Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
41 CHAPTER FIVE CONCLUSIONS impact on trips over 20 miles. The usefulness of these devices is also perceived by users to be greater in areas with complex travel patterns (e.g., one-way streets) or areas with poorly marked roadways and addresses. Limitation on effectives were noted where users were not familiar with the devices, or the underlying geographic data were incomplete or incorrect. As a result, some agencies have curtailed their use of GPS in favor of paper maps. The majority of survey respondents used GPS guidance of some sort, indicating that some utility is found in GPS guidance for emergency responders. Automated Crash Notification (ACN)/ Advanced Auto- matic Crash Notification (AACN) pilot programs were reported by one survey respondent. Studies have shown that ACN can reduce crash to notification times to no more than 1 minute, potentially saving several minutes of overall response time. AACN systems expand on the ACN concept by communicating data such as restraint use, air bag deploy- ment, change in velocity, and direction of impact to provide insight into the severity of injuries to the crash occupants. Data are not yet available on the effect of AACN systems on patient outcomes or the reliability of vehicle sensor systems. All of the DOT respondents indicated that they had sys- tems to monitor and report roadway conditions, including weather, construction, and maintenance activities that can affect traffic flow. Interoperable communication systems are in place or actively being developed by all states covered in this synthesis. Although these systems greatly enhance the ability for emergency respond- ers from different jurisdictions to communicate with each other, they are primarily used for voice communications and low-data- rate electronic information, making them unsuitable for higher- bandwidth applications such as multimedia telemedicine. TRAUMA CARE In the survey of EMS personnel, 50% indicated that equip- ment issues had delayed departures, and the same number said that there was no checklist or standard procedure to ensure that equipment was available an in working condi- tion. In the case examples, West Virginia reported that the EMS community has inspection criteria for vehicles and was not aware of readiness issues in the state. INTRODUCTION The synthesis examined a number of topic areas related to emergency medical services (EMS) response to rural crashes from both the EMS provider and transportation system steward perspectives. This chapter summarizes key findings, outlines possible areas of future study, and presents conclusions drawn from the literature search, survey, and interview data collection efforts. There are numerous efforts to characterize and improve EMS response to rural crashes, but these have tended to be conducted by individual agencies, generally covering a sin- gle state as the largest area of action. National efforts have focused on creating standards for care and data management structures, or have developed strategies for other units of government to implement. Although a sample of 14 states was used to prepare the synthesis, care should be taken to avoid generalizing to the remaining 36 states, as geography, demographics, and local needs may vary substantially. This chapter is organized into five sections to clearly syn- thesize information across a wide variety of functional areas: ⢠Dispatch, including crash detection and reporting, road condition reporting, dispatching functions, and com- munication systems. ⢠Trauma care, including equipment and preparation, on-scene and transport issues, air medical transport, telemedicine, tribal EMS, and care protocols and procedures. ⢠EMS management, including staff recruiting, reten- tions and training, interagency cooperation and coor- dination, and planning and innovation. ⢠Data inclusion with retrospective and real-time data linkages and data metrics. ⢠Areas of future study. DISPATCH Studies have shown that using Global Positioning System (GPS) guidance systems for emergency responders can reduce the time from departure to arrival on-scene; however, there are important limitations. The effect of GPS guidance devices is more pronounced on longer trips, with the greatest
42 A number of documents have been produced to provide guidance for on-scene care and crash scene traffic manage- ment. Half of the EMS survey respondents replied that there were standard protocols and procedures in place for care in their state, and approximately the same number indicated that there were programs in place to evaluate these pro- cesses. However, scant data are available to determine the effect of standardizing protocols on patient outcomes. The use of air medical transport is limited by its availabil- ity in rural areas. Further, the impact on patient outcomes is a subject of debate. 