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

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31 CHAPTER FOUR CASE EXAMPLES • Nebraska: Interview was conducted with represen- tatives of the Nebraska Department of Health and Human Services, the EMS program administrator, the EMS program coordinator, and the EMS program training coordinator. • Vermont: Interview was conducted with the EMS dep- uty director, an employee of the Vermont Department of Health, Office of Public Health Preparedness and EMS. • West Virginia: Interview was conducted with the director of the Division of Trauma, Designation and Categorization; part of the West Virginia Department of Health and Human Resources, Bureau of Public Health, Office of Emergency Services. EMS interview findings are summarized into 1 of 12 topic areas: • Record linkages/data metrics • Crash detection/locating/reporting • Dispatching • Equipment and preparation • On-scene and transport issues • Air medical transport • Telemedicine • Recruiting, retention, and training • Tribal EMS • Interagency cooperation and coordination • Planning and innovation • Other. Record Linkages and Data Metrics Nebraska An initiative to expand electronic patient data records is under way. Record linkages to the trauma registry will be used to track patient outcomes. Interviewees said that data accuracy needs to be improved in cooperation with the trauma centers, and that more emphasis is needed on data reporting, especially from volunteer EMS. The Nebraska Physician Medical Director and the Nebraska Statewide Trauma Data Committee are working on performance metrics and may have some findings to share. The trauma registry is another data source. SELECTION OF RESPONDENTS Five states were selected for follow-up informational inter- views in order to capture a more in-depth understanding of rural EMS practices that are identified as effective or inno- vative. Representatives of both the EMS and DOT communi- ties in each state were interviewed in order to capture each agency’s perspective on EMS. The following criteria were used to select these states: • Notable successes as reported by the agencies • Unusually extensive data collection efforts, record linkage capabilities, or collection mechanisms • Current or planned innovative technology deployments • Geographic diversity • Variety in the types of practices utilized • Specific requests to provide more information by the respondent. INTERVIEW METHOD The survey respondent for the relevant agency was contacted by phone and email in order to schedule an interview time. The EMS interviews were conducted first, followed by DOT inter- views. The interviews were structured to address the unique conditions and efforts under way in each state. An interview guide was developed to guide the interview process, one ver- sion for EMS interview and another for DOT interviews. These interview guides were distributed in advance of the scheduled interview and are provided in Appendices C and D. EMERGENCY MEDICAL SERVICES INTERVIEW REVIEW AND SUMMARIZATION The following five states were selected for interview and expressed a willingness to participate in a follow-up during the initial survey. • Arkansas: Interview was conducted with the state EMS section chief with the Arkansas Department of Health. • Idaho: Interview was conducted with the EMS com- munications manager for the Idaho State EMS Communications Center (StateComm). Also partici- pating was a StateComm communication supervisor.

32 Arkansas Arkansas recently began using trauma triage guidelines for ECS. These guidelines require the use of a centralized call center, referred to as “Trauma Call,” for every trauma-related response. EMS staff contacts the call center to provide infor- mation of injury severity and then receive direction on which trauma center to take the patient to. The system uses a “trauma dashboard” application to balance patient loads across the state on an hourly basis. Treatment recommendations can also be obtained from the call center, but most EMS providers utilize their local emergency department for this type of information. The call center is run by the Arkansas Trauma Communica- tion Center. A database is available that tracks a number of variables, including time of arrival on scene, time of departure, prehospital transport time, interfacility transport time, and time of day that call center was contacted. This system also supports patient tracking—a patient is given an identification (ID) bracelet by EMS, with an ID number that tracks the patient from emergency care through to follow-up care, including rehabilitation. This database is linked to trauma registry data. Efforts are ongoing to link with hospital data systems. Vermont Vermont is in the process of implementing a statewide electronic Patient Care Report (PCR) system. The system is called the Statewide Incident Reporting Network; Image Trend is the vendor. On January 1, 2013, all transporting EMS will be required to enter data into the system. EMS staff will likely enter data upon arrival at the hospital. The PCR data will be linked to hospital data in order to track patient outcomes. The PCR data will also be linked to crash data through collaboration with the Highway Safety Office. There is a vision to deploy a statewide trauma registry, which will also be linked to this database. Performance met- rics will be available from this system. Idaho Idaho is piloting a “CrashHelp” system that is currently deployed with two EMS agencies in the state. The system uses a mobile data platform deployed in EMS response vehicles to improve patient outcomes. The system provides a mechanism to communicate patient status quickly and effi- ciently between the hospital staff and response staff who are on the scene of a crash and during transport. The system is valuable in rural areas where cell phone coverage may be limited. In these cases, the flow of information can be done more quickly and efficiently than is possible by voice. West Virginia The Our Advanced Solutions