The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system

Landing sites and intubation may influence helicopter emergency medical services on-scene time

BACKGROUND

Reduced transport time of patients from the scene of an accident to definitive surgical treatment is one important reason to employ ambulance helicopters on trauma missions. However, if the helicopter is unable to land close to the scene, the transport time may be increased compared to transport with ground ambulance, due to time-consuming transfer of the patient between vehicles.

OBJECTIVE

The objective of this study was to evaluate how the landing site, as determined by distance from the scene, and rapid sequence intubation (RSI) affected on-scene time (OST).

METHODS

This was a prospective observational study performed during a 12-month period in a mixed urban and rural anesthesiologist-staffed Helicopter Emergency Medical Service in Norway. Data regarding the landing sites, the accident, and patient treatment were recorded.

RESULTS

A total of 252 primary trauma missions were included in the study. In 75% of the missions, the aircraft landed<50 meters from the scene, and in 7% the distance exceeded 200 meters. Mean OST when the patient was not intubated was 14.5 min (median 14 min). When an RSI was performed, the mean OST was significantly higher (22.7 min, median 20 min; p<0.001).

CONCLUSION

Usually, a helicopter can land close to the accident scene and the location of the landing site does not contribute to a delay in arrival of the patient at the hospital. The OST is significantly higher, however, in those patients who receive endotracheal intubation before take-off. This reflects the time needed for intubation, as well as the increased complexity and workload when the patient is severely injured.

Helicopter emergency medical services accident rates in different international air rescue systems

Aim

Each year approximately two to four helicopter emergency medical services (HEMS) crashes occur in Germany. The aim of the present study was to compare crash rates and fatal crash rates in Germany to rates in other countries.

Materials and methods

A MEDLINE search from 1970 to 2009 was performed using combinations of the keywords “HEMS”, “rescue helicopter”, “accident”, “accident rate”, “crash”, and “crash rate”. The search was supplemented by additional published data. Data were compared on the basis of 10,000 missions and 100,000 helicopter flying hours. These data were allocated to specific time frames for analyis.

Results

Eleven relevant studies were identified. Five studies (three from Germany, one from the US, one from Australia) analyzing HEMS accidents on the basis of 10,000 missions were identified. Crash rates per 10,000 missions ranged between 0.4 and 3.05 and fatal crash rates between 0.04 and 2.12. In addition, nine studies (six from the US, two from Germany, one from Australia) used 100,000 flying hours as a denominator. Here, crash rates ranged between 1.7 and 13.4 and fatal crash rates between 0.91 and 4.7.

Conclusions

Data and accident rates were inhomogeneous and differed significantly. Data analysis was impeded by publication of mean data, use of different time frames, and differences in HEMS systems.

Investigation of final destination hospitals for patients in helicopter emergency medical services (doctor-helicopter) in Fukushima Prefecture

PURPOSE

In using an emergency medical service helicopter with an emergency medicine doctor on board (doctor-helicopter), transporting all patients to the University Hospital (base hospital for the helicopter) could cause a chronic bed shortage at the University Hospital. It is also disadvantageous for patients from distant areas. We investigated whether appropriate hospital selections are being carried out in Fukushima Prefecture.

METHODS

The subjects of the study were patients who were transported by doctor-helicopter since the services started. We investigated the medical conditions of patients at emergency scenes, whether they were transported to a hospital inside or outside the region, the means of transportation, and the final destination hospital.

RESULTS

There were 450 flights, of which 295 were to emergency scenes, involving 307 patients. The majority were trauma patients (191 patients, 62.2%). The final destination hospital was the University Hospital for 104 patients (33.9%); 99 patients (30.3%) were transported to three emergency and critical care medical centers (ECCMCs) in other regions. Most patients were transported to appropriate hospitals in the respective regions. The means of transportation from the emergency scene was by doctor-helicopter in the largest number of cases (223 patients, 72.6%), and the final destination hospital was ECCMCs in 81.6% of cases.

CONCLUSION

Patients from emergency scenes are transported by doctor-helicopter to appropriate hospitals in the region, and hospitals in each region are cooperating with the doctor-helicopter operations.

