Helicopter vs. ground transportation of patients bound for primary percutaneous coronary intervention

Can Helicopters Solve the Transport Dilemma for Patients With Symptoms of Large-Vessel Occlusion Stroke in Intermediate Density Areas? A Simulation Model Based on Real Life Data

Background

This modeling study aimed to determine if helicopters may optimize the transportation of patients with symptoms of large vessel stroke in “intermediate density” areas, such as Denmark, by bringing them directly to the comprehensive stroke center.

Methods

We estimated the time for the treatment of patients requiring endovascular therapy or intravenous thrombolysis under four configurations: “drip and ship” with and without helicopter and “bypass” with and without helicopter. Time delays, stroke numbers per municipality, and helicopter dispatches for four helicopter bases from 2019 were obtained from the Danish Stroke and Helicopter Registries. Discrete event simulation (DES) was used to estimate the capacity of the helicopter fleet to meet patient transport requests, given the number of stroke codes per municipality.

Results

The median onset-to-needle time at the comprehensive stroke center (CSC) for the bypass model with the helicopter was 115 min [interquartile range (IQR): 108, 124]; the median onset-to-groin time was 157 min (IQR: 150, 166). The median onset-to-needle time at the primary stroke center (PSC) by ground transport was 112 min (IQR: 101, 125) and the median onset-to-groin time when primary transport to the PSC was prioritized was 234 min (IQR: 209, 261).

A linear correlation between travel time by ground and the number of patients transported by helicopter (rho = 0.69, p < 0.001) indicated that helicopters are being used to transport more remote patients. DES demonstrated that an increase in helicopter capture zone by 20 min increased the number of rejected patients by only 5%.

Conclusions

Our model calculations suggest that using helicopters to transport patients with stroke directly to the CSC in intermediate density areas markedly reduce onset-to-groin time without affecting time to thrombolysis. In this setting, helicopter capacity is not challenged by increasing the capture zone.

The Evaluation of Helicopter Emergency Medical Services With a Physician for Acute Myocardial Infarction in Japan: A Registry-Based Study of Prognosis and Time Reduction

OBJECTIVE

The aim of this study was to compare the prognosis and time reduction between helicopter emergency medical services (HEMS) with a physician and ground emergency medical services (GEMS) in acute myocardial infarction (AMI) cases.

METHODS

This is a registry-based study of the Japan Helicopter Emergency Medical Service Registry from April 1, 2015, to March 31, 2018.

RESULTS

A total of 605 cases of AMI were registered in the HEMS group and 794 cases in the GEMS group. In the cases of non-cardiopulmonary arrest (CPA), the prognosis between HEMS and GEMS did not differ significantly. Regarding the road distance, for ranges of 20 to 40 km and > 40 km, the times from the call to the angiography room were significantly shorter with HEMS than GEMS (median 91 vs. 97 minutes, P = .036 and 101 vs. 132 minutes, P = .002, respectively). In cases of CPA, HEMS had a higher rate of return of spontaneous circulation than GEMS (55.3% vs. 36.8%, P = .038), but HEMS had a lower prognosis than GEMS (22.9% vs. 38.9%, P = .036).

CONCLUSION

The present study suggested that HEMS had an advantage in reducing the time to angiography in AMI cases of non-CPA. In cases of CPA, HEMS increased the return of spontaneous circulation without improving the prognosis.

