Helicopter trauma transport: an overview of recent outcomes and triage literature

Aeromedical Transport for Critically Ill Patients

Aeromedical transport (AMT) is an integral part of healthcare systems worldwide. In this article, the personnel and equipment required, associated safety considerations, and evidence supporting the use of AMT is reviewed, with an emphasis on helicopter emergency medical services (HEMS). Indications for HEMS as guideded by the Air Medical Prehospital Triage Score are presented. Lastly, physiologic considerations, which are important to both AMT crews and receiving clinicians, are reviewed.

Comparative Study on the Outcome of Trauma Patients Transferred by Doctor Helicopters and Ground Ambulance in South Korea

OBJECTIVE

The purpose of this study was to analyze the cost-effectiveness of helicopter emergency medical services (HEMS) for its economic operations in South Korea.

METHODS

This study targeted trauma patients that were transported by either HEMS or ground emergency medical services (GEMS) from the scene of an accident to a regional emergency medical center. From this patient population, severe trauma patients (injury severity score ISS ≥ 16 points) with a distance travelled from the scene of the injury to the hospital that was 30 km or longer and with analyzable outcome data were extracted and included in this study. Cost-effectiveness was analyzed from survival and efficiency based on medical costs incurred from the pre-hospital setting to hospital discharge. This study included a total of 34 HEMS and 105 GEMS patients with an Injury Severity Score (ISS) ≥ 16 points from a pool of 357 potential patients.

RESULTS

The survival-to-discharge rate of HEMS was 29 of 34 patients (85.3%) and was significantly higher than that of GEMS, where only 66 of 105 patients (62.8%) survived to discharge (P = 0.024). The expected and the actual mortality was higher in HEMS than it was in GEMS. Statistical significant difference in cost was found between the 2 groups (P = 0.002).

CONCLUSIONS

The results of the present study indicate the increased discharge rate, survival rate and reduced in hospital mortality of HEMS with reduced admission time. This result association leads to reasonable cost effectiveness and efficient estimates overall.

Association of Pre-Hospital Helicopter Transport with Reduced Mortality in Traumatic Brain Injury in Japan: A Nationwide Retrospective Cohort Study

Patients with traumatic brain injury (TBI) are severely injured patients who require timely, efficient, and specialized care. The effectiveness of helicopter emergency medical services (HEMS) for patients with TBI remains unclear. This study aimed to compare the mortality of patients with TBI transported by HEMS and ground ambulance using propensity score-matching analysis, and to analyze the effects of HEMS in various subpopulations. We conducted a retrospective analysis of the Japan Trauma Data Bank. The study period was from January 2004 to December 2018. The participants were divided into two groups: the helicopter group (patients transported by HEMS) and ground group (patients transported by ground ambulance). The principal outcome was death at hospital discharge. In total, 58,532 patients were eligible for analysis (ground group, n = 54,820 [93.7%]; helicopter group, n = 3712 [6.3%]). Helicopter transport decreased patient mortality at hospital discharge (adjusted odds ratio [OR], 0.83; 95% confidence interval [CI], 0.74-0.92). In propensity score-matched patients, the proportion of deaths at hospital discharge was lower in the helicopter (18.76%) than in the ground (21.21%) group (crude OR, 0.86; 95% CI, 0.77-0.96). The mortality rate in the helicopter group was significantly reduced in many subpopulations, especially in cases of severe TBI with a decreased level of consciousness or higher Injury Severity Score (ISS; Japan Coma Scale score 2 [adjusted OR, 0.60; 95% CI, 0.45-0.80] and ISS ≥50 [adjusted OR, 0.69; 95% CI, 0.48-0.99]). Although the study design was non-randomized, our findings in patients with TBI showed that HEMS conferred a mortality benefit over ground ambulance.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis

BACKGROUND

As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.

METHODS

PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.

RESULTS

There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.

CONCLUSION

Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

The accuracy of medical dispatch - a systematic review

BACKGROUND

It is a challenge to dispatch Emergency medical Services (EMS) appropriately with limited resources and maintaining patient safety; this requires accurate dispatching systems. The objective of the current systematic review was to examine the evidence, according to GRADE, for medical dispatching systems to accurately dispatch EMS according to level of acuity and in recognition of specific conditions. A systematic search was performed trough PubMed, Web of Science, Embase (free text in all fields), Centre for Reviews and Dissemination (CRD), and Cochrane Central Register of Controlled Trials up to 16th of May, 2017. A combination of keywords and Medical Subject Heading (MeSH) terms relevant to "emergency medical dispatch criteria" were used, to search for articles published between 2012 and 2017. Publications were included according to the inclusion/exclusion criteria using the Systematic Reviews and Meta-Analyses (PRISMA) protocol. Level of evidence was evaluated in accordance with Grading of Recommendations Assessment, Development and Evaluation (GRADE). Articles included were those that provided evidence for at least one of the measures of dispatch system accuracy; i.e. sensitivity, specificity, positive and negative predictive and/or over- and under-triage. The search identified 1445 articles. After the removal of duplicates, 382 titles were reviewed for relevance and an additional 359 articles were excluded based on manuscript title and abstract. An additional five articles were excluded after review of the full text versions of the remaining articles. The current review included 18 publications which all were based on primary research.

