Factors Associated with the Use of Helicopter Inter-facility Transport of Trauma Patients to Tertiary Trauma Centers within an Organized Rural Trauma System

Objective: A review of the literature yielded little information regarding factors associated with the decision to use ground (GEMS) or helicopter (HEMS) emergency medical services for trauma patients transferred inter-facility. Furthermore, studies evaluating the impact of inter-facility transport mode on mortality have reported mixed findings. Since HEMS transport is generally reserved for more severely injured patients, this introduces indication bias, which may explain the mixed findings. Our objective was to identify factors at referring non-tertiary trauma centers (NTC) influencing transport mode decision. Methods: This was a case-control study of trauma patients transferred from a Level III or IV NTC to a tertiary trauma center (TTC) within 24-hours reported to the Oklahoma State Trauma Registry between 2005 and 2012. Multivariable logistic regression was used to determine clinical and non-clinical factors associated with the decision to use HEMS. Results: A total of 7380 patients met the study eligibility. Of these, 2803(38%) were transported inter-facility by HEMS. Penetrating injury, prehospital EMS transport, severe torso injury, hypovolemic shock, and TBI were significant predictors (p<0.05) of HEMS use regardless of distance to a TTC. Association between HEMS use and male gender, Level IV NTC, and local ground EMS resources varied by distance from the TTC. Many HEMS transported patients had minor injuries and normal vital signs. Conclusions: Our results suggest that while distance remains the most influential factor associated with HEMS use, significant differences exist in clinical and non-clinical factors between patients transported by HEMS versus GEMS. To ensure comparability of study groups, studies evaluating outcome differences between HEMS and GEMS should take factors determining transport mode into account. The findings will be used to develop propensity scores to balance baseline risk between GEMS and HEMS patients for use in subsequent studies of outcomes.     

An Evidence-based Guideline for the Air Medical Transportation of Prehospital Trauma Patients

Abstract

Background. Decisions about the transportation of trauma patients by helicopter are often not well informed by research assessing the risks, benefits, and costs of such transport. Objective. The objective of this evidence-based guideline (EBG) is to recommend a strategy for the selection of prehospital trauma patients who would benefit most from aeromedical transportation. Methods. A multidisciplinary panel was recruited consisting of experts in trauma, EBG development, and emergency medical services (EMS) outcomes research. Representatives of the Federal Interagency Committee on Emergency Medical Services (FICEMS), the National Highway Traffic Safety Administration (NHTSA) (funding agency), and the Children's National Medical Center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide question formulation, evidence retrieval, appraisal/synthesis, and formulate recommendations. The process followed the National Evidence-Based Guideline Model Process, which has been approved by the Federal Interagency Committee on EMS and the National EMS Advisory Council. Results. Two strong and three weak recommendations emerged from the process, all supported only by low or very low quality evidence. The panel strongly recommended that the 2011 CDC Guideline for the Field Triage of Injured Patients be used as the initial step in the triage process, and that ground emergency medical services (GEMS) be used for patients not meeting CDC anatomic, physiologic, and situational high-acuity criteria. The panel issued a weak recommendation to use helicopter emergency medical services (HEMS) for higher-acuity patients if there is a time-savings versus GEMS, or if an appropriate hospital is not accessible by GEMS due to systemic/logistical factors. The panel strongly recommended that online medical direction should not be required for activating HEMS. Special consideration was given to the potential need for local adaptation. Conclusions. Systematic and transparent methodology was used to develop an evidence-based guideline for the transportation of prehospital trauma patients. The recommendations provide specific guidance regarding the activation of GEMS and HEMS for patients of varying acuity. Future research is required to strengthen the data and recommendations, define optimal approaches for guideline implementation, and determine the impact of implementation on safety and outcomes including cost.     

