The Role of Integrated Air Transport System in Managing Patients with Abdominal Aortic Aneurysm Rupture

OBJECTIVE

Ruptured abdominal aortic aneurysms (rAAAs) are highly morbid emergencies. Not all hospitals are equipped to repair them, and an air ambulance network may aid in regionalising specialty care to quaternary referral centres. The association between travel distance by air ambulance and rAAA mortality in patients transferred as an emergency for repair was examined.

METHODS

A retrospective review of institutional data. Adults with rAAA (2002 - 2019) transferred from an outside hospital (OSH) to a single quaternary referral centre for repair via air ambulance were identified. Patients who arrived via ground transport or post-repair at an OSH for continued critical care were excluded. Patients were divided into near and far groups based on the 75th percentile of the straight line travel distance (> 72 miles) between hospitals. The primary outcome was 30 day mortality. Multivariable logistic regression was used to assess the association between distance and mortality after adjusting for age, sex, race, cardiovascular comorbidities, and repair type.

RESULTS

A total of 290 patients with rAAA were transported a median distance of 40.4 miles (interquartile range 25.5, 72.7) with 215 (74.1%) near and 75 (25.9%) far patients. Both the near and far groups had similar ages, sex, and race. There was no difference in pre-operative loss of consciousness, intubation, or cardiac arrest between groups. Endovascular aneurysm repair utilisation and intra-operative aortic occlusion balloon use were also similar. Neither the observed (26.8% vs. 23.9%, p = .61) nor the adjusted odds ratio (0.70, 95% confidence interval 0.36 - 1.39, p = .32) 30 day mortality rate differed significantly between the near and far groups.

CONCLUSION

Increasing distance travelled during transfer by air ambulance was not associated with worse outcomes in patients with rAAA. The findings support the regionalisation of rAAA repair to large quaternary centres via an integrated and robust air ambulance network.

The SEE-IT Trial: emergency medical services Streaming Enabled Evaluation In Trauma: a feasibility randomised controlled trial

BACKGROUND

Use of bystander video livestreaming from scene to Emergency Medical Services (EMS) is becoming increasingly common to aid decision making about the resources required. Possible benefits include earlier, more appropriate dispatch and clinical and financial gains, but evidence is sparse.

METHODS

A feasibility randomised controlled trial with an embedded process evaluation and exploratory economic evaluation where working shifts during six trial weeks were randomised 1:1 to use video livestreaming during eligible trauma incidents (using GoodSAM Instant-On-Scene) or standard care only. Pre-defined progression criteria were: (1) ≥ 70% callers (bystanders) with smartphones agreeing and able to activate live stream; (2) ≥ 50% requests to activate resulting in footage being viewed; (3) Helicopter Emergency Medical Services (HEMS) stand-down rate reducing by ≥ 10% as a result of live footage; (4) no evidence of psychological harm in callers or staff/dispatchers. Observational sub-studies included (i) an inner-city EMS who routinely use video livestreaming to explore acceptability in a diverse population; and (ii) staff wellbeing in an EMS not using video livestreaming for comparison to the trial site.

RESULTS

Sixty-two shifts were randomised, including 240 incidents (132 control; 108 intervention). Livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to determine appropriateness of dispatch), and caller recruitment (to measure potential harm) were low (58/269, 22% of patients; 4/244, 2% of callers). Two progression criteria were met: (1) 86% of callers with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in footage being obtained; and two were indeterminate due to insufficient data: (3) 2/6 (33%) HEMS stand down due to livestreaming; (4) no evidence of psychological harm from survey, observations or interviews, but insufficient survey data from callers or comparison EMS site to be confident. Language barriers and older age were reported in interviews as potential challenges to video livestreaming by dispatchers in the inner-city EMS.

CONCLUSIONS

Progression to a definitive RCT is supported by these findings. Bystander video livestreaming from scene is feasible to implement, acceptable to both 999 callers and dispatchers, and may aid dispatch decision-making. Further assessment of unintended consequences, benefits and harm is required.

TRIAL REGISTRATION

ISRCTN 11449333 (22 March 2022). https://www.isrctn.com/ISRCTN11449333.

Critical hypertension in trauma patients following prehospital emergency anaesthesia: a multi-centre retrospective observational study

BACKGROUND

Critical hypertension in major trauma patients is associated with increased mortality. Prehospital emergency anaesthesia (PHEA) is performed for 10% of the most seriously injured patients. Optimising oxygenation, ventilation, and cerebral perfusion, whilst avoiding extreme haemodynamic fluctuations are the cornerstones of reducing secondary brain injury. The aim of this study was to report the differential determinants of post-PHEA critical hypertension in a large regional dataset of trauma patients across three Helicopter Emergency Medical Service (HEMS) organisations.

METHODS

A multi-centre retrospective observational study of consecutive adult trauma patients undergoing PHEA across three HEMS in the United Kingdom; 2015-2022. Critical hypertension was defined as a new systolic blood pressure (SBP) > 180mmHg within 10 min of induction of anaesthesia, or > 10% increase if the baseline SBP was > 180mmHg prior to induction. Purposeful logistical regression was used to explore variables associated with post-PHEA critical hypertension in a multivariable model. Data are reported as number (percentage), and odds ratio (OR) with 95% confidence interval (95%CI).

RESULTS

30,744 patients were attended by HEMS during the study period; 2161 received PHEA and 1355 patients were included in the final analysis. 161 (11.9%) patients had one or more new episode(s) of critical hypertension ≤ 10 min post-PHEA. Increasing age (compared with 16-34 years): 35-54 years (OR 1.76, 95%CI 1.03-3.06); 55-74 years (OR 2.00, 95%CI 1.19-3.44); ≥75 years (OR 2.38, 95%CI 1.31-4.35), pre-PHEA Glasgow Coma Scale (GCS) motor score four (OR 2.17, 95%CI 1.19-4.01) and five (OR 2.82, 95%CI 1.60-7.09), patients with a pre-PHEA SBP > 140mmHg (OR 6.72, 95%CI 4.38-10.54), and more than one intubation attempt (OR 1.75, 95%CI 1.01-2.96) were associated with post-PHEA critical hypertension.

