Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients

Introduction

Physician-staffed helicopter emergency medical services (HEMS) are a well-established component of prehospital trauma care in Germany. Reduced rescue times and increased catchment area represent presumable specific advantages of HEMS. In contrast, the availability of HEMS is connected to a high financial burden and depends on the weather, day time and controlled visual flight rules. To date, clear evidence regarding the beneficial effects of HEMS in terms of improved clinical outcome has remained elusive.

Methods

Traumatized patients (Injury Severity Score; ISS ≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2007 and 2009 were analyzed using the TraumaRegister DGU^® of the German Society for Trauma Surgery. Only patients treated in German level I and II trauma centers with complete data referring to the transportation mode were included. Complications during hospital treatment included sepsis and organ failure according to the criteria of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) consensus conference committee and the Sequential Organ Failure Assessment (SOFA) score.

Results

A total of 13,220 patients with traumatic injuries were included in the present study. Of these, 62.3% (n = 8,231) were transported by GEMS and 37.7% (n = 4,989) by HEMS. Patients treated by HEMS were more seriously injured compared to GEMS (ISS 26.0 vs. 23.7, P < 0.001) with more severe chest and abdominal injuries. The extent of medical treatment on-scene, which involved intubation, chest and treatment with vasopressors, was more extensive in HEMS (P < 0.001) resulting in prolonged on-scene time (39.5 vs. 28.9 minutes, P < 0.001). During their clinical course, HEMS patients more frequently developed multiple organ dysfunction syndrome (MODS) (HEMS: 33.4% vs. GEMS: 25.0%; P < 0.001) and sepsis (HEMS: 8.9% vs. GEMS: 6.6%, P < 0.001) resulting in an increased length of ICU treatment and in-hospital time (P < 0.001). Multivariate logistic regression analysis found that after adjustment by 11 other variables the odds ratio for mortality in HEMS was 0.75 (95% CI: 0.636 to 862).Afterwards, a subgroup analysis was performed on patients transported to level I trauma centers during daytime with the intent of investigating a possible correlation between the level of the treating trauma center and posttraumatic outcome. According to this analysis, the Standardized Mortality Ratio, SMR, was significantly decreased following the Trauma Score and the Injury Severity Score (TRISS) method (HEMS: 0.647 vs. GEMS: 0.815; P = 0.002) as well as the Revised Injury Severity Classification (RISC) score (HEMS: 0.772 vs. GEMS: 0.864; P = 0.045) in the HEMS group.

Conclusions

Although HEMS patients were more seriously injured and had a significantly higher incidence of MODS and sepsis, these patients demonstrated a survival benefit compared to GEMS.     

The role of physician staffing of helicopter emergency medical services in prehospital trauma response

The crewing of Helicopter Emergency Medical Service (HEMS) for scene response to trauma patients is generally considered to be controversial, particularly regarding the role of physicians. This is reflected in HEMS in Australia with some services utilizing physician crewing for all prehospital missions. Others however, use physicians for selected missions only whilst others do not use physicians at all. This review seeks to determine whether the literature supports using physicians in addition to paramedics in HEMS teams for prehospital trauma care. Studies were excluded if they compared physician teams with basic life support teams (BLS) teams rather than paramedics. Ambulance officers were considered to be paramedics where they were able to administer intravenous fluids and use a method of airway management beyond bag-valve-mask ventilation. Studies were excluded if the skill set of the ambulance team was not defined, the level of staffing of the helicopter service was not stated, team composition varied without reporting outcomes for each team type, patient outcome data were not reported, or the majority of the transports were interhospital rather than prehospital transports.     

Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing.

OBJECTIVE: Patients, emergency department staff and hospital managers are often confronted with a prolonged length of stay of emergency department patients, with resulting overcrowding in the emergency department. We hypothesized that additional medical personnel would reduce the length of stay. METHODS: We prospectively studied consecutive patients managed in a medical emergency department by internal medicine residents during the evening shift. Data were collected on patients managed before (n=200) and after (n=160) the addition of a second physician on the shift. RESULTS: The addition of a physician in the busy evening shift decreased the length of stay from 176+/-137 to 141+/-86 min (mean+/-SD, P=0.012) for outpatients discharged after evaluation and management in the emergency department. The length of stay for emergency department inpatients admitted for hospitalization was not significantly reduced. CONCLUSION: An additional physician significantly reduced the length of stay of medical emergency department outpatients.     

