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Page 27
Suggested Citation:"CHAPTER THREE Survey Findings." National Academies of Sciences, Engineering, and Medicine. 2013. Emergency Medical Services Response to Motor Vehicle Crashes in Rural Areas. Washington, DC: The National Academies Press. doi: 10.17226/22503.
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Suggested Citation:"CHAPTER THREE Survey Findings." National Academies of Sciences, Engineering, and Medicine. 2013. Emergency Medical Services Response to Motor Vehicle Crashes in Rural Areas. Washington, DC: The National Academies Press. doi: 10.17226/22503.
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Page 28
Page 29
Suggested Citation:"CHAPTER THREE Survey Findings." National Academies of Sciences, Engineering, and Medicine. 2013. Emergency Medical Services Response to Motor Vehicle Crashes in Rural Areas. Washington, DC: The National Academies Press. doi: 10.17226/22503.
×
Page 29
Page 30
Suggested Citation:"CHAPTER THREE Survey Findings." National Academies of Sciences, Engineering, and Medicine. 2013. Emergency Medical Services Response to Motor Vehicle Crashes in Rural Areas. Washington, DC: The National Academies Press. doi: 10.17226/22503.
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Page 30

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27 CHAPTER THREE SURVEY FINDINGS survey to appropriate staff for completion as necessary. The DOT survey was sent to representatives that serve on AAS- HTO’s Standing Committee on Highway Traffic Safety. The surveys were distributed on June 21, 2012, with a 3-week deadline to have them completed (July 13, 2012). After this period, follow-up contacts were made, first by e-mail and then by telephone, to secure 100% participa- tion. The survey results were then extracted and organized for presentation. Responses were analyzed for similarities between responses and correlations in data, as well as for “outlier” information that may be useful for identifying novel or innovated practices. EMERGENCY MEDICAL SERVICES SURVEY— SUMMARIZED RESULTS Surveys were constructed from groups of questions in sev- eral topic areas to tie responses together conceptually for respondents. An overview of responses in each area is pre- sented here. Record Linkages and Data Metrics All respondents replied that they collected data on EMS crash response times, patient destinations, and transport times. Additionally, 75% or more also collected data for injury severity, interfacility patient transfers, and the type of responder (e.g., law enforcement, rescue) Only two respon- dents indicated that they collected any data for patient out- comes, and no respondents collected information related to costs, charges billed or collected, or agency compensation. There are a few indications that data were linked to other record systems. Six agencies responded to this question, with three indicating some link to hospital record systems and one to driver’s license data. From these responses, it appears that scant data are available for patient outcomes, and virtu- ally no cost data are available to assess cost-effectiveness or compensation for services. Dispatching Five of 13 respondents indicated that rural-crash specific programs existed to improve PSAP coordination and func- GOALS Survey questionnaires were administered for this synthesis study to collect data on emergency medical responses prac- tices in rural areas, with a focus on practices that are identi- fied as effective or innovative. The questionnaires targeted items provided in the scope of work, including: • Patient outcome metrics • Response and transport time metrics • Cost-effectiveness metrics • Identification of key partnerships • Use of technology to enhance emergency response sys- tem performance and patient outcomes • Innovative training and recruitment practices for emer- gency responders. To achieve these goals, the survey asked about 14 states that have high fatality rates on rural roads: Arkansas, Idaho, Iowa, Kansas, Kentucky, Mississippi, Montana, Nebraska, New Hampshire, South Carolina, South Dakota, Vermont, West Virginia, and Wyoming. SURVEY METHODOLOGY Two surveys were prepared, one for the EMS community and another for the DOT community. Surveying these groups separately was done to provide a balanced view of the EMS response practices in these focus states. Draft questionnaires were developed and distributed to the NCHRP liaison and Topic Panel members to solicit comments to either refine the content or questions. The final questionnaires balanced the need to acquire complete and accurate information with the need to make the survey pro- cess as efficient and unobtrusive as possible for respondents. Appendix A presents the final EMS and DOT questionnaires. The survey questionnaires were then adapted into an online survey instrument, which was evaluated by Topic Panel members. Comments were incorporated into the final survey and it was then made “live.” Each contact provided by the panel was sent an e-mail introducing the survey, describ- ing its purpose, and providing instructions for completion. Each state’s EMS director was instructed to forward the

