Establishing quality indicators for pre-hospital advanced airway management: a modified nominal group technique consensus process.

BACKGROUND: Pre-hospital advanced airway management is a complex intervention composed of numerous steps, interactions, and variables that can be delivered to a high standard in the pre-hospital setting. Standard research methods have struggled to evaluate this complex intervention because of considerable heterogeneity in patients, providers, and techniques. In this study, we aimed to develop a set of quality indicators to evaluate pre-hospital advanced airway management. METHODS: We used a modified nominal group technique consensus process comprising three email rounds and a consensus meeting among a group of 16 international experts. The final set of quality indicators was assessed for usability according to the National Quality Forum Measure Evaluation Criteria. RESULTS: Seventy-seven possible quality indicators were identified through a narrative literature review with a further 49 proposed by panel experts. A final set of 17 final quality indicators composed of three structure-, nine process-, and five outcome-related indicators, was identified through the consensus process. The quality indicators cover all steps of pre-hospital advanced airway management from preoxygenation and use of rapid sequence induction to the ventilatory state of the patient at hospital delivery, prior intubation experience of provider, success rates and complications. CONCLUSIONS: We identified a set of quality indicators for pre-hospital advanced airway management that represent a practical tool to measure, report, analyse, and monitor quality and performance of this complex intervention.

Airway management in a Helicopter Emergency Medical Service (HEMS): a retrospective observational study of 365 out-of-hospital intubations.

BACKGROUND: Airway management is a key skill in any helicopter emergency medical service (HEMS). Intubation is successful less often than in the hospital, and alternative forms of airway management are more often needed. METHODS: Retrospective observational cohort study in an anaesthesiologist-staffed HEMS in Switzerland. Patient charts were analysed for all calls to the scene (n = 9,035) taking place between June 2016 and May 2017 (12 months). The primary outcome parameter was intubation success rate. Secondary parameters included the number of alternative techniques that eventually secured the airway, and comparison of patients with and without difficulties in airway management. RESULTS: A total of 365 patients receiving invasive ventilatory support were identified. Difficulties in airway management occurred in 26 patients (7.1%). Severe traumatic brain injury was the most common indication for out-of-hospital Intubation (n = 130, 36%). Airway management was performed by 129 different Rega physicians and 47 different Rega paramedics. Paramedics were involved in out-of-hospital airway manoeuvres significantly more often than physicians: median 7 (IQR 4 to 9) versus 2 (IQR 1 to 4), p < 0.001. CONCLUSION: Despite high overall success rates for endotracheal intubation in the physician-staffed service, individual physicians get only limited real-life experience with advanced airway management in the field. This highlights the importance of solid basic competence in a discipline such as anaesthesiology.

Static Rope Rescue Operations in Western Norway: A Retrospective Analysis of 141 Missions.

INTRODUCTION: The Norwegian national standard for rescuers describes medical and rescue requirements for helicopter emergency medical services (HEMS) technical crew members, but there is a lack of scientific data supporting these requirements and their safety relevance. The study aims to analyze the rescue profile of Norwegian HEMS static rope human external cargo operations, emphasizing terrain challenges and additional safety measures utilized on-site. METHODS: We conducted a retrospective descriptive analysis of static rope missions performed in daylight by 3 HEMS bases in Western Norway in the period 2015 to 2019. The analysis measures evacuation methods, terrain, on-site safety measures, and medical treatment. RESULTS: Out of 8352 primary HEMS and search and rescue missions, a total of 141 (2%) static rope missions were performed by the 3 HEMS bases in Western Norway. The most commonly used evacuation method was triangle harness (62%) and a static rope length of 30 m (81%). Ninety-two (65%) missions were completed in simple terrain, 38 (27%) in challenging terrain, and 11 (8%) in complex terrain. There were no reported accidents, but a small number of adverse events were registered. The most frequent medical intervention administered on-site was pain management, followed by spinal immobilization. CONCLUSIONS: Thirty-five percent of the static rope missions performed by HEMS in Western Norway were completed in challenging or complex terrain, requiring additional safety measures on-site. The most common safety measure needed was the ability to operate in a mountain or alpine environment. Our findings support the safety relevance of a national standard for rescuers.