航空急救转运危重患者的效果分析

目的：探讨南方城市航空急救体系在危重患者长途转运中的优缺点。方法选取2004年8月至2014年12月期间所有接受过广东省人民医院航空急救转运的患者30例为观察组,情况基本匹配的经地面急救转运的患者30例为对照组,采集两种转运方式患者的病情、转运距离、运输时间、转运费用以及途中并发症等数据,根据数据类型,采用χ2检验以及成组 t 检验或相应的非参数方法进行统计分析。结果两种转运方式的转运距离（km）[578.0（313.0,707.5）vs.214.5（101.5,313.5）,P ＜0.05]、准备时间（min）[95.7（56.7,133.4）vs.10.7（6.8,15.7）,P ＜0.05]、转运时间（min）[112.3（64.3,152.4）vs.146.8（67.8,217.5）,P ＜0.05],费用（元）[14378.5（9887.0,16348.5） vs.557.0（356.5,787.5）,P ＜0.05]及距离／总时间值[2.8（1.3,4.8）vs.1.4（0.8,2.8）,P ＜0.05]比较差异有统计学意义;两组患者在转运途中并发症发生率差异无统计学意义（χ2＝0.058,P ＝0.834＞0.05）。结论航空急救转运能够缩短危重患者的长途转运时间,提高急救效率。但我国航空急救系统仍存在一定的不足,需进一步完善。     

Comparison of physician-staffed helicopter with ground-based emergency medical services for trauma patients

IntroductionFew studies have discussed whether physician-staffed helicopter emergency medical services (HEMS) provide temporal and geographical benefits for patients in remote locations compared to ground emergency medical services (GEMS). Our study seeks to clarify the significance of HEMS for patients with severe trauma by comparing the mortality of patients transported directly from crash scenes by HEMS or GEMS, taking geographical factors into account.MethodsUsing medical records from a single center, collected from January 2014 to December 2018, we retrospectively identified 1674 trauma patients. Using propensity score analysis, we selected adult patients with an injury severity score ≥16, divided them into groups depending on their transport to the hospital by HEMS or GEMS, and compared their mortality within 24 h of hospitalization. For propensity score-matched groups, we analyzed distance and time.ResultsOf the 317 eligible patients, 202 were transported by HEMS. In the propensity score matching analysis, there was no significant difference in mortality between the HEMS and GEMS groups: 8.7% vs. 5.8%, odds ratio (OR), 1.547 (95% confidence interval [CI], 0.530–4.514). The inverse probability of treatment weighting (IPTW): 11% vs. 7.8%, OR, 1.080 (95% CI, 0.640–1.823); stabilized IPTW: 11% vs. 7.8%, OR, 1.080 (95% CI, 0.502–2.324); and truncated IPTW: 10% vs. 6.4%, OR, 1.143 (95% CI, 0.654–1.997). The distance from the crash scene to the hospital was farther in the HEMS group, and it took a longer period of time to arrive at the hospital (P < 0.001).ConclusionsHEMS may provide equal treatment opportunities and minimize trauma deaths for patients transported from a greater distance to an emergency medical center compared to GEMS for patients transported from nearby regions.     

Association between helicopter with physician versus ground emergency medical services and survival of adults with major trauma in Japan

Introduction

Helicopter emergency medical services with a physician (HEMS) has been provided in Japan since 2001. However, HEMS and its possible effect on outcomes for severe trauma patients have still been debated as helicopter services require expensive and limited resources. Our aim was to analyze the association between the use of helicopters with a physician versus ground services and survival among adults with serious traumatic injuries.

Methods

This multicenter prospective observational study involved 24,293 patients. All patients were older than 15 years of age, had sustained blunt or penetrating trauma and had an Injury Severity Score (ISS) higher than 15. All of the patient data were recorded between 2004 and 2011 in the Japan Trauma Data Bank, which includes data from 114 major emergency hospitals in Japan. The primary outcome was survival to discharge from hospitals. The intervention was either transport by helicopter with a physician or ground emergency services.

Results

A total of 2,090 patients in the sample were transported by helicopter, and 22,203 were transported by ground. Overall, 546 patients (26.1%) transported by helicopter died compared to 5,765 patients (26.0%) transported by ground emergency services. Patients transported by helicopter had higher ISSs than those transported by ground. In multivariable logistic regression, helicopter transport had an odds ratio (OR) for survival to discharge of 1.277 (95% confidence interval (CI), 1.049 to 1.556) after adjusting for age, sex, mechanism of injury, type of trauma, initial vital signs (including systolic blood pressure, heart rate and respiratory rate), ISS and prehospital treatment (including intubation, airway protection maneuver and intravenous fluid). In the propensity score–matched cohort, helicopter transport was associated with improved odds of survival compared to ground transport (OR, 1.446; 95% CI, 1.220 to 1.714). In conditional logistic regression, after adjusting for prehospital treatment (including intubation, airway protection maneuver and intravenous fluid), similar positive associations were observed (OR, 1.230; 95% CI, 1.017 to 1.488).

