater percentage of rural crashes result in multiple fatalities and higher rates of head-on collisions, roll overs, and ejected crash occupants. In addition, rural EMS systems often rely on a volunteer force, and tends to have less financial resources for staffing, equipment, and training. Response times in rural areas are longer owing to the greater travel distances required to reach the scene of a crash. Additionally, some rural EMS systems operate in areas with limited telecommunication options. This synthesis study explores the state of the practice for a broad cross-section of EMS system characteristics. It identifies factors that affect the timely provision of effective medical care in rural areas. In addition, it examines broader issues such as personnel, data records, and interaction with other agencies. This synthesis was compiled through a combination of literature review, agency sur- veys, and follow-up interviews for case examples: • The literature review included a synthesis of current practices, relevant research, and recent statistics on highway crash rates and EMS response metrics in rural areas. Data collection focused on rural areas, defined as anywhere outside a U.S. Census- defined Urbanized Area with a population exceeding 50,000. • Surveys were conducted of departments of transportation (DOTs) and EMS agencies in 14 states with high rural crash fatalities in order to explore how emergency medi- cal response is approached by these two distinct groups, and what opportunities exist for improving the response of rural EMS systems. All 28 agencies responded to the survey. • Five states were selected for follow-up interviews based on their survey responses. Case examples were prepared for both the EMS and DOT agencies in order to capture an in-depth understanding of EMS issues in these states. Information collected was organized into the following categories: • Crash Detection/Locating/Reporting—Advanced Automatic Crash Notification (AACN), geographic data sets, and data collection. • Road Condition Reporting—weather, construction, and maintenance information and the data delivery systems (such as 511 telephone and web services).

2 • Dispatching—Computer-aided dispatch and Public Safety Answering Point (PSAP) technologies and integration. • Communications Systems—Interoperable data and voice networks. • Equipment and Preparation—Predeparture conditions of vehicles and equipment; pro- cedures for ensuring readiness. • Air Medical Transport—Fixed wing and helicopter use for scene-to-center and center- to-center transport. • On-Scene and Transport Issues—Management of the crash scene, care, loading, and transport. • Telemedicine—Use of communications and data collection technologies to provide enhanced medical care at a distance. • Record Linkages/Data Metrics—Integration and analysis of data relating to crashes, roadways emergency patient care, outcomes and costs. • Recruiting/Retention/Training—Staffing issues related to EMS and PSAP personnel. • Tribal EMS—EMS on tribal lands or by agencies operated by tribal organizations. • Interagency Cooperation and Coordination—Integration efforts between EMS agen- cies or between EMS and transportation agencies. • Planning and Innovation—Efforts to develop creative strategies to enhance rural EMS system response. • Care Protocols and Procedures—Processes used by EMS personnel to provide on- scene and in-transport care. The following are major findings and lessons learned from this synthesis effort. These findings are based on information obtained from the literature review, agency surveys, and interviews. • Prehospital times for crash occupants were substantially longer for rural crashes, aver- aging 25 minutes in urban areas and 42 minutes in rural areas. EMS arrive at the scene within 10 minutes of notification in more than 85% of urban fatal crashes but less than 54% of the time in rural crashes. • Shorter prehospital times are correlated with lower mortality rates. The Centers for Disease Control and Prevention found that severely injured crash occupants who receive care at a Level I trauma center within 1 hour had a 25% reduction in risk of death. • All of the 14 focus states have prepared Strategic Highway Safety Plans, but these varied in their emphasis on EMS. Some focused on interoperable communications sys- tems, whereas others had data linkage or scene management components. Five states did not have an EMS component in their Strategic Highway Safety Plans. • Survey responses indicate that the majority of DOTs in the focus states are actively par- ticipating in efforts to improve rural crash response. The survey also revealed that DOT personnel assist with response, primarily through traffic control or infrastructure repair. • Air medical transport was used to some extent in all states; however, the effects on patient outcomes are not well understood. Research appears to establish that ground transport can have shorter crash to hospital arrival times for distances less than 100 km. Also, the positive effects of air transport appear to be limited to only the most severely injured patients. • Telemedicine applications are used by roughly one-half of the EMS agencies surveyed. The majority of these transmit biometric data. The data regarding telemedicine’s effect on patient outcomes are incomplete. Some studies have found inconclusive results on objective outcome measures, where others have found positive outcomes. • The precursor to AACN, Automated Crash Notification (ACN), has been shown to produce measurable reductions in the time from crash occurrence to crash reporting. • Modeling suggests that the use of AACN may be able to reduce notification times to no more than 1 minute and realize up to a 20% reduction in fatalities. • Although 75% of EMS survey respondents indicated that data were collected about crash details, responses, and injury severity, only three indicated any linkage to hospi-

