A Guide for Enhancing Rural Emergency Medical Services (2005)

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III-1 SECTION III Type of Problem Being Addressed General Description of the Problem When comparing highway safety information between rural and urban areas, it becomes evident that a disproportionate number of severe crashes occur in rural areas. First, according to some inventory and operational data for the U.S. highway system, in 2002 there were 4,943,396 km (3,071,768 miles) of public roads in rural areas and 1,439,883 km (894,726 miles) in urban areas (FHWA, 2002). In 2002, approximately 60 percent of the total vehicle- miles traveled (VMT) on state agency roads were in urban areas (1,727,596 VMT in millions), and 40 percent (1,128,160 VMT in millions) were in rural areas (FHWA, 2002). These percentages show that although there are significantly more rural road miles, most of the travel takes place in urban areas. According to the crash data, more fatalities occur on rural roads. In 2002, 716 fatal crashes resulted in 25,849 fatalities in rural areas. Urban areas accounted for 15,440 fatal crashes resulting in 16,792 fatalities (NHTSA, undated [d]). Exhibit III-1 graphs the fatal crash and VMT data and displays the related crash rates. 0 5,000 10,000 15,000 20,000 25,000 0 0.5 mill 1.0 mill 1.5 mill 2.0 mill VMT N o. F at al C ra sh es Rural Urban 2.01 crashes 100 m 0.89 crashes 100 m EXHIBIT III-1 Rural and Urban Fatal Crashes Compared Using VMT Sources: NHTSA, undated (b); NHTSA, undated (d); FHWA, undated Exhibit III-2 and Exhibit III-3 illustrate some overall trends between rural and urban areas. Exhibit III-2 compares the number of fatalities by year and location from 1995 to 2002. From 1995 to 2002, approximately 8,000 more fatalities occurred annually in rural areas. Exhibit III-3 compares the fatality rates by year and location from 1995 to 2002. From a positive perspective, the fatality rates have been decreasing in both rural and urban areas; however, the fatality rate in rural areas has consistently been about 1.3 percentage points higher than the fatality rate in urban areas.

SECTION III—TYPE OF PROBLEM BEING ADDRESSED III-2 0 5,000 10,000 15,000 20,000 25,000 30,000 1995 1996 1997 1998 1999 2000 2001 2002 Year N um be r o f F at al iti es Rural Urban EXHIBIT III-2 Number of Traffic Fatalities by Year and Location, 1995–2002 Sources: FHWA, 2002; NHTSA, undated (b); NHTSA, undated (d) EXHIBIT III-3 Fatality Rates by Year and Location, 1995–2002 Sources: FHWA, 2002; NHTSA, undated (b); NHTSA, undated (d) 0 0.5 1 1.5 2 2.5 3 1995 1996 1997 1998 1999 2000 2001 2002 Year Fa ta lit ie s pe r 1 00 M ill io n VM T Rural Urban

SECTION III—TYPE OF PROBLEM BEING ADDRESSED Exhibit III-4 illustrates geographical variations in death rates from motor vehicle crashes. Based upon data from 1979 to 1981, population-based death rates of occupants of motor vehicles were calculated and mapped according to county for the continental United States (Baker et al., 1987). The average death rate was 18.7 per 100,000 people for the entire United States, but the rate varied dramatically from one county to another. Mortality was highest in counties with low population density, and the highest death rates were seen predominantly in counties with fewer than five people per square mile. Thus, Exhibit III-4 implies that mortality rate is inversely correlated with the population density pattern. III-3 EXHIBIT III-4 Death Rates of Occupants of Motor Vehicles per 100,000 People According to County, 1979–1981 Source: Baker et al., 1987 The highway safety community often focuses on mortality, and most of the data that are presented in this chapter are for fatal crashes. It should be recognized, however, that morbidity is also an important issue. Morbidity is often not a focus in part because the data are difficult to obtain. Data collection, interpretation, and evaluation are hampered by a variety of obstacles that require careful consideration and must be addressed in a systematic manner. The evolution and establishment of an EMS data collection system from which outcome measures can be derived have progressed slowly and sporadically. A compounding factor is the lack of standard nomenclature within EMS to describe patient conditions or to document patient care. In addition, EMS agencies and programs do not currently have either the appropriate number or type of personnel, or adequate funding, to support EMS evaluation efforts. The out-of-hospital setting is often considered to be a difficult environment in which to conduct outcome evaluations due to the lack of standardized care and the difficulty in identifying representative populations to study (NHTSA, 1994[a]). The following section discusses specific attributes of the safety problems in rural areas and identifies a host of the challenges that EMS providers face in rural settings.