CONCLUSIONS

The 18 articles addressed the identification of cardiac arrest, stroke, medical priority and major trauma using different dispatching systems. The results of the current review show that there is a very low to low overall level of evidence for the accuracy of medical dispatching systems. We suggest that it is necessary to create a consensus on common standards for reporting before consensus can be reached for the level of accuracy in medical dispatching systems.

Mode of Transport and Clinical Outcome in Rural Trauma: A Helicopter versus Ambulance Comparison

Helicopter Emergency Medical Services (HEMS) is presumably an effective way of patient transport in rural trauma, yet the literature addressing its effectiveness is scarce. In this study, we compared the clinical outcome of rural trauma patients between Ground Emergency Medical Services (GEMS) and HEMS transportation from the beginning of 2006 to the end of 2012. Focus was placed on identifying factors associated with survival to discharge in these patients. Over the seven-year study period, 4492 patients met the inclusion criteria with 2414 patients (54%) being transferred by GEMS and 2078 patients (46%) being transferred by HEMS. In comparison with GEMS, patients transferred by HEMS were younger men who were admitted with a higher mean Injury Severity Score and a lower mean Glasgow Coma Score (all Ps < 0.0001). HEMS patients were more frequently intubated before arrival at the trauma center (32% vs 9%, P < 0.0001) and were more frequently transferred to the operating room from the emergency department (11% vs 5%, P < 0.0001). In multivariate analysis, transfer by HEMS was associated with a significant increase in survival to discharge (odds ratio: 1.57, 95% confidence interval: 1.03–2.40, P = 0.036). Blunt injury, no intubation, and Glasgow Coma Score >8 were also associated with significantly improved odds of survival to discharge (all P < 0.0001). These findings show that although patients transferred by HEMS arrived in less favorable clinical conditions, HEMS transfer was associated with significantly higher odds of survival in rural trauma.

Reduced Mortality in Severely Injured Patients Using Hospital-based Helicopter Emergency Medical Services in Interhospital Transport

Recent evidence has demonstrated the survival benefits of helicopter transport for trauma patients. The purpose of this study was to evaluate the effectiveness of hospital-based helicopter emergency medical services (H-HEMS) in comparison with ground ambulance transport in improving mortality outcomes in patients with major trauma. Study participants were divided into 2 groups according to type of transport to the trauma center; that is, either via ground emergency medical services (GEMS) or via H-HEMS. The study was conducted from October 2013 to July 2015. Mortality outcomes in the H-HEMS group were compared with those in the GEMS group by using the Trauma and Injury Severity Score (TRISS) analysis. The number of participants finally included in the study was 312. Among these patients, 63 were adult major trauma patients transported via H-HEMS, and 47.6% were involved in traffic accidents. For interhospital transport, the Z and W statistics revealed significantly higher scores in the H-HEMS group than in the GEMS group (Z statistic, 2.02 vs. 1.16; P = 0.043 vs. 0.246; W statistic, 8.87 vs. 2.85), and 6.02 more patients could be saved per 100 patients when H-HEMS was used for transportation. TRISS analysis revealed that the use of H-HEMS for transporting adult major trauma patients was associated with significantly improved survival compared to the use of GEMS.

Impact of Prehospital Transportation on Survival in Skiers and Snowboarders with Traumatic Brain Injury

INTRODUCTION

Prehospital helicopter use and its impact on outcomes in snowboarders and skiers incurring traumatic brain injury (TBI) is unknown. The present study investigates the association of helicopter transport with survival of snowboarders and skiers with TBI, in comparison with ground emergency medical services (EMS), by using data derived from the National Trauma Data Bank (2007-2014).

METHODS

Primary and secondary endpoints were defined as in-hospital survival and absolute risk reduction based upon number needed to transport (treat) respectively. Multivariable regression models including traditional logit model, model fitted with generalized estimating equations, and those incorporating results from propensity score matching methods were used to investigate the association of helicopter transport with survival compared with ground EMS.