with Integrated Systems (OASIS) Project is a statewide collaborative effort to bring to together crash, EMS, and trauma data. One of the project’s objectives is to quantify aspects of the crash care process and identify solutions that can improve patient outcomes. Poten- tial improvements include reduction in response times, such as through better geographic positioning of resources. One limitation of the trauma registry is that it only includes serious injuries. The West Virginia DOT is a partner in this effort. Crash Detection, Locating, and Reporting Nebraska CCTVs are deployed along key roadways where they can be used to monitor crash scenes and assist with providing appropriate crash response. The DOT is working on improv- ing highway condition monitoring so that advisory informa- tion, such as the presence of black ice, can be provided to the public. Communication between agencies is improving, but still has a ways to go. Some ambulance crews are able to pull up the crash location and current road condition information through their on-board devices. The technology is there, getting it implemented is the challenge. Additional mobile computer deployments will help. The Nebraska Department of Roads (NDOR) also has road data and live CCTV images posted on the 511 website, again trying to get ambulance and law enforcement to use the technology on their own. Dispatch helps EMS to be aware of construction zones, weather issues, and the like by monitoring the 511 website. EMS per- sonnel can also check weather conditions before departing. Mobile networks are being improved throughout the state to improve communications for these applications. OnStar calls, cell phone calls, and E911 have all proven helpful in providing dispatch with the location of crashes. OnStar calls are not frequent, but have helped save lives when they do come in. There is a push under way in Nebraska to establish addresses for all rural areas of the state. This address- ing effort is developing roadway numbering conventions and assigning address numbers for all rural residents. The addressing scheme will benefit emergency responders by providing a consistent way of entering location information into on-board GPS devices. Some emergency responders are still asking dispatch for directions while en route. The next challenge is getting the residents to use the new addressing scheme when reporting an incident. Arkansas Approximately 10% of the EMS service providers have in-vehicle computer systems that provide crash location information. Other service providers have used GPS or smartphone applications to aid in navigation, but a study conducted by Little Rock Metro EMS found that a 2- to

33 4-minute delay was associated with using these devices. The study found that delays were caused by the devices being faulty or difficult to operate. The use of these devices is cur- rently banned, with an emphasis placed instead on the use of paper maps and improved familiarity with the service area. Dispatcher-provided EMS routing is available in some of the larger EMS service areas, but in rural areas the dispatchers provide only a description of the crash location. The DOT maintains a 511 website that includes road closure information. Weather-related events are primarily monitored through phone conversations with State Patrol or sheriff offices. Some EMS staff has commented that the information on 511 is not updated frequently enough for use during an emergency. E911 has proven to be an effective tool in determining crash location. The respondent was not familiar with any AACN efforts in Arkansas, but will look into it and provide any information found. Vermont E911 is utilized by PSAPs throughout the state. The PSAP centers are regionally based and have a fairly uniform opera- tion. However, the EMS dispatch layer functions indepen- dently from location to location. There is variation in who these dispatchers are, who they dispatch to and the use of third parties for dispatching. EMS may be dispatched by police departments, fire departments, sheriff departments or multi-jurisdictional entities, depending on the area. The state EMS office is currently working to improve linkages to PSAPs, local EMS dispatch entities and the 911 Board. They are in the process of obtaining a better under- standing of the interrelationship of these functions. Emer- gency Medical Dispatch (EMD) services are not provided by PSAPs or other dispatchers. Respondent was not aware of any substantial issues with vehicle or equipment preparedness. New England weather can pose challenges; so many EMS vehicles are four-wheel drive and have snow/ice chains available for use. Idaho StateComm has initiated a “Condition Acquisition and Report- ing System (CARS) May Day” project in collaboration with ITD, the University of Miami, Castle Rock Consultants, OnStar, and the CDC. The system pulls data from OnStar-equipped vehicles that is generated when a motor vehicle crash occurs (OnStar is a proprietary AACN system available through Gen- eral Motors). These data include vehicle location, change in velocity, air bag deployment status, seat belt status, and occur- rence of a roll over event. The system then applies an algorithm to the data to estimate the severity of injury to the passengers and generates recommended emergency responses. Possible recommendations include the need for: air medical transport, advanced life support units, extrication equipment, and early hospital notification. The system went live in early summer 2012, but will operate in “shadow” mode while the algorithm’s performance is evaluated against actual crash outcomes as obtained from the Trauma Registry. The evaluation period is expected to take a couple of years or more because only two or three crashes per month occur with OnStar-equipped vehicles. When the project stakeholders are comfortable with the auto- mated emergency response recommendations, the system will be made live and the recommendations automatically provided directly to the appropriate PSAP for them to