What risk managers should know about air medical patient transport

The use of air medical services (AMS) has become an essential component of the healthcare system. Appropriately used air medical critical care transport can save lives and reduce the cost of healthcare. It does so by minimizing the time the critically ill and injured spend out of a hospital, by bringing more medical capabilities to the patient than are normally provided by ground emergency medical services, and by helping get the patient to the appropriate specialty care quickly. Risk managers should be aware of the everyday decisions made in critical care transport to ensure the most appropriate utilization of resources to benefit the patient.

Validation of a prehospital trauma triage tool: a 10-year perspective

BACKGROUND

Triage of the trauma patient in the field is a complex and challenging issue, especially deciding when to use aeromedical transport. The American College of Surgeons Committee on Trauma recently defined an acceptable under-triage rate [seriously injured patient not taken to a trauma center (TC)] as 5%, whereas over-triage rates may be as high as 25% to 50%. Effective utilization of prehospital helicopter transport requires both accurate assessment of patients and effective communication. The rural county adjacent to our developed trauma system uses standardized triage criteria to identify patients for direct transport to our TCs. We hypothesized these criteria accurately identify major trauma victims (MTV) and further that communication could be simplified to expedite transport.

METHODS

Prehospital personnel use a MAP (mechanism, anatomy, and physiology) scoring system to triage trauma patients. Patients with > or = 2 "hits" are defined as MTV. In 2004, the triage policy was changed so that MTV would be transported directly to a TC without base hospital consultation (previously required). The Emergency Medical Services (EMS) Medical Director reviewed cases transported to the TC to determine the appropriateness of triage decisions (over- and under-triage using the American College of Surgeons Committee on Trauma definitions). Data were compared before and after this policy change.

RESULTS

For 2004 to 2006, we evaluated 676 air transports to TC and compared them to 468 in the prior 56 months. The overall transport rate increased slightly 7% to 10%. During the study period the over-triage rate was 31% compared with 21%, before the policy change. The MAP triage tool yielded a 93.8% sensitivity and a 99.5% specificity. Therefore, it determined the need for air-medical transport out of a rural environment into an established trauma system with > 90% accuracy.

CONCLUSIONS

Prehospital personnel can accurately use a trauma triage tool to identify MTV. Eliminating base station contact, a potential for introducing communication error, did increase over-triage but still well within accepted limits. The system change also resulted in the transport of a greater proportion of minor trauma patients who later proved to have major injuries.

A prospective study of the impact of multiple patient transports on care provided during aeromedical transport

OBJECTIVES

The purpose of the current study was to determine reasons for multiple-patient transports using a helicopter emergency medical services (HEMS) and to observe for any negative impact on patient care caused by the presence of the second patient.

METHODS

The study was a prospective observational study of all two-patient trauma transports (doubles) over a 12-month period, from January 2004 through December 2004. The authors selected a sample of 20% of single-patient transports (singles) from the same time period for comparison. Flight crews completed a study form after the flight. Information requested included Glasgow Coma Scale (GCS) score, Revised Trauma Score (RTS), and negative impact on care of the primary patient caused by transporting the secondary patient. Data were analyzed using Mann-Whitney rank test and descriptive statistics.

RESULTS

There were a total of 59 double-trauma transports. A total of 269 single-trauma transports were identified for comparison. Although there was no statistically significant difference in GCS score or RTS (single vs. primary double), doubles never included the most severely injured trauma patients. The secondary patients from the doubles were the least severely injured. There were nine patients in whom the crew felt there was a negative impact from the second patient. Need for trauma center evaluation of the second patient and distance of transport were common reasons for double transports.

CONCLUSIONS

Patients transported as doubles do not include the most severely injured trauma patients. In only a small percentage of doubles did the second patient have a perceived impact on care of the primary patient.

The effectiveness of video-telemedicine for screening of patients requesting emergency air medical transport (EAMT)

BACKGROUND

Demand for emergency air medical transport (EAMT) services have increased in recent years. However, the high costs of these services have raised questions on the benefit to patient outcomes. In this study, we evaluate the effectiveness of video-telemedicine for the preflight screening of patients for air medical transports.