Specific Attributes of the Problem Victims of motor vehicle crashes suffer disproportionately higher fatality rates in rural areas than in urban areas. This fact can be attributed to several factors, including differences in travel speeds, seat belt use, types of vehicles, and availability of emergency care (Baker et al., 1987). Exhibit III-5 shows the percentage of fatal crashes by speed limit and location for 2002 (NHTSA, 2004[a]). The exhibit reveals that most of the fatal crashes in rural areas are occurring on roads with higher speed limits. Approximately 70 percent of all fatal crashes on roadways with lower speed limits (40 mph or less) are in urban areas. Fatal crashes occurring on roadways with moderately high speed limits (45 to 50 mph) are evenly split. Over 70 percent of the fatal crashes on roadways with high speed limits (55 mph or higher) occur in rural areas. Thus, EMS providers in rural areas must respond to a disproportionately high number of calls where the crash victims are likely to be severely or fatally injured as a result of high-speed travel. SECTION III—TYPE OF PROBLEM BEING ADDRESSED III-4 0 10 20 30 40 50 60 70 80 90 30 mph or less 35 or 40 mph 45 or 50 mph 55 mph 60 mph or higher Speed Limit Pe rc en t o f F at al C ra sh es b y Lo ca tio n Rural Urban EXHIBIT III-5 Percent of Fatal Crashes by Speed Limit and Location in 2002 Source: NHTSA, 2004(a) Seat belt use and vehicle type may also contribute to the higher fatality rate in rural areas. Vehicle occupants involved in rural fatal crashes are ejected 27 percent of the time, while vehicle occupants involved in urban fatal crashes are ejected 15 percent of the time (NHTSA, undated [d]). This suggests that vehicle occupants in rural areas are less likely to wear seat belts. Over recent years, the seat belt use in rural areas has increased. In 2002, seat belt use reached 73 percent in rural areas, which is very close to the 2002 national average of 75 percent (NHTSA, 2003[b]). However, the use of seat belts is very low (54 percent) among occupants of pickup trucks in rural areas, so the lower use of seat belts in these popular vehicles in rural areas may contribute to the high severities.