A comparative study on the frequency of simulation-based training and assessment of non-technical skills in the Norwegian ground ambulance services and helicopter emergency medical services.

BACKGROUND: Inadequate non-technical skills (NTSs) among employees in the Norwegian prehospital emergency medical services (EMSs) are a risk for patient and operational safety. Simulation-based training and assessment is promising with respect to improving NTSs. The frequency of simulation-based training in and assessment of NTSs among crewmembers in the Norwegian helicopter emergency medical service (HEMS) has gained increased attention over recent years, whereas there has been much less focus on the Norwegian ground emergency medical service (GEMS). The aim of the study was to compare and document the frequencies of simulation-based training in and assessment of seven NTSs between the Norwegian HEMS and GEMS, conditional on workplace and occupation. METHOD: A comparative study of the results from cross-sectional questionnaires responded to by employees in the Norwegian prehospital EMSs in 2016 regarding training in and assessment of NTSs during 2015, with a focus on the Norwegian GEMS and HEMS. Professional groups of interest are: pilots, HEMS crew members (HCMs), physicians, paramedics, emergency medical technicians (EMTs), EMT apprentices, nurses and nurses with an EMT licence. RESULTS: The frequency of simulation-based training in and assessment of seven generic NTSs was statistically significantly greater for HEMS than for GEMS during 2015. Compared with pilots and HCMs, other health care providers in GEMS and HEMS undergo statistically significantly less frequent simulation-based training in and assessment of NTSs. Physicians working in the HEMS appear to be undergoing training and assessment more frequently than the rest of the health trust employees. The study indicates a tendency for lesser focus on the assessment of NTSs compared to simulation-based training. CONCLUSION: HEMS has become superior to GEMS, in terms of frequency of training in and assessment of NTSs. The low frequency of training in and assessment of NTSs in GEMS suggests that there is a great potential to learn from HEMS and to strengthen the focus on NTSs. Increased frequency of assessment of NTSs in both HEMS and GEMS is called for.

Psychometric properties of the Norwegian version of the hospital survey on patient safety culture in a prehospital environment.

BACKGROUND: To develop a culture of patient safety in a regime that strongly focuses on saving patients from emergencies may seem counter-intuitive and challenging. Little research exists on patient safety culture in the context of Emergency Medical Services (EMS), and the use of survey tools represents an appropriate approach to improve patient safety. Research indicates that safety climate studies may predict safety behavior and safety-related outcomes. In this study we apply the Norwegian versions of Hospital Survey on Patient Safety Culture (HSOPSC) and assess the psychometric properties when tested on a national sample from the EMS. METHODS: This study adopted a web based survey design. The Norwegian HSOPSC has 13 dimensions, consisting of 46 items, in addition to two single-item outcome variables. SPSS (version 21) was used for descriptive data analysis, estimating internal consistency, and performing exploratory factor analysis. Confirmatory factor analysis (CFA) was applied to test the dimensional structure of the instruments using Amos (version 21). RESULTS: N = 1387 (27%) EMS employees participated in the survey. Overall, acceptable psychometric properties were observed, i.e. acceptable internal consistencies and construct validity. The patient safety climate dimensions with highest scores (number of positive answers) were "teamwork within units" and "manager expectations & actions promoting patient safety". The dimension "hospital management support for patient safety" had the lowest score. CONCLUSIONS: The results provided a validated instrument, the Prehospital Survey on Patient Safety Culture (PreHSOPSC), for measuring patient safety climate in an EMS setting. In addition, the explanatory power was strong for several of the outcome dimensions; i.e., several of the safety climate dimensions have a strong predictive effect on outcome variables related to employees' perceptions on patient safety and safety-related attitude.

