A standard operating procedure for prehospital anaesthesia and its effect on mortality-An observational study.

BACKGROUND: Prehospital anaesthesia is a complex intervention performed for critically ill patients. To minimise complications, a standard operating procedure (SOP) outlining the process is considered valuable. We investigated the implementation of an SOP for prehospital anaesthesia in helicopter emergency medical services (HEMS). METHODS: We performed a retrospective observational study of patients receiving prehospital anaesthesia by Finnish HEMS from January 2012 to August 2019. The intervention studied was the implementation of an SOP at two of the five bases during 2015-2016. Patients were stratified according to whether they were anaesthetised before, during or after implementation and the primary outcomes were 1- and 30-day mortality. Secondary outcomes included anaesthesia quality indicators. Confounding factors was assessed via logistic regression. RESULTS: A total of 3902 tracheal intubations were performed without an SOP, 430 during implementation and 1525 after implementation. The SOP had a significant effect on 1-day mortality during implementation with an odds ratio (OR) of 0.56, 95% confidence interval (95% CI) 0.37-0.81 and a further trend towards benefit after implementation (OR 0.84, 95% CI 0.68-1.04), but no difference in 30-day mortality (OR after implementation 1.10, 95% CI 0.92-1.30). Implementation of an SOP improved first-pass success rate from 87.3% to 96.5%, p < 0.001. CONCLUSION: Implementation of an SOP for prehospital anaesthesia was associated with a trend towards lower 1-day mortality and an improved first-pass success but did not affect 30-day mortality. Despite this, we advocate prehospital systems to consider implementation of a prehospital anaesthesia SOP as immediate performance markers improved significantly.

The Estimated Cost-Effectiveness of Physician-Staffed Helicopter Emergency Medical Services Compared to Ground-Based Emergency Medical Services in Finland.

OBJECTIVE: Because the unit cost of helicopter emergency medical services (HEMS) is higher than traditional ground-based emergency medical services (EMS), it is important to further investigate the impact of HEMS. The aim of this study was to evaluate the cost-effectiveness of physician-staffed HEMS compared with ground-based EMS in Finland under current practices. METHODS: The incremental cost-effectiveness ratio was evaluated using the differences in outcomes and costs between HEMS and ground-based EMS. The estimated mortality within 30 days and quality-adjusted life years (QALYs) were used to measure health benefits. Quality of life was estimated according to the EuroQoL scale, and a 1-way sensitivity analysis was conducted on the QALY indexes ranging from 0.6 to 0.8. Survival rates were calculated according to the national HEMS database, and the cost structure was estimated at 48 million euros based on financial statements. RESULTS: HEMS prevented the 30-day mortality of 68.1 patients annually, with an incremental cost-effectiveness ratio of €43,688 to €56,918/QALY. Fixed costs accounted for 93% of HEMS expenses because of 24/7 operations, making the capacity utilization rate a major determinant of total costs. CONCLUSION: HEMS intervention is cost-effective compared with ground-based EMS and is acceptable from a societal willingness-to-pay perspective. These findings contribute valuable insights for health care management decision making and highlight the need for future research for service optimization.

Association among blood pressure, end-tidal carbon dioxide, peripheral oxygen saturation and mortality in prehospital post-resuscitation care.