CONCLUSION

Delivery of PHEA to seriously injured trauma patients risks haemodynamic fluctuation. In adult trauma patients undergoing PHEA, 11.9% of patients experienced post-PHEA critical hypertension. Increasing age, pre-PHEA GCS motor score four and five, patients with a pre-PHEA SBP > 140mmHg, and more than intubation attempt were independently associated with post-PHEA critical hypertension.

Challenges in the management of high-altitude illnesses and emergencies in Bhutan and Nepal

Many popular tourist attractions and trekking routes in Bhutan and Nepal are situated between 3000 and 6000 m in elevation. High-altitude emergencies are becoming more common and medical providers must be aware of the practical and medical issues in managing these disorders. We reflect on the challenges in providing high-altitude emergency medical services in Bhutan and Nepal.

Locating helicopter ambulance bases in Iceland: efficient and fair solutions

BACKGROUND

Fixed-wing air ambulances play an important role in healthcare in rural Iceland. More frequent use of helicopter ambulances has been suggested to shorten response times and increase equity in access to advanced emergency care. In finding optimal base locations, the objective is often efficiency-maximizing the number of individuals who can be reached within a given time. This approach benefits people in densely populated areas more than people living in remote areas and the solution is not necessarily fair. This study aimed to find efficient and fair helicopter ambulance base locations in Iceland.

METHODS

We used high-resolution population and incident location data to estimate the service demand for helicopter ambulances, with possible base locations limited to twenty-one airports and landing strips around the country. Base locations were estimated using both the maximal covering location problem (MCLP) optimization model, which aimed for maximal coverage of demand, and the fringe sensitive location problem (FSLP) model, which also considered uncovered demand (i.e., beyond the response time threshold). We explored the percentage of the population and incidents covered by one to three helicopter bases within 45-, 60-, and 75-min response time thresholds, conditioned or not, on the single existing base located at Reykjavík Airport. This resulted in a total of eighteen combinations of conditions for each model. The models were implemented in R and solved using Gurobi.

RESULTS

Model solutions for base locations differed between the demand datasets for two out of eighteen combinations, both with the lowest service standard. Base locations differed between the MCLP and FSLP models for one combination involving a single base, and for two combinations involving two bases. Three bases covered all or almost all demand with longer response time thresholds, and the models differed in four of six combinations. The two helicopter ambulance bases can possibly obtain 97% coverage within 60 min, with bases in Húsafell and Grímsstaðir. Bases at Reykjavík Airport and Akureyri would cover 94.2%, whereas bases at Reykjavík Airport and Egilsstaðir would cover 88.5% of demand.

CONCLUSION

An efficient and fair solution would be to locate bases at Reykjavík Airport and in Akureyri or Egilsstaðir.

Post traumatic growth among military enroute care nurses: A secondary analysis

To date, little is known about the experience of military nurses and post traumatic growth (PTG). An analysis focusing on PTG was performed using data from the surveys and qualitative interviews of military enroute care nurses. In a mixed methods study designed to understand behavioral health symptoms experienced by military enroute care nurses, the qualitative data confirmed the experiences of nurses found in the quantitative data regarding the presence of PTG. Although the mean PTG total score was low in the quantitative findings, the qualitative data supported the presence of important factors comprising PTG. More research is needed to determine the experience of PTG among nurses.

Please get me out of here: The difficult decision making in fit-to-fly assessments for international fixed-wing air ambulance operations

INTRODUCTION

With international travel for leisure and business almost back to pre-pandemic levels, demand for repatriation due to illness and injury abroad is increasing [1,2]. In any repatriation, there is considerable pressure on all involved to organize a rapid transport back home. Delay in such action may be perceived by the patient, relatives, and the public as an attempt by the underwriter to hold off on an expensive air ambulance mission [3-5].

METHODS

Review of the available literature and analysis of assistance and air ambulance Companies' infrastructure and processes to identify risk and benefit of executing or delaying aeromedical transport for international travellers.

KEY FINDINGS

While patients of almost any severity can be safely transported over great distances in modern air ambulance aircraft, immediate transport is not always in the patient's best interest. Each call for assistance requires a complex and dynamic risk-benefit analysis with multiple stakeholders involved to achieve an optimized outcome. Opportunities for risk mitigation within the assistance team include active case management with clearly assigned ownership, as well as medical and logistical experience with knowledge on local treatment opportunities and limitations. On the air ambulance side, modern equipment, experience, standards and procedures as well as accreditation can reduce risk.

CONCLUSIONS

Each patient evaluation remains a highly individual risk-benefit assessment. Optimal outcomes require a clear understanding of responsibilities, flawless communication and significant expertise among the key decision-makers. Negative outcomes are mostly associated with insufficient information, communication, inadequate experience or a lack of ownership/assigned responsibility.

Air ambulance retrievals of patients with suspected appendicitis and acute abdominal pain: The patients' journeys, referral pathways and appendectomy outcomes using linked data in Central Queensland, Australia

INTRODUCTION

Acute appendicitis is the most common cause of acute abdominal pain presentations to the ED and common air ambulance transfer.

AIMS

describe how linked data can be used to explore patients' journeys, referral pathways and request-to-activation responsiveness of patients' appendectomy outcomes (minor vs major complexity).

METHODS

Data sources were linked: aeromedical, hospital and death. Request-to-activation intervals showed strong right-tailed skewness. Quantile regression examined whether the longest request-to-activation intervals were associated with appendicitis complexity in patients who underwent an appendectomy.

