Helicopter-based emergency medical services for a sparsely populated region: A study of 42,500 dispatches

Background

The Helicopter Emergency Medical Service (HEMS) in Norway is operated day and night, despite challenging geography and weather. In Western Norway, three ambulance helicopters, with a rapid response car as an alternative, cover close to 1 million inhabitants in an area of 45,000 km². Our objective was to assess patterns of emergency medical problems and treatments in HEMS in a geographically large, but sparsely populated region.

Methods

Data from all HEMS dispatches during 2004–2013 were assessed retrospectively. Information was analyzed with respect to patient treatment and characteristics, in addition to variations in services use during the day, week, and seasons.

Results

A total of 42,456 dispatches were analyzed. One third of the patients encountered were severely ill or injured, and two thirds of these received advanced treatment. Median activation time and on‐scene time in primary helicopter missions were 5 and 11 min, respectively. Most patients (95%) were reached within 45 min by helicopter or rapid response car. Patterns of use did not change. More than one third of all dispatches were declined or aborted, mostly due to no longer medical indication, bad weather conditions, or competing missions.

Conclusion

One third of the patients encountered were severely ill or injured, and more than two thirds of these received advanced treatment. HEMS use did not change over the 10‐year period, however HEMS use peaked during daytime, weekends, and the summer. More than one third of all dispatches were declined or aborted.

The effect of a simple checklist on frequent pre-induction deficiencies

BACKGROUND

A substantial proportion of anaesthesia-related adverse events are preventable by identification and correction of errors in planning, communication, fatigue, stress, and equipment. The aim of this study was to develop and implement a pre-induction checklist in order to identify and solve problems before induction of anaesthesia.

METHODS

The checklist was developed in a stepwise manner using a modified Delphi technique, literature search, expert's opinion, and a pilot version, and then implemented in a clinical environment during a 13-week study period. Each list was registered and analysed using statistical process control. The checklist was mandatory, but emergency cases were excluded.

RESULTS

The checklist, containing 26 items, was used in 502 (61%) of a total of 829 inductions. Eighty-five checklists (17%) identified one or more missing items. The number of missing items decreased significantly throughout the study period. The most important missing items were lack of a second laryngoscope available, introducer not having been fitted to the endotracheal tube, the endotracheal tube cuff not having been tested, and no separate ventilation bag being available. It took a median of 88.5 s (range 52-118) to perform the checklist when no items were missing. The pre-induction time was the same before and after the checklist was introduced (25.1 vs. 24.3 min, P50.25).

CONCLUSIONS

It is possible to develop, introduce, and use a pre-induction checklist even in a hectic and stressful clinical environment. The checklist identified and reduced a surprisingly large number of missing items required in a standard induction protocol.

Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit

PROBLEM

Need for improved sedation strategy for adults receiving ventilator support.

DESIGN

Observational study of effect of introduction of guidelines to improve the doctors' and nurses' performance. The project was a prospective improvement and was part of a national quality improvement collaborative.

BACKGROUND AND SETTING

A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours.

KEY MEASURES FOR IMPROVEMENT

Reduction in patients' mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes.

STRATEGIES FOR CHANGE

Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial.

EFFECTS OF CHANGE

Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified.

LESSONS LEARNT

Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.

Intrathecal anaesthesia in patients under 45 years: incidence of postdural puncture symptoms after spinal anaesthesia with 27G needles

Postoperative headache and backpain has limited the use of intrathecal anaesthesia in younger patients (15-45 years). We studied postoperative complaints among 133 healthy young patients (mean age 30.0 years, 47% females) who received spinal anaesthesia with a 27G needle. Postoperatively, 5 patients (4%) complained of postdural puncture headache (PDPH), 18 (14%) reported nonspecific headache, while 27 (20%) suffered from backpain. PDPH was not related to sex, age, day-care surgery, number of puncture attempts, or obstetric procedures. Backpain was significantly more common among females, and among in-patients. One hundred and sixteen patients (87%) would accept spinal anaesthesia if they were to undergo the same surgical procedure again. Compared to other studies, we find the incidence of postanaesthetic complaints to be acceptable, also among day-care patients. The PDPH seemed to be lightly incapacitating, and only one patient required blood patching.

Keeping the spirit high: why trauma team training is (sometimes) implemented

BACKGROUND

Systematic and multiprofessional trauma team training using simulation was introduced in Norway in 1997. The concept was developed out of necessity in two district general hospitals and one university hospital but gradually spread to 45 of Norway's 50 acute-care hospitals over the next decade. Implementation in the hospitals has varied from being a single training experience to becoming a regular training and part of quality improvement. The aim of this study was to better understand why only some hospitals achieved implementation of regular trauma team training, despite the intentions of all hospitals to do so.

METHODS

Focus group interviews were conducted with multiprofessional respondents in seven hospitals, including small and large hospitals and hospitals with and without regular team training. Interviews were transcribed and analyzed using a Grounded Theory approach.