The Role of a Physician-Staffed Helicopter in Emergency Care of Patients on Isolated Danish Islands

Emergency calls may lead to the dispatch of either ground ambulances or helicopter emergency medical services (HEMS). For residents on isolated islands, the HEMS can reduce the time to hospital admission and lead to improved outcomes. This study investigated the emergency care for residents on isolated islands with a focus on the role of a physician-staffed helicopter. The data were obtained from Danish national registries and databases. We included data on emergency calls from isolated islands from the time of emergency call to discharge. We identified 1130 emergency calls from which 775 patients were registered with a hospital admission. Of these, 41% were transported by the HEMS and 36% by a ground ambulance. The median time to admission was 83 min (IQR 66-104) and 90 min (IQR 45-144) for the HEMS and ground ambulance, respectively (p = 0.26). The overall 30-day mortality was 6.2% (95% CI: 4.6-8.1%), and 37% of all the patients were admitted to the hospital with an unspecified diagnosis. The emergency calls from isolated islands led to the dispatch of the HEMS in 41% of the cases. The use of the HEMS did not significantly reduce the time to admission but was used in a greater proportion of patients with an acute cardiac disease (66%) or stroke (67%).

Helicopter emergency medical services missions to islands and the mainland during a 3-year period in Denmark: a population-based study on patient and sociodemographic characteristics, comorbidity, and use of healthcare services

Background

The Danish Helicopter Emergency Medical Services (HEMS) is part of the Danish Emergency Medical Services System serving 5.7 million citizens with 1% living on islands not connected to the mainland by road. HEMS is dispatched based on pre-defined criteria including severity and urgency, and moreover to islands for less urgent cases, when rapid transport to further care is needed. The study aim was to characterize patient and sociodemographic factors, comorbidity and use of healthcare services for patients with HEMS missions to islands versus mainland.

Methods

Descriptive study of data from the HEMS database in a three-year period from 1 October 2014 to 30 September 2017. All missions in which a patient was either treated on scene or transported by HEMS were included.

Results

Of 5776 included HEMS missions, 1023 (17.7%) were island missions. In total, 90.2% of island missions resulted in patient transport by HEMS compared with 62.1% of missions to the mainland. Disease severity was serious or life-threatening in 34.7% of missions to islands compared with 65.1% of missions to mainland and less interventions were performed by HEMS on island missions. The disease pattern differed with more “Other diseases” registered on islands compared with the mainland where cardiovascular diseases and trauma were the leading causes of contact. Patients from islands were older than patients from the mainland. Sociodemographic characteristics varied between inhabiting island patients and mainland patients: more island patients lived alone, less were employed, more were retired, and more had low income. In addition, residing island patients had to a higher extend severe comorbidity and more contacts to general practitioners and hospitals compared with the mainland patients.

Conclusions

HEMS missions to islands count for 17.7% of HEMS missions and 90.2% of island missions result in patient transport. The island patients encountered by HEMS are less severely diseased or injured and interventions are less frequently performed. Residing island patients are older than mainland patients and have lower socioeconomic position, more comorbidities and a higher use of health care services. Whether these socio-economic differences result in longer hospital stay or higher mortality is still to be investigated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00963-6.

Impact of Helicopter Transport on Reperfusion Times and Long-Term Outcomes in Acute Myocardial Infarction Patients in Rural Areas: A Report From the Mie Acute Coronary Syndrome Registry

OBJECTIVE

Helicopter emergency medical services (HEMS) are effective for time-sensitive conditions, such as stroke and trauma. However, prognostic data on helicopter transport for acute myocardial infarction (AMI) patients are insufficient.

METHODS

We registered 2,681 AMI patients in the Mie Acute Coronary Syndrome Registry and enrolled 163 patients from rural areas to HEMS base hospitals with HEMS or ground emergency medical services (GEMS). They were categorized into 4 groups according to the transportation method for interhospital transfer (direct HEMS: n = 52, direct GEMS: n = 54, interhospital HEMS: n = 32, and interhospital GEMS: n = 25). The primary end point was the emergency medical services (EMS) call-to-balloon time. The secondary end point was 2-year major adverse cardiac and cerebrovascular events.

RESULTS

The direct HEMS group was younger than the direct GEMS group (P = .029). The EMS call-to-balloon time was shorter in the direct HEMS and interhospital HEMS groups than in each GEMS group (P = .015 and P = .046). The incidence of 2-year major adverse cardiac and cerebrovascular events tended to be lower in both HEMS groups than in each GEMS group.