RESULTS

There were 684 patients in three referral pathways based on hospital capability levels. In total, 5.6 % patients were discharged from ED. 83.3 % of all rural origins entered via the ED. 3.8 % of appendicitis patients were triaged to tertiary hospitals. Appendectomy patients with major complexity outcomes were less likely to have longer request-to-activation wait times & had longer lengths of stay than patients with minor complexity outcomes.

CONCLUSIONS

Linked data highlighted four aspects of a functioning referral system: appendectomy outcomes of major complexity were less likely to have longer request-to-activation intervals compared to minor (sicker patients were identified); few were discharged from EDs (validated transfer); few were triaged to tertiary hospitals (appropriate level for need), and no deaths relating to appendectomy.

Prehospital Whole Blood Transfusion Programs in Norway

BACKGROUND

Prehospital management of severe hemorrhage has evolved significantly in Norwegian medical emergency services in the last 10 years. Treatment algorithms for severe bleeding were previously focused on restoration of the blood volume by administration of crystalloids and colloids, but now the national trauma system guidelines recommend early balanced transfusion therapy according to remote damage control resuscitation principles.

MATERIALS AND METHODS

This survey describes the implementation, utilization, and experience of the use of low titer group O whole blood (LTOWB) and blood components in air ambulance services in Norway. Medical directors from all air ambulance bases in Norway as well as the blood banks that support LTOWB were invited to participate.

RESULTS

Medical directors from all 13 helicopter emergency medical services (HEMS) bases, the 7 search and rescue (SAR) helicopter bases, and the 4 blood banks that support HEMS with LTOWB responded to the survey. All HEMS and SAR helicopter services carry LTOWB or blood components. Four of 20 (20%) HEMS bases have implemented LTOWB. A majority of services (18/20, 90%) have a preference for LTOWB, primarily because LTOWB enables early balanced transfusion and has logistical benefits in time-critical emergencies and during prolonged evacuations.

CONCLUSION

HEMS services and blood banks report favorable experiences in the implementation and utilization of LTOWB. Prehospital balanced blood transfusion using whole blood is feasible in Norway.

Challenges to the implementation of in situ simulation at HEMS bases: a qualitative study of facilitators' expectations and strategies

INTRODUCTION

Facilitators play an essential role in simulation-based training on helicopter emergency medical services (HEMS) bases. There is scant literature about the barriers to the implementation of simulation training in HEMS. The purpose of this explorative interview study was to identify factors that the local facilitators anticipated would challenge the smooth implementation of the program, and their strategies to overcome these before the national implementation of in situ simulation-based training locally, and subsequently, one year after the programme was initiated, to identify the actual challenges they had indeed experienced, and their solutions to overcome these.

METHODS

A qualitative study with semi-structured group interviews of facilitators was undertaken before and after one year of simulation-based training on all HEMS bases and one Search and Rescue base. Systematic text condensation was used to extract facilitators' expectations and experiences.

RESULTS

Facilitators identified 17 themes in the pre-study-year interviews. Pedagogical, motivational and logistical issues were amongst the dominant themes. Other key themes included management support, dedicated time for the facilitators and ongoing development of the facilitator. In the post-study-year interviews, the same themes were identified. Despite anxiety about the perceptions of, and enthusiasm for, simulation training amongst the HEMS crews, our facilitators describe increasing levels of motivation over the study period.

CONCLUSION

Facilitators prognosticated the anticipated challenges to the successful implementation of simulation-based training on HEMS bases and suggested solutions for overcoming these challenges. After one year of simulation-based training, the facilitators reflected on the key factors for successful implementation.

Analgesia in pediatric trauma patients in physician-staffed Austrian helicopter rescue: a 12-year registry analysis

BACKGROUND

As pediatric patients are typically rare among helicopter emergency medical systems (HEMS), children might be at risk for oligo-analgesia due to the rescuer's lack of experience and the fear of side effects.

METHODS

In this retrospective analysis, data was obtained from the ÖAMTC HEMS digital database including 14 physician staffed helicopter bases in Austria over a 12-year timeframe. Primary missions involving pediatric trauma patients (< 15 years) not mechanically ventilated on-site were included. Analgesia was assessed and compared between the age groups 0-5, 6-10 and 11-14 years.

RESULTS

Of all flight missions, 8.2% were dedicated to children < 15 years. Analgetic drugs were administered in 31.4% of all primary missions (3874 of 12,324), wherefrom 2885 were injured and non-ventilated (0-5 yrs.: n = 443; 6-10 yrs.: n = 902; 11-14 yrs.: n = 1540). The majority of these patients (> 75%) suffered moderate to severe pain, justifying immediate analgesia. HEMS physicians typically chose a monotherapy with an opioid (n = 1277; 44.3%) or Esketamine (n = 1187; 41.1%) followed by the combination of both (n = 324; 11.2%). Opioid use increased (37.2% to 63.4%) and Esketamine use decreased (66.1% to 48.3%) in children < 6 vs. > 10 years. Esketamine was more often administered in extremity (57.3%) than in head (41.5%) or spine injuries (32.3%). An intravenous access was less often established in children < 6 years (74.3% vs. 90.8%; p < 0.001). Despite the use of potent analgesics, 396 missions (13.7%) were performed without technical monitoring. Particularly regarding patient data at handover in hospital, merely < 10% of all missions featured complete documentation. Therefore, sufficient evaluation of the efficacy of pain relief was not possible. Yet, by means of respiratory measures required during transport, severe side effects such as respiratory insufficiency, were barely noted.

CONCLUSIONS

In the physician-staffed HEMS setting, pediatric trauma patients liberally receive opioids and Esketamine for analgesia. With regard to severe respiratory insufficiency during transport, the application of these potent analgesics seems safe.

Resource utilisation for patients brought to a major trauma centre by helicopter

BACKGROUND

Helicopter Emergency Medical Services (HEMS) allow critical care personnel to attend incidents alongside transporting patients to hospital. The study site is a UK based emergency department and major trauma centre, accepting flights from a wide geographical area.