implement. The system interface includes an online map of the crash loca- tion. Idaho is the first state to deploy this system. The system is targeted at rural areas where crash response times are the most critical. The system is planned to be expanded to include AACN systems available from other motor vehicle companies. Dispatching Nebraska In most portions of Nebraska 911 calls are automatically routed to the appropriate Public Safety Answering Point (PSAP). However in some larger urban areas, calls come into one dispatch center and then need to be routed to the appropriate local PSAP. This can result in some dispatch centers becoming overwhelmed in emergency situations. The panhandle region of Nebraska was identified as an effective program for reducing dispatch and response times. The trauma unit at Region West Medical Center received a grant to deploy GPS in EMS, fire department, and law enforcement vehicles. The GPS system is integrated with dis- patch operations and with air medical transport operations. Two dispatch centers in the 17 county areas are EMD certi- fied, which allows for some medical advice to be provided by dispatchers. Some EMS crews have been using GPS over the past 6 months to assist in routing. The use of GPS has proven effective at estimating the time of arrival. GPS was found to be more effective when travel times are longer. Gage County has implemented an AVL system in ambulances, allowing dispatchers to track their location. However, some areas of the county are not able to afford the cost of this device. Arkansas Arkansas’s statewide EMS communication is provided by the Arkansas Wireless Information Network (AWIN) sys- tem. Every EMS vehicle has an AWIN radio that is used for placing calls to the statewide trauma call center and for mass casualty coordination (as needed). Communication to other agencies, such as DOT or state patrol, is relayed through the dispatch center.

34 Equipment and Preparation Nebraska Vehicle readiness has not been an issue in EMS response in Nebraska. An occasional ambulance has had to be jumped or has not started, but no issues are noteworthy. EMS are pre- pared for these possibilities through mutual aid agreements, and regular maintenance is performed on vehicles to try to minimize problems. No hard data are available because the crash record database does not track maintenance/opera- tions issues affecting EMS response vehicles. West Virginia The EMS community has vehicle inspection criteria that are followed to minimize issues with mechanical/maintenance issues that may affect response times. On-Scene and Transport Issues Nebraska The EMS group is working with the fire department to look for ways to reduce the amount of equipment sent to the scene of an accident. Unneeded equipment at the scene may result in traffic delays and secondary crashes. When equipment is sent to a scene, but is not needed, it is then not available for dispatch to other incidents. A better approach is to wait and see what is needed by responders. A greater emphasis is being placed on obtaining the Glas- cow Coma Score (GCS) by EMS personnel at the scene in order to better track patient conditions. A recent review of more than 500 EMS runs identified what appears to be too much time spent at the crash scene. The cause of this time is currently being investigated further. State trauma centers understand the critical role that EMS plays in improving patient outcomes, and the two communities communicate well and work well together. This EMS/trauma center collaboration has improved noncrash incidents, such as center-to-center transfer, responses to nursing homes, and the like. However, get- ting patients from a smaller hospital to a higher level of care in a timely fashion is an area that needs more focus because transfer has a big impact on patient outcome. The availability of a properly equipped ambulance for interfa- cility transport is critical. Arkansas Crash data are tracked by EMS service area on a statewide basis. The data are analyzed in various ways, including an assessment of whether on-scene times are longer than aver- age in any particular service area. Opportunities to improve these times are then identified. Vermont Some EMS dispatchers will prompt EMS staff after they have been on the scene 10 minutes as a reminder to mini- mize on-scene time. West Virginia Statewide protocols are in place to address on-scene activi- ties. These protocols emphasize steps that can be taken to minimize the time EMS personnel spend at the scene of a crash. The following web address was provided for more information: www.wvoems.org. A review of this website found several documents that detail on-scene procedures for providing efficient and effective treatment. Air Medical Transport Nebraska Nebraska has its own air medical association and is work- ing to improve service, but currently air medical transport is not always available when needed because of limited services offered. Arkansas Emergency air medical transport is provided by eight dif- ferent service areas. A request for air assistance can only be made by EMS or state patrol. An effort is under way to develop guidelines for which service area to contact in the event of an incident. The current practice results in some agencies consistently calling the same air medical transport provider regardless of the proximity to the crash scene. Vermont There are no Vermont-based air medical transport entities. Medical air service is provided by either Dartmouth-Hitch- cock Advanced Response Team Hancock trauma center out of Lebanon, New Hampshire, or LifeNet trauma center out of Albany, New York. Statewide protocols for air medical transport operations are currently being updated. Telemedicine Nebraska Telemedicine, referred to as Teletrauma in Nebraska, is an underutilized resource. Teletrauma is not used between scene of a crash and hospital because of the cost and lack of availability. However, Teletrauma is a valuable resource in a state with broad population distribution such as Nebraska.