Does Medical Staffing Influence Perceived Safety? An International Survey on Medical Crew Models in Helicopter Emergency Medical Services.

OBJECTIVE: The competence, composition, and number of crewmembers have generally been considered to influence the degree of patient care and safety in helicopter emergency medical services (HEMS), but evidence to support the advantages of one crew concept over another is ambiguous; additionally, the benefit of physicians as crewmembers is still highly debated. METHODS: To compare perceived safety in different medical crew models, we surveyed international HEMS medical directors regarding the types of crew compositions their system currently used and their supportive rationales and to evaluate patient and flight safety within their services. RESULTS: Perceived patient and flight safety is higher when HEMS is staffed with a dual medical crew in the cabin. Tradition and scientific evidence are the most common reasons for the choice of medical crew. Most respondents would rather retain their current crew configuration, but some would prefer to add a physician or supplement the physician with an assistant in the cabin. CONCLUSION: Our survey shows a wide variety of medical staffing models in HEMS and indicates that these differences are mainly related to medical competencies and the availability of an assistant in the medical cabin. The responses suggest that differences in medical staffing influence perceived flight and patient safety.

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.

The role of the anaesthesiologist in air ambulance medicine.

PURPOSE OF REVIEW: The care administered on air ambulances has become increasing complex. This has led to a discussion among experts as to whether air ambulance travel should be manned by physicians. This review provides evidence in support of anaesthesiologists being the physician-leaders in air ambulance medicine, because of their training in advanced airway management, critical care, and resuscitation. RECENT FINDINGS: Successful prehospital care requires the ability to perform a complex set of advanced diagnostics and interventions. These include airway management, haemorrhage control, pain management, point-of-care diagnostics, complex interfacility transport, and advanced interventions. This skill set closely mirrors the training and expertise of anaesthesiologists. SUMMARY: There are few studies investigating the specific benefit of anaesthesiologists in air ambulance medicine. However, current evidence indicates that their presence does improve patient care and safety. Future studies on this topic should use evidence-based quality indicators and standardized data sets to seek answers to optimal staffing of air ambulance teams.

Reporting Helicopter Emergency Medical Services in Major Incidents: A Delphi Study.

OBJECTIVE: Research on helicopter emergency medical services (HEMS) in major incidents is predominately based on case descriptions reported in a heterogeneous fashion. Uniform data reported with a consensus-based template could facilitate the collection, analysis, and exchange of experiences. This type of database presently exists for major incident reporting at www.majorincidentreporting.net. This study aimed to develop a HEMS-specific major incident template. METHODS: This Delphi study included 17 prehospital critical care physicians with current or previous HEMS experience. All participants interacted through e-mail. We asked these experts to define data variables and rank which were most important to report during an immediate prehospital medical response to a major incident. Five rounds were conducted. RESULTS: In the first round, the experts suggested 98 variables. After 5 rounds, 21 variables were determined by consensus. These variables were formatted in a template with 4 main categories: HEMS background information, the major incident characteristics relevant to HEMS, the HEMS response to the major incident, and the key lessons learned. CONCLUSION: Based on opinions from European experts, we established a consensus-based template for reporting on HEMS responses to major incidents. This template will facilitate uniformity in the collection, analysis, and exchange of experience.

Simulation-based training and assessment of non-technical skills in the Norwegian Helicopter Emergency Medical Services: a cross-sectional survey.

