Benefits of such a system are thought to include greater standardization in the quality of patient care through employer oversight, mandated training, and quality assurance and improvement. Many states and communities, however, still rely heavily on volunteers to provide ambulance coverage; in particular, volunteer personnel have traditionally been the lifeblood of rural EMS agencies. Volunteers may also have preassigned shifts but generally are not paid for their time, although recent research suggests that a fairly large percentage of volunteers receive financial compensation for their EMS activity Margolis and Studnek, Equipment and vehicles are frequently maintained using donations or public funds.
Oversight of volunteer systems is sometimes provided by the municipal or county agency responsible for EMS, if one exists. The benefits of a volunteer system include the significant cost savings from not having to pay personnel. However, the challenge is maintaining a response system that consistently meets the public demand for quality services. Most experts agree that there appears to be a national trend toward decreasing volunteerism and an increase in EMS personnel seeking paid careers. During the early stages of EMS, it was not uncommon for volunteers to be on call nearly 24 hours a day.
As a result, rural EMS agencies in particular are currently faced with volunteer staffing shortages, particularly during weekday work hours.
Many systems are a combination of volunteer- and career-based because of the challenges of maintaining an entirely volunteer system. Such combined systems represent an attempt to achieve cost savings while ensuring adequate services to the public. However, the sustainability of each type of system—career, volunteer, and combination—is unclear as a result of the resource demands on career systems and the lack of personnel for volunteer systems. Air medical operations have grown substantially since their inception in the s. Today there are an estimated — medical helicopters operating in the United States Gearhart et al.
These helicopter operations are owned and managed by a variety of entities, including for-profit providers, nonprofit organizations such as local hospitals, government agencies such as the state police, and military air medical service providers. Many air medical providers were originally employed as hospital contractors but now work on an independent basis.
Typically, the base helipads for these providers are located in airports, independent hangars and helipads, and designated areas of a hospital Branas et al. Air ambulance operations have served thousands of critically ill or injured persons over the past several decades Blumen and UCAN Safety Committee, However, there has been growing concern about the safety of these operations.
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Approximately people have lost their lives as a result of air medical crashes since , and these deaths have been increasing as the industry continues to expand Blumen and UCAN Safety Committee, ; Bledsoe, ; Baker et al. Crashes are often attributable to pilots flying in poor weather or at night. Li and colleagues found a four-fold risk of a fatal crash in flights that encountered reduced visibility.
Baker and colleagues found that crashes in darkness represented 48 percent of all crashes and 68 percent of all fatal crashes. In addition, some companies are flying older, single-engine helicopters that lack the instruments needed to help pilots navigate safely Meier, Recent increases in Medicare payments have led to greater competition in the industry, which has added to concerns regarding safety Meier, Air medical services are believed to improve patient outcomes because of two primary factors: reduced transport time to definitive care and a higher skill mix applied during transport.
However, presumed gains in transport time do not necessarily occur, given the time it takes the helicopter crew to launch, find a suitable landing position, and provide care at the scene. This is especially true when the distance to the scene is short. Questions have also been raised regarding the appropriateness of air ambulance deployments in specific patient care situations Schiller et al.
A study found that helicopters were used excessively for patients who were not. On the other hand, a number of other studies suggest benefits of air ambulance service relative to ground transport. Davis and colleagues found that patients with moderate to severe traumatic brain injury who received care through air ambulance had improved outcomes.
In addition, the study found that out-of-hospital intubation among air-transported patients resulted in better outcomes than ED intubation among ground-transported patients. Patients with more severe injuries appeared to derive the greatest benefit from air medical transport. And Gearhart and colleagues reviewed the literature and reported 1—12 additional survivors per patients flown. According to the U.
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Residents of these areas experience significant health disparities relative to their urban counterparts Pollock, A large portion of these disparities results from the distinctive cultural, social, economic, and geographic characteristics that define rural America, but the situation also reflects the difficulty of applying medical systems designed for urban environments to rural and frontier communities. Rural EMS systems face a multitude of challenges. A particularly daunting challenge is providing adequate access to care given the distances involved and the limited assets available.
Ensuring the delivery of quality EMS to rural populations is also complicated by the makeup and skill level of prehospital EMS personnel and associated issues of management, funding, and medical direction for rural EMS systems. A more recent national assessment found that 77 percent of EMS personnel in rural areas were volunteers, compared with 33 percent in urban areas Minnesota Department of Health, Office of Rural Health Primary Care, In a survey of national and state rural health experts, 73 percent identified access to health care as a priority issue, and EMS access was cited as a primary concern Gamm et al.
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In its report Quality Through. As noted in Chapter 1 , EMS response times from the instigating event to arrival at the hospital are significantly longer in rural than in urban areas. These prolonged response times occur at each step in EMS activation and response, including time to EMS notification, time from EMS notification to arrival at the scene, and time from arrival at the scene to arrival at the hospital. A survey found that 30 percent of rural patients fatally injured in a crash compared with 8. These prolonged response times are attributable to the increased distances involved, but also to other factors, such as the limits of availability in sparsely populated areas.