35 Broadband service in the state is improving, which will pro- vide the needed communication backbone. Arkansas A pilot project has deployed telemedicine, including live video feeds and various biometrics, between EMS vehicles and emergency departments. Currently, a few vehicles in urban areas have been outfitted with the system. The system would have more impact in a rural environment where trans- port times are longer, but system expansion depends on the outcome of the pilot project and on funding. Vermont Some EMS providers will transmit heart monitoring data, including during transport from the crash scene to the hospital. Recruiting, Retention, and Training Nebraska At a national level, a high turnover in statewide EMS direc- tors creates challenges in developing and implementing meaningful changes in EMS programs. In addition, state- wide EMS agencies tend to have an immediate need/crisis- focused approach to EMS programs. These issues make research less of a focus. A leadership training initiative is under way to improve relations between ambulance services to improve communi- cation and operational integration. The leadership training is designed for ambulance service managers to learn how to better communicate and lead ambulance service personnel. The training has the following sections: • Listening skills • Conflict resolution • Stress awareness • How to organize and manage a meeting • Professionalism • Public relations. The training is not designed to improve relations with other ambulance services but is designed to improve internal relations which in the long run will help ambulance person- nel work with other ambulance services. A train-the-trainer course involves having an EMS coordinator train about 30 instructors to teach ambulance providers how to transport children more safely. The Community EMS Assessment Program solicits input from individual communities to see what their expec- tations are for the local ambulance service. The program brings in law enforcement, dispatch, hospital administra- tors, nursing home administrators, and the general public to gather information and look for opportunities to improve. The interviewee said that the “program is a great idea, but is only as successful as the community wants to make it.” Sometimes, the report’s recommendations are shelved by the community. Three of the 15 sessions resulted in meaningful changes. Some of the items examined through the program include the following: • Geographic area • Finances • Availability of personnel • Public relations/image in the community • Organizational structure of ambulance service. The Nebraska Volunteer Fire-fighters Association received a grant to look into ways of retaining volunteer EMS staff. Paramedic training to become an EMT offers $300 of reimbursement. Arkansas In Arkansas, about 95% of the EMS service providers are private. The remainder is either provided by fire departments or by volunteers. The volunteer providers are all secondary, not primary providers for a given area. Therefore EMS vol- unteer recruiting/retention is not an issue. Vermont Volunteer recruiting and retention is a recognized need in Vermont, especially given the state’s low population and rural character. Recruitment is done through various local means, including outreach at fundraisers and county fairs. A statewide effort is under way to support the 13 EMS districts with educational outreach/recruitment programs. The Office of Public Health Preparedness and EMS is working with the Medical Reserve Corps (MRC) to get more people involved in medical-related volunteer activities. A new position has been created to within the office to head this initiative. MRC participation is expected to generate interest in EMS volunteering as well. Funding is in place to deploy a “Learning Management System,”an online training tool that will provide EMS train- ing throughout the state. Idaho The Idaho EMS Bureau is leading an effort to reach out to EMS providers throughout the state to address challenges that are encountered in recruiting and retaining what is largely a volunteer EMS response force. The legislatively mandated initiative included 16 town hall meetings that were held throughout the state to gather information on cur- rent practices and challenges. A report is currently being

36 assembled that will detail what is and not working, and make recommendations. West Virginia West Virginia has identified challenges in EMS staff recruitment and retention. The number of volunteers avail- able fluctuates depending on job availability in the area. This is a particular challenge in West Virginia where the coal mining industry generates dynamic labor demands. They have programs in place to visit schools to deliver a recruiting message. Other notes from the interview include the following: • E911 has proven an effective tool. It is often the main tool that dispatchers use to locate a crash and route emergency responders to the scene. • Key partnering agencies include the West Virginia DOT, the Department of Homeland Security, and the Governor’s Highway Safety Program. Much