3 tal records and one to driver’s license data. Almost no cost or compensation data are linked to response or crash records. • A model system to enable real-time and recorded data to be shared has been deployed in Idaho. This smartphone-based solution has been evaluated in a “production” envi- ronment. Systems of this type create electronic records that can be more easily refer- enced to other data sets. • Frameworks for linking records between different data sets have been created, nota- bly the National Emergency Medical Services Information System database. Efforts to link these data to other data sets have proven only partially successful and unique identifiers that can easily relate records between different sources do not exist, result- ing in data “silos.” Statistical matching techniques have been attempted, but have been only partially able to match records. • More than half of the survey respondents indicated that vehicle or equipment condi- tion has caused delay in an EMS response. However, follow-up interviews revealed that these issues are not endemic and are managed through proper maintenance pro- cedures, such as the inspection criteria used in West Virginia or mutual-aid agree- ments similar to those in place in Nebraska. • Three-quarters of EMS survey respondents indicated that EMS responders are vol- unteer or part time. • Staffing issues were identified as negatively affecting response times by 75% of EMS survey respondents. Recruitment and retention of qualified personnel were frequently identified as causes for staffing problems. • According to EMS survey results, 75% of respondents used Global Positioning System guidance systems. However, there is contradictory evidence on the impact of these systems. Some studies have shown there to be no significant difference in mean times to arrival. More recent evidence has shown significant differences when used on trips over five miles. • Data on issues involved with EMS provided by tribal organizations are sparse. Anecdotal information from EMS interviews indicates improving service, but spe- cific data are not readily available. • Although all DOTs surveyed indicated that they provide road condition information through telephone (511), web, broadcast media, or mobile applications, only one-third of EMS survey respondents said they could easily access condition information. • DOTs and EMS agencies have complimentary responsibilities and areas of action when responding to rural crashes. DOTs focus on traffic management and mainte- nance of the infrastructure, whereas EMS agencies focus on injured crash occupants and their care. In some cases, EMS and DOT personnel may share dispatch facilities or communications equipment, but coordination largely takes the form of organizing related actions, rather than sharing responsibility for any single task. Several areas of gaps in existing knowledge or conflicting results have been observed and identified. Several areas for future research are outlined here that may improve under- standing on EMS response to rural motor vehicle crashes. • Although evidence suggest that using Global Positioning System guidance can reduce time to arrival on-scene, particularly for longer distance, some agencies avoid using the devices because of difficulties with use or poor-quality geographic data. To address these issues, research into the mapping data used by devices and guidelines for training users could be conducted. • AACN offers the potential to provide an early assessment of injuries, which can assist providers with predeparture preparation and dispatchers with responder selection (e.g., air transport, rescue units). However, little is known about the long- term reliability of vehicle-based sensors for these applications or AACN’s effect on patient outcomes.

4 • All DOTs provide near real-time information on state-jurisdiction roadways, including construction information and roadway condition. The lack of easy-to-access data for emergency responders may be addressable through improved interfaces and appropri- ate access devices. • Interoperable digital communications networks primarily serve voice and low band- width data communications functions, which limit some applications such as tele- medicine that requires images or audio/video streams. The impact of low bandwidth availability on these applications and the feasibility of enabling higher data rates could be explored. • With EMS equipment condition or availability identified as a factor in response times, methods for ensuring readiness may be a valuable research topic. • Use of air medical transport and its impact on patient outcomes does not have definitive evidence; however, patient injury severity, rather than distance, appears to be the factor that benefits most from air transport. Investigation of injury-severity based dispatch using AACN or other inputs may provide a way to maximize the cost-effectiveness of air medical transport. • There is conflicting information from the literature search on the efficacy of telemed- icine in the center-to-center environment. Further studies of objective measures of patient outcomes may provide insight into the viability and effectiveness of telemedi- cine applications. • The use of telemedicine in the scene-to-center or mobile telemedicine is depen- dent on the availability of suitable communications networks to transport the data. Investigation of the limits of data requirements and how these can be met with existing or augmented networks would define the broad parameters of mobile telemedicine uses and limits of deployment. • A study of existing efforts to collect real-time patient data and link that information to emergency room preparation and other record sets and the impact of this information on patient outcomes would be valuable. A related research need is to connect patient outcomes to cost data to permit cost-effectiveness analysis. • There appears to be little data on differences in procedures or outcomes between tribal and nontribal EMS providers. Investigation of opportunities to work with tribal gov- ernments to assess performance and to enhance services through coordination, unified training or care protocols, and sharing of resources may highlight ways to improve care for patients on or near tribal lands. • Both DOT and EMS agencies compile a variety of information and statistics related to crashes; additional coordination between these data stewards and additional data collectors (e.g., hospitals) may provide valuable insight into factors and processes that affect patient outcomes.

