Characteristics of the most severely ill and injured patients in a Norwegian helicopter emergency medical service: a retrospective cohort study.

BACKGROUND: Physician-staffed helicopter emergency medical services (HEMS) are dispatched to a variety of incidents, ranging from less serious to life-threatening. The skillset of a physician may be important to provide appropriate care for the most critically ill and severely injured patients. A better understanding of these patients may therefore be important to optimize dispatch criteria, training, and equipment setups for HEMS units. The aim of this study was to describe the characteristics of patients with the national advisory committee on aeronautics (NACA) score 5 and 6, primarily by diagnostic group and interventions performed. METHODS: Retrospective cohort study on aggregated data from the HEMS-base in Trondheim, Norway. All patients with NACA score 5 and 6 in the 10-year period from 2013 to 2022 were included. Patients with return of spontaneous circulation (ROSC) after successful cardiopulmonary resuscitation were described separately from non-cardiac arrest patients. RESULTS: Out of 9546 patient encounters, 2598 patients were included, with 1640 in the NACA 5 and 958 in NACA 6 group. Patient age was median 63 (interquartile range 45-74) and 64% of the patients were male. Post-ROSC patients accounted for 24% of patients. Of the non-cardiac arrest patients, the most frequent aetiology was trauma (16%), cardiac (15%), neurologic (14%) and respiratory (11%). The most common physician-requiring advanced interventions were general anaesthesia (22%), intubation (21%), invasive blood pressure monitoring (21%) and ventilator treatment (18%). The mean number of advanced interventions per mission were consistent during the study period (1,78, SD 0,25). CONCLUSION: Twenty-seven percent of all HEMS dispatches were to NACA 5 and 6 patients. Twenty-four percent of these were post-ROSC patients. Sixty-three percent of all patients received at least one advanced physician-requiring intervention and the average number of interventions were consistent during the last 10 years. Hence, the competence a physician-staffed HEMS resource provide is utilized in a high number of critically ill and injured patients.

Prehospital tracheal intubations by anaesthetist-staffed critical care teams: a prospective observational multicentre study.

BACKGROUND: Prehospital tracheal intubation is a potentially lifesaving intervention, but is associated with prolonged time on-scene. Some services strongly advocate performing the procedure outside of the ambulance or aircraft, while others also perform the procedure inside the vehicle. This study was designed as a non-inferiority trial registering the rate of successful tracheal intubation and incidence of complications performed by a critical care team either inside or outside an ambulance or helicopter. METHODS: This observational multicentre study was performed between March 2020 and September 2021 and involved 12 anaesthetist-staffed critical care teams providing emergency medical services by helicopter in Denmark, Norway, and Sweden. The primary outcome was first-pass successful tracheal intubations. RESULTS: Of the 422 drug-assisted tracheal intubations examined, 240 (57%) took place in the cabin of the ambulance or helicopter. The rate of first-pass success was 89.2% for intubations in-cabin vs 86.3% outside. This difference of 2.9% (confidence interval -2.4% to 8.2%) (two sided 10%, including 0, but not the non-inferiority limit Δ=-4.5) fulfils our criteria for non-inferiority, but not significant superiority. These results withstand after performing a propensity score analysis. The mean on-scene time associated with the helicopter in-cabin procedures (27 min) was significantly shorter than for outside the cabin (32 min, P=0.004). CONCLUSIONS: Both in-cabin and outside the cabin, prehospital tracheal intubation by anaesthetists was performed with a high success rate. The mean on-scene time was shorter in the in-cabin helicopter cohort. CLINICAL TRIAL REGISTRATION: NCT04206566.

The introduction of a regional Norwegian HEMS coordinator: an assessment of the effects on response times, geographical service areas and severity scores.

BACKGROUND: Due to unwanted delays and suboptimal resource control of helicopter emergency medical services (HEMS), regional HEMS coordinators have recently been introduced in Norway. This may represent an unnecessary link in the alarm chain, which could cause delays in HEMS dispatch. Systematic evaluations of this intervention are lacking. We wanted to conduct this study to assess possible changes in HEMS response times, mission distribution patterns and patient characteristics within our region following this intervention. METHODS: We retrospectively collected timeline parameters, patient characteristics and GPS positions from HEMS missions executed by three regional HEMS bases in Mid-Norway during 2017-2018 (preintervention) and 2019 (postintervention). The mean regional response time in HEMS missions was assessed by an interrupted time series analysis (ITS). The geographical mission distribution between regional HEMS resources was assessed by a before-after study with a convex hull-based method. RESULTS: There was no significant change in the level (-0.13 min/month, p = 0.88) or slope (-0.13 min/month, p = 0.30) of the mean regional response time trend line pre- and postintervention. For one HEMS base, the service area was increased, and the median mission distance was significantly longer. For the two other bases, the service areas were reduced. Both the mean NACA score (4.13 ± SD 0.027 vs 3.98 ± SD 0.04, p < 0.01) and the proportion of patients with severe illness or injury (NACA 4-7, 68.2% vs 61.5%, p < 0.001) were higher in the postintervention group. CONCLUSION: The introduction of a regional HEMS coordinator in Mid-Norway did not cause prolonged response times in acute HEMS missions during the first year after implementation. Higher NACA scores in the patients treated postintervention suggest better selection of HEMS use.