METHOD

A prospective cohort study. Medical records of patients transported from the Penghu Islands to Taiwan were retrospectively collected from November 1999 to October 2002 (stage 1). In addition, we collected medical records of patients who were preflight-screened by physicians using video Web cameras from November 1, 2002 through August 30, 2003 (stage 2). The intervention in stage 2 included a set of protocols and screening criteria for EAMT implemented by the National Aeromedical Consultation Center (NACC). In stage 1, there were no standardized protocols or screening guidelines for EAMT. The EAMT system before implementing preflight screening and telemedicine was mostly based on patient's requests and their health condition determined by the treating medical officers (TMO).

RESULTS

A total of 822 transfers were included in this study. Patient demographic backgrounds in the two groups were similar on gender, age, disease classification, and types of illnesses. Patients in stage 2 were significantly older than those in stage 1. In a comparison of flight frequencies between the two stages, the results revealed a 36.2% reduction of EAMT applications in stage 2. The flight approval rate was 91.2%. The intervention in stage 2 also presented a significant reduction in cross-zone transport (16.1% to 0.1% to the northern Taiwan region). Within-zone transfers increased from 74.9% to 88.3%. Cost analysis showed that physician triage in stage 2 resulted in a total annual savings on EAMTs of US 448,986 dollars.

CONCLUSIONS

This study demonstrates the physician-assisted preflight screening using video-telemedicine significantly reduced the frequency of unnecessary air medical transports and consequently led to reduced costs. Video-telemedicine can be an essential tool to support physicians in decision-making for patient screening.

The Fastest Route Between Two Points is Not Always a Straight Line: An Analysis of Air and Land Transfer of Nonpenetrating Trauma Patients

BACKGROUND

The distance beyond which helicopter transport is faster than ground for interfacility transfer of trauma patients has not been established. Our objective was to determine whether such a threshold exists.

METHODS

A retrospective cohort study was conducted involving 243 patients transported by land and 139 patients by air from 13 sites during a 3-year period. Time intervals between critical events were compared for the two modes of transport at each site.

RESULTS

The time interval between the decision to transfer and the actual departure time was shorter for patients transferred by land from all sites studied (mean 41.3 versus 89.7 minutes, p < 0.001). The travel time was shorter by helicopter from all sites (mean 58.4 versus 78.9 minutes, p < 0.001). The time between the decision to transfer and the arrival at the trauma center was similar at most sites but faster by land overall (mean 120.3 versus 150.0 minutes, p = 0.014). No threshold was detected beyond which helicopter transport was superior.

CONCLUSIONS

Several factors other than the distance to be traveled determine the time required for interfacility transfer of trauma patients. A fixed distance threshold beyond which helicopter transport should be used does not exist. The decision as to which mode of transport to use for emergent trauma patient transfers should be based upon multiple factors including the distance traveled and ambulance availability, and must be individualized for each site that transfers patients.

Helicopter Scene Transport of Trauma Patients with Nonlife-Threatening Injuries: A Meta-Analysis

BACKGROUND

Helicopters have become a major part of the modern trauma care system and are frequently used to transport patients from the scene of their injury to a trauma center. While early studies reported decreased mortality for trauma patients transported by helicopters when compared with those transported by ground ambulances, more recent research has questioned the benefit of helicopter transport of trauma patients. The purpose of this study was to determine the percentage of patients transported by helicopter who have nonlife-threatening injuries.

METHODS

A meta-analysis was performed on peer-review research on helicopter utilization. The inclusion criteria were all studies that evaluated trauma patients transported by helicopter from the scene of their injury to a trauma center with baseline parameters defined by Injury Severity Score (ISS), Trauma Score (TS), Revised Trauma Score (RTS), and the likelihood of survival as determined via Trauma Score-Injury Severity Score (TRISS) methodology.