RESULTS

Of the 1018 snowboarders and skiers who met the criteria, 360 (35.4%) were transported via helicopters whereas 658 (64.6%) via ground EMS with a mortality rate of 1.7% and 1.5%, respectively. Multivariable log-binomial models demonstrated association of prehospital helicopter transport with increased survival (odds ratio 8.58; 95% confidence interval 1.09-67.64; P = 0.041; absolute risk reduction: 10.06%). This finding persisted after propensity score matching (odds ratio 24.73; 95% confidence interval 5.74-152.55; P < 0.001). The corresponding absolute risk reduction implies that approximately 10 patients need to be transported via helicopter to save 1 life.

CONCLUSIONS

Based on our robust statistical analysis of retrospective data, our findings suggest prehospital helicopter transport improved survival in patients incurring TBI after snowboard- or ski-related falls compared with those transported via ground EMS. Policies directed at using helicopter services at remote winter resorts or ski or snowboarding locations should be implemented.

Helicopter emergency medical services for adults with major trauma

BACKGROUND

Although helicopters are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured people derive the greatest benefit.

OBJECTIVES

To determine if helicopter emergency medical services (HEMS) transport, compared with ground emergency medical services (GEMS) transport, is associated with improved morbidity and mortality for adults with major trauma.

SEARCH METHODS

We ran the most recent search on 29 April 2015. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library (Cochrane Central Register of Controlled Trials; CENTRAL), MEDLINE (OvidSP), EMBASE Classic + EMBASE (OvidSP), CINAHL Plus (EBSCOhost), four other sources, and clinical trials registers. We screened reference lists.

SELECTION CRITERIA

Eligible trials included randomized controlled trials (RCTs) and nonrandomized intervention studies. We also evaluated nonrandomized studies (NRS), including controlled trials and cohort studies. Each study was required to have a GEMS comparison group. An Injury Severity Score (ISS) of at least 15 or an equivalent marker for injury severity was required. We included adults age 16 years or older.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data and assessed the risk of bias of included studies. We applied the Downs and Black quality assessment tool for NRS. We analyzed the results in a narrative review, and with studies grouped by methodology and injury type. We constructed 'Summary of findings' tables in accordance with the GRADE Working Group criteria.

MAIN RESULTS

This review includes 38 studies, of which 34 studies examined survival following transportation by HEMS compared with GEMS for adults with major trauma. Four studies were of inter-facility transfer to a higher level trauma center by HEMS compared with GEMS. All studies were NRS; we found no RCTs. The primary outcome was survival at hospital discharge. We calculated unadjusted mortality using data from 282,258 people from 28 of the 38 studies included in the primary analysis. Overall, there was considerable heterogeneity and we could not determine an accurate estimate of overall effect.Based on the unadjusted mortality data from six trials that focused on traumatic brain injury, there was no decreased risk of death with HEMS. Twenty-one studies used multivariate regression to adjust for confounding. Results varied, some studies found a benefit of HEMS while others did not. Trauma-Related Injury Severity Score (TRISS)-based analysis methods were used in 14 studies; studies showed survival benefits in both the HEMS and GEMS groups as compared with MTOS. We found no studies evaluating the secondary outcome, morbidity, as assessed by quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). Four studies suggested a small to moderate benefit when HEMS was used to transfer people to higher level trauma centers. Road traffic and helicopter crashes are adverse effects which can occur with either method of transport. Data regarding safety were not available in any of the included studies. Overall, the quality of the included studies was very low as assessed by the GRADE Working Group criteria.

AUTHORS' CONCLUSIONS

Due to the methodological weakness of the available literature, and the considerable heterogeneity of effects and study methodologies, we could not determine an accurate composite estimate of the benefit of HEMS. Although some of the 19 multivariate regression studies indicated improved survival associated with HEMS, others did not. This was also the case for the TRISS-based studies. All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their nonrandomized design. The question of which elements of HEMS may be beneficial has not been fully answered. The results from this review provide motivation for future work in this area. This includes an ongoing need for diligent reporting of research methods, which is imperative for transparency and to maximize the potential utility of results. Large, multicenter studies are warranted as these will help produce more robust estimates of treatment effects. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.

Prehospital helicopter transport and survival of patients with traumatic brain injury

OBJECTIVE

To investigate the association of helicopter transport with survival of patients with traumatic brain injury (TBI), in comparison with ground emergency medical services (EMS).

BACKGROUND

Helicopter utilization and its effect on the outcomes of TBI remain controversial.

METHODS

We performed a retrospective cohort study involving patients with TBI who were registered in the National Trauma Data Bank between 2009 and 2011. Regression techniques with propensity score matching were used to investigate the association of helicopter transport with survival of patients with TBI, in comparison with ground EMS.