5 • Technology used to improve EMS performance • Innovative training and recruitment strategies. FIGURE 1 Rural EMS response sequence. This synthesis study also identifies current knowledge gaps and recommends opportunities for further research. CHAPTER ONE INTRODUCTION DEFINITION OF PROBLEM Rural vehicle crashes represent a disproportionate number of fatalities, with less than one-quarter of the driving popula- tion involved in more than half of crash fatalities (NHTSA 2012). A number of safety initiatives (Toward Zero Deaths, various studies and organizational efforts) have been imple- mented to reduce the number and rate of fatal crashes in gen- eral and in rural areas specifically. In addition to improving the roadway, vehicle systems, and driver behavior to reduce crashes, enhancing emergency medical services (EMS) is a possible avenue to lower fatality rates. Emergency medical response may be viewed as a sequence of events beginning at the moment of the inci- dent. From there, an interval of time is required for detec- tion, reporting, dispatch, preparation, travel to the scene, triage/evaluation, stabilization, transport to a care facil- ity, transfer to a specialty care center (if needed), and finally the provision of definitive care and rehabilitation. Figure 1 illustrates this EMS sequence and common tasks at each stage. Improvements to the process outlined previously may help reduce the time needed to provide definitive medical care, and positively affect the ultimate outcome for the patient. For this synthesis, “rural areas” follows the U.S. Census definition of being outside a U.S. Census-defined Urbanized Area with a population exceeding 50,000. Previous EMS studies (mentioned in the literature review) have used other definitions of rural. PURPOSE OF THIS REPORT The purpose of this synthesis study is to document the cur- rent state of the practice, strategies that have been identified as effective, and deficiencies in emergency medical response to motor vehicle crashes in rural areas. Some of the informa- tion captured in this study includes— • Measurable quality of care and outcomes • Collection and analysis of response and transport times • Evaluation of cost-effectiveness of EMS practices • Integrated partnerships between key stakeholders

6 INTENDED AUDIENCE This synthesis report will be of particular interest to manag- ers of EMS programs throughout the country. Typically, state and local EMS officials comprise a small component of a larger department, often a health department, and are often dealing with issues that are unique to EMS. The information in this report will connect these managers with the EMS challenges and opportunities faced by other states. DOT officials will also find the contents of the synthesis of interest when designing and assessing roadway safety and incident management programs. The report should also be of interest to DOT staff who are involved in traffic safety, operations, and maintenance of roadway infrastructure. ORGANIZATION OF THIS REPORT Following this introduction chapter, this synthesis report is organized into four remaining chapters: Literature Review, Survey Findings, Case Examples and Conclusions. A ref- erence section is followed by appendices that provide the survey questionnaires, interview guides, and the raw survey numerical results. PROJECT METHODOLOGY This synthesis was compiled through a literature review, agency surveys, and case examples: • The literature review included a synthesis of current prac- tices, relevant research, and the latest statistics on high- way crash rates and EMS response metrics in rural areas. • Surveys were conducted of both departments of trans- portation (DOTs) and EMS agencies in selected states with high fatality rates on rural roadways. These surveys explore how emergency medical response is approached by these two distinct groups, and what opportunities exist for improving EMS. The survey was administered online to DOTs in Arkansas, Iowa, Idaho, Kansas, Kentucky, Mississippi, Montana, Nebraska, New Hampshire, South Carolina, South Dakota, Vermont, West Virginia, and Wyoming. All 28 agencies responded to the survey. • Five states were selected for follow-up interviews based on their survey responses: Arkansas, Idaho, Nebraska, Vermont, and West Virginia. Case examples were pre- pared from both the EMS and DOT agencies in order to capture an in-depth understanding of EMS issues in these states.