AIMS

To characterise the impact of HEMS on a major trauma centre clinical resources and the impact of the UK regional trauma network launch on HEMS asset provision.

METHODS

Flight case-mix data were obtained from Emergency Department (ED) records (non-trauma patients) and from the Trauma Audit and Research Network database (trauma patients). Statistical analysis was in Excel.

RESULTS

432 flights landed at the site between August 2018 and July 2019. 178 flights originated from the incident scene (145 trauma, 26 non-trauma), 107 from other hospitals, and 5 to other hospitals. Hospitalisation was reduced to a median of 6 days.

CONCLUSIONS

Primary HEMS trauma patients utilised significant clinical resources but had shorter hospitalisations than those without HEMS intervention. The regional trauma network improved HEMS tasking and utilised critical car cars to provide advanced pre-hospital care locally. Further work should compare HEMS versus ground ambulance to determine the impact of HEMS on patient outcomes and cost implications to both HEMS operators and receiving hospital.

Factors affecting development of air ambulance base: A systematic review and thematic analysis

Nowadays, air ambulances have been developed as part of advanced emergency medicine services with many countries employing these services for transferring patients in usual and emergency conditions. However, there are challenges concerning the optimal development of air ambulance base. The present research aimed to identify factors affecting the development of air ambulance bases to provide the opportunity of planning to improve the quality of emergency medical services. In this systematic literature review, the peer-reviewed papers in fiv electronic databases, including Medline through PubMed, Scopus, Web of Science, ScienceDirect, and ProQuest, as well as available gray literature, were searched and selected. Two combinations of groups were used as keywords: the Health Planning and development factor, air ambulance base. The focus was on the PRISMA checklist, with no time limitations until from 1990 to January 2020. Finally, through 5156 related citations, 20 articles were included. Descriptive and thematic content analyses were evaluated. The factors affecting the development of the air ambulance base were classified in fiv categories and 14 subcategories as follows: navigation criteria, process indications and standards, sociopolitical factors, and current situation of the area. There are few studies on factors affecting the development of air ambulance bases. It is necessary to apply multidimensional models to consider various factors for development. The development of high populated cities, events and ceremonies with a crowd of participants, and increase of human-made disasters are making these services increasingly indispensable.

Identifying causes of delay in interfacility transfer of patients by air ambulance

OBJECTIVES

Population density can limit the level of care that can be provided in local facilities in Ontario, and as such, patients with severe illnesses often require interfacility transfers to access specialized care. This study aimed to identify causes of delay in interfacility transport by air ambulance in Ontario.

METHODS

Causes of delay were identified by manual review of electronic patient care records (ePCRs). All emergent interfacility transfers conducted by Ornge, the sole provider of air-based medical transport in Ontario, between January 1, 2016 and December 31, 2016 were included. The ePCRs were reviewed if they met one or more of the following: (1) contained a standardized delay code; (2) contained free text including "delay", "wait", or "duty-out"; (3) were above the 75th percentile in total transport time; or (4) were above the 90th percentile in time to bedside, time at the sending hospital, or time to receiving facility.

RESULTS

Our search strategy identified 1,220 ePCRs for manual review, which identified a total of 872 delays. Common delays cited included aircraft refueling (234 delays), waiting for land emergency medical service (EMS) escort (146), and staffing- or dispatch-related issues (124). Other delays included weather/environmental hazards (43); mechanical issues (36); and procedures, imaging, or stabilization (80).

CONCLUSIONS

Some common causes of interfacility delay are potentially modifiable: better trip planning around refueling and improved coordination with local EMS, could reduce delays experienced during interfacility trips. To better understand causes of delay, we would benefit from improved documentation and record availability which limited the results in this study.

Introducing fairness in Norwegian air ambulance base location planning

Background

A primary task of the Norwegian helicopter emergency medical services (HEMS) is to provide advanced medical care to the critical ill and injured outside of hospitals. Where HEMS bases are located, directly influences who in the population can be reached within a given response time threshold and who cannot. When studying the locations of bases, the focus is often on efficiency, that is, maximizing the total number of people that can be reached within a given set time. This approach is known to benefit people living in densely populated areas, such as cities, over people living in remote areas. The most efficient solution is thus typically not necessarily a fair one. This study aims to incorporate fairness in finding optimal air ambulance base locations.

Methods

We solve multiple advanced mathematical optimization models to determine optimal helicopter base locations, with different optimization criteria related to the level of aversion to inequality, including the utilitarian, Bernoulli-Nash and iso-elastic social welfare functions. This is the first study to use the latter social welfare function for HEMS.

Results

Focusing on efficiency, a utilitarian objective function focuses on covering the larger cities in Norway, leaving parts of Norway largely uncovered. Including fairness by rather using an iso-elastic social welfare function in the optimization avoids leaving whole areas uncovered and in particular increases service levels in the north of Norway.

Conclusions

Including fairness in determining optimal HEMS base locations has great impact on population coverage, in particular when the number of base locations is not enough to give full coverage of the country. As results differ depending on the mathematical objective, the work shows the importance of not only looking for optimal solutions, but also raising the essential question of ‘optimal with respect to what’.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00842-0.

Measuring More than Mortality: A scoping review of air ambulance outcome measures in a combined Institutes of Medicine and Donabedian quality framework

INTRODUCTION

Measuring the performance of air ambulance services are complex and dynamic due to the variability and interconnectedness of emergency systems. The aim of this study is to review the range and nature of air ambulance outcome measures published in peer review articles and construct a quality framework based on the results. A scoping review of the literature was conducted to identify outcome measures that evaluate the quality of air ambulance services. Combined frameworks from the Institutes of Medicine (IOM) and Dr. Avedia Donabedian were used to create a dashboard structure for a framework of air ambulance outcome measures.

METHODS

A literature search strategy was undertaken, following PRISMA-ScR guidelines and included eight databases over the period 2001-2019. Qualitative content analysis was conducted in 4-phases: 1) table summary of selected article outcome measures, 2) content analysis themes, codes of outcome measures and independent variables 3) narrative description of main themes 4) visual dashboard diagram of service priorities and quality strategies, based on the findings.