Injury Mortality Following the Loss of Air Medical Support for Rural Interhospital Transport

OBJECTIVES: This study evaluated variation in mortality among interfacility transfers three years before and after discontinuation of a rotor-wing transport service. METHODS: A retrospective cohort assessment was conducted among severely injured patients transferred from four rural hospitals to a single tertiary center in regions with continued versus discontinued rotor-wing service. Thirty-day mortality following discharge from the receiving tertiary facility served as the primary outcome measure. RESULTS: Discontinuation of rotor-wing transport decreased interfacility transfers and increased transfer time. Transferred patients were four times more likely to die after (compared with before) rotor-wing service was discontinued (p = 0.05). No difference was noted in the region with continued rotor-wing service [odds ratio (OR) = 0.53, p = 0.47]. CONCLUSIONS: Injury mortality increased with loss of air transport for interfacility transfer in a rural area.     

Role of Pilot Instrument Proficiency in the Safety of Helicopter Emergency Medical Services

Objectives : To determine whether instrument-proficient pilots would more safely manage a flight into unplanned instrument meteorologic conditions (IMC) than would nonproficient pilots.
Methods : A controlled experimental study was performed using a full-motion helicopter simulator. Participants were emergency medical services (EMS) pilots with commercial licenses and previous simulator experience who were blinded to the study design and hypothesis. During a simulated EMS mission, cloud ceiling and visibility were decreased until IMC prevailed, and pilot actions were recorded. Data included the altitude at which the aircraft entered IMC, and whether the pilots maintained control of the aircraft, flew within aviation standards (i.e., bank angle, airspeed), and safely landed.
Results : Twenty-eight pilots (13 instrument-proficient, 15 nonproficient) participated; they had a median of 6,300 hours of helicopter experience. Two pilots crashed, both from the nonproficient group. The instrument-proficient pilots lost control less often (15% vs 67%, p < 0.05), maintained instrument standards more often (77% vs 40%, p < 0.05), and entered IMC at a higher altitude (689 feet vs 517 feet, p < 0.05) compared with the nonproficient pilots. Instructor comments indicated that the nonproficient pilots made more errors than did the instrument-proficient pilots.
Conclusions : Instrument-proficient pilots more safely manage an unexpected encounter with IMC. Helicopter EMS programs should strongly consider maintaining instrument proficiency to enhance safety.     

Ventilation Practices and Critical Events during Transport of Ventilated Patients outside of Hospital: A Retrospective Cohort Study

Introduction. Little is known about mechanical ventilation practices during patient transport outside of hospital in the civilian setting, although these practices may have clinical impact. Objective. We set out to describe ventilation practice, the use of lung-protective ventilation strategies, administration of sedation and neuromuscular blockade, and related critical events during out-of-hospital transport of ventilated patients. Methods. We conducted a population-based retrospective cohort study. Ventilator, pharmacy, and clinical data were extracted from the database of the provincial transport medicine agency in Ontario, Canada. Patients at risk for acute lung injury were identified by explicit screening criteria and lung-protective ventilation was assessed according to evidence-based thresholds. Critical events occurring during transport consisting of clinical deterioration or resuscitative procedures were recorded. Results. We identified 1,735 mechanically ventilated adults who received out-of-hospital transport. Volume control and pressure control were the most commonly used ventilation modes. The median tidal volume delivered during transport was 500 mL (interquartile range 450–600) with positive end-expiratory pressure (PEEP) of 5 cmH₂O (5–7) and peak inspiratory pressure of 24 cmH₂O (20–29). Most patients (92%) were ventilated with peak pressures ≤ 35 cmH₂O; 22% of patients were ventilated with PEEP < 5 cmH₂O. Ventilation in patients at risk of acute lung injury was not significantly different, and 68% of this subgroup was ventilated within lung-protective thresholds. Sedation was administered in 1,235 transports (71.2%) with frequent repeat administration. Neuromuscular blockade was administered in 385 transports (22.2%). Critical events occurred during 297 (17.1%) transports, due primarily to new-onset hypotension (n = 208). New in-transit hypotension was independently associated with sedative administration. Conclusions. In-transit mechanical ventilation practices are variable, although patient exposure to potentially injurious pressures and volumes is uncommon. The application of PEEP is modest. In-transit hypotension is common and associated with sedative administration. The extent to which these practices impact patient outcome is unclear.     