SECTION III—TYPE OF PROBLEM BEING ADDRESSED Two fundamental issues are apparent in assessing potential improvements to EMS care for victims of rural highway crashes: (1) minimizing response times for personnel and equipment to treat crash victims and (2) improving the quality of medical care afforded to victims. Emergency medical care experience has shown that for many serious injuries, time is critical (Champion, 1999). The “golden hour” of trauma care is a concept that emphasizes this time dependency. For polytrauma patients (i.e., patients who suffer multiple injuries), the first hour of care is critical. If the time from the incident to hospital treatment is within this critical first hour, the patient’s likelihood of survival is greatly increased (Rawlinson and Crews, 2003). In trauma care, the goal is to get seriously injured patients into the operating room of a trauma center with an experienced team of appropriately specialized trauma surgeons within this golden hour. Meeting this goal requires a highly efficient and effective EMS system. In general, the time to deliver patients to definitive care consists of the six time intervals: 1. Time between crash occurrence and EMS notification, 2. Response time for EMS personnel to be notified and depart the station (i.e., chute time), 3. Travel time to the crash scene by EMS, 4. On-scene EMS rescue time, 5. Transport time to a hospital or trauma center, and 6. Emergency department resuscitation time. The average elapsed time for several of these time intervals typically is longer in rural areas, as illustrated below. Exhibit III-6 compares the national average response times for fatal crashes in rural and urban environments as reported by NHTSA. The exhibit divides response time into three time intervals. The exhibit reveals that average response times for each of the intervals is greater in rural areas than in urban areas. This trend has remained relatively consistent during recent years. Exhibit III-7 compares the EMS response times nationally within designated minutes for fatal crashes in 2002 as reported by NHTSA. Approximately 30 percent of the rural fatal crashes exceeded the golden hour, while only about 8 percent of the urban fatal crashes exceeded it. The percentage of fatal crashes with a response time greater than 60 minutes has remained relatively constant since at least the early 1990s (Champion, 1999). There are many reasons why EMS response times in rural areas are typically longer than in urban areas. For example, delays or greater response times in rural areas are related to increased travel distances in rural areas and personnel distribution across the response areas. Significant delays may also occur as volunteers travel to the EMS station and pick up the ambulance. Unfortunately, because greater distances are involved and because volunteers are distributed throughout the community, longer response times may be unavoidable in rural areas. In addition, in rural areas without well-designed trauma systems, delays may occur in moving patients from rural hospitals with limited surgical capabilities to tertiary care centers (i.e., trauma centers) specifically established to treat such patients. Regardless, a key concern of any program to meaningfully address the EMS role in fatal crashes should be the minimizing of EMS response times. Note that caution is needed in analyzing response times for rural EMS systems. In some cases, the ability of rural EMS systems to effectively measure and understand response time III-5

SECTION III—TYPE OF PROBLEM BEING ADDRESSED III-6 0 5 10 15 20 25 30 35 40 0 to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 120 Response Time (Minutes) Pe rc en ta ge Rural Urban EXHIBIT III-7 Fatal Crashes by EMS Response Times within Designated Minutes in 2002 Source: NHTSA, 2004(a) 3 7 min. 27 min. 0 10 20 30 40 50 Note: Times rounded to the nearest minute. 60 Arrival at Scene to Time of Arrival at Hospital Notification to the Time of Arrival at Scene Time of Crash to Notification Time 7 min. 12 min. 37 min. EXHIBIT III-6 National Average EMS Response Times for Fatal Crashes in 2002 Source, NHTSA, 2004(a)

SECTION III—TYPE OF PROBLEM BEING ADDRESSED performance is limited. Many data points are self reported, and accurate response time intervals are often not collected. There also appear to be significant differences in the definitions used for certain response intervals. For example, in some parts of the country, “response time” means the time it took the provider to be notified and respond to the station and does not include time to the scene. These differences in definitions often result in distorted or inaccurate data or comparisons. Effective data collection systems to adequately evaluate performance are also limited. Most useable data are based on fatal crashes with little emphasis on morbidity, even though the majority of responses are for morbid crashes. Improvements in the quality of medical care also appear possible. According to a study of preventable deaths and inappropriate care in a rural state, there is definite room for improvement in EMS systems (Esposito et al., 2003). A review of 347 trauma-related deaths revealed an overall preventable death rate of 8 percent after implementation of a voluntary trauma system. The overall rate of inappropriate care was 22 percent during prehospital care, 40 percent during the emergency department phase of care, and 29 percent during the post–emergency department phase. This guide focuses on approaches to improve the quality of care and reduce the response time during the prehospital phase. However, it should be recognized that delays in secondary transfers and the quality of care following the prehospital phase significantly impact the overall outcome of the crash victim. In summary, travel speed, seat belt use, type of vehicle, and availability of emergency care in rural areas are a few of the factors that contribute to the disproportionately high fatality rate for rural crash victims. There is also a need for better data on which to base management decisions, as well as to improve the quality of care. Several other implementation guides have been developed to address some of these issues (e.g., roadway characteristics and seat belt usage). This implementation guide focuses on the availability of emergency care in rural areas and ways to improve the response and quality of care provided by EMS in rural areas. III-7