RESULTS

Thirty-four articles were screened by full text and eighteen met the selection criteria. Twenty codes emerged and were grouped to form eight consistent outcome themes; asset/ team type, access to definitive interventions, prehospital factors, mortality, morbidity, responsiveness of service, accessibility of service and patient disposition.

CONCLUSIONS

A quality framework consisting of eight outcome measures was created, it also identified seven gaps which ordinarily require performance evaluation; patient comfort and satisfaction reporting, cultural awareness training, safety alarms in place to identify volume stress, optimal coordination of resources, cost of service analysis, comprehensive patient journey time and an adaptive referral system analysis. The measures in the framework provide a broad perspective of air ambulance performance we believe will help decision-making and planning to improve patients experience and outcomes.

Intubation during a medevac flight: safety and effect on total prehospital time in the helicopter emergency medical service system

INTRODUCTION

The Helicopter Emergency Medical Service (HEMS) commonly intubates patients who require advanced airway support prior to takeoff. In-flight intubation (IFI) is avoided because it is considered difficult due to limited space, difficulty communicating, and vibration in flight. However, IFI may shorten the total prehospital time. We tested whether IFI can be performed safely by the HEMS.

METHODS

We conducted a retrospective cohort study in adult patients transported from 2010 to 2017 who received prehospital, non-emergent intubation from a single HEMS. We divided the cohort in two groups, patients intubated during flight (flight group, FG) and patients intubated before takeoff (ground group, GG). The primary outcome was the proportion of successful intubations. Secondary outcomes included total prehospital time and the incidence of complications.

RESULTS

We analyzed 376 patients transported during the study period, 192 patients in the FG and 184 patients in the GG. The intubation success rate did not differ between the two groups (FG 189/192 [98.4%] vs. GG 179/184 [97.3%], p = 0.50). There were also no differences in hypoxia (FG 4/117 [3.4%] vs. GG 4/95 [4.2%], p = 1.00) or hypotension (FG 6/117 [5.1%] vs. GG 5/95 [5.3%], p = 1.00) between the two groups. Scene time and total prehospital time were shorter in the FG (scene time 7 min vs. 14 min, p <  0.001; total prehospital time 33.5 min vs. 40.0 min, p <  0.001).

CONCLUSIONS

IFI was safely performed with high success rates, similar to intubation on the ground, without increasing the risk of hypoxia or hypotension. IFI by experienced providers shortened transportation time, which may improve patient outcomes.

In situ simulation training in helicopter emergency medical services: feasible for on-call crews?

Simulation-based training of emergency teams offers a safe learning environment in which training in the management of the critically ill patient can be planned and practiced without harming the patient. We developed a concept for in situ simulation that can be carried out during on-call time. The aim of this study is to investigate the feasibility of introducing in situ, simulation-based training for the on-call team on a busy helicopter emergency medical service (HEMS) base. We carried out a one-year prospective study on simulation training during active duty at a busy Norwegian HEMS base, which has two helicopter crews on call 24/7. Training was conducted as low fidelity in situ simulation while the teams were on call. The training took place on or near the HEMS base. Eight scenarios were developed with learning objectives related to the mission profile of the base which includes primary missions for both medical and trauma patients of all ages, and interhospital transport of adults, children, and neonates. All scenarios included learning objectives for non-technical skills. A total of 44 simulations were carried out. Total median (quartiles) time consumption for on-call HEMS crew was 65 (59-73) min. Time for preparation of scenarios was 10 (5-11) min, time for simulations was 20 (19-26) min, cleaning up 7 (6-10) min, and debrief 35 (30-40) min. For all items on the questionnaire, the majority of respondents replied with the two most positive categories on the Likert scale. Our results demonstrate that in situ simulation training for on-call crews on a busy HEMS base is feasible with judicious investment of time and money. The participants were very positive about their experience and the impact of this type of training.

Transport of COVID-19 and other highly contagious patients by helicopter and fixed-wing air ambulance: a narrative review and experience of the Swiss air rescue Rega

Background

The current COVID-19 pandemic highlights the challenges air ambulance services are facing when transporting highly infectious patients for several hours in enclosed spaces. This overview provides an example of a standard operating procedure (SOP) for infection prevention measures in HEMS missions during the COVID-19 pandemic. Furthermore, we describe different methods used by several organizations in Europe and the experience of the Swiss air rescue organization Rega in transporting these patients.

Possible benefits of the use of small patient isolation units (PIU) are discussed, including the fact that accompanying medical personnel do not need to wear personal protective equipment (PPE) during the transport but can still maintain full access to the patient. Rega has developed and patented its own PIU. This device allows spontaneously breathing or mechanically ventilated patients to be transported in pressurized jet cabins, small helicopters and ambulance vehicles, without the need to change between transport units. This PIU is unique, as it remains air-tight even when there is a sudden loss of cabin pressure.

Conclusion

A wide variety of means are being used for the aeromedical transport of infectious patients. These involve isolating either the patient or the medical crew. One benefit of PIUs is that the means of transport can be easily changed without contaminating the surroundings and while still allowing access to the patient.

Air ambulance outcome measures using Institutes of Medicine and Donabedian quality frameworks: protocol for a systematic scoping review

BACKGROUND

Dedicated air ambulance services provide a vital link for critically ill and injured patients to higher levels of care. The recent developments of pre-hospital and retrieval medicine create an opportunity for air ambulance providers and policy-makers to utilize a dashboard of quality performance measures to assess service performance. The objective of this scoping systematic review will be to identify and evaluate the range of air ambulance outcome measures reported in the literature and help to construct a quality dashboard based on a healthcare quality framework.