RESULTS

There were 22 studies comprising 37,350 patients that met the inclusion criteria. According to the ISS, 60.0% [99% confidence interval (CI): 54.5-64.8] of patients had minor injuries, According to the TS, 61.4% (99% CI: 60.8-62.0) of patients had minor injuries. According to TRISS methodology, 69.3% (99% CI: 58.5-80.2) of patients had a greater than 90% chance of survival and thus nonlife-threatening injuries. There were 25.8% (99% CI: -1.0-52.6) of patients discharged within 24 hours after arrival at the trauma center.

CONCLUSIONS

The majority of trauma patients transported from the scene by helicopter have nonlife-threatening injuries. Efforts to more accurately identify those patients who would benefit most from helicopter transport from the accident scene to the trauma center are needed to reduce helicopter overutilization.

[Polytrauma and air rescue. A retrospective analysis of trauma care in eastern Austria exemplified by an urban trauma center]

OBJECTIVE

The aim of this study was a retrospective analysis of polytraumatized patients who were treated by a helicopter emergency medical service (HEMS) crew. This study was performed to evaluate the level of prehospital care provided for severely injured patients. Special consideration was given to treatment strategies of specific injuries which led to multiple injuries, defined as "polytrauma."

METHODS

From September 1992 to April 2001 data of 386 patients treated in the Department of Traumatology of the University of Vienna were collected. A total of 104 patients (26.9%) were transported by helicopter directly from the accident scene. This collective was analyzed demographically; relevant prehospital data such as therapeutic interventions and the early clinical course were examined.

RESULTS

The mean Injury Severity Score (ISS) was 36.9: 70 (67.3%) patients were male and 34 (32.7%) female; the median age was 36.1 years. Traffic accidents were the most frequent trauma mechanism (78.9%) followed by falls from height (17.3%). The mean period between trauma and trauma emergency room was 0.73 h; 77 (74.0%) patients were intubated and mechanically ventilated at the scene and all patients received analgosedation. The mean preclinical fluid load was 1673 ml. The mean duration of treatment in the emergency room was 53 min. The mean length of intensive care was 8.6 days and the mortality rate was 19.2% within the first 24 h.

CONCLUSION

Major trauma is an important cause for requesting a primary HEMS mission. As the results of this study show, immediate and invasive interventions at the scene lead to an improvement of vital functions at admission. For the patients' further course of treatment, the choice of a trauma center seems to be important, too.

The Impact of Aeromedical Response to Patients With Moderate to Severe Traumatic Brain Injury

STUDY OBJECTIVE

Aeromedical crews offer an advanced level of practice and rapid transport to definitive care; however, their efficacy remains unproven. Previous studies have used relatively small sample sizes or have been unable to adequately control for the effect of other potentially influential variables. Here we explore the impact of aeromedical response in patients with moderate to severe traumatic brain injury.

METHODS

This was a retrospective analysis using our county trauma registry. All patients with head Abbreviated Injury Score of 3 or greater were included; interfacility transfers were excluded. The impact of aeromedical response was determined using logistic regression, adjusting for age, sex, mechanism, preadmission Glasgow Coma Scale score, head Abbreviated Injury Score, Injury Severity Score, and the presence of preadmission hypotension. Propensity scores were used to account for variability in selection of patients to undergo air versus ground transport. Patients with moderate and severe traumatic brain injury, as defined by head Abbreviated Injury Score and Glasgow Coma Scale score, were compared. Finally, aeromedical patients undergoing field intubation were compared with ground patients undergoing emergency department (ED) intubation.

RESULTS

A total of 10,314 patients meeting all inclusion and exclusion criteria and with complete data sets were identified and included 3,017 transported by aeromedical crews. Overall mortality was 25% in the air- and ground-transported cohorts, but outcomes were significantly better for the aeromedical patients when adjusted for age, sex, mechanism of injury, hypotension, Glasgow Coma Scale score, head Abbreviated Injury Score, and Injury Severity Score (adjusted odds ratio [OR] 1.90; 95% confidence interval [CI] 1.60 to 2.25; P<.0001). Good outcomes (discharge to home, jail, psychiatric facility, rehabilitation, or leaving against medical advice) were also higher in aeromedical patients (adjusted OR 1.36; 95% CI 1.18 to 1.58; P<.0001). The primary benefit appeared to be in more severely injured patients, as reflected by head Abbreviated Injury Score and Glasgow Coma Scale score. Improved survival was also observed for air-transported patients intubated in the field versus ground-transported patients given emergency intubation in the ED (adjusted OR 1.42; 95% CI 1.13 to 1.78; P<.001).

