Retrospective comparative analysis of two medical evacuation systems for Ukrainian patients affected by war.

INTRODUCTION: Coordinated medical evacuations represent an important strategy for emergency response when healthcare systems are impaired by armed conflict, particularly for patients diagnosed with life-threatening conditions such as cancer. In this study, we compare the experiences of two parallel medical evacuation systems developed to meet the medical needs of Ukrainians affected by war. METHODS: This retrospective study compared outcomes of two medical evacuation systems, developed by the European Union Emergency Response Coordination Centre (ERCC) and Supporting Action for Emergency Response in Ukraine (SAFER Ukraine) collaborative, in the first 10 months after the war's intensification in Ukraine (February 24 to December 21, 2022). Each groups' respective registries served as data sources. Patient demographics and allocation data were summarized descriptively. Median time for patient referral were analyzed statistically. RESULTS: The ERCC pathway evacuated 1385 patients (median age: 36 [0 - 85] years) to 16 European countries; 78.7 % (n = 1091) suffered from trauma-related injuries and 13.4 % (n = 185) from cancer. SAFER Ukraine evacuated 550 patients (median age: 9 [0 - 22] years) to 14 European and North American countries; 97.1 % (n = 534) were children diagnosed with cancer or blood disorders. The median evacuation time for the SAFER Ukraine cohort was shorter than the ERCC cohort (p < 0.001), though comparable (six versus seven days). CONCLUSION: The ERCC and SAFER Ukraine collaborative successfully developed medical evacuation pathways to meet the needs of Ukrainian patients impacted by war. System comparison provides opportunity to identify strategies for parallel system harmonization and a pragmatic example of how to anticipate support of these patients in future armed conflicts.

Transportation and equipment needs for emergency medical services development in low- and middle-income countries.

Prehospital emergency medical services play a vital role in reducing mortality and disease burden in low- and middle-income countries. However, the availability of adequate prehospital emergency care remains a significant challenge in many resource-limited communities, with over 91% of the African population lacking access to sufficient emergency medical services. This commentary aims to highlight the critical components of transportation infrastructure and medical supply chain challenges for emergency medical service development and propose potential solutions for future study. Transportation is a key factor influencing prehospital mortality, yet many low- and middle-income countries face issues related to timely prehospital transportation, with patients often relying on family members or private vehicles for transportation, leading to delays in reaching healthcare facilities due to poor road infrastructure. Dysfunctional and inadequate vehicles are also common barriers to timely care. Response times and transport times often exceed high-income standards, with some rural areas experiencing total prehospital time, defined as the time of injury to arrival at definitive care, exceeding 24 hours. To address these transportation challenges, some low- and middle-income countries have developed tier-1 emergency medical services programs that use existing transportation infrastructure and involve lay first responders using motorized and non-motorized vehicles. These programs prioritize rapid transportation over advanced on-scene intervention, potentially providing faster response times. A combination of tier-1 and tier-2 emergency medical services systems, as seen in some successful examples, allows for early on-scene guidance and resource allocation. In addition to transportation, the availability of medical equipment is crucial for effective prehospital interventions, particularly in tier-2 systems. However, low- and middle-income countries often face shortages of even basic supplies, limiting the scope of care that emergency medical services personnel can provide. Developing tier-2 emergency medical services upon a foundation of tier-1 prehospital care utilizing sustainable local supply chains and common household items for basic care can help alleviate these equipment challenges. The integration of tier-1 and tier-2 systems may offer a promising solution to address resource limitations and improve timely access to emergency care in low- and middle-income countries. Further research and investment are required to explore and implement these solutions, ultimately reducing mortality and enhancing healthcare services in resource-limited communities.

Addressing transportation barriers in oncology: existing programs and new solutions.