Posttraumatic Stress Responses and Psychological Well-being in Norwegian Medical Helicopter Personnel.

OBJECTIVE: Emergency medical personnel are exposed to multiple stressors, including those of psychological etiologies. The aim of this study was to report the prevalence of anxiety, depression, and posttraumatic stress symptoms in Norwegian medical helicopter personnel and to determine to what degree they report personal growth or deprecation due to exposure to work-related events. METHODS: This was a web-based, cross-sectional survey performed among rescue paramedics and physicians staffing helicopter emergency medical services and search and rescue helicopters between May 5, 2021, and July 5, 2021. Questions included demographic data, the traumatic events exposure index, the Generalized Anxiety Disorder 7 scale, the Patient Health Questionnaire 9 (Depression), the posttraumatic change scale, and the posttraumatic symptom scale. RESULTS: Of the 245 eligible participants, 10 declined to take part and 74 failed to answer, producing a response rate of 66% (72 rescue paramedics and 89 physicians). Of the study population, 3.9 % reported manifest posttraumatic stress disorder symptoms, and 1.9% described moderate to severe depression and anxiety. The majority (76%) described posttraumatic emotional growth because of their work experience. CONCLUSION: Despite exposure to several traumatic stressors, participants reported a lower prevalence of posttraumatic stress symptoms, depression, and anxiety compared with a Norwegian adult population.

The effect of the new rescue helicopters on the rescue service's mission profile. / Nytt redningshelikopters innvirkning på redningstjenestens oppdragsprofil.

BACKGROUND: The change of rescue helicopter type from the Sea King to the SAR Queen has been controversial. Some hospitals can no longer receive rescue helicopters because of the stronger rotor downwash from the SAR Queen. For the same reason, it has been unclear whether the SAR Queen would be able to land near patients for air ambulance missions. The objective of the study was to investigate whether the change of helicopter type has changed the rescue service's mission profile. MATERIAL AND METHOD: Mission data from the first eight months with the SAR Queen at Ørland Air Base (14 May 2021-14 January 2022) were compared with the last equivalent period with the Sea King (14 May 2020-14 January 2021). RESULTS: The number of requests increased from 249 to 349 (40 %) after the introduction of the new rescue helicopter. Response time increased from 11 to 13 minutes (18 %), while the on-scene time remained unchanged at 10 minutes for primary missions and search and rescue missions. The patients' average degree of severity, assessed by NACA scores, remained unchanged at 3.7. The proportion of missions where hoisting of a rescue paramedic or a doctor was required to gain access to the patient remained unchanged. INTERPRETATION: The study showed that the use of the rescue helicopter at Ørland Air Base increased after the phasing-in of the SAR Queen. The service's mission profile remained the same. The unchanged proportion of missions that involved hoisting indicates that suitable landing sites close to the patients were found to the same extent as with the Sea King.

Developing Quality Indicators for Helicopter Emergency Medical Services Coordination in Norwegian Emergency Medical Communication Centrals: A Consensus Process.

OBJECTIVE: Efforts to optimize the use, availability, and safety of helicopter emergency medical services (HEMS) is important. A lack of consistent and comprehensive flight dispatch procedures and a lack of use of safety technology are recurring safety problems. Reports after several major incidents pointed toward a possible gain by coordinating Norwegian HEMS from regional emergency medical communication centrals. Our objective was to develop and implement relevant quality indicators before such implementation in central Norway. METHODS: We recruited an expert panel of 24 persons representing Norwegian health authorities, emergency medical communication centrals, and HEMS bases and performed a 3-step e-mail-based Delphi process to develop relevant quality indicators. Each indicator was assessed according to their feasibility, rankability, actionability, and variability. To reach a consensus, a median score of 5 or more on a 6-point Likert scale in step 3 was needed. RESULTS: A total of 61 quality indicators were proposed. Of the 14 indicators that reached a consensus, 12 of these were considered process indicators, and 2 were bordering to outcome indicators. CONCLUSION: We applied a Delphi process method to develop quality indicators for HEMS coordination and flight following. An experienced and heterogeneous expert panel suggested and reached a consensus on which quality indicators should be applied.