collabora- tion is also required with neighboring states give West Virginia’s geographic characteristics. • The Medical Command Process provides EMS staff with medical guidance during a response. Information is available both online and by phone. • The EMS community collaborated with the West Virginia DOT to write the state’s NHTSA Safety Plan. • West Virginia is working toward greater interoperabil- ity in its communication systems. Agencies targeted for shared communication capabilities include fire, police, hospital, and EMS. • The state EMS department is conducting a perfor- mance improvement initiative that is reaching out to the EMS community to discuss best practices and look for opportunities to make improvements. The initiative is aimed at taking a proactive look at what changes can be made. Tribal EMS Nebraska Nebraska has three tribal ambulance services. The statewide EMS program is working closely with cardiac-related cases with two of the tribes, an area of opportunity for improved patient outcomes. Work is under way to review data being collected, and work with the tribal EMS providers in areas they may need to improve. Arkansas There are no tribal lands in Arkansas. Vermont There are no tribal lands in Vermont. Interagency Cooperation and Coordination Arkansas The state EMS community meets quarterly with the DOT and the Highway Safety Department. These agencies work collaboratively with the EMS community to provide good service. In rural areas, the local EMS providers have good working relationships with their DOT, fire department, and law enforcement counterparts. Vermont The Vermont EMS Office collaborates with the Office for Rural Health and the Governor Highway Safety Program on EMS-related issues in rural areas. Federal funding is provided through HRSA, NHTSA, and the state Depart- ment of Public Safety. EMS Office staff also sits on the Traffic Record Coordinating Committee, which meets monthly. Idaho StateComm manages traffic incidents on the state highway system, dispatches ITD highway maintenance personnel and equipment statewide, and operates much of the traffic operations-related infrastructure, including CCTV, DMS, 511 system, and HAR—even though ITD is not co-located at this facility. StateComm staff follows ITD policy for things such as message selection for DMS. Staff consults ITD when nonstandard messages are required, such as for presence of smoke from wildfires that are present along a roadway cor- ridor. StateComm monitors weather data from the National Oceanic and Atmospheric Administration out of Spokane, Washington; Missoula, Montana; Salt Lake City, Utah; and Pocatello and Boise, Idaho, and distributes key information to counties, Bureau of Homeland Security, air medical agen- cies, and Idaho Power as warranted. StateComm is also the primary state warning point for North American Warning Activation System, part of the Federal Homeland Security system and the primary activation center for the Emergency Alert System. Planning and Innovation West Virginia Another relevant effort in West Virginia is the Governor’s Highway Safety Program. EMS representatives assisted in writing the program’s strategic plan. The plan addresses ele- ments such as motorcycle safety, including safety awareness and helmet laws. The EMS community was involved in the West Virginia DOT Highway Safety Task Force. Some aspects of this study included the following:

37 • Engineering solutions, such as center line rumble strips and median cable barrier • EMS response times • Legislative recommendations, including primary seat belt law, primary texting law (currently in place), and secondary cell phone usage law (set to become primary in July 2013). The OASIS project will generate performance metrics for these initiatives. Other Nebraska Of 46 trauma centers in Nebraska, about 30 are critical access hospitals. Critical access hospitals are generally in rural areas. Once a hospital is identified as critical access, it is eligible for special funding. Critical access certification is dependent on the level of training, the amount of hospi- tal beds, the level of care provided, and other factors. The designation is reviewed every 3 years. Trauma centers have different education requirements. A breakdown of the 46 trauma centers in Nebraska follows: • Level 1 (comprehensive), one center: Omaha • Level 2 (access), three centers: Lincoln, Carney, and Scotts Bluff • Level 3 (general), five centers • Level 4 (basic), 46 centers There is interest in partnering with the anti-texting and seat belt use education outreach efforts. Vermont Vermont has two levels of licensed EMS agencies. EMS- licensed first responder units are generally volunteer- based and use their personal vehicles or fire rescue vehicles to respond to an incident. Their personnel are certified or licensed by the state as EMRs or EMTs and are either associated with the local fire department, or are stand-alone (referred to as “fast” squads). “Transporting” EMS agencies generally arrive on the scene after the first responders and use ambulances to transport patients for hospital care. There are