METHODS

We will search PubMed, MEDLINE, CINAHL, Scopus, and Cochrane Database of Systematic Reviews (from January 2001 onwards). Complementary searches will be conducted in selected relevant journals. We will include systematic reviews and observational studies (cohort, cross-sectional, interrupted time series) in critically ill or injured patients published in English and focusing on air ambulance delivery and quality measures. Two reviewers will independently screen all citations, full-text articles, and abstract data. The study methodological quality (or bias) will be appraised using appropriate tools. Analysis of the characteristics associated with outcome measure will be mapped and described according to the proposed healthcare quality framework.

DISCUSSION

This review will contribute to the development of an air ambulance quality dashboard designed to combine multiple quality frameworks. Our findings will provide a basis for helping decision-making in health planning and policy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019144652.

Cross-sectional study of the healthcare provided by a medicalized helicopter from Extremadura (Spain)

OBJECTIVE

To analyze geographic dispersion, demographic factors, clinical features of patients attended and response times of a helicopter emergency medical service in a region of Spain.

METHODS

According to the principles of the Declaration of Helsinki and to the standards of Good Clinical Practice, a cross-sectional observational study from January 2014 to December 2016 was carried out. Socio-demographic, clinical and transfer related variables were analyzed from an anonymized database loaned by the service.

RESULTS

642 missions were flown (on average 0.59 flights per day). The patients were 65.6% males (they were significantly younger than women were) and 79% older than 45. Primary transfers composed 68.8% of cases. Medical pathologies were the most prevalent (74.9%), followed by traumatic pathologies (19.8%). Cardiovascular pathologies took up 68.8% of attended medical pathologies and 51.56% of the total of recorded cases. The accident rate was 20.25% and the response time in 75% of cases was under 32 min. Twenty deceased patients were registered (70% males).

CONCLUSIONS

This study reports for the international community the features of several Spanish HEMS and profile of patients attended. Adult men are a common profile and cardiovascular issues have replaced traumatic issues as main healthcare demand. However, it should be confirmed because it could be due to differences in local profile of patients. Men had higher risk of road traffic and occupational accidents as well as a higher mortality than women did. Socio-demographical and organizational aspects have been provided that could be taken into consideration to implement new air emergency services.

Sleepiness among personnel in the Norwegian Air Ambulance Service

Abstract

Purpose To examine the effects of shift work and extended working hours on sleepiness among pilots and Helicopter Emergency Medical Service (HEMS) crew members in the Norwegian Air Ambulance.

Methods

This field study investigated sleepiness during 3 consecutive weeks: the week before work, the work week, and the week after work. The pilots and HEMS crew members (N = 50) kept a wake diary during all 3 weeks and completed reaction time tests during the work week.

Results

The overall sleepiness scores were low during all 3 weeks. When comparing the 3 weeks, the lowest sleepiness levels were found for the work week. There was a small difference across work days, in which subjective sleepiness scores were highest the first duty day. No change in the reaction time tests was evident during the work week. The crew members reported being most sleepy at midnight, compared to all the other timepoints over the course of a duty day. Regarding workload and total work time, having larger workload was associated with lower sleepiness scores, while having higher total work time was associated with higher sleepiness score, both compared to the medium category.

Conclusions

The findings indicate that the work schedules and setting for this distinct occupational group do not seem to negatively affect the sleepiness levels.

Loss of life years due to unavailable helicopter emergency medical service: a single base study from a rural area of Norway

Background: Despite the potential benefits of physician-staffed Helicopter Emergency Medical Service (HEMS), many dispatches to primary HEMS missions in Norway are cancelled before patient encounter. Information is sparse regarding the health consequences when medically indicated HEMS missions are cancelled and the patients are treated by a GP and ambulance staff only. We aimed to estimate the potential loss of life years for patients in these situations. Method: We included all HEMS requests in the period 2010-2013 from Sogn and Fjordane County that were medically indicated but subsequently cancelled. This provided a selection of patients, with the purpose of studying cancellations independently of the patient's medical status A multidisciplinary expert panel retrospectively assessed each patient's potential loss of life years due to the lack of helicopter transport and intervention by a HEMS physician. Results: The study included 184 patients from 176 missions. Because of unavailable HEMS, seven patients (4%) were anticipated to have lost a total of 18 life years. Three patients suffered from myocardial infarction, three from stroke and one from abdominal haemorrhage. The main contribution from HEMS care in these seven cases might have been rapid transport to definitive care. The probability of a patient losing life years when in need of HEMS evacuation was found to be 0.2%. Conclusion: During the four years period seven patients lost 18 life years. Lack of rapid transport seems to be the primary cause of lost life years in this specific geographical area. Key Points Knowledge about to what extent HEMS contributes to an increased survival and a better outcome for patients is limited. Compared to similar studies on life years gained the estimated loss of life years was minor when HEMS evacuation was unavailable in this rural area. The findings indicates that lack of rapid HEMS transport was the primary cause of the estimated loss of life years.

[Experience of transportation of mass severe burn patients for long distance by air ambulance with fixed wing]

Objective: To explore the experience of transportation of mass severe burn patients for long distance by air ambulance with fixed wing. Methods: The organization and implementation process of transportation of 5 patients in the devastating forest fire of Greater Khingan on 2nd, May 2017, for long distance by air ambulance with fixed wing were reviewed and analyzed. All the patients were severely burned and complicated with inhalation injury. Four hours after accident, the relevant authority dispatched national medical team with 2 specialists of burn, 1 specialist of intensive care medicine, 1 head nurse of burn intensive care unit (ICU) to treat and cure the patients before transportation. Three patients had tracheotomy and four patients had escharotomy. Patients and their relatives, expert group of transportation, and aircrew members were arranged according to the scheme before transportation. Patients were monitored and treated with the equipments of air ambulance during the transportation. Patients were transferred to the burn ICU in our hospital from the airport through the green channel. Results: All the five patients were transported to the destination safely for long distance of 1 700 kilometres and air flight 3.5 hours one way by air ambulance with fixed wing in 4 batches at 26 to 44 hours post burn, and transported from tarmac to burn ICU of our hospital. All the patients were in stable condition during the transportation and had successful subsequent rescue. All the patients were discharged in three months. Conclusions: It is feasible to transfer mass severe burn patients for long distance by air ambulance with fixed wing, and it is safer and more effective to transfer according to the standardization process, and the opportunity of transportation of severe burn patients can be moved up to shock stage.