28 tion. One of the positive responses indicated that a data-shar- ing project existed as part of the Highway Safety Program, and one reported that an AACN pilot program was in place. All respondents reported that dispatchers will guide emer- gency vehicles to a crash scene if needed, and 92% indicated that paper maps were commonly used. Agency-approved GPS devices or personal GPS devices (including smartphones) were used by 75% and 50% of respondents, respectively. Literature search information indicates that, if properly deployed and staff adequately trained, GPS guidance can reduce the time needed for responders to reach rural crash scenes. Further deployments for those not currently using the technology could be explored as a way to reduce travel times. Of the 12 respondents who answered, 7 reported that there was a state- or regional-level organization that worked toward improving PSAP functions. The organizations were listed as primarily public safety, emergency management or a communications interoperability board. With crash detection and responder dispatch represent- ing a significant portion of total crash-to-care time, a coor- dinated effort to improve dispatching functions could yield significant benefits for patient outcome. Implementation of a coordinated program or the addition of PSAP-related func- tion planning to an existing agency (as in those respondents who indicated that these efforts were organized by a state public safety department) could provide the framework for deployment of AACN systems and improve communica- tions between facilities. Nine of 13 responses indicated that there were no active efforts by their agency to reduce rural crash response times. Of those who answered that there were efforts under way, the focus was on expediting dispatch and improving guidance. Crash notification and locating were identified as having the greatest effect on response times. These responses compliment the results obtained in the Dispatch Function section of the survey and agree with infor- mation found during the literature search. AACN and GPS systems have been shown to improve rural crash response times, but are not commonly in use. Telemedicine Six of 13 responses indicated that their agency used some form of telemedicine or telepresence technology, which was used primarily by emergency department or other hospital- based staff. Only three respondents said that the technology was used by emergency responders on-scene or en-route. The benefits of medical expertise at the crash site, and conversely the ability for hospital staff to review multimedia information related to a crash incident, could be significantly enhanced by wider use of mobile telemedicine technologies. The majority (80%) of telemedicine applications primar- ily involved transmitting biometric data, suggesting further opportunities for integrating additional media types (e.g., live or recorded video) into the portfolio of communication tools. A limiting factor for field or mobile telemedicine is the availability of a satisfactory communications network. The majority of those responding said that the cellular data network is the primary method of moving telemedicine data, which implies that the coverage of that network will be a driving factor in the availability of telemedicine tools on-scene. Care Protocols and Procedures Approximately half of all respondents indicated that uni- form protocols and procedures were mandated in their state, with roughly one-third of respondents stating that these were uniform for all jurisdictions. Seven of 13 respondents indi- cated the present of an active program to evaluate protocols. The majority of those indicating an evaluation program said that it focused on patient treatment (stabilization and triage procedures), with an additional four replying that responder destination routing was being evaluated. Standard protocols and procedures can simplify training and allow training resources to be pooled, as there is only a single set to be taught. The ability to recruit, retain, and train EMS personnel may be enhanced by standardizing the materials needed for study. Air Medical Transport All respondents indicated their agencies used air transport, and all reported that it was used to convey patients from a crash scene to a trauma center or an emergency depart- ment to a trauma center (interfacility transfer). In all cases, on-scene personnel (scene commander or medical person- nel) are able to cancel requests for air transport, with a smaller number (41%) stating that dispatchers could also cancel transport requests. Paramedics or flight nurses were reported to be on-board personnel for all responses, with an additional response indicating that an inhalation therapist would be present. Only two responses indicated that any evaluations of the effectiveness of air transport had been conducted. Examina- tion of the on-board staffing, request/cancellation protocols, destination choices, and comparisons to wheeled transport may be able to provide insight into ways to improve the effi- ciency of air transport and patient outcomes. Weather condi- tions may also limit the availability of air transport, and the relationships of weather factors to crashes, air transport, and patient outcomes do not appear to have been investigated.

