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The decision to add a second hospital-based EMS helicopter
PROGRAM MANAGEMENT
The Decision to Add A Second Hospital-Based EMS Helicopter Robert Friedman, MD; Michael J. Leicht, MD, FAGEP; Sheldon BrotmanMD, FAGS
Carraway Medical center's LIfe Saver program (Birmingham, AL) grew from one helicopter and 391 transports In 1981 to three ships and more than 1,900 annual transports currently.
Abstract An analysis of the first seven years of performance of our hospital-based emergency medical services (EMS) helicopter was conducted to evaluate the possible need for a second aircraft. A survey of seven hospitals currently operating two or more helicopters resulted in a consensus that one helicopter can effectively perform only 70 to 90 flights per month. The number of requests for our helicopter service has increased 148% from 610 to 1,512 in seven years while the number of completed missions has increased only 92% from 486 (40.5/month) to 935 (78/month). Requests denied due to inclement weather (265 in 1988) cannot be captured with a second visual-flight-
rated (VFR) EMS helicopter; however, those missed due to maintenance requirementsof the helicopter and overlapping requests (232 in 1988) can be captured. The need for a second aircraft exists when the number of requests for the service grows while the number of captured flights plateaus. Our data and industry survey suggests this will occur at 75 captured flights per month. Affordability and continued overall growth of trauma and other critical care referrals to the base hospital(s) is mandatory. This study provides a model for hospital-basedEMS helicopter operators to apply to the decision whether to add a second aircraft.
-------_._-----_._-_. -----
Introduction Helicopters have played an increasing role in emergency medical services (EMS) missions since the Korean War. By 1972, dedicated EMS helicopters were being stationed at major hospitals. Recent studies have attempted to demonstrate that air medical evacuation of accident victims to trauma centers with or without a physician on-board can have a positive impact on patient outcome. Over the 14
last 15 years, most major population centers have obtained paramedic or emergency medical technician prehospital care services and some areas have developed regional trauma care centers. Medical personnel, now more attuned to helicopter usage, have greatly increased requests for retrieval. At our institution, an increasing inability to respond to aeromedical transport requests with the existing single dedicated helicopter led to a
study of the need for an additional aircraft. The results of the study supported the complex decision to add a second EMS helicopter. Methods We retrospectively analyzed the first seven years of performance with a single helicopter system with attention to total requests and missed flights and the reasons for the increases in both. Additionally, a market-
The Journal of Air Medical Transport· November 1989
PROGRAM MANAGEMENT ing survey of seven hospitals with two or more EMS helicopters was conducted in order to predict the need and impact of a second helicopter. Finally, the estimated cost of acquiring a second helicopter was considered.
Results Requests for helicopter service more than doubled from 1982 (610) to 1988 (1,512). At the same time actual patient transports have increased at a slower rate (fable 1). When these figures are plotted it is clear that, although requests have continued to grow significantly, the number of captured flights has begun to plateau (Figure 1). The number of trauma patients transported by helicopter increased 85% between 1982 and 1988 from 185 (36 scene calls) to 326 (146 scene calls), respectively. A breakdown of missed flights is necessary to determine how many can be captured by a second dedicated VFR helicopter (fable 2). While none of the inclement weather category can be captured without addition of an instrumentflight-rated (lFR) helicopter, almost all of those missed because of maintenance downtime and overlapping requests (232in 1988)could be captured with a second VFR helicopter. We surveyed seven hospitals with more than one EMS helicopter:Jewish Hospital (Louisville, KY), Allegheny General (Pittsburgh, PAl, University of Minnesota, (St. Paul, MN), Carraway Methodistl, (Birmingham, AL), Cleveland Metropolitan General (Cleveland, Om, Grant Medical Center, (Columbus, OH), and Methodist, (Memphis,1N). The survey indicated:
Air Meet at the University Medical Center (Salt lake City, UT) flies two helicopters and nearly 1,000 patients annually.
1.A single helicopter can adequately handle only 70 to 90 flights per month due to limitations of servicing time between flights, length of flights, unscheduled maintenance and overlapping requests. The number of missed flights with a single helicopter servicing greater than 70 to 90 flights per month was felt to be unacceptable. 2. Introduction of a second EMS helicopter at the surveyed institutions doubled the number of transported patients within 6 months to 2 years. 3. The addition of a second helicopter also enlarged the referral area, decreased both missed and delayed flights and improved response time. In another independent survey of 26 programs in the United States with two or more EMS helicopters, there were 18 respondents. Among these, the average number of patient flights per month for the first helicopter was 74.5 prior to adding the second ship'. The average number of annual missions for single helicopter programs
Table 1 Flights per year Year
1982
1983
1984
1985
1986
1987
1988
Requested 610 Completed 486 (Avg. per month) (40)
663 504 (42)
878 713 (59)
1088 825 (69)
1157 879 (73)
1376 889 (74)
1512 935 (78)
Flights
The Journalof Air Medical Transport· November 1989
indicate that our current helicopter is being used near capacity. Nationally, there are over 200 programs that utilize an EMS helicopter: the Association of Air Medical Services (AAMS) has utilization information from 43 single helicopter programs. Based on June 1986 to January 1987 statistics, the average number of annual flights for these 43 programs was 609 (range, 184 to 1,146). Our fiscal 1987-1988 flights of 935 ranks over the 90th percentile for that range. The first-year operating expenses for our proposed second VFRhelicopter available 12 hours a day,seven days a week, is estimated at $815,000. This expense would be offset by an estimated 240 additional flights in 1989, and by a 12% rate increase.