While the availability of extends to the vast majority of the U. Moreover, enhanced , which provides geographic data to the dispatch center so the location of an incident can be pinpointed, is difficult to implement when a large portion of the rural population uses rural routes and post office boxes to designate addresses Gausche and Seidel, In addition, the small number of ambulances available in some rural regions and the inability to priority dispatch these ambulances if there is only one unit available remain a challenge Key, One of the first obstacles to timely EMS activation in rural areas is the delay that commonly occurs in the discovery of crash scenes.
On infrequently traveled rural roads, a long time may elapse before victims are discovered. This delay may be the single largest contributor to prolonged times until transport to a hospital Esposito et al. In a study of rural Missouri, only 39 percent of calls alerting EMS came within 5 minutes of the collision, compared with 90 percent in urban study areas Brodsky, Automated collision notification systems offer the potential for significant improvement in this area see Chapter 5.
When prehospital EMS is activated, there is significant local variation in the type and quality of services provided.
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Rural EMTs working in an isolated environment while treating a critically ill or injured patient will spend more time with the patient and use fewer resources than urban EMTs or paramedics. Certain clinical scenarios may actually require a greater skill level and more multitasking on the part of rural EMTs as compared with their urban counterparts. As noted, however, EMS systems in rural areas are staffed largely by volunteers with highly variable levels of expertise, training, and experience. A rural EMT may encounter highly critical cases.
For the limited number of EMS personnel in a largely volunteer system, formal training and critical care experience are often lacking, and even when such training is attained, the low volume of calls contributes to the degradation of critical care skills. Moreover, access to continuing education may be scarce in rural areas Key, Additionally, volunteer organizations experience a higher level of provider turnover, which may reduce the number of experienced volunteers.
Taken together, these factors mean that rural EMS providers may be less proficient than urban providers. Even when rural EMTs are trained to perform critical tasks, such as endotracheal intubation, their success rate is poor Sayre et al. In one study, despite training, rural EMS personnel were able to intubate only 49 percent of their patients successfully.
Cited as possible explanations for this low success rate were training deficiencies, infrequent intubation opportunities, and inconsistent supervision Bradley et al. Likewise, Spaite pointed out that rural EMS personnel with defibrillator training may defibrillate a patient only two or three times in a decade, emphasizing a pivotal role for the use of automated external defibrillators.
In addition, even when ALS is available in rural areas, the services have repeatedly been demonstrated to be provided at much lower levels of quality than in urban settings Gausche et al. The availability and qualifications of EMS medical directors are also an issue. Many of these individuals have little or no experience in EMS medical direction. A survey of state EMS directors indicated that recruitment of medical directors is frequently very difficult and that providers serving in that role are often primary care physicians with little or no emergency medicine training.
While on-line continuing medical education is becoming more available, it has been slow to take hold; moreover, such training can impart cognitive information, but typically does not teach technical and procedural skills. Nevertheless, the use of telemedicine and distance learning allows previously inaccessible training to penetrate remote areas, while new, more realistic and dynamic patient simulators enable case-based honing of critical skills and decision-making abilities.
These tools may be able to offset some of the problems with skill deterioration due to the limited experience attained in rural areas McGinnis, A number of strategies for optimizing EMS resources have been proposed to deal with the paucity of funding, response units, and other resources in rural areas. One such proposal is the dynamic load-responsive deployment of ambulance units. With this approach, ambulances are positioned strategically throughout an area and are dispatched centrally in an effort to reduce response times.
Determination of where to position individual units is based on the demand in each area combined with the distance to be traveled, using an established average response time. In one study, load-responsive deployment in a rural area resulted in a 32 percent increase in the number of calls responded to within the established time allowance of 8 minutes Peleg and Pliskin, While promising, however, this approach is not possible in very isolated rural communities where EMS units are staffed by volunteers who respond from home. Another method found to increase the efficiency of EMS systems in rural areas is the establishment of regionally based systems.
Such systems may be organized in countywide or larger areas, with ambulances being prepositioned in strategic locations and dispatched centrally Key, Basic EMS providers and fire departments scattered throughout the area can act as first responders, with fully equipped units responding after dispatch.
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Such a system has been used successfully on San Juan Island, a rural island off the coast of Washington State. Killien and colleagues demonstrated a survival to discharge rate for out-of-hospital cardiac arrest of 22 percent employing this type of system, whereas most studies in rural areas have found survival rates of less than 10 percent Killien et al.
This system serves nearly 17, square miles over 17 counties, with 85 ambulance units and two helicopters. Units are dispatched through a central dispatcher using a modern global positioning system for geographic information East Texas Medical Center Regional Healthcare System, In this way, a large rural area encompassing many counties can be served by an EMS system with up-to-date equipment and resources that could not be sustained financially by any one county alone.
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