Lights and Siren Transport and the Need for Hospital Intervention in Trauma Patients

Emergent ambulance transportation is associated with increased risk of collision, injury, and death for EMS professionals, patients, and the general public. Time saved using lights and siren (L&S) is typically small, and often provides minimal clinical benefit. Our objective was to investigate the frequency of L&S transports, describe the precision of the decision to employ L&S to predict the need for a time critical hospital intervention (TCHI) within 15 minutes of hospital arrival, identify clinical predictors of a TCHI, and compare clinical outcomes in patients transported by Emergency Medical Services (EMS) with and without L&S in a trauma-specific population. EMS patient care reports and trauma registry data were retrospectively reviewed for trauma patients consecutively transported from the field by three EMS agencies to three trauma centers within urban and suburban settings over a two-year period. TCHIs were collaboratively developed by the study team. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were utilized to report the precision of the decision to employ L&S to predict the need of a TCHI. Univariate and multivariate analyses determined predictors of a TCHI and compared clinical outcomes. 2,091 patients were included in the study. Of the 19.8% of patients transported with L&S, 22.9% received a TCHI. The most common TCHI was airway or respiratory procedures (87.2% of all TCHI's). The sensitivity and specificity of L&S to predict the need for a TCHI was 87.2% (95% CI 79.4–92.8) and 84.0% (95% CI 82.2–85.5), respectively. PPV was 23.0% (95% CI 23.53–38.01); NPV was 99.2% (95% CI 98.6–99.6). L&S was predictive for the need for a TCHI (p < 0.001), as was abnormal Glasgow Coma Score (p < 0.001), abnormal systolic blood pressure and age (p < 0.05 for all). Among patients that received a TCHI, over a third that were transported with L&S (36.8%) expired, compared with two of 14 patients (14.3%) not transported L&S. EMS professionals in this study demonstrated a high ability to discern which trauma patients did not require L&S. Nevertheless, L&S transport resulted in a TCHI less than one quarter of the time, suggesting an opportunity for further reduction of L&S transports in trauma patients.     

T HE U SE OF E TOMIDATE FOR R APID - SEQUENCE I NTUBATION IN THE A IR M EDICAL S ETTING

Objective. To describe the use of etomidate for rapid-sequence intubation (RSI) in the air medical environment. Methods. This was a retrospective review of a consecutive series of patients receiving etomidate for RSI by a university hospital-based air medical program. Records of all patients more than 10 years of age requiring intubation during a 13-month period were reviewed. Data collected included demographics, site of intubation, person performing intubation, indication, diagnosis, medications administered, complications, and pre- and post-RSI vital signs. Results. Of 79 patients who underwent intubation, 53 (67%) received etomidate for RSI. Forty-two (79%) patients who received etomidate were also given succinylcholine. The overall intubation success rate was 96%. Two patients required a cricothyrotomy. Hemodynamic data were complete for 46 patients. The average systolic blood pressures (SBPs) were 139.11 ± 31.21?mm?Hg prior to RSI and 137.85 ± 32.00?mm?Hg after RSI. These were not significantly different (p = 0.82). The mean change in SBP was ?1.26 ± 37.03?mm?Hg (95% CI ?6.61 to 4.09). The average heart rates (HRs) were 101.59 ± 23.95 beats/min prior to RSI and 97.76 ± 23.45 beats/min after RSI. These were also not significantly different (p = 0.15). The mean change in HR was ?3.52 ± 15.67 beats/min (95% CI ?5.79 to ?1.26). Conclusion. This study supports the safety of etomidate for RSI in the air medical setting. The intubation success rate was comparable to those in other studies evaluating RSI. There was no significant change in average SBP or HR during RSI.     