Discussion In the past three years, the number of completed flights has begun to plateau, failing increasingly below the growing number of requests for transports. Over the past seven years, we have witnessed a 148% increase in requests for helicopter transport due to several factors: 1. The biggest single factor is the growing acceptance of helicopter transportation and its perceived ability to provide rapid critical care transportation by physicians and pre-hospital providers. 15
PROGRAM MANAGEMENT 2. The Pennsylvania Trauma Foundation designation of our medical center as a Level I Regional Resource Trauma Center. 3. Our large rural service area with primarily Basic Life Support (BLS) scene response. 4. In 1987, the Acute Myocardial Infarction Intervention Program was initiated at Geisinger Medical Center. 5. The continued overall growth of critical care referrals to our institution. The percentage of missed flights has increased 190% over the past seven years. Most missed flights are due to inclement weather which cannot be accommodated by a second VFRhelicopter. Other major reasons for missed flights include those resulting from overlapping requests and aircraft out of service time due to unscheduled maintenance. Currently, our average round-trip distance is 94 miles. Given the rural nature of our service area, average flight times are longer than those of some urban-based programs, resulting in a higher number of overlapping flights missed. At the present time, with only one helicopter, many calls that come in during unscheduled maintenance are either missed or delayed due to unavailability of a back-up aircraft. The addition of a second helicopter would help decrease the number of nonresponses. The two hospital surveys as well as our experience taken from Figure 1 support the addition of a second helicopter. The annual operating cost of an additional leased VFR-equipped BK117 helicopter, operating 12 hours per day, will be approximately $815,000. How-
Cause 1. 2. 3. 4.
16
Figure 1 FLIGHTS PERFISCAL YEAR ENDING JUNE 30 1600
REQU~/~-----
1400
1200
_._.-._._......-...
,.;.,,/
.;
,/
1000
//-/
800
600
-_._
_.-
..
MISSIONS
400 2OO.L----,---.---------r---~---r-----.----.,---
1982
1983
1984
1985
1986
1987
1988
ever, these costs are not as great incurred with the start-up of a first or single helicopter operation. Those costs incurred as part of the initial expenditure-hangar, fuel tanks, landing deck, communications center, some personnel, and maintenance equipment-will not have to be borne again. The issues of helicopter finances, patient reimbursement, etc., are beyond the scope and intent of this paper.
average flight times and less unscheduled maintenance. 2. Evidence of continued growth of trauma and other critical care referrals to the institution(s) serviced by the helicopter. 3. Affordability of a second dedicated EMS helicopter by the sponsoring institution(s) as well as commitment to trauma center/tertiary care services. Analysis of study results led to the decision to add a second EMS helicopter. Approval was contingent on a oneConclusions The indications for considering a year trial basis with coverage 12 hours second dedicated hospital-based EMS daily, seven days a week, and 240 more helicopter are: patient transports as a goal. 1. A plateauing in the number of This study provides a model for responses to requests for the helicop- other hospital-based EMS helicopter ter in the face of continued growth of operators to apply to the complex requests as in Figure 1. This should decision regarding the addition of a occur when the average number of second aircraft. 0 responses exceeds 70-80per month in programs similar to ours, possibly at a Reference: Costello, T., Bothwell, J., ByamC.,Thorhigher level for programs with shorter burn, J.: Assessingthe Need to Expandor Supplement an Existing Medevac ProTable 2 gram. Presentedatthe 8thAnnual Meeting Missed Flights of the American Society of Hospital-Based Year Emergency Air Medical Services, Milwaukee,WI Oct 13-16, 1987. 1988 1982
Inclement Weather Maintenance Overlapping requests Other: (Patient expired, inappropriate requests, half missions, etc.)