RESULTS

During the study period, there were 209,529 patients with TBI who were registered in the National Trauma Data Bank and met the inclusion criteria. Of these patients, 35,334 were transported via helicopters and 174,195 via ground EMS. For patients transported to level I trauma centers, 2797 deaths (12%) were recorded after helicopter transport and 8161 (7.8%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival [OR (odds ratio), 1.95; 95% confidence interval (CI), 1.81-2.10; absolute risk reduction (ARR), 6.37%]. This persisted after propensity score matching (OR, 1.88; 95% CI, 1.74-2.03; ARR, 5.93%). For patients transported to level II trauma centers, 1282 deaths (10.6%) were recorded after helicopter transport and 5097 (7.3%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival (OR, 1.81; 95% CI, 1.64-2.00; ARR 5.17%). This again persisted after propensity score matching (OR, 1.73; 95% CI, 1.55-1.94; ARR, 4.69).

CONCLUSIONS

Helicopter transport of patients with TBI to level I and II trauma centers was associated with improved survival, in comparison with ground EMS.

The Effectiveness Evaluation of Helicopter Ambulance Transport among Neurotrauma Patients in Korea

Objective

Helicopter ambulance transport (HAT) is a highly resource-intensive facility that is a well-established part of the trauma transport system in many developed countries. Here, we review the benefit of HAT for neurosurgical patients in Korea.

Methods

This retrospective study followed neurotrauma patients who were transferred by HAT to a single emergency trauma center over a period of 2 years. The clinical benefits of HAT were measured according to the necessity of emergency surgical intervention and the differences in the time taken to transport patients by ground ambulance transport (GAT) and HAT.

Results

Ninety-nine patients were transferred to a single university hospital using HAT, of whom 32 were taken to the neurosurgery department. Of these 32 patients, 10 (31.3%) needed neurosurgical intervention, 14 (43.8%) needed non-neurosurgical intervention, 3 (9.4%) required both, and 11 (34.4%) did not require any intervention. The transfer time was faster using HAT than the estimated time needed for GAT, although for a relatively close distance (<50 km) without ground obstacles (mountain or sea) HAT did not improve transfer time. The cost comparison showed that HAT was more expensive than GAT (3,292,000 vs. 84,000 KRW, p<0.001).

Conclusion

In this Korean-based study, we found that HAT has a clinical benefit for neurotrauma cases involving a transfer from a distant site or an isolated area. A more precise triage for using HAT should be considered to prevent overuse of this expensive transport method.

Triaging the right patient to the right place in the shortest time

Trauma systems have been successful in saving lives and preventing disability. Making sure that the right patient gets the right treatment in the shortest possible time is integral to this success. Most trauma systems have not fully developed trauma triage to optimize outcomes. For trauma triage to be effective, there must be a well-developed pre-hospital system with an efficient dispatch system and adequately resourced ambulance system. Hospitals must have clear designations of the level of service provided and agreed protocols for reception of patients. The response within the hospital must be targeted to ensure the sickest patients get an immediate response. To enable the most appropriate response to trauma patients across the system, a well-developed monitoring programme must be in place to ensure constant refinement of the clinical response. This article gives a brief overview of the current approach to triaging trauma from time of dispatch to definitive treatment.

Transport mode to level I and II trauma centers and survival of pediatric patients with traumatic brain injury

The use of helicopter emergency medical services (EMS) for pediatric trauma patients is an issue of debate. We investigated the association of helicopter transport with survival of pediatric patients with traumatic brain injury (TBI). We conducted a retrospective cohort study of pediatric patients with TBI who were transported to level I and II trauma centers and were registered in the National Trauma Data Bank (NTDB) between 2009 and 2011. We used regression techniques, integrating the results of propensity score matching, to investigate the association of helicopter transport with survival, in comparison with ground EMS. There were 15,704 pediatric patients with TBI who met the inclusion criteria. Of these, 3142 were transported via helicopters, and 12,562 via ground EMS. The mortality for children transported to level I trauma centers was 7.5% (183 deaths) for helicopter transport and 3.8% (337 deaths) for ground. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.27-2.46; absolute risk reduction [ARR], 2.70%). This persisted after propensity score matching (OR, 1.77; 95% CI, 1.25-2.52; ARR 2.73%). The mortality for children transported to level II trauma centers was 8.0% (52 deaths) for helicopter transport, and 4.4% (163 deaths) for ground. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival (OR, 2.35; 95% CI, 1.30-4.25; ARR 5.36%). This again persisted after propensity score matching (OR 2.56; 95% CI 1.28-5.11; ARR 6.14). Pediatric patients with TBI transported to level I and II trauma centers had improved survival in comparison with similar patients transported via ground EMS.