A novel method of non-clinical dispatch is associated with a higher rate of critical Helicopter Emergency Medical Service intervention

Background

Helicopter Emergency Medical Services (HEMS) are a scarce resource that can provide advanced emergency medical care to unwell or injured patients. Accurate tasking of HEMS is required to incidents where advanced pre-hospital clinical care is needed. We sought to evaluate any association between non-clinically trained dispatchers, following a bespoke algorithm, compared with HEMS paramedic dispatchers with respect to incidents requiring a critical HEMS intervention.

Methods

Retrospective analysis of prospectively collected data from two 12-month periods was performed (Period one: 1st April 2014 – 1st April 2015; Period two: 1st April 2016 – 1st April 2017). Period 1 was a Paramedic-led dispatch process. Period 2 was a non-clinical HEMS dispatcher assisted by a bespoke algorithm. Kent, Surrey & Sussex HEMS (KSS HEMS) is tasked to approximately 2500 cases annually and operates 24/7 across south-east England. The primary outcome measure was incidence of a HEMS intervention.

Results

A total of 4703 incidents were included; 2510 in period one and 2184 in period two. Variation in tasking was reduced by introducing non-clinical dispatchers. There was no difference in median time from 999 call to HEMS activation between period one and two (period one; median 7 min (IQR 4–17) vs period two; median 7 min (IQR 4–18). Non-clinical dispatch improved accuracy of HEMS tasking to a mission where a critical care intervention was required (OR 1.25, 95% CI 1.04–1.51, p = 0.02).

Conclusion

The introduction of non-clinical, HEMS-specific dispatch, aided by a bespoke algorithm improved accuracy of HEMS tasking. Further research is warranted to explore where this model could be effective in other HEMS services.

The mission characteristics of a newly implemented rural helicopter emergency medical service

Background

Physician-staffed helicopter emergency services (HEMS) can provide benefit through the delivery of specialist competence and equipment to the prehospital scene and through expedient transport of critically ill patients to specialist care. This paper describes the integration of such a system in a rural Swedish county.

Methods

This is a retrospective database study recording the outcomes of every emergency call centre dispatch request as well as the clinical and operational data from all completed missions during this service’s first year in operation.

Results

During the study period, HEMS completed 478 missions out of which 405 (84,7%) were primary missions to prehospital settings and 73 (15,3%) were inter-hospital critical care transfers. A majority (55,3%) of primary missions occurred in the regions furthest from our hospitals, in municipalities housing only 15,6% of the county’s population. The NACA (IQR) score on primary and secondary missions was 4 (2) and 5 (1), respectively.

Conclusions

This study describes the successful integration of a physician-based air ambulance service in a Scandinavian rural region. Municipalities distant from our hospitals benefitted as they now have access to early specialist intervention and expedient transport to critical hospital care. Our hospitals and most populated areas benefitted from HEMS secondary mission capability as they gained a dedicated ICU transport service that could provide specialist intensive care during rapid inter-hospital transfer.

Comparing population and incident data for optimal air ambulance base locations in Norway

Background

Helicopter emergency medical services are important in many health care systems. Norway has a nationwide physician manned air ambulance service servicing a country with large geographical variations in population density and incident frequencies. The aim of the study was to compare optimal air ambulance base locations using both population and incident data.

Methods

We used municipality population and incident data for Norway from 2015. The 428 municipalities had a median (5–95 percentile) of 4675 (940–36,264) inhabitants and 10 (2–38) incidents. Optimal helicopter base locations were estimated using the Maximal Covering Location Problem (MCLP) optimization model, exploring the number and location of bases needed to cover various fractions of the population for time thresholds 30 and 45 min, in green field scenarios and conditioned on the existing base structure.

Results

The existing bases covered 96.90% of the population and 91.86% of the incidents for time threshold 45 min. Correlation between municipality population and incident frequencies was −0.0027, and optimal base locations varied markedly between the two data types, particularly when lowering the target time. The optimal solution using population density data put focus on the greater Oslo area, where one third of Norwegians live, while using incident data put focus on low population high incident areas, such as northern Norway and winter sport resorts.

Conclusion

Using population density data as a proxy for incident frequency is not recommended, as the two data types lead to different optimal base locations. Lowering the target time increases the sensitivity to choice of data.

Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study

BACKGROUND

The effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS.

METHODS

Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran-Mantel-Haenszel methods and mixed-effects models.

RESULTS

Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO₂ compared to trauma patients. Post-intervention and admission SpO₂ for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4-5.4).

CONCLUSIONS

Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01502111 . Registered 22 Desember 2011.

Risk for intracranial pressure increase related to enclosed air in post-craniotomy patients during air ambulance transport: a retrospective cohort study with simulation

Background

Post-craniotomy intracranial air can be present in patients scheduled for air ambulance transport to their home hospital. We aimed to assess risk for in-flight intracranial pressure (ICP) increases related to observed intracranial air volumes, hypothetical sea level pre-transport ICP, and different potential flight levels and cabin pressures.

Methods

A cohort of consecutive subdural hematoma evacuation patients from one University Medical Centre was assessed with post-operative intracranial air volume measurements by computed tomography. Intracranial pressure changes related to estimated intracranial air volume effects of changing atmospheric pressure (simulating flight and cabin pressure changes up to 8000 ft) were simulated using an established model for intracranial pressure and volume relations.