71 7 32 14
265 91 141
80
Robert Friedman, MD; Michael ]. Leicht, MD, FACEP; Sheldon Brotman MD, FACS, Department of Emergency Medicine, Geisinger Medical Center, DanvillePA
The Journal of Air Medical Transport· November 1989
The Decision to Add A Second Hospital-Based EMS Helicopter Robert Friedman, MD; Michael J. Leicht, MD, FAGEP; Sheldon BrotmanMD, FAGS
Carraway Medical center's LIfe Saver program (Birmingham, AL) grew from one helicopter and 391 transports In 1981 to three ships and more than 1,900 annual transports currently.
Abstract An analysis of the first seven years of performance of our hospital-based emergency medical services (EMS) helicopter was conducted to evaluate the possible need for a second aircraft. A survey of seven hospitals currently operating two or more helicopters resulted in a consensus that one helicopter can effectively perform only 70 to 90 flights per month. The number of requests for our helicopter service has increased 148% from 610 to 1,512 in seven years while the number of completed missions has increased only 92% from 486 (40.5/month) to 935 (78/month). Requests denied due to inclement weather (265 in 1988) cannot be captured with a second visual-flight-
rated (VFR) EMS helicopter; however, those missed due to maintenance requirementsof the helicopter and overlapping requests (232 in 1988) can be captured. The need for a second aircraft exists when the number of requests for the service grows while the number of captured flights plateaus. Our data and industry survey suggests this will occur at 75 captured flights per month. Affordability and continued overall growth of trauma and other critical care referrals to the base hospital(s) is mandatory. This study provides a model for hospital-basedEMS helicopter operators to apply to the decision whether to add a second aircraft.
-------_._-----_._-_. -----
Introduction Helicopters have played an increasing role in emergency medical services (EMS) missions since the Korean War. By 1972, dedicated EMS helicopters were being stationed at major hospitals. Recent studies have attempted to demonstrate that air medical evacuation of accident victims to trauma centers with or without a physician on-board can have a positive impact on patient outcome. Over the 14
last 15 years, most major population centers have obtained paramedic or emergency medical technician prehospital care services and some areas have developed regional trauma care centers. Medical personnel, now more attuned to helicopter usage, have greatly increased requests for retrieval. At our institution, an increasing inability to respond to aeromedical transport requests with the existing single dedicated helicopter led to a
study of the need for an additional aircraft. The results of the study supported the complex decision to add a second EMS helicopter. Methods We retrospectively analyzed the first seven years of performance with a single helicopter system with attention to total requests and missed flights and the reasons for the increases in both. Additionally, a market-
The Journal of Air Medical Transport· November 1989
PROGRAM MANAGEMENT ing survey of seven hospitals with two or more EMS helicopters was conducted in order to predict the need and impact of a second helicopter. Finally, the estimated cost of acquiring a second helicopter was considered.
Results Requests for helicopter service more than doubled from 1982 (610) to 1988 (1,512). At the same time actual patient transports have increased at a slower rate (fable 1). When these figures are plotted it is clear that, although requests have continued to grow significantly, the number of captured flights has begun to plateau (Figure 1). The number of trauma patients transported by helicopter increased 85% between 1982 and 1988 from 185 (36 scene calls) to 326 (146 scene calls), respectively. A breakdown of missed flights is necessary to determine how many can be captured by a second dedicated VFR helicopter (fable 2). While none of the inclement weather category can be captured without addition of an instrumentflight-rated (lFR) helicopter, almost all of those missed because of maintenance downtime and overlapping requests (232in 1988)could be captured with a second VFR helicopter. We surveyed seven hospitals with more than one EMS helicopter:Jewish Hospital (Louisville, KY), Allegheny General (Pittsburgh, PAl, University of Minnesota, (St. Paul, MN), Carraway Methodistl, (Birmingham, AL), Cleveland Metropolitan General (Cleveland, Om, Grant Medical Center, (Columbus, OH), and Methodist, (Memphis,1N). The survey indicated:
Air Meet at the University Medical Center (Salt lake City, UT) flies two helicopters and nearly 1,000 patients annually.
1.A single helicopter can adequately handle only 70 to 90 flights per month due to limitations of servicing time between flights, length of flights, unscheduled maintenance and overlapping requests. The number of missed flights with a single helicopter servicing greater than 70 to 90 flights per month was felt to be unacceptable. 2. Introduction of a second EMS helicopter at the surveyed institutions doubled the number of transported patients within 6 months to 2 years. 3. The addition of a second helicopter also enlarged the referral area, decreased both missed and delayed flights and improved response time. In another independent survey of 26 programs in the United States with two or more EMS helicopters, there were 18 respondents. Among these, the average number of patient flights per month for the first helicopter was 74.5 prior to adding the second ship'. The average number of annual missions for single helicopter programs
Table 1 Flights per year Year
1982
1983
1984
1985
1986
1987
1988
Requested 610 Completed 486 (Avg. per month) (40)
663 504 (42)
878 713 (59)
1088 825 (69)
1157 879 (73)
1376 889 (74)
1512 935 (78)
Flights
The Journalof Air Medical Transport· November 1989
indicate that our current helicopter is being used near capacity. Nationally, there are over 200 programs that utilize an EMS helicopter: the Association of Air Medical Services (AAMS) has utilization information from 43 single helicopter programs. Based on June 1986 to January 1987 statistics, the average number of annual flights for these 43 programs was 609 (range, 184 to 1,146). Our fiscal 1987-1988 flights of 935 ranks over the 90th percentile for that range. The first-year operating expenses for our proposed second VFRhelicopter available 12 hours a day,seven days a week, is estimated at $815,000. This expense would be offset by an estimated 240 additional flights in 1989, and by a 12% rate increase.