Impact of helicopter emergency medical services in major incidents: systematic literature review

INTRODUCTION

Helicopter emergency medical services (HEMS) aim to bring highly specialised crews to the major incident for triage, treatment and transport. When the site is difficult to access, HEMS may be the only mode of transportation of both personnel and patients. This systematic review will identify, describe and appraise literature regarding the role of HEMS in medical response to major incidents. We aim to improve knowledge on HEMS role in a major incident and provide a basis for future research.

METHODS AND ANALYSIS

A systematic literature review will be conducted with search phrases that combine HEMS and major incidents to identify when and how HEMS have been used. Included literature will be subject to quality appraisal and data extraction.

ETHICS

No ethical approval is sought because this is a literature review. It will be submitted to a peer-reviewed journal and the PRISMA guidelines will be followed.

REGISTRATION DETAILS

PROSPERO CRD42013004473.

Comparative effectiveness of helicopter emergency medical services compared to ground emergency medical services

The use of helicopter emergency medical services (HEMS) for the transportation and treatment of trauma patients, while commonplace in most developed nations, remains controversial. The purported beneficial effects of HEMS compared to ground emergency medical services is likely to be some combination of speed, crew expertise, and the fact that HEMS is part of an organized trauma system. When the HEMS literature is assessed as a whole, considerable heterogeneity of effects and study methodologies preclude an accurate estimate of composite effect. However, when the outcome of mortality is studied using advanced multivariable regression techniques to control for multiple known confounders, an improved odds of survival has been repeatedly demonstrated. Future HEMS research must rely on robust observational study designs and assessments of a variety of patient outcomes. Questions about the role of speed, distance, and other potentially beneficial elements of HEMS remain.

Helicopter emergency medical services for adults with major trauma

BACKGROUND

Although helicopters are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured patients derive the greatest benefit.

OBJECTIVES

The purpose of this review is to determine if helicopter emergency medical services transport (HEMS) is associated with improved morbidity and mortality, compared to ground emergency medical services transport (GEMS), for adults with major trauma. The primary outcome was survival to hospital discharge. Secondary outcomes were quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs).

SEARCH METHODS

Searches were run in CENTRAL, MEDLINE, EMBASE, CINAHL (EBSCOhost), SCI-EXPANDED, CPCI-S, and ZETOC in January 2012. Relevant websites were also searched, including controlled trials registers, HSRProj, the World Health Organization (WHO) ICTRP, and OpenSIGLE. Searches were not restricted by date, language, or publication status. Attempts were made to contact authors in the case of missing data.

SELECTION CRITERIA

Eligible trials included randomised controlled trials (RCTs) and non-randomised intervention studies. Non-randomised studies (NRS), including controlled trials and cohort studies, were also evaluated. Each study was required to have a GEMS comparison group. An injury severity score (ISS) > 15 or an equivalent marker for injury severity was required. Only adults aged 16 years or older were included.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data and assessed the risk of bias of included studies. The Downs and Black quality assessment tool was applied for NRS. The results were analysed in a narrative review, and with studies grouped by methodology and injury type. A predefined subgroup was comprised of four additional studies that examined the role of HEMS versus GEMS for inter-facility transfer. Summary of findings tables were constructed in accordance with the GRADE Working Group criteria.

MAIN RESULTS

Twenty-five studies met the entry criteria for this review. Four additional studies met the criteria for a separate, predefined subgroup analysis of patients transferred to trauma centres by HEMS or GEMS. All studies were non-randomised studies; no RCTs were found. Survival at hospital discharge was the primary outcome. Data from 163,748 people from 21 of the 25 studies included in the primary analysis were available to calculate unadjusted mortality. Overall, considerable heterogeneity was observed and an accurate estimate of overall effect could not be determined. Based on the unadjusted mortality data from five trials that focused on traumatic brain injury, there was no decreased risk of death with HEMS (relative risk (RR) 1.02; 95% CI 0.85 to 1.23). Nine studies used multivariate regression to adjust for confounding, the five largest indicated a statistically significant increased odds of survival associated with HEMS. All Trauma-Related Injury Severity Score (TRISS)-based studies indicated improved survival in the HEMS group as compared to the Major Trauma Outcomes Study (MTOS) cohort; some studies showed survival benefits in both the HEMS and GEMS groups as compared to MTOS. No studies were found to evaluate the secondary outcome of morbidity as assessed by QALYs and DALYs. All four studies suggested a positive benefit when HEMS was used to transfer patients to higher level trauma centres. Overall, the quality of the included studies was very low as assessed by the GRADE Working Group criteria.