Results

Approximately one third of the cohort had post-operative intracranial air. Of these, approximately one third had intracranial air volumes less than 11 ml. The simulation estimated that the expected changes in intracranial pressure during ‘flight’ would not result in intracranial hypertension. For intracranial air volumes above 11 ml, the simulation suggested that it was possible that intracranial hypertension could develop ‘inflight’ related to cabin pressure drop. Depending on the pre-flight intracranial pressure and air volume, this could occur quite early during the assent phase in the flight profile.

Discussion

These findings support the idea that there should be radiographic verification of the presence or absence of intracranial air after craniotomy for patients planned for long distance air transport.

Conclusions

Very small amounts of air are clinically inconsequential. Otherwise, air transport with maintained ground-level cabin pressure should be a priority for these patients.

Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest

BACKGROUND

Improving survival after out-of-hospital cardiac arrest (OHCA) is a priority for modern emergency medical services (EMS) and prehospital research. Advanced life support (ALS) is now the standard of care in most EMS. In some EMS, prehospital critical care providers are also dispatched to attend OHCA. This systematic review presents the evidence for prehospital critical care for OHCA, when compared to standard ALS care.

METHODS

We searched the following electronic databases: PubMed, EmBASE, CINAHL Plus and AMED (via EBSCO), Cochrane Database of Systematic Reviews, DARE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, NIHR Health Technology Assessment Database, Google Scholar and ClinicalTrials.gov. Search terms related to cardiac arrest and prehospital critical care. All studies that compared patient-centred outcomes between prehospital critical care and ALS for OHCA were included.

RESULTS

The review identified six full text publications that matched the inclusion criteria, all of which are observational studies. Three studies showed no benefit from prehospital critical care but were underpowered with sample sizes of 1028-1851. The other three publications showed benefit from prehospital critical care delivered by physicians. However, an imbalance of prognostic factors and hospital treatment in these studies systematically favoured the prehospital critical care group.

CONCLUSION

Current evidence to support prehospital critical care for OHCA is limited by the logistic difficulties of undertaking high quality research in this area. Further research needs an appropriate sample size with adjustments for confounding factors in observational research design.

Ambulance helicopter contribution to search and rescue in North Norway

Background

Search and rescue (SAR) operations constitute a significant proportion of Norwegian ambulance helicopter missions, and they may limit the service’s capacity for medical operations. We compared the relative contribution of the different helicopter resources using a common definition of SAR-operation in order to investigate how the SAR workload had changed over the last years.

Methods

We searched the mission databases at the relevant SAR and helicopter emergency medical service (HEMS) bases and the Joint Rescue Coordination Centre (North) for helicopter-supported SAR operations within the potential operation area of the Tromsø HEMS base in 2000–2010. We defined SAR operations as missions over land or sea within 10 nautical miles from the coast with an initial search phase, missions with use of rescue hoist or static rope, and avalanche operations.

Results

There were 769 requests in 639 different SAR operations, and 600 missions were completed. The number increased during the study period, from 46 in 2000 to 77 in 2010. The Tromsø HEMS contributed with the highest number of missions and experienced the largest increase, from 10 % of the operations in 2000 to 50 % in 2010. Simple terrain and sea operations dominated, and avalanches accounted for as many as 12 % of all missions. The helicopter crews used static rope or rescue hoist in 141 operations.

Discussion

We have described all helicopter supported SAR operations in our area by combining databases. The Tromsø HEMS service had taken over one half of the missions by 2010. Increased availability for SAR work is one potential explanation.

Conclusions

The number of SAR missions increased during 2000-2010, and the Tromsø HEMS experienced the greatest increase in workload.

Air medical transportation in India: Our experience

BACKGROUND AND AIMS

Long distance air travel for medical needs is on the increase worldwide. The condition of some patients necessitates specially modified aircraft, and monitoring and interventions during transport by trained medical personnel. This article presents our experience in domestic and international interhospital air medical transportation from January 2010 to January 2014.

MATERIAL AND METHODS

Hospital records of all air medical transportation undertaken to the institute during the period were analyzed for demographics, primary etiology, and events during transport.

RESULTS

586 patients, 453 (77.3%) males and 133 (22.6%) females of ages 46.7 ± 12.6 years and 53.4 ± 9.7 years were transported by us to the institute. It took 3030 flying hours with an average of 474 ± 72 min for each mission. The most common indication for transport was cardiovascular diseases in 210 (35.8%) and central nervous system disease in 120 (20.4%) cases. The overall complication rate was 5.3% There was no transport related mortality.

CONCLUSION

Cardiac and central nervous system ailments are the most common indication for air medical transportation. These patients may need attention and interventions as any critical patient in the hospital but in a difficult environment lacking space and help. Air medical transport carries no more risk than ground transportation.

Invasive and surgical procedures in pre-hospital care: what is the need?

BACKGROUND

On occasion, advanced invasive procedures in pre-hospital care can be life saving. This study aimed to identify the contemporary use of these procedures on a regional doctor-led air ambulance unit, and to define the need, skill set and training requirements for a regional pre-hospital team in the UK.

METHODS

Mission data were recorded prospectively and the database reviewed to identify invasive procedures over a 76-month period. These cases were reviewed with indications, mechanism of injury, presence of cardiac arrest at any time point (±return of spontaneous circulation) and procedural failure or morbidity.

RESULTS

Two hundred and thirty-five procedures were performed: 16 for injuries affecting the airway, 111 for breathing and 108 for circulation. Almost a third of patients in cardiac arrest regained spontaneous circulation. Procedures performed increased fivefold from 2003 to 2009, with a marked increase in the use of thoracostomy and intra-osseous access. Procedural failure or inadequacy was high with needle cricothyroidotomy, needle chest decompression and early intra-osseous access experience.

CONCLUSIONS

A steady increase in the number of procedures was observed over time. Less invasive methods of airway and breathing support were frequently inadequate, though definitive surgical airway or chest decompression was effective each time it was performed. Thoracotomy was performed infrequently. There are implications for the training of pre-hospital doctors who work in the majority of the UK.