RESULTS

'Keeping the spirit high' appeared to be the way to achieve implementation. This was achieved through 'enthusiasm,''strategies and alliances,' and 'using spin-offs.' It seems that the combination of enthusiasts, managerial support, and strategic planning are key factors for professionals trying to implement new activities.

CONCLUSIONS

Committed health professionals planning to implement new methods for training and preparedness in hospitals should have one or more enthusiasts, secure support at the administrative level, and plan the implementation taking all stakeholders into consideration.

Preparing teams for low-frequency emergencies in Norwegian hospitals

BACKGROUND

Medical emergencies and major trauma require optimal team function. Leadership, co-operation and communication are the most essential issues. Due to low caseloads such emergencies occur rarely in most Norwegian hospitals. Team training of personnel between real emergencies is expected to improve performance in comparable settings. Most hospitals have cardiac arrest teams, but it is known that the training of such multiprofessional teams varies widely. We wanted to know if this also was the case for trauma teams and resuscitation teams for newborns.

METHODS

A telephone survey of training practices in all the Norwegian hospitals with acute cover was conducted in 2002. Information was obtained on whether trauma teams and neonatal resuscitation teams had participated in practical multiprofessional training during the previous 6 or 12 months.

RESULTS

Information was obtained from all 50 hospitals. Of the acute care hospitals, 30% had trained their trauma teams during the previous 6 months, and an additional 18% when considering the previous year, while 38% of neonatal wards had multiprofessional training during the previous 6 months, and additionally 13% had had training during the previous year. Additionally four neonatal wards had had regular training of nurses only. More than 80% of all respondents judged regular team training to be achievable, and none considered this training impossible.

CONCLUSION

Only half the Norwegian acute care hospitals reported at least yearly training of trauma and neonatal resuscitation teams. Regular team training represents an underused potential to improve handling of low-frequency emergencies.

Is the pencil point spinal needle a better choice in younger patients? A comparison of 24G Sprotte with 27G Quincke needles in an unselected group of general surgical patients below 46 years of age

Reports have indicated that there are less postoperative complaints after the use of pencil pointed spinal needles. We compared a 24G Sprotte needle with a 27G Quincke needle in a randomised study of 200 healthy patients (49% females), aged 15-46 years. Four patients (2%) reported postdural puncture headache, three with the 24G Sprotte needle and one with the 27G Quincke needle. Thirteen patients (7%) suffered with nonspecific headache, with no significant difference between the two groups. Of the 57 (29%) who reported backpain, a significantly higher proportion had received spinal anaesthesia with the Sprotte needle (OR = 2.06). There was a significantly higher incidence of insufficient blocks after dural puncture with the Sprotte needle. Ease of needle insertion and number of puncture attempts was the same for both needle types.

Health workers and the human immunodeficiency virus: knowledge, ignorance and behaviour

The attitude of health personnel towards the human immunodeficiency virus (HIV) has a great influence on public opinion. Thus appropriate knowledge about HIV and its routes of transmission, plus safe and professional behaviour are crucial. A survey of 359 Norwegian health workers (75% response) revealed that factual knowledge was good. Fear of occupational transmission was substantial, but was not reflected in behaviour: 25-50% of the personnel reported not using gloves when exposed to blood. No relationship was found between knowledge and behaviour. A majority (79%) of the sample held the view that every hospital patient should be routinely tested on admission. Seventy-four per cent advocated preoperative screening, with special precautions if the results are positive. Knowledge did not seem to influence these attitudes. It is concluded that the behaviour of health personnel in relation to occupational risks is unrelated to factual knowledge, and further studies are needed to uncover behavioral determinants.

Outcomes after cancelled helicopter emergency medical service missions due to concurrencies: a retrospective cohort study

BACKGROUND

Appropriate dispatch criteria and helicopter emergency medical service (HEMS) crew decisions are crucial for avoiding over-triage and reducing the number of concurrencies. The aim of the present study was to compare patient outcomes after completed HEMS missions and missions cancelled by the HEMS due to concurrencies.

METHODS

Missions cancelled due to concurrencies (AMB group) and completed HEMS missions (HEMS group) in Western Norway from 2004 to 2013 were assessed. Outcomes were survival to hospital discharge, physiology score in the emergency department, emergency interventions in the hospital, type of department for patient admittance, and length of hospital stay.

RESULTS

Survival to discharge was similar in the two groups. One-third of the primary missions in the HEMS group and 13% in the AMB group were patients with pre-hospital conditions posing an acute threat to life. In a sub group analysis of these patients, HEMS patients were younger, more often admitted to an intensive care unit, and had an increased survival to discharge. In addition, the HEMS group had a greater proportion of patients with deranged physiology in the emergency department according to an early warning score.

CONCLUSION

Patients in the HEMS group seemed to be critically ill more often and received more emergency interventions, but the two groups had similar in-hospital mortality. Patients with pre-hospital signs of acute threat to life were younger and presented increased survival in the HEMS group.