Information Loss in Emergency Medical Services Handover of Trauma Patients

Introduction. Little is known about how effectively information is transferred from emergency medical services (EMS) personnel to clinicians in the emergency department receiving the patient. Information about prehospital events and findings can help ensure expedient and appropriate care. The trauma literature describes 16 prehospital data points that affect outcome and therefore should be included in the EMS report when applicable. Objective. To determine the degree to which information presented in the EMS trauma patient handover is degraded. Methods. At a level I trauma center, patients meeting criteria for the highest level of trauma team activation (“full trauma”) were enrolled. As part of routine performance improvement, the physician leadership of the trauma program watched all available video-recorded full trauma responses, checking off whether the data points appropriate to the case were verbally “transmitted” by the EMS provider. Two EMS physicians then each independently reviewed the trauma team's chart notes for 50% of the sample (and a randomly selected 15% of the charts to assess agreement) and checked off whether the same elements were documented (“received”) by the trauma team. The focus was on data elements that were “transmitted” but not “received.” Results. In 96 patient handovers, a total of 473 elements were transmitted, of which 329 were received (69.6%). On the average chart, 72.9% of the transmitted items were received (95% confidence interval 69.0%–76.8%). The most commonly transmitted data elements were mechanism of injury (94 times), anatomic location of injury (81), and age (67). Prehospital hypotension was received in only 10 of the 28 times it was transmitted; prehospital Glasgow Coma Scale [GCS] score 10 of 22 times; and pulse rate 13 of 49 times. Conclusions. Even in the controlled setting of a single-patient handover with direct verbal contact between EMS providers and in-hospital clinicians, only 72.9% of the key prehospital data points that were transmitted by the EMS personnel were documented by the receiving hospital staff. Elements such as prehospital hypotension, GCS score, and other prehospital vital signs were often not recorded. Methods of “transmitting” and “receiving” data in trauma as well as all other patients need further scrutiny.     

Air Ambulance Medical Transport Advertising and Marketing

Abstract

The National Association of EMS Physicians (NAEMSP), the American College of Emergency Physicians (ACEP), the Air Medical Physician Association (AMPA), the Association of Air Medical Services (AAMS), and the National Association of State EMS Officials (NASEMSO) believe that patient care and outcomes are optimized by using air medical transport services that are licensed air ambulance providers with robust physician medical director oversight and ongoing quality assessment and review. Only air ambulance medical transport services with these credentials should advertise/market themselves as air ambulance services.     

手术患者接送流程的再造与实施

目的优化手术患者接送流程,确保手术患者的准确性和安全性,提高工作效率。方法对手术患者的接送流程进行再造,包括建立手术患者的接送登记本和物品交接卡,手术患者腕带信息和手术通知单的核对,病区护士、手术患者和护工三方核对确认后接走患者,恢复室护士护送术后患者等环节,取消术后在手术间等待患者清醒、拔管及连台手术患者在手术间穿刺的流程。结果流程再造后日手术量、每日每手术间台次、连台手术间隔时间与再造前比较,有显著性差异（P〈0.05,P〈0.01）。结论手术患者接送流程再造有利于提升医疗和管理品质,是实现资源成本最小化、提高时效的重要方法之一。     

Flying Home

In the rapidly progressing field of critical care, the diverse delivery of such care seems to be reaching new heights. In particular, aeromedical transport of critically ill patients involves detailed preparation for the worst possibilities but with expectations for the best outcomes. The following case is presented as testimony to the challenges of critical care transport.     