about 90 transporting EMS and 90 EMS-licensed first responder units within the state. The Vermont EMS Office is looking into these rela- tionships to see if EMS resources are properly aligned. Recommendations will likely include improvements in dispatch functions and establishing quality control pro- cedures. Legislation was recently created that establishes an annual EMS funding source for training, education, and future needs. DEPARTMENT OF TRANSPORTATION INTERVIEW REVIEW AND SUMMARIZATION DOT interview findings are summarized into one of nine topic areas: • Record linkages/data metrics • Crash detection/locating/reporting • Road condition reporting • Dispatching • On-scene and transport issues • Air medical transport • Recruiting, retention, and training • Tribal EMS • Interagency cooperation. Four states (Idaho, Arkansas, Vermont, and Nebraska) were selected for a follow-up interview. Idaho The interview was conducted with the Highway Safety Man- ager with the Idaho Transportation Department (ITD). Arkansas The interview was conducted with the assistant division head of Planning and Research, and the section head of Safety within the Arkansas DOT. Vermont The interview was conducted with the traffic safety and pave- ment manager of the Vermont Agency of Transportation. Nebraska The interview was conducted with the NDOR state traffic engineer. Record Linkages and Data Metrics Idaho There are efforts under way to link crash records to trauma registry to provide a more robust database. Crash report- ing currently does not indicate injury severity, outcome, or medical costs. At one time, Idaho EMS personnel placed a medical ID band on patients to track them from the field through to the treatment they received. The practice was discontinued because of chal- lenges in getting emergency departments to retain the bands and process the data when patients were admitted.

38 Vermont Crash data are housed in the traffic safety office. A system is being deployed to place EMS records online. It is hoped that these record systems will be connected in the future. Nebraska Data collection forms are being updated to allow for law enforcement to indicate if there is a secondary crash. Law enforcement CAD does not integrate with EMS CAD or traf- fic management software. Frequent requests for workshops and good attendance at those held indicate a desire for better and more data. Crash Detection, Locating, and Reporting Idaho The Ada County Highway District manages the regional TMC for the Boise area. The TMC supports EMS by provid- ing traffic congestion information. Vermont Enhanced reference mile markers have been placed to ease location identification by callers. Nebraska Access to CCTV cameras is being provided to PSAPs in Douglas County (Omaha area). Road Condition Reporting Idaho ITD and StateComm jointly operate a Condition Acquisition and Reporting System (CARS) 511 traveler information sys- tem. This system provides more functionality than conven- tional 511 systems, including real-time information online and by phone on road closures, special events, weather events, and major traffic incidents. A CARS Mayday project is under way to examine the capabilities of automatic crash notifica- tion (see description provided in Idaho EMS Case Example). StateComm operates several Highway Advisory Radio stations in remote areas. The system is used to inform trav- elers of weather events and major incidents. ITD operates a Road Weather Information System that provides road weather information to the public and EMS community. Arkansas Traffic management plans are developed for major construc- tion projects. These plans include EMS stakeholders when projects are being done in major metropolitan areas, or along interstate roadways. The DOT posts road construction information and weather-related road condition information on their website in text and map form. No 511 system is in place and no direct communication with EMS providers is done regarding road condition information. Vermont Road conditions are communicated through voice radio to state police from the statewide traffic management center. Nebraska Nebraska uses 70 environmental sensor stations to provide road condition information on 30-mile segments of roadway through Meridian Environmental. Weather information is available through the 511 traveler information service. Dispatching Idaho The statewide radio system is supported by StateComm. Arkansas Arkansas has a statewide wireless information network. This network is used by the highway police (DOT employ- ees) as well as other first responders for communication. See http://www.awin.arkansas.gov/systemInformation/Pages/ usage.aspx for more information. Vermont Vermont has a statewide radio network for maintenance and other transportation-related dispatch and uses a central dispatching location. The interviewee did not believe this network is interoperable with EMS networks; therefore, the information hand-off is between dispatchers. Nebraska Deployment of an interoperable voice and data radio network is under way. Handheld radios are available for EMS use.