Conclusions

Among patients with major trauma in Japan, transport by helicopter with a physician may be associated with improved survival to hospital discharge compared to ground emergency services after controlling for multiple known confounders.     

Triage ability of emergency medical services providers and patient disposition: a prospective study

STUDY OBJECTIVE: To determine the ability of emergency medical services (EMS) providers to subjectively triage patients with respect to hospital admission and to determine patient characteristics associated with increased likelihood of admission. METHODS: A prospective, cross-sectional study of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban, university hospital, Emergency Department. Emergency medical services providers completed a questionnaire asking them to predict admission to the hospital and requested patient demographic information. Predictions were compared to actual patient disposition. RESULTS: A total of 887 patients were included in the study, and 315 were admitted to the hospital (36%). With respect to admission, EMS providers had an accuracy rate of 79%, with a sensitivity of 72% and specificity of 83% (kappa = 0.56). Blunt traumatic injury and altered mental status were the most common medical reasons for admission. Variables significantly associated with high admission rates were patients with age > 50 years, chest pain or cardiac complaints, shortness of breath or respiratory complaints, Medicare insurance, and Hispanic ethnicity. The EMS providers most accurately predicted admission for patients presenting with labor (kappa = 1.0), shortness of breath/respiratory complaints (kappa = 0.84), and chest pain (kappa = 0.77). CONCLUSION: Emergency medical services providers can predict final patient disposition with reasonable accuracy, especially for patients presenting with labor, shortness of breath, or chest pain. Certain patient characteristics are associated with a higher rate of actual admission.     

Involvement in emergency situations by primary care doctors on-call in Norway - a prospective population-based observational study

Background

Many emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology - hand-held computers with computerised clinical decision support (CCDS) software - to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services.

Methods/Design

Pragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial. Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders. The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically.

Discussion

Since the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services. In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen.

Trial Registration

ISRCTN10538608     

Correction Involvement in emergency situations by primary care doctors on-call in Norway - a prospective population-based observational study

ABSTRACT: We have discovered that the regression analyses presented in Tables 5 and 6 in our original study [Zakariassen and Hunskaar, BMC Emerg Med 2010, 10:5] were not correct. The dependent variables were coded opposite of what intended. Here we present correct Tables 5 and 6. When comparing the original printed tables with the new ones, the reader will see that almost all odds ratios are inverted.     

Inappropriate helicopter emergency medical services transports: results of a national cohort utilization review

Abstract Background. Medical transport using helicopter emergency medical services (HEMS) has rapidly proliferated over the past decade. Because of issues of cost and safety, appropriate utilization is of increasing concern. Objective. This study sought to describe the medical appropriateness of HEMS transports, using established guidelines, in a large national patient cohort. Methods. A review was performed of all flights designated as inappropriate by a large national air medical company, Air Evac EMS Inc. (which operates Air Evac Lifeteam [AEL]), for the period from January 1, 2009, through December 31, 2009. Every flight was reviewed initially through a resource utilization process as well as a utilization review process. Medical appropriateness review criteria were derived from the Medicare Benefit Policy Manual and industry guidelines outlined by the Commission on Accreditation of Medical Transport Systems (CAMTS), Air Medical Physicians Association (AMPA) position papers, the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) Guidelines for Field Triage, and published clinical peer-reviewed articles, as well as previous interactions with Medicare contractors and reimbursement appeal decisions. Higher scrutiny was given to flights of <30 or >100 miles. Records indicating a possible inappropriate flight (i.e., review criteria were not satisfied, but special circumstances existed) were further reviewed by a senior quality assurance/quality improvement (QA/QI) nurse and/or senior medical director and were categorized. Results. During the study period, 27,697 flights were completed and reviewed, with 582 (2.1%) flights identified for further review by a senior QA/QI nurse and/or senior medical director. Of those, 367 (1.3%) were determined to be medically inappropriate flights. Inappropriate flights were most often on-scene flights (59.9%), were most often for adult patients (92.9%; median age 56.9 years; 25-75% interquartile range 42-75?years), and most often represented medical diagnoses (57.8%). Conclusions. Based on established criteria, only 1.3% of total flights were determined to be inappropriate. This large national cohort demonstrated compliance with current industry standards.     