Aim: Post-resuscitation care is described as the fourth link in a chain of survival in resuscitation guidelines. However, data on prehospital post-resuscitation care is scarce. We aimed to examine the association among systolic blood pressure (SBP), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide (EtCO2) after prehospital stabilisation and outcome among patients resuscitated from out-of-hospital cardiac arrest (OHCA). Methods: In this retrospective study, we evaluated association of the last measured prehospital SBP, SpO2 and EtCO2 before patient handover with 30-day and one-year mortality in 2,611 patients receiving prehospital post-resuscitation care by helicopter emergency medical services in Finland. Statistical analyses were completed through locally estimated scatterplot smoothing (LOESS) and multivariable logistic regression. The regression analyses were adjusted by sex, age, initial rhythm, bystander CPR, and time interval from collapse to the return of spontaneous circulation (ROSC). Results: Mortality related to SBP and EtCO2 values were U-shaped and lowest at 135 mmHg and 4.7 kPa, respectively, whereas higher SpO2 shifted towards lower mortality. In adjusted analyses, increased 30-day mortality and one year mortality was observed in patients with SBP < 100 mmHg (OR 1.9 [95% CI 1.4-2.4]) and SBP < 100 (OR 1.8 [1.2-2.6]) or EtCO2 < 4.0 kPa (OR 1.4 [1.1-1.5]), respectively. SpO2 was not significantly associated with either 30-day or one year mortality. Conclusions: After prehospital post-resuscitation stabilization, SBP < 100 mmHg and EtCO2 < 4.0 kPa were observed to be independently associated with higher mortality. The optimal targets for prehospital post-resuscitation care need to be established in the prospective studies.

The creation, implementation, and harmonisation of medical standard operating procedures and checklists of Finnish Helicopter Emergency Medical Service units.

INTRODUCTION: The purpose of this study was to investigate the creation, implementation, and harmonisation of medical Standard Operating Procedures (SOP) in Finnish Helicopter Emergency Medical Services (HEMS). The research questions are: (1) What factors influence the creation and implementation of medical SOPs for Finnish HEMS units? and (2) What can be done to harmonise the medical SOPs of Finnish HEMS units? METHODS: The research was conducted as a qualitative interview study with HEMS physicians who worked full-time in Finnish HEMS units or had worked in HEMS for more than five years. Three HEMS physicians from each of the six HEMS units in Finland participated in the study (n = 18). The thematic interviews (average duration 32 min) were transcribed (70,176 words in Finnish) and analysed using inductive content analysis. RESULTS: The results of the first research question formed three main categories: (1) Background to developing medical SOPs and checklists (CLs), (2) Creation of medical SOPs in Finnish HEMS units, and (3) Implementation of medical SOPs and CLs. The main categories were divided into eight upper categories and twelve subcategories. The results of the second research question formed four main categories: (1) Prerequisites for harmonising procedures, (2) System-level changes needed, (3) Integrating common medical SOPs into HEMS, and (4) Cultural change. The main categories were divided into nine upper categories and nine subcategories. CONCLUSIONS: Medical SOPs and CLs are an integral part of Finnish HEMS. Each unit creates its own SOPs and CLs; their development, implementation, and follow-up are relatively unstructured. Harmonising existing SOPs would be possible, but developing common SOPs would require structural changes in HEMS and a stronger sense of community belonging among HEMS physicians.

A scenario based approach to optimizing cost-effectiveness of physician-staffed Helicopter Emergency Medical Services compared to ground-based Emergency Medical Services in Finland.

OBJECTIVES: Since Helicopter Emergency Medical Services (HEMS) is an expensive resource in terms of unit price compared to ground-based Emergency Medical Service (EMS), it is important to further investigate which methods would allow for the optimization of these services. The aim of this study was to evaluate the cost-effectiveness of physician-staffed HEMS compared to ground-based EMS in developed scenarios with improvements in triage, aviation performance, and the inclusion of ischemic stroke patients. METHODS: Incremental cost-effectiveness ratio (ICER) was assessed by comparing health outcomes and costs of HEMS versus ground-based EMS across six different scenarios. Estimated 30-day mortality and quality-adjusted life years (QALYs) were used to measure health benefits. Quality-of-Life (QoL) was assessed with EuroQoL instrument, and a one-way sensitivity analysis was carried out across different patient groups. Survival estimates were evaluated from the national FinnHEMS database, with cost analysis based on the most recent financial reports. RESULTS: The best outcome was achieved in Scenario 3.1 which included a reduction in over-alerts, aviation performance enhancement, and assessment of ischemic stroke patients. This scenario yielded 1077.07-1436.09 additional QALYs with an ICER of 33,703-44,937 €/QALY. This represented a 27.72% increase in the additional QALYs and a 21.05% reduction in the ICER compared to the current practice. CONCLUSIONS: The cost-effectiveness of HEMS can be highly improved by adding stroke patients into the dispatch criteria, as the overall costs are fixed, and the cost-effectiveness is determined based on the utilization rate of capacity.