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. This conflicts with dispatch requests for air transport, which are typically based on distance from a trauma facility rather than injury severity, as this information is generally not available during initial dispatch. There may be a synergy between AACN, which can indicate severity and more efficient use of air transport for rural crash patients. The efficacy of center-to-center telemedicine systems in improving patient outcomes is still under study. Objective measures have not uniformly shown improvements in the quality or effectiveness of care; however, many of the users surveyed believed that these systems were helpful in provid- ing treatment. The use of scene-to-center telemedicine is not well understood in rural environments, as the availability of a supporting communication system is a limiting factor. DATA Although information about crashes, transport times and injuries is routinely collected, only two survey respondents replied that they collected any data related to patient out- comes and no costs or agency compensation. This lack of information makes it difficult to assess the efficacy of medical interventions or to determine their cost-effectiveness. Link- ing these records has proven challenging as there are no direct identifiers to allow them to be related, and as a result statisti- cal matching approaches have been applied with some suc- cess. A program to collect crash scene and patient data during response and transmit it to hospital staff has been deployed as an evaluation in Idaho. This approach allows for direct con- nection between data collected at the scene and patient out- come data as the information is part of the patient care record. EMERGENCY MEDICAL SERVICES MANAGEMENT Data regarding performance of tribal EMS providers are scarce. During the EMS case example interviews, one respondent identified cooperation with tribal providers on cardiac-related cases as an opportunity to improve patient outcomes. Anecdotal evidence indicates that the practices used by tribal providers are improving, but objective mea- sures are not available. Ensuring cooperation and coordina- tion of resources may offer an opportunity to improve care on and near tribal lands. All EMS case example participants identified concerns over the ability to recruit, retain, and train EMS person- nel. The majority of EMS survey respondents indicated that staffing levels had adversely affected response times. Only one survey reported that there was any program in place to recruit volunteers from other agencies [such as depart- ment of transportation (DOT) maintenance staffs]. Idaho is currently studying this issue through a public participation process, and most states have a recruiting effort though a presence at public events or appearances at schools. All EMS and DOT respondents for both the surveys and case examples indicated that an ongoing relationship existed and regular exchanges of information occurred. These rela- tionships have been the foundation for incident management coordination and will play a key role both for direct coopera- tion for scene management (e.g., maintenance, traffic con- trol) and for enabling record linkages. AREAS OF FUTURE STUDY Based on the information collected for this report, several areas are presented as possible avenues of future study: ⢠Although evidence suggests that using GPS 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, a standard or method of verifica- tion of the mapping data used by devices and guidelines for training users could be implemented. ⢠AACN deployments have largely been ad hoc through OnStar or a similar service, or have been conducted as evaluations and tests. Coordinated deployment on a larger scale to mainstream the use of automatic notifi- cations could allow for a more complete assessment of its impact on arrival times. ⢠AACN offers the potential to provide an early assess- ment of the risk of severe injury, which can assist pro- viders with predeparture preparation and dispatchers with responder selection (e.g., air transport, rescue units). Little is known about the long-term reliability of vehicle-based sensors for these applications or AACNs effect on patient outcomes. ⢠EMS responses indicate that access to road condition information is valuable, but not easily accessible in the predeparture sequence of events. All DOTs provide near real-time information on state-jurisdiction road- ways, including construction information and roadway
43 condition. EMS personnelâs inability to easily access data may be addressable through purpose-designed interfaces and appropriate access devices. ⢠All states included in the study have or are deploying interoperable digital communications networks that encompass a number of agencies. These networks primar- ily serve voice and low-bandwidth data communications functions, which limit some applications such as telemed- icine using 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 equipment condition or availability identified as a factor in response times, methods for ensuring readi- ness may be a useful tool. ⢠Use of air medical transport and its impact on patient outcomes does not have definitive evidence; however, it appears that patient injury severity rather than dis- tance is 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. ⢠The literature review revealed conflicting information regarding the efficacy of telemedicine in the center-to- center environment. Further studies of objective mea- sures of patient outcomes may provide insight into the viability and effectiveness of telemedicine applications. ⢠The use of telemedicine in the scene-to-center or mobile telemedicine is dependent 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 will define the broad parameters of mobile telemedicine uses and limits of deployment. ⢠The existing efforts to collect real-time patient data and link that information to other record sets should be examined to determine the effect on patient outcomes. As a related effort, ways to connect outcomes to cost data will permit cost-effectiveness analysis that is not currently possible. ⢠There appears to be little data on differences in proce- dures or outcomes between tribal and nontribal EMS providers. Investigation of opportunities to work with tribal governments to assess performance, and enhance services through coordination, unified training or care protocols, and sharing of resources may highlight way to improve care for patients on or near tribal lands.