Teleconsultation in pre-hospital emergency medical services: real-time telemedical support in a prospective controlled simulation study

Background

Teleconsultation from the scene of an emergency to an experienced physician including real-time transmission of monitoring, audio and visual information seems to be feasible.In preparation for bringing such a system into practice within the research project “Med-on-@ix”, a simulation study has been conducted to investigate whether telemedical assistance (TMA) in Emergency Medical Services (EMS) has an impact on compatibility to guidelines and timing.

Material and methods

In a controlled simulation study 29 EMS teams (one EMS physician, two paramedics) ran through standardized scenarios (STEMI: ST-elevation myocardial infarction; MT: major trauma) on high-fidelity patient simulators with defined complications (treatable clearly following guidelines). Team assignments were randomized and each team had to complete one scenario with and another without TMA. Analysis was based on videotaped scenarios using pre-defined scoring items and measured time intervals for each scenario.

Results

Adherence to treatment algorithms improved using TMA. STEMI: cathlab informed (9/14 vs. 15/15; p = 0.0169); allergies checked prior to acetylsalicylic acid (5/14 vs. 13/15; p = 0.0078); analgosedation prior to cardioversion (10/14 vs. 15/15; p = 0.0421); synchronized shock (6/14 vs. 14/15; p = 0.0052). MT: adequate medication for intubation (3/15 vs. 10/14; p = 0.0092); mean time to inform trauma centre 547 vs. 189 s (p = 0.0001). No significant impairment of performance was detected in TMA groups.

Conclusions

In simulated setting TMA was able to improve treatment and safety without decline in timing. Nevertheless, further research is necessary to optimize the system for medical, organizational and technical reasons prior to the evaluation of this system in routine EMS.     

Treatment,transport, and primary care involvement when helicopter emergency medical services are inaccessible: a retrospective study

Abstract

Objective: To examine handling of cancelled helicopter emergency medical services (HEMS) missions with a persisting medical indication.

Design: Retrospective observational study.

Setting and subjects: Cancelled HEMS missions with persisting medical indication within Sogn og Fjordane county in Norway during the period of 2010–2013. Both primary and secondary missions were included.

Main outcome measures: Primary care involvement, treatment and cooperation within the prehospital system.

Results: Our analysis included 172 missions with 180 patients. Two-thirds of the patients (118/180) were from primary missions. In 95% (112/118) of primary missions, GPs were alerted, and they examined 62% (70/112) of these patients. Among the patients examined by a GP, 30% (21/70) were accompanied by a GP during transport to hospital. GP involvement did not differ according to time of day (p?=?0.601), diagnostic group (p?=?0.309), or patient’s age (p?=?0.409). In 41% of primary missions, the patients received no treatment or oxygen only during transport. Among the secondary missions, 10% (6/62) of patients were intubated or received non-invasive ventilation and were accompanied by a physician or nurse anaesthetist during transport.

Conclusions: Ambulance workers and GPs have an important role when HEMS is unavailable. Our findings indicated good collaboration among the prehospital personnel. Many of the patients were provided minimal or no treatment, and treatment did not differ according to GP involvement.

• Key Points

• Knowledge about handling and involvement of prehospital services in cancelled helicopter emergency medical services (HEMS) missions are scarce.

• Ambulance workers and general practitioners have an important role when HEMS is unavailable

• Minimal or no treatment was given to a large amount of the patients, regardless of which health personnel who encountered the patient.

     

The evolving role of helicopter emergency medical services in the transfer of stroke patients to specialized centers