Skills of pre-registration house officers: gender differences reported in Norway

During training pre-registration house officers should acquire skills, practical clinical procedures, and good clinical judgement, in order to be able to practice on their own. This is not always the case (Flaatten et al. 1987). Ten years ago the Norwegian Health Authorities issued a regulation regarding the content of hospital training (6 months internal medicine and surgery, respectively). A number of practical skills to be learned were listed. As part of an assessment of the quality of the internship, a study was carried out into what extent the pre-registration house officers had acquired these clinical skills.

Mortality after hospital admission for trauma in Norway: A retrospective observational national cohort study

BACKGROUND

National quality data for trauma care in Norway have not previously been reported. We have therefore assessed crude and risk-adjusted 30-day mortality in trauma cases after primary hospital admission on national and regional levels for 36 acute care hospitals and four regional trauma centres.

METHODS

All patients in the Norwegian Trauma Registry in 2015-2018 were included. Crude and risk-adjusted 30-day mortality was assessed for the total cohort and for severe injuries (Injury Severity Score ≥16), and individual and combined effects of health region, hospital level, and hospital size were studied.

RESULTS

28,415 trauma cases were included. Crude mortality was 3.1% for the total cohort and 14.5% for severe injuries, with no statistically significant difference between regions. Risk-adjusted survival was lower in acute care hospitals than in trauma centres (0.48 fewer excess survivors per 100 patients, P<0.0001), amongst severely injured patients in the Northern health region (4.80 fewer excess survivors per 100 patients, P = 0.004), and in hospitals with <100 trauma admissions per year (0.65 fewer excess survivors than in hospitals with ≥100 admissions, P = 0.01). However, the only statistically significant effects in a multivariable logistic case mix-adjusted descriptive model were hospital level and health region. Case-mix adjusted odds ratio for survival for severely injured patients directly admitted to a trauma centre vs. an acute care hospital was 2.04 (95% CI 1.04-4.00, P = 0.04), and if admitted in the Northern health region vs. all other health regions was 0.47 (95% CI 0.27-0.84, P = 0.01). The proportion of cases admitted directly to the regional trauma centre in the sparsely populated Northern health region was half of that in the other regions (18.4% vs. 37.6%, P<0.0001).

CONCLUSION

Differences in risk-adjusted survival for severe injuries can to a large extent be attributed to whether patients are directly admitted to a trauma centre. This should have implications for planning of transport capacity in remote areas.

HIV infection and health personnel: health care workers' opinions concerning some ethical dilemmas

A survey was made of a sample of 359 Norwegian health workers to assess attitudes towards HIV infected colleagues, and how the respondents would behave if they themselves became HIV infected. Two thirds of the 268 (75%) who responded would not allow that a HIV positive health worker treated their family, and 47% supported routine HIV screening of health workers to protect patients. Most of the respondents were opposed to disability pensioning of HIV infected health personnel in general, and would not ask for this if were found HIV positive. One hundred ninety-six would not tell colleagues if they became HIV infected. Within this group, the proportion (153/196) that would not accept practising HIV positive health personnel was significantly larger than that among those who would report own seropositivity (24/64). The study revealed substantial anxiety, and inconsistencies between expected behaviour of others, and the respondents' own reactions also were found.

[Spinal anesthesia in ambulatory surgery. Extent, routines and patient satisfaction]

Spinal anaesthesia has been used in day-care surgery for a long time, but the fear of past dural puncture headache has limited its use in younger patients. A survey was conducted in order to assess the extent to which spinal anaesthesia is used for day-care surgery, and the routines governing the present practice in Norwegian anaesthetic departments. Information was obtained on the use of spinal anaesthesia for day-care surgery. In half of the anaesthetic departments spinal anaesthesia was used regularly. A large proportion of the departments worked with a lower age limit over 30 years of age for use of spinal anaesthesia. This does not seem to be justified on the basis of the scientific evidence. A prospective patient study revealed that out of 120 day-care patients aged 15 to 45 years who were given spinal anaesthesia, 93% would accept the same kind of anaesthetic again. Based on recent studies, the fear of post dural puncture headache should not preclude the use of spinal anaesthesia as a good alternative to general anaesthesia in day-care surgery.

[Instruction and training in emergency care procedures of recently deceased patients]

The need for medical personnel to be able to perform certain emergency medical procedures, such as endotracheal intubation, intravascular acess, defibrillation, and tracheotomy cannot be questioned. However, it is difficult to practise these techniques on patients and mannequins. Using newly deceased persons is an alternative which allows the procedures to be performed under nearly realistic circumstances, but this educational approach could raise certain ethical objections among staff who are not adequately informed about the educational objectives. A survey of the ten largest Norwegian hospitals revealed that only two had adopted this practice. The rest had considered it, but had decided not to start this routine. None of the hospitals had refrained from it after thoroughly analysing the ethical issues involved. Six hospitals used cadavers for other instruction. The practice represents a unique opportunity for training, and the ethical implications are justifiable provided that the training is conducted with respect and compassion for the deceased.