CONCLUSION

Direct HEMS for AMI in rural areas shortens the time from the EMS call to reperfusion when the transport distance is expected to exceed 30 km, which may result in a better patient prognosis. In addition, prehospital diagnostic modalities, such as 12-lead electrocardiography and echocardiography, may shorten the duration from the EMS call to reperfusion.

Search and Rescue Helicopters for Emergency Medical Service Assistance: A Retrospective Study

OBJECTIVE

The time until treatment is a crucial factor for the outcome after medical emergencies. One way of reducing transportation time is the use of helicopter-based emergency medical services, but poor weather conditions, commitment to another mission, or technical problems may limit the availability. In these cases, military search and rescue (SAR) helicopters can be used. The aim of this study was to investigate the role of SAR helicopters in the civilian emergency medical system.

METHODS

We conducted a retrospective study of SAR mission reports and SAR medical records collected from the archives of the Royal Danish Air Force for the years 2016 and 2017.

RESULTS

A total of 1,262 mission reports were included with a total of 628 medical records available in the study period. There were 490 of 1,246 (39.3%) missions involving patients. Interhospital transfers accounted for 306 of 604 (50.7%) of cases, whereas island evacuation constituted 110 of 604 (18.2%) cases. The most prevalent suspected diagnosis was acute coronary syndrome (14.4%). The 30-day survival rate was 87.6%.

CONCLUSION

The military SAR helicopters were most commonly activated for civilian emergency medical service mission assistance due to poor weather conditions. The most frequent medical condition was acute coronary syndrome.

Assessment of Transportation by Air for Patients with Acute ST-Elevation Myocardial Infarction from Non-PCI Centers

The aim of this study was to assess the delays that can potentially occur in the emergency transfer of patients with ST-elevation myocardial infarction (STEMI) to percutaneous coronary intervention (PCI) centers. We conducted a retrospective study using the medical reports pertaining to 97 patients who presented to the Emergency Department of the Emergency County Hospital of Galati during the year of 2018 with the diagnosis of STEMI and meeting eligibility criteria for PCI, thus warranting transfer to a hospital with PCI facilities. The pick-up time of patients diagnosed with acute myocardial infarction from the emergency department by the transfer crew is significantly shorter (p < 0.05) than those transferred by air, regardless of the PCI center to which the transfer was performed, Iasi or Bucharest, when compared to the time required to process the patients transferred by land to the same PCI centers. The results of the study shows that the helicopter use for transferring acute myocardial infarction patients to a PCI center must be considered, given the distance between non-PCI and PCI centers is over 200 km.

Does helicopter transport delay prehospital transfer for STEMI patients in rural areas? Findings from the CRAC France PCI registry

Aims:

The aim of this study was to analyse delays in emergency medical system transfer of ST-segment elevation myocardial infarction (STEMI) patients to percutaneous coronary intervention (PCI) centres according to transport modality in a rural French region.

Methods and results:

Data from the prospective multicentre CRAC / France PCI registry were analysed for 1911 STEMI patients: 410 transferred by helicopter and 1501 by ground transport. The primary endpoint was the percentage of transfers with first medical contact to primary percutaneous coronary intervention within the 90 minutes recommended in guidelines. The secondary endpoint was time of first medical contact to primary percutaneous coronary intervention. With helicopter transport, time of first medical contact to primary percutaneous coronary intervention in under 90 minutes was less frequently achieved than with ground transport (9.8% vs. 37.2%; odds ratio 5.49; 95% confidence interval 3.90; 7.73; P&lt;0.0001). Differences were greatest for transfers under 50 km (13.7% vs. 44.7%; P&lt;0.0001) and for primary transfers (22.4% vs. 49.6%; P&lt;0.0001). The median time from first medical contact to primary percutaneous coronary intervention and from symptom onset to primary percutaneous coronary intervention (total ischaemic time) were significantly higher in the helicopter transport group than in the ground transport group (respectively, 137 vs. 103 minutes; P&lt;0.0001 and 261 vs. 195 minutes; P&lt;0.0001). There was no significant difference in inhospital mortality between the helicopter and ground transport groups (6.9% vs. 6.6%; P=0.88).