Discussion In the past three years, the number of completed flights has begun to plateau, failing increasingly below the growing number of requests for transports. Over the past seven years, we have witnessed a 148% increase in requests for helicopter transport due to several factors: 1. The biggest single factor is the growing acceptance of helicopter transportation and its perceived ability to provide rapid critical care transportation by physicians and pre-hospital providers. 15
PROGRAM MANAGEMENT 2. The Pennsylvania Trauma Foundation designation of our medical center as a Level I Regional Resource Trauma Center. 3. Our large rural service area with primarily Basic Life Support (BLS) scene response. 4. In 1987, the Acute Myocardial Infarction Intervention Program was initiated at Geisinger Medical Center. 5. The continued overall growth of critical care referrals to our institution. The percentage of missed flights has increased 190% over the past seven years. Most missed flights are due to inclement weather which cannot be accommodated by a second VFRhelicopter. Other major reasons for missed flights include those resulting from overlapping requests and aircraft out of service time due to unscheduled maintenance. Currently, our average round-trip distance is 94 miles. Given the rural nature of our service area, average flight times are longer than those of some urban-based programs, resulting in a higher number of overlapping flights missed. At the present time, with only one helicopter, many calls that come in during unscheduled maintenance are either missed or delayed due to unavailability of a back-up aircraft. The addition of a second helicopter would help decrease the number of nonresponses. The two hospital surveys as well as our experience taken from Figure 1 support the addition of a second helicopter. The annual operating cost of an additional leased VFR-equipped BK117 helicopter, operating 12 hours per day, will be approximately $815,000. How-
Cause 1. 2. 3. 4.
16
Figure 1 FLIGHTS PERFISCAL YEAR ENDING JUNE 30 1600
REQU~/~-----
1400
1200
_._.-._._......-...
,.;.,,/
.;
,/
1000
//-/
800
600
-_._
_.-
..
MISSIONS
400 2OO.L----,---.---------r---~---r-----.----.,---
1982
1983
1984
1985
1986
1987
1988
ever, these costs are not as great incurred with the start-up of a first or single helicopter operation. Those costs incurred as part of the initial expenditure-hangar, fuel tanks, landing deck, communications center, some personnel, and maintenance equipment-will not have to be borne again. The issues of helicopter finances, patient reimbursement, etc., are beyond the scope and intent of this paper.
average flight times and less unscheduled maintenance. 2. Evidence of continued growth of trauma and other critical care referrals to the institution(s) serviced by the helicopter. 3. Affordability of a second dedicated EMS helicopter by the sponsoring institution(s) as well as commitment to trauma center/tertiary care services. Analysis of study results led to the decision to add a second EMS helicopter. Approval was contingent on a oneConclusions The indications for considering a year trial basis with coverage 12 hours second dedicated hospital-based EMS daily, seven days a week, and 240 more helicopter are: patient transports as a goal. 1. A plateauing in the number of This study provides a model for responses to requests for the helicop- other hospital-based EMS helicopter ter in the face of continued growth of operators to apply to the complex requests as in Figure 1. This should decision regarding the addition of a occur when the average number of second aircraft. 0 responses exceeds 70-80per month in programs similar to ours, possibly at a Reference: Costello, T., Bothwell, J., ByamC.,Thorhigher level for programs with shorter burn, J.: Assessingthe Need to Expandor Supplement an Existing Medevac ProTable 2 gram. Presentedatthe 8thAnnual Meeting Missed Flights of the American Society of Hospital-Based Year Emergency Air Medical Services, Milwaukee,WI Oct 13-16, 1987. 1988 1982
Inclement Weather Maintenance Overlapping requests Other: (Patient expired, inappropriate requests, half missions, etc.)
71 7 32 14
265 91 141
80
Robert Friedman, MD; Michael ]. Leicht, MD, FACEP; Sheldon Brotman MD, FACS, Department of Emergency Medicine, Geisinger Medical Center, DanvillePA
The Journal of Air Medical Transport· November 1989