Transportation is an underrecognized, but modifiable barrier to accessing cancer care, especially for clinical trials. Clinicians, insurers, and health systems can screen patients for transportation needs and link them to transportation. Direct transportation services (i.e., ride-sharing, insurance-provided transportation) have high rates of patient satisfaction and visit completion. Patient financial reimbursements provide necessary funds to counteract the effects of transportation barriers, which can lead to higher trial enrollment, especially for low socioeconomic status and racially and ethnically diverse patients. Expanding transportation interventions to more cancer patients, and addressing knowledge, service, and system gaps, can help more patients access needed cancer care.

Does destination make a difference? Outcomes after a policy change affecting cutoff times for prehospital transport.

BACKGROUND: Facilitating primary triage and care at pediatric trauma centers (PTCs) can improve outcomes for children after trauma. However, scene location and regional emergency medical services regulations may result in initial evaluation occurring at nonpediatric facilities with later transportation to PTCs for definitive care. In this study, we assessed the results of a change in transport time cutoff from 30 to 45 minutes on pediatric patient outcomes. METHODS: After institutional review board approval, the Pediatric Trauma Database at a level 1 PTC was queried for patients seen before (January 1, 2015, to December 31, 2017) and after (January 1, 2018, to December 31, 2020) the implementation of a policy increasing transport cutoff time from 30 to 45 minutes. Patient outcomes were compared by transport status and Injury Severity Score (ISS) using generalized linear regression analysis. RESULTS: A total of 505 patients were seen before policy changes, and 413 patients, after policy changes. Both groups had similar numbers of severely injured patients (ISS, ≥15; pre, 64 [13%]; post, 61 [15%]). Average transport time increased after change (pre, 20 minutes [95% confidence interval, 18-22 minutes]; post, 29 minutes [95% confidence interval, 26-33 minutes]; p = 0.0252), consistent with policy compliance. The proportion of transferred patients did not change after policy implementation ( p = 0.5856), and the complications among all patients with an ISS of ≥15 did not significantly decrease (pre, 75%; post, 65.6%). However, those patients with an ISS of ≥15 admitted directly from the scene had a lower frequency of complications after the policy changes (pre, 76%; post, 59%; p = 0.0319), and in the postperiod, transferred patients with an ISS of ≥15 had a higher complication rate than those admitted directly from the scene ( p < 0.0001). CONCLUSION: Direct scene admission to a PTC is associated with a lower complication profile for patients with higher ISS. Methods to ensure adherence to cutoff thresholds for emergency medical services transport may have a positive benefit on patient outcomes. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Which Method of Transportation Is Associated With Better Outcomes for Patients With Firearm Injuries to the Head and Neck?

BACKGROUND: In firearm injuries (FI), rapid transportation is important for survival. Information regarding different methods of transportation for head and neck FI is limited. PURPOSE: The purpose of the study was to measure the association between method of transportation and the need for tracheostomy and/or intensive care unit (ICU). STUDY DESIGN, SETTING, SAMPLE: This retrospective cross-sectional study reviewed patients in Trauma Registry at Grady Memorial Hospital (GMH) in Atlanta, Georgia, from January 2016 to June 2021. Patients ≥18 years old who sustained FI to the head and neck and were transported via ground emergency medical services (GEMS) or helicopter emergency medical services (HEMS) were included. Patients who arrived at the hospital by foot, private vehicle, or transported from a different hospital were excluded. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: The primary predictor variable was method of transportation (GEMS: ambulance transportation to GMH vs HEMS: helicopter transportation to GMH helipad). MAIN OUTCOME VARIABLE(S): The primary outcome variables were tracheostomy (yes/no) and ICU admission (yes/no). COVARIATES: Patient, injury, and hospital-related covariates were collected. ANALYSES: Univariate analysis, χ2 test for categorical variables, and independent t test for continuous variables were calculated. Statistical significance was P < .05. RESULTS: Of total, 609 patients met the inclusion criteria. There were 560 patients (483 males) with a mean age of 33.6 years old (range, 18 to 90) transported by GEMS. There were 49 patients (40 males) with a mean age of 44 years old (range, 18 to 82) transported by HEMS. Patients transported by HEMS were statistically more likely to have longer transportation time in minutes [13.2 (range, 5 to 132) versus 24.2 (range, 9 to 46), P= <.001], lower Glasgow Coma Scale score [9.9 (range, 3 to 15) versus 6.3 (range, 3 to 15); P= <.001], higher Injury Severity Score [19.3 (range, 3.7 to 98) versus 24.2 (range, 10.3 to 98); P = .007], require transfusion [195 (34.8%); versus 26 (53.1%); P = .013], tracheostomy [46(8.2%) versus 13 (26.5%); P = <.001], and/or admitted to ICU [169, 30.2% versus 24 (49%); P = .007]. CONCLUSION AND RELEVANCE: HEMS was positively associated with more tracheostomy and/or ICU admission. Additionally, patients transported by HEMS experienced longer transportation time and severe injuries. HEMS triage criteria specific for FI to the head and neck should be developed.