AUTHORS' CONCLUSIONS

Due to the methodological weakness of the available literature, and the considerable heterogeneity of effects and study methodologies, an accurate composite estimate of the benefit of HEMS could not be determined. Although five of the nine multivariate regression studies indicated improved survival associated with HEMS, the remainder did not. All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their non-randomised design. Similarly, TRISS-based studies, which all demonstrated improved survival, cannot be considered strong evidence because of their methodology, which did not randomize the use of HEMS. The question of which elements of HEMS may be beneficial for patients has not been fully answered. The results from this review provide motivation for future work in this area. This includes an ongoing need for diligent reporting of research methods, which is imperative for transparency and to maximise the potential utility of results. Large, multicentre studies are warranted as these will help produce more robust estimates of treatment effects. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.

A comparison of the treatment of severe injuries between the former East and West German States

BACKGROUND

The annual number of persons killed in road-traffic accidents in Germany declined by 36% from 2001 to 2008, yet official traffic statistics still reveal a marked difference in fatalities between the federal states of the former East and West Germany twenty years after German reunification.

METHODS

We retrospectively analyzed data from the Trauma Registry of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie; TR-DGU). Patients receiving primary treatment that had an Injury Severity Score (ISS) of 9 or above were analyzed separately depending on whether they were treated in the former East Germany or the former West Germany.

RESULTS

Data were obtained from a total of 26 866 road-accident trauma cases. With Berlin excluded, 2597 cases (10.2%) were from the former East Germany (EG), and 22 966 (89.9%) were from the former West Germany (WG). The percentage of the population living in these two parts of the country is 16.7% and 83.3%, respectively. The two groups did not differ significantly in either the mortality of injuries (EG 15.8%, WG 15.7%) or in the standardized mortality rate (0.89 [EG] vs. 0.88 [WG]). Over the years 2002-2008, the mean time to arrival of the emergency medical services on the scene was 19 minutes (EG) vs. 17 minutes (WG), and the mean time to arrival in hospital was 76 minutes (EG) vs. 69 minutes (WG).

CONCLUSION

Among the hospitals whose cases are included in the TR-DGU, there is no significant difference between the former East and West Germany with respect to mortality or any other clinically relevant variable. Hypothetically, the higher rate of death from road-traffic accidents in the former East Germany, as revealed by national traffic statistics, might be attributable to a difference in the quality of care received by trauma patients, but no such difference was found. Other potential reasons for it might be poorer road conditions, more initially fatal accidents, and lower accessibility of medical care in less densely populated areas.

Primary scene responses by Helicopter Emergency Medical Services in New South Wales Australia 2008-2009

BACKGROUND

Despite numerous studies evaluating the benefits of Helicopter Emergency Medical Services (HEMS) in primary scene responses, little information exists on the scope of HEMS activities in Australia. We describe HEMS primary scene responses with respect to the time taken, the distances travelled relative to the closest designated trauma hospital and the receiving hospital; as well as the clinical characteristics of patients attended.

METHODS

Clinical service data were retrospectively obtained from three HEMS in New South Wales between July 2008 and June 2009. All available primary scene response data were extracted and examined. Geographic Information System (GIS) based network analysis was used to estimate hypothetical ground transport distances from the locality of each primary scene response to firstly the closest designated trauma hospital and secondly the receiving hospital. Predictors of bypassing the closest designated trauma hospital were analysed using logistic regression.

RESULTS

Analyses included 596 primary missions. Overall the HEMS had a median return trip time of 94min including a median of 9min for activation, 34min travelling to the scene, 30min on-scene and 25min transporting patients to the receiving hospital. 72% of missions were within 100km of the receiving hospital and 87% of missions were in areas classified as 'major cities' or 'inner regional'. The majority of incidents attended by HEMS were trauma-related, with road trauma the predominant cause (44%). The majority of trauma patients (81%) had normal physiology at HEMS arrival (RTS = 7.84). We found 62% of missions bypassed the closest designated trauma hospital. Multivariate predictors of bypass included: age; presence of spinal or burns trauma; the level of the closest designated trauma hospital; the transporting HEMS.

CONCLUSION

Our results document the large distances travelled by HEMS in NSW, especially in rural areas. The high proportion of HEMS missions that bypass the closest designated trauma hospital is a seldom mentioned benefit of HEMS transport. These results along with the characteristics of patients attended and the time HEMS take to complete primary scene responses are useful in understanding the benefit HEMS provides and the services it replaces.

The cost-effectiveness of physician staffed Helicopter Emergency Medical Service (HEMS) transport to a major trauma centre in NSW, Australia

BACKGROUND AND CONTEXT

Helicopter Emergency Medical Services (HEMS) are highly resource-intensive facilities that are well established as part of trauma systems in many high-income countries. We evaluated the cost-effectiveness of a physician-staffed HEMS intervention in combination with treatment at a major trauma centre versus ground ambulance or indirect transport (via a referral hospital) in New South Wales (NSW), Australia.