Conclusions:

Helicopter transport of STEMI patients was five times less effective than ground transport in maintaining the 90-minute first medical contact to primary percutaneous coronary intervention time recommended in guidelines, particularly for transfer distances less than 50 km.

Long-term effects of a standardized feedback-driven quality improvement program for timely reperfusion therapy in regional STEMI care networks

AIMS

Current European Society of Cardiology guidelines state that repetitive monitoring and feedback should be implemented for ST-elevation myocardial infarction (STEMI) treatment, but no evidence is available supporting this recommendation. We aimed to analyze the long-term effects of a formalized data assessment and systematic feedback on performance and mortality within the prospective, multicenter Feedback Intervention and Treatment Times in STEMI (FITT-STEMI) study.

METHODS

Regular interactive feedback sessions with local STEMI management teams were performed at six participating German percutaneous coronary intervention (PCI) centers over a 10-year period starting from October 2007.

RESULTS

From the first to the 10th year of study participation, all predefined key-quality indicators for performance measurement used for feedback improved significantly in all 4926 consecutive PCI-treated patients - namely, the percentages of patients with pre-hospital electrocardiogram (ECG) recordings (83.3% vs 97.1%, p < 0.0001) and ECG recordings within 10 minutes after first medical contact (41.7% vs 63.8%, p < 0.0001), pre-announcement by telephone (77.0% vs 85.4%, p = 0.0007), direct transfer to the catheterization laboratory bypassing the emergency department (29.4% vs 64.2%, p < 0.0001), and contact-to-balloon times of less than 90 minutes (37.2% vs 53.7%, p < 0.0001). Moreover, this feedback-related continuous improvement of key-quality indicators was linked to a significant reduction in in-hospital mortality from 10.8% to 6.8% (p = 0.0244). Logistic regression models confirmed an independent beneficial effect of duration of study participation on hospital mortality (odds ratio = 0.986, 95% confidence interval = 0.976-0.996, p = 0.0087). In contrast, data from a nationwide PCI registry showed a continuous increase in in-hospital mortality in all PCI-treated STEMI patients in Germany from 2008 to 2015 (n = 398,027; 6.7% to 9.2%, p < 0.0001).

CONCLUSIONS

Our results indicate that systematic data assessment and regular feedback is a feasible long-term strategy and may be linked to improved performance and a reduction in mortality in STEMI management.

The first seven years of nationally organized helicopter emergency medical services in Finland - the data from quality registry

Background

Helicopter Emergency Medical Services (HEMS) play an important role in prehospital care of the critically ill. Differences in funding, crew composition, dispatch criteria and mission profile make comparison between systems challenging. Several systems incorporate databases for quality control, performance evaluation and scientific purposes. FinnHEMS database was incorporated for such purposes following the national organization of HEMS in Finland 2012. The aims of this study are to describe information recorded in the database, data collection, and operational characteristics of Finnish HEMS during 2012–2018.

Methods

All dispatches of the six Finnish HEMS units recorded in the national database from 2012 to 2018 were included in this observational registry study. Five of the units are physician staffed, and all are on call 24/7. The database follows a template for uniform reporting in physician staffed pre-hospital services, exceeding the recommended variables of relevant guidelines.

Results

The study included 100,482 dispatches, resulting in 33,844 (34%) patient contacts. Variables were recorded with little or no missing data. A total of 16,045 patients (16%) were escorted by HEMS to hospital, of which 2239 (2%) by helicopter. Of encountered patients 4195 (4%) were declared deceased on scene. The number of denied or cancelled dispatches was 66,638 (66%). The majority of patients were male (21,185, 63%), and the median age was 57.7 years. The median American Society of Anesthesiologists Physical Scale classification was 2 and Eastern Cooperative Oncology Group performance class 0. The most common reason for response was trauma representing 26% (8897) of the patients, followed by out-of-hospital cardiac arrest 20% (6900), acute neurological reason excluding stroke 13% (4366) and intoxication and related psychiatric conditions 10% (3318). Blunt trauma (86%, 7653) predominated in the trauma classification.