Front of neck airway in Finnish helicopter emergency medical services.

INTRODUCTION: An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of airway management. Two techniques exist for FONA, with literature favouring the surgical technique over the percutaneous. The reported need for a prehospital FONA is fortunately rare as the mortality has been shown to be high. Due to the low incidence, literature on FONA is limited with regards to different settings, techniques and operators. As a foundation for future research and improvement of patient care, we aim to describe the frequency, indications, technique, success, and outcomes of FONA in the Finnish helicopter emergency medical services (HEMS). MATERIALS AND METHODS: This retrospective descriptive study reviews FONA performed at the Finnish HEMS during 1.1.2012 to 8.9.2019. The Finnish HEMS consists of six units, staffed mainly by anaesthesiologists. Clinical data was gathered from a national HEMS database and trough chart reviews. Data on mortality was obtained from a population registry. Only descriptive statistics were performed. RESULTS: A total of 22 FONA were performed during the study period, 7 were primary and 14 performed after failure to intubate (missing data regarding indication for one attempt). This equals a 0.13 % (14/10,813) need for a rescue FONA and a rate of 0.20 % (22/10,813) FONA out of all advanced airway management. All but one FONA was performed using a surgical approach (20/21, 95 %, missing data = 1) and all were successful (22/22, 100 %). Indications were mainly cardiac arrest (10/22, 45 %) and trauma (6/22, 27 %), and the most common reason for a need for a secondary FONA was obstruction of airway by food or fluids (7/14, 50 %). On-scene mortality was 36 % (8/22) and 30-day mortality 90 % (19/21, missing data = 1). CONCLUSION: The need for FONA is scarce in a HEMS system with experienced airway providers. Even though the procedure is successfully performed, the mortality is markedly high.

Development and internal validation of an algorithm for estimating mortality in patients encountered by physician-staffed helicopter emergency medical services.

BACKGROUND: Severity of illness scoring systems are used in intensive care units to enable the calculation of adjusted outcomes for audit and benchmarking purposes. Similar tools are lacking for pre-hospital emergency medicine. Therefore, using a national helicopter emergency medical services database, we developed and internally validated a mortality prediction algorithm. METHODS: We conducted a multicentre retrospective observational register-based cohort study based on the patients treated by five physician-staffed Finnish helicopter emergency medical service units between 2012 and 2019. Only patients aged 16 and over treated by physician-staffed units were included. We analysed the relationship between 30-day mortality and physiological, patient-related and circumstantial variables. The data were imputed using multiple imputations employing chained equations. We used multivariate logistic regression to estimate the variable effects and performed derivation of multiple multivariable models with different combinations of variables. The models were combined into an algorithm to allow a risk estimation tool that accounts for missing variables. Internal validation was assessed by calculating the optimism of each performance estimate using the von Hippel method with four imputed sets. RESULTS: After exclusions, 30 186 patients were included in the analysis. 8611 (29%) patients died within the first 30 days after the incident. Eleven predictor variables (systolic blood pressure, heart rate, oxygen saturation, Glasgow Coma Scale, sex, age, emergency medical services vehicle type [helicopter vs ground unit], whether the mission was located in a medical facility or nursing home, cardiac rhythm [asystole, pulseless electrical activity, ventricular fibrillation, ventricular tachycardia vs others], time from emergency call to physician arrival and patient category) were included. Adjusted for optimism after internal validation, the algorithm had an area under the receiver operating characteristic curve of 0.921 (95% CI 0.918 to 0.924), Brier score of 0.097, calibration intercept of 0.000 (95% CI -0.040 to 0.040) and slope of 1.000 (95% CI 0.977 to 1.023). CONCLUSIONS: Based on 11 demographic, mission-specific, and physiologic variables, we developed and internally validated a novel severity of illness algorithm for use with patients encountered by physician-staffed helicopter emergency medical services, which may help in future quality improvement.