29 Equipment and Preparation Only half of respondents reported that there was a standard checklist to ensure equipment availability and conditions prior to departure to a crash scene. In addition, only one-third said they were able to quickly check road conditions before depar- ture, and 86% indicated that they depended on voice commu- nications to a dispatcher to check conditions. More than 50% of respondents indicated that vehicle and equipment condition had delayed departures, thereby increasing response times. The lack of quickly accessible information about roadway and equipment conditions appears to have adversely affected response times. Communicating roadway conditions effec- tively may require the development of a responder-specific “no-touch” interface that shows surface and construction conditions without requiring direct interaction. A standard- ized program to verify that equipment is present and in working order may also improve response times. Recruiting, Retention, and Training Three-quarters of EMS personnel are volunteer or part-time paid employees, primarily recruited through advertising in local publications or word-of-mouth. Nearly all (92%) indicated that there were no incentive programs in place to recruit or encour- age training of employees in other agencies (such as highway operations staff). Staffing levels have also been identified as adversely affecting response times by 75% of respondents. The ability to attract, train, and retain staff appears to be a major concern for emergency response. Partnering oppor- tunities and incentives to increase staffing levels, as well as responder proficiency, could be investigated. Planning and Innovation All respondents reported one or more active partnerships to improve crash response. Eleven of 12 replied that they cur- rently worked with a state DOT, with more than half also reporting partnerships with hospitals or other agencies. Only two of those surveyed indicated that they worked with PSAPs to improve response. A variety of innovative approaches toward improving crash response were reported; however, only recruiting and triage/ responder routing had more than five respondents that indi- cated the presence of an active program. The issues reported in previous sections imply that there are additional opportunities for innovative approaches beyond those currently in place. Summary From the EMS agency responses, several areas for future action emerged as potential avenues to improve rural crash response: • Improved data collection (specifically cost, agency charges, and patient outcomes) to evaluate cost-effec- tiveness of procedures. • Development and integration of AACN into dispatch and routing functions. • Cooperative programs to share best practices for PSAP functions. • Exploration of partnerships with cellular providers or other creative solutions to enhance high-bandwidth data con- nection that can enable on-scene and mobile telemedicine. • Creation of a set of standards for GPS guidance quality and procedures for their use to maximize their benefit. • Active evaluation of air transport on patient outcomes. • Development of roadway information systems with interfaces optimized for the EMS responder. • Creation of standardized equipment checklists and processes to ensure that equipment issues do not delay departures. • Creation of creative incentives and recruiting tools to improve the availability and proficiency of EMS staff. • Coordination of innovative efforts to improve crash response that share resources and disseminate lessons learned. DEPARTMENT OF TRANSPORTATION SURVEY— SUMMARIZED RESULTS The DOT survey collected data on emergency medical responses in rural areas, focusing on practices that are iden- tified as effective or innovative. This survey was distributed to members of the AASHTO Highway Traffic Safety Sub- committee on Safety Management and forms the basis for a series of follow-up interviews to collect more detailed data on specific approaches or study results. As with EMS agencies, surveys were constructed from groups of questions in several topic areas. An overview of responses in each area is presented here. Record Linkages and Data Metrics All of the responding DOTs collect data on the number and causes of rural crashes, with 13 of 14 also collecting fatality rates. However, few collect any information on the medical response aspects of a crash (no more than 2 of 14). This indi- cates an opportunity to integrate data from the DOTs’ crash- related data with EMS patient and response data. Interagency Cooperation and Coordination In general, maintenance and emergency response dispatch- ing functions are not co-located (10 of 13 responses). A greater number (9 of 14) have communications systems that are able to interoperate with emergency response or use a cell phone to coordinate (50%).

30 Emergency response and maintenance dispatch func- tions have been fully integrated (facility, communications, and dispatch software) in several locations. These could be examined for potential applicability to other locations and the benefits of such a deployment quantified. Road Condition Reporting Thirteen of 14 respondents indicated that they provide real-time roadway condition information, usually accessible through a 511 telephone number or a web-based information service. Smaller numbers used dedicated mobile smartphone applica- tions, Twitter social media applications, radio broadcasts. With only one-third of EMS personnel indicating that they were easily able to check roadway conditions, exploration of novel methods of delivering roadway condition information beyond telephone and web-based systems may be beneficial. Planning and Innovation Nine of 14 (64%) responded that their department partic- ipated in efforts to improve rural crash response, and the same percentage also indicated that their staff regularly assists with response. For those that do, the most common activities were traffic control and repairs of traffic control devices and bridges. A small number (3 of 14) also assisted with management of the crash site. Respondents did not specify the site management func- tions. Further investigation may reveal functions beyond traffic control and facility maintenance suitable for trans- portation staffs to undertake. FHWA Traffic Incident Management Handbook guidance and the strategies defined in the National Unified Goal for incident management were implemented by 8 of 13 respon- dents. All departments have active programs to improve their roadway condition data, with the majority (57%) engaged in vehicle telematics projects (e.g., AVL, signal pre-emption). Smaller numbers have ongoing projects involving AACN/ severity determination, on-scene practices, staffing or fund- ing, and data integration with EMS records. These efforts compliment many of the activities described in the EMS survey as active projects, particularly the AACN and AVL/guidance aspects. Opportunities for combined efforts could be investigated. Summary DOTs are active in data collection and emergency response, but appear to conduct activities within a narrow range of disciplines. Opportunities appear to exist to com- bine efforts with EMS agencies on a larger scale than is currently practiced. Specific areas that warrant additional investigation include: • Integration of crash data with EMS and hospital record systems. • Improved roadway and construction information deliv- ery interfaces for EMS applications. • Tighter integration of dispatch functions and sharing of communications resources. • Cooperation on automated crash notification and route guidance systems.

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TRB’s National Cooperative Highway Research Program (NCHRP) Synthesis 451: Emergency Medical Services Response to Motor Vehicle Crashes in Rural Areas identifies potential factors that may help reduce the time needed to provide effective medical care to crash occupants on rural roads.

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