METHODS

Cost and effectiveness estimates were derived from a cohort of trauma patients arriving at St George Hospital in NSW, Australia during an 11-year period. Adjusted estimates of in-hospital mortality were derived using logistic regression and adjusted hospital costs were estimated through a general linear model incorporating a gamma distribution and log link. These estimates along with other assumptions were incorporated into a Markov model with an annual cycle length to estimate a cost per life saved and a cost per life-year saved at one year and over a patient's lifetime respectively in three patient groups (all patients; patients with serious injury [Injury Severity Score>12]; patients with traumatic brain injury [TBI]).

RESULTS

Results showed HEMS to be more costly but more effective at reducing in-hospital mortality leading to a cost per life saved of $1,566,379, $533,781 and $519,787 in all patients, patients with serious injury and patients with TBI respectively. When modelled over a patient's lifetime, the improved mortality associated with HEMS led to a cost per life year saved of $96,524, $50,035 and $49,159 in the three patient groups respectively. Sensitivity analyses revealed a higher probability of HEMS being cost-effective in patients with serious injury and TBI.

CONCLUSION

Our investigation confirms a HEMS intervention is associated with improved mortality in trauma patients, especially in patients with serious injury and TBI. The improved benefit of HEMS in patients with serious injury and TBI leads to improved estimated cost-effectiveness.

Association between helicopter vs ground emergency medical services and survival for adults with major trauma

CONTEXT

Helicopter emergency medical services and their possible effect on outcomes for traumatically injured patients remain a subject of debate. Because helicopter services are a limited and expensive resource, a methodologically rigorous investigation of its effectiveness compared with ground emergency medical services is warranted.

OBJECTIVE

To assess the association between the use of helicopter vs ground services and survival among adults with serious traumatic injuries.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study involving 223,475 patients older than 15 years, having an injury severity score higher than 15, and sustaining blunt or penetrating trauma that required transport to US level I or II trauma centers and whose data were recorded in the 2007-2009 versions of the American College of Surgeons National Trauma Data Bank.

INTERVENTIONS

Transport by helicopter or ground emergency services to level I or level II trauma centers.

MAIN OUTCOME MEASURES

Survival to hospital discharge and discharge disposition.

RESULTS

A total of 61,909 patients were transported by helicopter and 161,566 patients were transported by ground. Overall, 7813 patients (12.6%) transported by helicopter died compared with 17,775 patients (11%) transported by ground services. Before propensity score matching, patients transported by helicopter to level I and level II trauma centers had higher Injury Severity Scores. In the propensity score-matched multivariable regression model, for patients transported to level I trauma centers, helicopter transport was associated with an improved odds of survival compared with ground transport (odds ratio [OR], 1.16; 95% CI, 1.14-1.17; P < .001; absolute risk reduction [ARR], 1.5%). For patients transported to level II trauma centers, helicopter transport was associated with an improved odds of survival (OR, 1.15; 95% CI, 1.13-1.17; P < .001; ARR, 1.4%). A greater proportion (18.2%) of those transported to level I trauma centers by helicopter were discharged to rehabilitation compared with 12.7% transported by ground services (P < .001), and 9.3% transported by helicopter were discharged to intermediate facilities compared with 6.5% by ground services (P < .001). Fewer patients transported by helicopter left level II trauma centers against medical advice (0.5% vs 1.0%, P < .001).

CONCLUSION

Among patients with major trauma admitted to level I or level II trauma centers, transport by helicopter compared with ground services was associated with improved survival to hospital discharge after controlling for multiple known confounders.

Helicopter rescue involving the winching of a physician

INTRODUCTION

We sought to study the operational and medical aspects of helicopter rescue missions involving the use of a winch.

SETTING

A single helicopter-based medical service of a pre-alpine region of Switzerland.

METHODS

We prospectively studied consecutive primary rescue interventions involving winching of a physician, from October 1, 1998 to October 1, 2002. Demographic, medical and operational aspects as well as outcome at 48 hours were analyzed.

RESULTS

We included 133 patients. Most (74%) were male, with traumatic injuries (77%). The median scene time of the nine severely injured patients (Injury Severity Scale [ISS] > 15) was significantly longer compared with the other patients (54 vs 37 minutes; P < .05). The main medical procedures performed were orotracheal intubation (n = 5), fracture reductions (n = 5), major analgesia with sedation (n = 4), and intravenous fluid administration of more than 1,500 mL (n = 4). Fourteen (10%) patients suffering from minor injuries were triaged by the physician and not airlifted to the hospital. All 133 patients were alive at 48 hours. Sixty-nine (52%) were still hospitalized. No secondary interhospital transfer was required.