Pediatric Blunt Neck Trauma Causing Esophageal and Complete Tracheal Transection

Background: Blunt injuries to the cervical trachea remain rare but present unique and challenging clinical scenarios for prehospital providers. These injuries depend on prehospital providers either definitively securing the injured airway or bridging the patient to a treatment facility that can mobilize the necessary resources. Case Summary: The case presented here involves a clothesline injury to a pediatric patient that resulted in complete tracheal transection and partial esophageal transection. Ground and air prehospital providers utilized a stepwise approach to this airway injury and achieved a favorable outcome. The patient was serendipitously intubated through a blind nasal approach that entered the proximal esophagus, exited through the tear and entered the distal trachea. Discussion: There is a paucity of literature describing the successful management of these devastating injuries. While some authors have advocated for early flexible fiberoptic intubation or proceeding directly to tracheostomy, these techniques are not available in the prehospital environment. This case also highlights the inherent issues with proceeding to cricothyroidotomy in patients with tracheal trauma and should give all providers pause before considering this management technique. Conclusion: Ultimately, a systematic approach to all airways will ensure that prehospital providers are best prepared for even the most challenging scenarios.     

Location of Airway Management in Air Medical Transport

Background. Prehospital providers are constantly challenged with the task of managing airways in unpredictable andoften inhospitable environments. Air medical transport (AMT) crews must be prepared to work in restrictive spaces with limited resources while in the aircraft. This study examines flight crew success rate andcircumstances surrounding airway management in different locations. Methods. This was a retrospective analysis of intubations performed by a university-based air medical transport team from January 1, 1995, to May 31, 2007. Patient records andprospectively gathered airway management quality assurance data were reviewed for location of intubation, patient characteristics, andsuccess rates. Success was defined as placing a cuffed tube in the trachea nonsurgically. Results. Nine hundred thirty-eight patients required 939 advanced airway management procedures, and936 cases had information sufficient for analysis. Six hundred twenty-seven (67%) of these intubations took place on scene, 235 (25.1%) at the referring hospital, 67 en-route (7.2%), andseven (0.7%) at the receiving hospital. The overall intubation success rate was 96% andthe highest rate was for hospital intubations (98.8%), followed by scene (94.9%) anden-route (89.6%) airway encounters. Intubation success was more likely in the hospital setting (odds ratio [OR] = 8.7, 95% confidence interval [CI] 2.2–35.0, p = 0.002] andon the scene [OR = 2.3, 95% CI 0.95–5.7, p = 0.065] compared with those en-route. Unanticipated patient deterioration was noted as the most common reason for in-flight airway management. Type of aircraft was not significantly associated with intubation success (p = 0.132). Conclusions. Airway management was performed with a high success rate in a variety of locations andpatient characteristics by our air medical crew. When in the hospital environment, flight crew success rates were comparable to those of other emergency personnel. Caution should be used, however, when considering intubating in-flight because of slightly lower success rates.     

A review of infection control practices,risk reduction,and legislative regulations for blood-borne disease: Applications for emergency medical services

Objective. To determine the time saving associated with lights and siren (L&S) use during emergency response in an urban EMS system. Methods. This prospective study evaluated ambulance response times from the location at time of dispatch to the scene of an emergency in an urban area. A control group of responses using L&S was compared with an experimental group that did not use L&S. An observer was assigned to ride along with ambulance crews and record actual times for all L&S responses. At a later date, an observer and an off-duty paramedic in an identical ambulance retraced the route—at the same time of day on the same day of the week—without using L&S and recorded the travel time. Response times for the two groups were compared using paired t-test. Results. The 32 responses with L&S averaged 105.8 seconds (1 minute, 46 seconds) faster than those without (95% confidence interval: 60.2 to 151.5 seconds, p = 0.0001). The time difference ranged from 425 seconds (7 minutes, 5 seconds) faster with L&S to 210 seconds (3 minutes, 30 seconds) slower with L&S. Conclusion. In this urban EMS system, L&S reduce ambulance response times by an average of 1 minute, 46 seconds. Although statistically significant, this time saving is likely to be clinically relevant in only a very few cases. A large-scale multicenter L&S trial may help address this issue on a national level.