[Preclinical patient transport at the end of life]. / Präklinischer Patiententransport am Lebensende.

BACKGROUND: Although most people would like to die at home, many die in hospitals. The study shows physicians' and paramedics' experiences with prehospital care of patients at the end of life. METHOD: Using an anonymous online questionnaire, primary care physicians and ambulance personnel in the Frankfurt am Main metropolitan area were surveyed about their experiences with end of life care. RESULTS: A total of 63 primary care physicians (PCP) and 62 emergency medical service staff (EMS) answered the questionnaire (female 31.2%, male 68.8%). Of the respondents 65.8% reported that patients are often still transported to hospital at the end of life. Of the participants 17.9% felt confident in their assessment of a patient at the end of life, 33.3% of PCP and 8.5% of EMS felt confident about subsequent treatment and 91.9% of PCP and 96.2% of EMS reported that they always/often ask about an advance healthcare directive. Of the participants 98.3% felt that EMS rarely/never ask about advance care planning, 78.7% of all participants would rarely/never ask about it and 90.4% of EMS would like to have a legally secure emergency document to guide their actions. CONCLUSION: Transporting patients at the end of life is part of everyday prehospital practice. There are uncertainties in the assessment and care of these patients. In the future, rescue service and medical training should include specific palliative care strategies. Advance healthcare directive and advance care planning must be more widely recognized by the medical community, so that in emergency situations the desired corridors of action in the best interests of the patient are quickly made known.

Transportation of patients under extracorporeal membrane oxygenation support on an airliner: Flying bridge to transplantation.

BACKGROUND: A retrieval programme was developed in Martinique (French West Indies) to provide extracorporeal membrane oxygenation for patients in the Caribbean, where heart transplantation and ventricular assist devices are not available. In 2011, the Department of Cardiac Surgery at the University Hospital of Fort-de-France (Martinique) developed a transfer programme to Paris (France) on an airliner, to refer patients for whom extracorporeal membrane oxygenation was not weanable to heart transplantation or a ventricular assist device. AIM: To report this unique experience of transportation of patients under extracorporeal membrane oxygenation support on an airliner from the French West Indies to Paris. METHODS: This was an observational and retrospective study of all patients under extracorporeal membrane oxygenation support who were transferred from Martinique to the Pitié-Salpêtrière Hospital/Sorbonne University in Paris between September 2011 and September 2019. Transport characteristics, complications during repatriation, cost and clinical outcomes at 30days and 1year were reported. RESULTS: Twenty-six patients were transferred on an airliner; the retrieval distance was 7260km, and the mean duration was 14hours. Only two patients developed complications (pulmonary oedema and leg ischaemia), and no patient died during the flight. Nine patients had a ventricular assist device implanted, and six patients were transplanted. Thirty-day survival was 65.4%, and 1-year survival was 38.5%. CONCLUSIONS: Transport under extracorporeal membrane oxygenation support on an airliner is safe and efficient, with an acceptable cost. This programme allowed patients under extracorporeal membrane oxygenation support in a remote centre, without access to transplantation or a ventricular assist device, to be referred for these techniques in specialized centres. This experience strengthens the strategy of developing regional networks around specialized extracorporeal membrane oxygenation centres.