CONCLUSION

Our study provides a better knowledge of injury profile, medical aspects, and outcomes of patients rescued necessitating a winching procedure.

Helicopter EMS: Research Endpoints and Potential Benefits

Patients, EMS systems, and healthcare regions benefit from Helicopter EMS (HEMS) utilization. This article discusses these benefits in terms of specific endpoints utilized in research projects. The endpoint of interest, be it primary, secondary, or surrogate, is important to understand in the deployment of HEMS resources or in planning further HEMS outcomes research. The most important outcomes are those which show potential benefits to the patients, such as functional survival, pain relief, and earlier ALS care. Case reports are also important "outcomes" publications. The benefits of HEMS in the rural setting is the ability to provide timely access to Level I or Level II trauma centers and in nontrauma, interfacility transport of cardiac, stroke, and even sepsis patients. Many HEMS crews have pharmacologic and procedural capabilities that bring a different level of care to a trauma scene or small referring hospital, especially in the rural setting. Regional healthcare and EMS system's benefit from HEMS by their capability to extend the advanced level of care throughout a region, provide a "backup" for areas with limited ALS coverage, minimize transport times, make available direct transport to specialized centers, and offer flexibility of transport in overloaded hospital systems.

A systematic review of the costs and benefits of helicopter emergency medical services

INTRODUCTION

Helicopter emergency medical services (HEMS) are popular in first world health systems despite inconsistent evidence in the scientific literature to support their use. The aim of the current study was to perform a systematic review of economic evaluations of HEMS, in order to determine the economic cost of HEMS and the associated patient-centered benefits.

METHOD

A systematic review was performed of studies that provided a cost estimate of HEMS. The inclusion criteria consisted of English language articles that estimated both the costs and outcomes of a HEMS and fulfilled pre-specified criteria in relation to a cost analysis, cost-minimisation, cost-effectiveness or cost-benefit evaluation. Identified studies were synthesised according to the patient diagnosis (trauma, non-trauma or non-specific) and the type of HEMS transport under review (primary scene retrieval or secondary inter-facility transport). All costs were converted to US dollars and indexed for inflation.

RESULTS

Fifteen studies met the inclusion criteria. Among all studies the annual cost of HEMS ranged from $115,777 to $5,571,578. Five studies showed HEMS to be a more expensive transport alternative without an associated benefit while eight studies provided cost-effectiveness ratios of $3292 and $2227 per life year saved for trauma, $3258 per life saved and $7138 and $12,022 per quality adjusted life year for non-trauma and $30,365 and $91,478 per beneficial mission for non-specific patient populations. One study also evaluated the cost of HEMS to societal benefit, producing a ratio of 1:6.

INTERPRETATION

The cost and effectiveness of HEMS varied considerably between studies. Despite generally being more expensive than ground transport, a number of studies found HEMS to be cost-effective. However, given the variation in the intervention design, context and study methods between studies it was not possible to assess the cost-effectiveness of HEMS in general. Given the variation inherent in the health systems in which HEMS operate, synthesis and extrapolation of study findings across differing health environments is difficult. To address economic and clinical evidence in relation to HEMS, future research that is tailored to account for local system factors is required.

Emergency air medical services for patients with head injury

BACKGROUND

Patients suffering head injury in remote islands of Taiwan, which have a shortage of manpower and facilities, depend on EAMS for prompt and definitive treatment. Emergency air medical services are becoming an increasingly important issue in improving the quality of primary care and avoiding medicolegal problems. The purpose of this study was to investigate the characteristics of patients with head injury and use of EAMS.

METHODS

We reviewed all patients, especially head injury transported by air ambulance from a remote island, Kinmen (400 km from Taiwan Main Island), from January 2001 to December 2003. Data were collected with regard to demographics, disease classification, mechanism of injury, severity of head injury, ventilator use, and mortality rate.

RESULTS

A total of 215 patients were transferred, of whom 57 (27%) had head injury. The mean age of patients was 48.6 +/- 23.8 years. Males accounted for 72% of the cases (male/female ratio, 2.6:1). Motor-vehicle accidents were the most common mechanism of injury (68%). There were 21 (37%), 20 (35%), and 16 (28%) patients in the minor, moderate, and severe head-injury groups, respectively. Nineteen patients (33%) received mechanical ventilation. The overall mortality rate was 14 % (8/57). In the severe head-injury group, the mortality rate was 44% (7/16).

CONCLUSIONS

The higher incidence of head injury (26.5%) in EAMS than in ground transportation (19.8%) suggests that preflight assessment and in-flight management of patients conducted by an experienced escort team following guidelines for head injury in EAMS are a very important issue.