39 On-Scene and Transport Issues Idaho StateComm monitors CCTV along key roadways to aid in managing crash scenes. Idaho responders understand the importance of quick incident clearance to minimize the occurrence of secondary crashes and the disruption of traf- fic flow that impacts commerce. Idaho is pilot testing a Crash Help system that improves patient care in the field. The system also reduces the amount of time that EMS personnel spend at the scene of a crash by making information communications more efficiently (see description provided in Idaho EMS Case Example). Arkansas DOT staff strives to minimize traffic disruptions created by incidents. Highway police officers receive work zone and traffic incident management training on best on-scene prac- tices, but their primary role is in heavy commercial vehicle enforcement and permitting. Arkansas State Police is the designated state agency for public safety, and along with local police/sheriff departments is primarily responsible for handling crash scenes. Air Medical Transport Idaho ITD is starting a research project to examine the feasibil- ity of installing a series of helipads along rural high-crash corridors to facilitate medical transport by air. Helicopters currently require a full roadway closure for a significant amount of time, creating safety and delay impacts. Placing designated landing sites off the roadway right-of-way could provide an improved evacuation practice. The EMS vehicle would transport a patient to the nearest landing site where the patient transfer could be done away from the roadway. The research project will examine crash data and cost to deter- mine the feasibility of moving forward with deployment. Recruiting, Retention, and Training Idaho Because Idaho is largely a rural state, ITD maintenance workers are often the first to come upon crash scenes. ITD requires all maintenance personnel to be trained in cardio- pulmonary resuscitation (CPR) and basic first aid so they can render aid in these emergency situations. Several main- tenance workers have more advanced training, including EMT certification. Refresher courses are required to keep training current. A culture of maintenance staff providing emergency aid exists, and is made clear to new hires. The StateComm dispatchers have medical dispatcher certifica- tion, allowing them to provide remote support as needed. Vermont Staff has been trained on incident management through the I-95 Corridor Coalition. Outreach between transportation and fire departments/EMS has been discussed, but there is no momentum for further action. Nebraska Traffic incident management is taught to NDOR mainte- nance personnel. This generates some interest in getting further training, such as CPR. Some efforts have been made through workshops to engage with fire departments to use NDOR resources, such as advanced warning signs. There is some interest in using safety funds for this engagement. Tribal EMS Nebraska Tribal governments provide law enforcement, but EMS is provided by non-native personnel. Interagency Cooperation Idaho The ITD highway safety manager interviewed for this case example was recently appointed to the EMS Advisory Committee, the first time that ITD has been represented on this committee. This role will provide an opportu- nity to strengthen ties between the transportation and EMS communities. StateComm is part of the Idaho Department of Health and Welfare. StateComm employees perform traffic opera- tions functions at the center, including traveler information and traffic surveillance functions. Since these employees are part of the health department, they are more connected to the EMS community than a conventional DOT-operated TMC would be, and are well equipped to provide effective infor- mation to EMS personnel. StateComm has performed traffic operations functions since the EMS Bureau deployed a statewide radio system. ITD contracted with the EMS Bureau to use this communi- cation backbone to provide dispatch functions to ITD main- tenance vehicles in the state’s six districts. Maintenance vehicles coordinate snow plowing and other maintenance operations directly with StateComm. This role evolved into StateComm taking on more traffic operations functions.

40 StateComm is co-located with Idaho State Police. Arkansas The DOT works with the Governor’s Highway Safety Office (part of the Arkansas State Police) on NHTSA grants that are used for safety improvements. Representatives from various agencies are on the SHSP steering committee that provides valuable input for improving highway safety in the state. The participating agencies are shown in the following list: • Arkansas State Highway and Transportation Department, and its Arkansas Highway Police division • Arkansas State Police, and its Arkansas Highway Safety Office division • Arkansas Department of Health • Arkansas Department of Finance and Administration • Arkansas Administrative Office of the Courts • Little Rock Police Department • Metroplan • Pulaski County • West Memphis Metropolitan Planning Organization • FHWA • FMCSA • NHTSA. Vermont The agency has had some success coordinating and partner- ing with EMS agencies in the SHSP framework. Value is seen in more interaction with the state department of health and EMS. Nebraska Most planning and collaboration with EMS is pre-incident and during-incident review. NDOR typically assists with road closures.