Background. In 1996, when the Food and Drug Administration (FDA) approved use of thrombolytic therapy for ischemic stroke, interfacility transport of stroke patients assumed increasing urgency. Objective. To describe one helicopter emergency medical services (HEMS) program's 15-year experience with interfacility transport of patients with suspected stroke, with emphasis on reporting changing patterns seen after the advent of thrombolytic therapy for stroke. Methods. This was a retrospective study of patients undergoing HEMS transport, during 1985-1999, with a pretransport diagnosis of suspected ischemic stroke. Data collected included patient demographics and times of symptom onset, community hospital arrival, community hospital request for HEMS, and receiving hospital arrival. Patients were divided into pre-thrombolysis era (1985-1995) and thrombolysis era (1996-1999). Group characteristics were compared using Pearson chi-square, Fisher's exact, rank-sum, and logistic regression analysis. Results. There were 192 total transports, 76 (40%) pre-thrombolysis era and 116 (60%) thrombolysis era. Thrombolysis era patients were more likely (p < 0.0001) to have time of symptom onset documented, and also had significantly (p = 0.0003) shorter time intervals between referring and receiving hospital arrival. The shorter time intervals were due in part to decreased time lapse between referring hospital arrival and that hospital's request for helicopter transport; thrombolysis era patients were 2.5 times more likely than pre-thrombolysis era patients to have HEMS activation within three hours of community hospital arrival. Conclusions. Helicopter EMS transport is playing an increasing role in interfacility transfer of patients with ischemic stroke. Earlier HEMS activation is associated with decreased time lapse between referral and receiving hospital arrival. PREHOSPITAL EMERGENCY CARE 2002;6:210-214     

Postal survey methodology to assess patient satisfaction in a suburban emergency medical services system: an observational study

Background

The epidemiology of acute pancreatitis in the United States is largely unknown, particularly episodes that lead to an emergency department (ED) visit. We sought to address this gap and describe ED practice patterns.

Methods

Data were collected from the National Hospital Ambulatory Medical Care Survey between 1993 and 2003. We examined demographic factors and ED management including medication administration, diagnostic imaging, and disposition.

Results

ED visits for acute pancreatitis increased over the study period from the 1994 low of 128,000 visits to a 2003 peak of 318,000 visits (p = 0.01). The corresponding ED visit rate per 10,000 U.S. population also increased from 4.9 visits (95%CI, 3.1–6.7) to 10.9 (95%CI, 7.6–14.3) (p = 0.01). The average age for patients making ED visits for acute pancreatitis during the study period was 49.7 years, 54% were male, and 27% were black. The ED visit rate was higher among blacks (14.7; 95%CI, 11.9–17.5) than whites (5.8; 95%CI, 5.0–6.6). At 42% of ED visits, patients did not receive analgesics. At 10% of ED visits patients underwent CT or MRI imaging, and at 13% of visits they underwent ultrasound testing. Two-thirds of ED visits resulted in hospitalization. Risk factors for hospitalization were older age (multivariate odds ratio for each increasing decade 1.5; 95%CI, 1.3–1.8) and white race (multivariate odds ratio 2.3; 95%CI, 1.2–4.6).

Conclusion

ED visits for acute pancreatitis are rising in the U.S., and ED visit rates are higher among blacks than whites. At many visits analgesics are not administered, and diagnostic imaging is rare. There was greater likelihood of admission among whites than blacks. The observed race disparities in ED visit and admission rates merit further study.     

Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-centre observational study

OBJECTIVE: To determine how frequently life support is withheld or withdrawn from adult critically ill patients, and how physicians and patients families agree on the decision regarding the limitation of life support. DESIGN: Prospective multi-centre cohort study. SETTING: Six adult medical-surgical Spanish intensive care units (ICUs). PATIENTS AND PARTICIPANTS: Three thousand four hundred ninety-eight consecutive patients admitted to six ICUs were enrolled. MEASUREMENTS AND RESULTS: Data collected included age, sex, SAPS II score on admission and within 24 h of the decision to limit treatment, length of ICU stay, outcome at ICU discharge, cause and mode of death, time to death after the decision to withhold or withdraw life support, consultation and agreement with patient's family regarding withholding or withdrawal, and the modalities of therapies withdrawn or withheld. Two hundred twenty-six (6.6%) of 3,498 patients had therapy withheld or withdrawn and 221 of them died in the ICU. Age, SAPS II and length of ICU stay were significantly higher in patients dying patients who had therapy withheld or withdrawn than in patients dying despite active treatment. The proposal to withhold or withdraw life support was initiated by physicians in 210 (92.9%) of 226 patients and by the family in the remaining cases. The patient's family was not involved in the decision to withhold or withdraw life support therapy in 64 (28.3%) of 226 cases. Only 21 (9%) patients had expressed their wish to decline life-prolonging therapy prior to ICU admission. CONCLUSIONS: The withholding and withdrawing of treatment was frequent in critically ill patients and was initiated primarily by physicians.     

Medical direction in emergency medical services: the role of the physician

The past two decades has seen the development of sophisticated systems of prehospital care. The task now is to intensify the input of well-trained physicians into all aspects of EMS systems. This article tracks the history of EMS in this country and provides some suggested answers to the difficult questions facing this new specialty.