BACKGROUND: Human error and deficient non-technical skills (NTSs) among providers of ALS in helicopter emergency medical services (HEMS) is a threat to patient and operational safety. Skills can be improved through simulation-based training and assessment. OBJECTIVE: To document the current level of simulation-based training and assessment of seven generic NTSs in crew members in the Norwegian HEMS. METHODS: A cross-sectional survey, either electronic or paper-based, of all 207 physicians, HEMS crew members (HCMs) and pilots working in the civilian Norwegian HEMS (11 bases), between 8 May and 25 July 2012. RESULTS: The response rate was 82% (n=193). A large proportion of each of the professional groups lacked simulation-based training and assessment of their NTSs. Compared with pilots and HCMs, physicians undergo statistically significantly less frequent simulation-based training and assessment of their NTSs. Fifty out of 82 (61%) physicians were on call for more than 72 consecutive hours on a regular basis. Of these, 79% did not have any training in coping with fatigue. In contrast, 72 out of 73 (99%) pilots and HCMs were on call for more than 3 days in a row. Of these, 54% did not have any training in coping with fatigue. CONCLUSIONS: Our study indicates a lack of simulation-based training and assessment. Pilots and HCMs train and are assessed more frequently than physicians. All professional groups are on call for extended hours, but receive limited training in how to cope with fatigue.

Exploring use of coercion in the Norwegian ambulance service - a qualitative study.

BACKGROUND: Healthcare laws allow for exceptions from the consent requirement when patients are not competent to consent or pose a danger to themselves or others. In these cases, the use of coercion may be an alternative to voluntary health care. Ambulance personnel are regularly confronted with patients who need healthcare but refuse it and/or refuse to cooperate. This study aimed to explore ambulance personnel`s experience with use of coercion and factors influencing the use of coercion in the ambulance service in Norway. METHOD: We conducted two focus group interviews with a total of eight informants, all ambulance personnel from a large Norwegian ambulance service. Digital recordings of the interviews were transcribed verbatim and analysed using systematic text condensation. RESULTS: The informants` stories revealed several methods of coercion used by the ambulance personnel; physical coercion, pragmatic coercion, pharmacological coercion and coercion used to ensure the patient is secured during transportation. The main reasons for using coercion were preventing patients from harming themselves or others and to ensure that patients unable to consent receive healthcare considered necessary. Systemic factors as difficulty of applying the law to real-life situations, and organizational factors as fear of breaching guidelines, experienced lack of support from the management, fear of charges of misconduct, and lack of training in assessing patients´ competence to consent seem to influence ambulance personnels use of coercion. CONCLUSION: Ethical grey areas in clinical practice emphasize the need for clinical discretion. Despite the fact that regulatory provisions allow for exceptions from the requirement to obtain consent, transferring these regulations to real life prehospital settings can be difficult. Consequently, the decisions made by ambulance personnel in clinical situations are highly influenced by organizational ethos and guidelines. The informants describe the coercive interventions they have employed to manage patients who are deemed to require healthcare but refuse it and/or refuse to cooperate.

Team training program's impact on medication administration, teamwork and patient safety culture in an ambulance service (TEAM-AMB): a longitudinal multimethod study protocol.

INTRODUCTION: Medication administration errors (MAEs) have the potential for significant patient harm, and the frequency of MAEs in the ambulance services is not well known. Effective teamwork is paramount for providing safe and effective patient care, especially in a time-sensitive, high-risk environment such as the ambulance services. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based team training programme that, to our knowledge, has not been studied in the ambulance services previously. TeamSTEPPS is based on the five principles: team structure, communication, leadership, situation monitoring and mutual support. This study aims to advance the knowledge of the medication administration process in the ambulance services and study the impact of a team training programme on the frequency of MAEs, and the perception of teamwork, and patient safety culture. METHODS AND ANALYSIS: This study uses a longitudinal multimethod design to evaluate medication administration and the implementation of the team training programme TeamSTEPPS in an ambulance service. A review of electronic patient journals 6 months prior to the intervention, and 12 months after the intervention will provide data on the frequency of MAEs. Focus group interviews and questionnaires will be carried out before and after the intervention to describe the perception of teamwork and patient safety culture among ambulance professionals. Observations, individual interviews and a review of guidelines will be conducted in the first and second quarters of 2022 to study the medication administration process in ambulance services. ETHICS AND DISSEMINATION: The study protocol was reviewed by the Regional Committees for Medical and Health Research Ethics Central Norway and approved by the Hospital Trust data protection officer, and the head of the Prehospital Division at the Hospital Trust. The data material will be managed confidentially and stored according to regulations. The results will be disseminated through scientific papers, reports, conference presentations, popular press, and social media. TRIAL REGISTRATION NUMBER: NCT05244928.

Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables.

INTRODUCTION: Although tracheal intubation (TI) in the pre-hospital setting is regularly carried out by emergency medical service (EMS) providers throughout the world, its value is widely debated. Heterogeneity in procedures, providers, patients, systems and stated outcomes, and inconsistency in data reporting make scientific reports difficult to interpret and compare, and the majority are of limited quality. To hunt down what is really known about the value of pre-hospital TI, we determined the rate of reported Utstein airway variables (28 core variables and 12 fixed-system variables) found in current scientific publications on pre-hospital TI. METHODS: We performed an all time systematic search according to the PRISMA guidelines of Medline and EMBASE to identify original research pertaining to pre-hospital TI in adult patients. RESULTS: From 1,076 identified records, 73 original papers were selected. Information was extracted according to an Utstein template for data reporting from in-the-field advanced airway management. Fifty-nine studies were from North American EMS systems. Of these, 46 (78%) described services in which non-physicians conducted TI. In 12 of the 13 non-North American EMS systems, physicians performed the pre-hospital TI. Overall, two were randomised controlled trials (RCTs), and 65 were observational studies. None of the studies presented the complete set of recommended Utstein airway variables. The median number of core variables reported was 10 (max 21, min 2, IQR 8-12), and the median number of fixed system variables was 5 (max 11, min 0, IQR 4-8). Among the most frequently reported variables were "patient category" and "service mission type", reported in 86% and 71% of the studies, respectively. Among the least-reported variables were "co-morbidity" and "type of available ventilator", both reported in 2% and 1% of the studies, respectively. CONCLUSIONS: Core data required for proper interpretation of results were frequently not recorded and reported in studies investigating TI in adults. This makes it difficult to compare scientific reports, assess their validity, and extrapolate to other EMS systems. Pre-hospital TI is a complex intervention, and terminology and study design must be improved to substantiate future evidence based clinical practice.

End-tidal to arterial carbon dioxide gradient is associated with increased mortality in patients with traumatic brain injury: a retrospective observational study.

Early definitive airway protection and normoventilation are key principles in the treatment of severe traumatic brain injury. These are currently guided by end tidal CO2 as a proxy for PaCO2. We assessed whether the difference between end tidal CO2 and PaCO2 at hospital admission is associated with in-hospital mortality. We conducted a retrospective observational cohort study of consecutive patients with traumatic brain injury who were intubated and transported by Helicopter Emergency Medical Services to a Level 1 trauma center between January 2014 and December 2019. We assessed the association between the CO2 gap-defined as the difference between end tidal CO2 and PaCO2-and in-hospital mortality using multivariate logistic regression models. 105 patients were included in this study. The mean ± SD CO2 gap at admission was 1.64 ± 1.09 kPa and significantly greater in non-survivors than survivors (2.26 ± 1.30 kPa vs. 1.42 ± 0.92 kPa, p < .001). The correlation between EtCO2 and PaCO2 at admission was low (Pearson's r = .287). The mean CO2 gap after 24 h was only 0.64 ± 0.82 kPa, and no longer significantly different between non-survivors and survivors. The multivariate logistic regression model showed that the CO2 gap was independently associated with increased mortality in this cohort and associated with a 2.7-fold increased mortality for every 1 kPa increase in the CO2 gap (OR 2.692, 95% CI 1.293 to 5.646, p = .009). This study demonstrates that the difference between EtCO2 and PaCO2 is significantly associated with in-hospital mortality in patients with traumatic brain injury. EtCO2 was significantly lower than PaCO2, making it an unreliable proxy for PaCO2 when aiming for normocapnic ventilation. The CO2 gap can lead to iatrogenic hypoventilation when normocapnic ventilation is aimed and might thereby increase in-hospital mortality.