CONCLUSION

Here we analyze a large database of patients with moderate to severe traumatic brain injury. Aeromedical response appears to result in improved outcomes after adjustment for multiple influential factors in patients with moderate to severe traumatic brain injury. In addition, out-of-hospital intubation among air-transported patients resulted in better outcomes than ED intubation among ground-transported patients. Patients with more severe injuries appeared to derive the greatest benefit from aeromedical transport.

South African Red Cross Flying Doctors Service quality and safety in the rural and remote South African environment

CONTEXT

The South African Red Cross Air Mercy Service and its Flying Doctors Service provides health care to far flung and disadvantaged communities in South Africa.

PURPOSE

The purpose of this article is to highlight the importance and effectiveness of the service in providing health care to a range of people who have poor or no access to certain health services in South Africa.

METHODS

Data and information was collected from records and statistical data of our service. Data was evaluated and compiled into a report highlighting the achievements of this organisation from its infancy to the present day.

FINDINGS

The Flying Doctor and Health Outreach Programme has made a difference in improving health care by providing specialist services, transport of patients and training of medical personnel in outlying areas of South Africa that have poor access to health care. Emergency Air Ambulance and Rescue Services have proven to be supportive in providing rapid advanced life support and rescue services to patients in emergency situations. Many lives have been saved through this service.

CONCLUSION

The South African Red Cross Air Mercy Service plays a crucial role in delivering specialised health care to disadvantaged communities in South Africa.

Regional Air Transport of Burn Patients: A Case for Telemedicine?

BACKGROUND

Air transport of burn patients is plagued by frequent "overtriage." We examined the use of air transport and the feasibility of using alternative methods such as telemedicine to assist in evaluation and treatment of burn patients within our region.

METHODS

We reviewed all burn patients transported by air during 2000 to 2001. Each patient was classified as being most appropriate for air, ground, or family transport. In addition, a decision was made regarding whether telemedicine evaluation of the patient before transport could have significantly altered initial treatment decisions.

RESULTS

Two hundred twenty-five acutely burned patients were transferred from referring hospitals in nine states, at a mean distance of 246 air miles. Mean burn size calculated by burn center physicians was 19.7% total body surface area, whereas referring physicians' mean estimate was 29% total body surface area. In 92 cases, over- or underestimation of burn size by referring physicians of as much as 560% or decisions regarding performance of endotracheal intubation suggested that telemedicine evaluation before transport might have significantly altered transport decisions or care. Air transport charges exceeded hospital charges in 21 cases.

CONCLUSION

Frequent discrepancies in burn assessment contribute to overuse of air transport. The ability to evaluate burn patients by telemedicine may have the potential to assist decisions regarding transfer, avoid errors in initial care, and reduce costs. We are currently attempting to develop and test such a system.

Medical Helicopter Accidents in the United States: A 10-Year Review

OBJECTIVE

There has been a significant proliferation of medical helicopters and medical helicopter operations in the United States over the last decade. The purpose of this study was to determine whether the proliferation of medical helicopter operations in the United States was associated with a subsequent increase in the number of accidents

METHODS

We used univariate descriptive analysis of all pertinent medical accident files obtained from United States aviation databases for a 10-year period (1993-2002).

RESULTS

There were 84 medical helicopter accidents involving 260 persons (passengers, patients, crew, and pilots) during the 10-year study period. Of these, there were 72 fatalities and 64 injuries. The incidence of fatalities was 0.86 fatalities per accident. The incidence of nonfatal injuries was 0.76 per accident. Fifty-two percent of all reported accidents occurred during the last 3 years of the study period (2000-2002).

CONCLUSION

There was a steady and marked increase in the number of medical helicopter accidents in the United States during the 10-year period (1993-2002). These findings are worrisome in light of recent research that has indicated use of medical helicopters may be excessive and nonbeneficial for most patients.