PROJECT ABSTRACT Patients injured in rural America are more likely to die than their urban counterparts. This is due in part to poor access to specialized care such as regional trauma centers, and rural patients are more likely to be taken to a non-trauma center as a result. For rural patients, air medical transport (AMT) by helicopter is the only way to get timely access to life-saving trauma care because of poor geographic access to trauma centers. AMT brings life-saving care otherwise unavailable from ground ambulances to the patient even before reaching a trauma center and gets the patient to definitive care at a trauma center faster. AMT when used appropriately can mitigate this under-triage and save lives after injury. In remote rural regions, use of AMT may also preserve local emergency response resources for other patients. Unnecessary use of AMT – over-triage – occurs in up to 60% of helicopter flights for patients with only minor injuries and is also more common in rural areas. A major driver of this inaccurate triage for AMT is the lack of a standardize definition of what patients and/or circumstances warrant the use of AMT, reflected in significant variation in the measures used in prior literature for appropriate AMT. This makes it impossible to compared or build on prior work, representing a critical barrier to improving air medical triage of rural patients. Inaccurate AMT triage disproportionally impacts patients in underserved rural areas and has serious negative consequences: Under-triage of rural patients increases the risk of death by not transporting them to a facility that can treat their injuries. Over-triage, unnecessary AMT, increases cost, makes this scarce resource unavailable for other patients that need it, and increases risk to the patient and the crew. AMT crashes are a serious safety issue with a third of crashes experiencing a fatality compared to just 1% of ground ambulance crashes, an avoidable risk if the flight is unnecessary. Further, AMT fees are over $10,000 per transport, creating a significant financial burden for patients and healthcare systems. This proposal seeks to develop the first definition of AMT need after injury through consensus from multiple diverse perspectives with experts in prehospital trauma care and regionalized care delivery. This project will then validate the definition using actual patient outcomes. In Aim 1 we will use web-based real-time modified Delphi methods to develop a consensus definition of criteria that warrant AMT after trauma. In Aim 2 we will assess the multiple aspects of validity for our consensus definition of AMT need. We will solicit feedback from rural EMS professionals to assess face validity and refine the definition. We will then assess criterion validity by applying the definition to patients in a state trauma registry to assess outcomes among those that do and do not meet the definition. This proposal is foundational to developing evidence-based air medical triage guidelines and will inform future work using this consensus definition to prospectively validate, implement, and pilot an air medical triage algorithm. Successful completion will improve outcomes and trauma care value, reducing the disparities after injury in rural America by getting the right patients the right care at the right time.

PROJECT NARRATIVE People living in rural areas are more likely to have a serious injury and more like to die from that injury than their urban counterparts. This disparity can be reduced by appropriate use of air medical helicopters to quickly transport injured patients to a trauma center from rural regions, but use of this resource when others may need it, risk of crashing, and high cost make it important to use air medical transport (AMT) by helicopter appropriately. Decisions by first responders about which patients benefit from AMT are frequently inaccurate, and this research will help us identify who needs to be transported by helicopter and ultimately reduce disparities for rural patients that rely on air medical helicopters for life-saving care after injury.