Conclusions

Gathering detailed and comprehensive data nationally on all HEMS missions is feasible. A national database provides valuable insights into where the operation of HEMS could be improved. We observed a high number of cancelled or denied missions and a low percentage of patients transported by helicopter. The medical problem of encountered patients also differs from comparable systems.

Impact of Physician-staffed Helicopters on Pre-hospital Patient Outcomes: A systematic review

BACKGROUND

Management of pre-hospital patients remains a challenge. In developed countries a physician-staffed helicopter emergency medical service (PS-HEMS) is used in addition to ground emergency medical service (GEMS), but the effect is debated. This systematic review aimed to evaluate the effect of PS-HEMS compared with GEMS on patient outcomes based on the published scientific literature.

METHODS

Medline, EMBASE and the Cochrane Library were systematically searched on November 15, 2019 for prospective, interventional studies comparing outcomes of patients transported by either PS-HEMS or GEMS. Outcomes of interest were mortality, time to hospital and quality of life.

RESULTS

The majority of 18 studies included were observational and difficult to summarize because of heterogeneity. Meta-analysis could not be carried out. Three studies found reduced mortality in patients transported by PS-HEMS compared with GEMS with Odds ratios (OR) of 0.68 (0.47-0.98); 0.29 (0.10-0.82) and 0.21 (0.06-0.73) respectively. Another two studies found improved survival with OR 1.2 (1.0-1.5) and 6.9 (1.48-32.5) in patients transported by PS-HEMS compared with GEMS. In three studies, PS-HEMS was associated with shorter time to hospital. Three studies reported quality of life and found no benefit of PS-HEMS.

CONCLUSION

In this systematic review the studies comparing PS-HEMS with GEMS were difficult to summarize because of heterogeneity. We found a possible survival benefit of PS-HEMS but were unable to conduct a meta-analysis. The overall quality of evidence was low.

Helicopter vs. ground transportation of patients bound for primary percutaneous coronary intervention

BACKGROUND

Implementation of the first Danish helicopter emergency medical service (HEMS) was associated with reduced time from first medical contact to treatment at a specialized centre for patients with suspected ST elevation myocardial infarction (STEMI). We aimed to investigate effects of HEMS on mortality and labour market affiliation in patients admitted for primary percutaneous coronary intervention (PCI).

METHODS

In this prospective observational study, we included patients with suspected STEMI within the region covered by the HEMS from January 1, 2010, to April 30, 2013, transported by either HEMS or ground emergency medical services (GEMS) to the regional PCI centre. The primary outcome was 30-day mortality.

RESULTS

Among the 384 HEMS and 1220 GEMS patients, time from diagnostic ECG to PCI centre arrival was lower with HEMS (median 71 min vs. 78 min with GEMS; P = 0.004). Thirty-day mortality was 5.0% and 6.2%, respectively (adjusted OR = 0.82, 95% CI 0.44-1.51, P = 0.52. Involuntary early retirement rates were 0.62 (HEMS) and 0.94 (GEMS) per 100 PYR (adjusted IRR = 0.68, 0.15-3.23, P = 0.63). The proportion of patients on social transfer payments longer than half of the follow-up time was 22.1% (HEMS) vs. 21.2% (adjusted OR = 1.10, 0.64-1.90, P = 0.73).

CONCLUSION

In an observational study of patients with suspected STEMI in eastern Denmark, no significant beneficial effect of helicopter transport could be detected on mortality, premature labour market exit or work ability. Only a study with random allocation to one system vs. another, along with a large sample size, will allow determination of superiority of helicopter transport.