Efficacy and efficiency of indoor nighttime human external cargo mission simulation in a high-fidelity training Centre.

BACKGROUND: The human external cargo (HEC) operations conducted by Helicopter Emergency Medical Services (HEMS) rarely take place at night, making it difficult for crew members to attain and maintain the level of expertise needed to perform winch operations in the dark. As EASA requirements for training cannot currently be met, we evaluated whether simulation training could be an option. METHODS: This paper reports on a training concept using indoor simulation for the training of nighttime HEC operations. Participants' experience and perceptions were evaluated with a survey and the procedural and economic advantages of the simulation approach were compared with those of the usual outdoor HEC training. RESULTS: Most participants had limited exposure to real-life nighttime HEC missions before undergoing the simulation-based training. The frequency of training cycles in simulation was much higher compared to conventional training (60 cycles indoors vs. 20 outdoors for HEMS-TC, 20 cycles indoors vs. 4 outdoors for MCM). Trainees perceived that their technical and non-technical skills (NTS) improved with the training. The estimated costs of standard outdoor-based nighttime HEC training (138€ per cycle) are at least 6.5 times higher than the costs of indoor simulated training (approximately 21€ per cycle). With a change to simulation, carbon dioxide emissions could potentially be reduced by more than 35 tons. CONCLUSIONS: Indoor simulation training of night HEC operations has advantages with regard to cost-effectiveness, environmental friendliness, and self-reported improvements in skills and knowledge. Its use is feasible and could improve crew and patient safety and fulfill regulatory demands for training intensity.

Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process.

OBJECTIVES: There is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore initiated to define priorities in health care simulation that contribute the most to improve patient safety. METHODS: An international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies for these problems. RESULTS: The expert group agreed on the following topics: technical skills, nontechnical skills, system probing, assessment, and effectiveness. For each topic, 5 patient safety problems were suggested that each topic might contribute to solve. Solutions to these problems and implementation strategies for these solutions were identified for technical skills, nontechnical skills, and system probing. In the case of assessment and effectiveness, the expert group found it difficult to suggest solutions and implementation strategies mainly because of lacking consensus on metrics and methodology. CONCLUSIONS: The expert group recommends that the 5 topics identified in this consensus process should be the main focus when health care simulation is implemented in patient safety curricula.

Training and assessment of non-technical skills in Norwegian helicopter emergency services: a cross-sectional and longitudinal study.

BACKGROUND: Deficient non-technical skills (NTS) among providers of critical care in helicopter emergency medical services (HEMS) is a threat to patient and operational safety. Skills can be improved through simulation-based training and assessment. A previous study indicated that physicians underwent less frequent training compared to pilots and HEMS crew members (HCM) and that all professional groups in Norwegian HEMS received limited training in how to cope with fatigue. Since then, training initiatives and a fatigue risk management project has been initiated. Our study aimed to explore if the frequency of simulation-based training and assessment of NTS in Norwegian HEMS has changed since 2011 following these measures. METHODS: A cross-sectional web-based survey from October through December 2016, of physicians, HCM and pilots from all civilian Norwegian HEMS-bases reporting the overall extent of simulation-based training and assessment of NTS. RESULTS: Of 214 invited, 109 responses were eligible for analysis. The frequency of simulation-based training and assessment of NTS has increased significantly for all professional groups in Norwegian HEMS, most prominently for the physicians. For all groups, the frequency of assessment is generally lower than the frequency of training. CONCLUSIONS: Physicians in Norwegian HEMS seem to have adjusted to the NTS training culture of the other crew member groups. This might be a consequence of improved NTS training programs. The use of behavioural marker systems systematically in HEMS should be emphasized.