[Management of helicopter medical transport in 36 patients with critical cardiac disease].

OBJECTIVE: To summarize the management experience of helicopter medical transport in patients with critical heart disease, so as to provide reference for transport of patients with critical heart disease under the background of major natural disasters. METHODS: The clinical and transport data of 36 critically ill cardiac patients in Fuwai Central China Cardiovascular Hospital from 16:30 on July 21 to 19:30 on July 22, 2021 due to historically rare heavy rainstorms were collected. All 36 critically ill cardiac patients were transported by helicopter. The safe transportation was implemented under the measures of quickly forming a transport leadership and coordination group, clarifying responsibilities and division of labor, doing a good job in the pretreatment of the patient's condition, pipeline assessment and mechanical circulation support (MCS) equipment, simulating and practicing the transfer process, improving the safety of the transfer implementation process, and effectively handing over with the target hospital. The gender, age, disease type, MCS, transport and outcome of patients were collected. RESULTS: Thirty-six patients with cardiac critical illness were from adult extracardiac intensive care unit (ICU), adult cardiac care unit (CCU), children's CCU, comprehensive ICU and department of neurology. There were 24 males and 12 females; age (50.93±20.86) years old. There were 12 patients using respirator, 7 patients needing MCS, 2 of whom needed both extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP), and 7 patients with post-cardiac surgery. The total distance of transportation of 36 patients was 1 638.4 km, the transit time was 10.5 hours, one way flight time of helicopter was about 8 minutes, and the average transport time per patient was about 17.5 minutes. The vital signs of 36 patients during transport were basically stable, without complications, and all of them reached the target hospital safely. CONCLUSIONS: Under the seamless connection of the rapid establishment of the transfer leadership coordination group, assessment of the patient's condition and pretreatment, the simulation of the transfer process, and the effective handover with the receiving hospital, the use of helicopter for medical transport for critically ill heart patients is feasible and safe, which can buy valuable time for saving patients' lives and further treatment.

An Analysis of Cancer Center-Provided Rideshare Utilization for Radiation Therapy.

OBJECTIVES: The potential of rideshare services to facilitate timely radiation therapy (RT), especially for resource-limited patients, is understudied. METHODS: Patients (n = 63) who received 73 courses of RT (1,513 fractions) and utilized free hospital-provided rideshare service (537 rides) were included in this retrospective study. A multidimensional analysis was conducted including a comparison of demographic, disease characteristics, and treatment completion data; a revenue analysis to evaluate the financial impact of rideshare services; and a geospatial analysis to evaluate community-level characteristics of patients. RESULTS: Median age was 59; most were female (56%) and self-identified as Black or African American (56%), not working (91%), not partnered (83%), high school educated or less (78%), and insured with Medicaid (51%). Geospatial analysis revealed that patients lived in communities with significantly higher rates of resource deprivation. Median rideshare distance was 6.4 miles (interquartile range 3.4-11.2) with a median cost of $13.04 per rideshare (interquartile range 9-19). Of the rideshare-facilitated treatments, 100% were completed, with an overall course completion rate of 97.3% compared with 85.4% for those who did not use rideshare (P = .001); two patients discontinued RT for reasons unrelated to transportation. High rideshare utilization (n = 32), defined as utilization ≥ 45% of the treatment course, was associated with significantly shorter treatment courses and lower radiation doses compared with low rideshare utilization (P = .04). Total rideshare cost for high utilizers and whole cohort was $11,589 and $16,895, facilitating an estimated revenue of $401,952 and $1,175,119, respectively. CONCLUSIONS: Free hospital-provided rideshare service is economically feasible and associated with high RT completion rates. It may help enhance quality radiation care for those who come from resource-limited communities.