Prehospital Stressors: A Cross-sectional Study of Norwegian Helicopter Emergency Medical Physicians.

OBJECTIVE: Personnel working in helicopter emergency medical services (HEMS) and search and rescue (SAR) are exposed to environmental stressors, which may impair performance. The aim of this survey was to study the extent HEMS and SAR physicians report the influence of specific danger-based and non-danger-based stressors. METHODS: The study was performed as a cross-sectional, anonymous, Web-based (Questback AS, Bogstadveien 54, 0366 Oslo, Norway) survey of Norwegian HEMS and SAR physicians between December 2, 2019, and February 25, 2020. RESULTS: Of the recipients, 119 (79.3%) responded. In helicopter operations, 33.6% (n = 40) reported involvement in a minor accident and 44.5% (n = 53) a near accident. In the rapid response car, 26.1% (n = 31) reported near accidents, whereas 26.9% (32) reported this in an ambulance. Of physicians, 20.2% (n = 24) received verbal abuse or threats during the last 12 months. When on call, 50.4% (n = 60) of physicians reported sometimes or often being influenced by fatigue. CONCLUSION: This study shows that Norwegian HEMS and SAR physicians are exposed to several stressors of both a danger-based and non-danger-based nature, especially regarding accidents, threatening patient behavior, and fatigue. Very serious incidents appear to be seldom, and job satisfaction is high.

Quality measurement in physician-staffed emergency medical services: a systematic literature review.

PURPOSE: Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS. DATA SOURCES: The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus. STUDY SELECTION: The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool. DATA EXTRACTION: The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well. RESULTS OF DATA SYNTHESIS: In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were 'Adherence to medical protocols', 'Provision of advanced interventions', 'Response time' and 'Adverse events'. CONCLUSION: The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement.

Search and Rescue and Remote Medical Evacuation in a Norwegian Setting: Comparison of Two Systems.

INTRODUCTION: Helicopter emergency medical services (HEMS) contribute to and complement other specialized search and rescue (SAR) services. Conversely, traditional SAR services perform medical evacuation (medevac), depending on crew, training, medical equipment, and procedures for interdisciplinary cooperation. We aim to describe and compare SAR and remote medevac mission characteristics in a military SAR helicopter system to a civilian HEMS operating in the same region. METHODS: Retrospective, observational study of SAR and remote medevac missions performed at a Norwegian military SAR helicopter and civilian HEMS base in the 5-y period from January 1, 2013 to December 31, 2017. Descriptive statistics and median values with interquartile range (IQR) were applied where appropriate. Comparisons were performed with the Mann-Whitney U test. RESULTS: We included 721 missions. The SAR service performed 359 (50%) missions, of which 237 (33%) were SAR and 122 (17%) were remote medevac missions. The HEMS service performed 85 (12%) SAR and 277 (38%) remote medevac missions. Median mission time for SAR missions was 152 (IQR 100-235) min for the SAR service and 57 (IQR 34-89) min for the HEMS service. Trauma was the dominating mechanism in 48% of patients, followed by medical conditions (21%) and psychiatric disorders (9%). Medevac patients in both services had a higher median National Advisory Committee for Aeronautics score of 3 (IQR 2-4) compared to 1 (IQR 0-3) in SAR missions (P<0.05). CONCLUSIONS: Both SAR and HEMS services perform SAR and remote medevac missions extensively and mission profiles vary.

Static Rope Evacuation by Helicopter Emergency Medical Services in Rescue Operations in Southeast Norway.

INTRODUCTION: Physician-staffed helicopter emergency medical services (HEMS) in Norway are an adjunct to existing search and rescue services. Our aims were to study the epidemiological, operational, and medical aspects of HEMS daylight static rope operations performed in the southeastern part of the country and to examine several quality dimensions that are characteristic of this service. METHODS: We reviewed the static rope operations performed at 3 HEMS bases during a 3-y period and applied a set of quality indicators designed for physician-staffed emergency medical services to evaluate the quality of care. Data are presented as medians with quartiles, except National Advisory Committee for Aeronautics (NACA) scores, which are presented as mean (SD). RESULTS: Fifty-nine static rope operations were identified, involving 60 patients. Median (quartiles) age was 43 (27-55) y. Median (quartiles) take-off time was 9 (5-13) min. Trauma-related injuries were found in 48 patients. The main conditions were lower limb injuries, found in 32 patients. Ten patients experienced medical conditions. Mean (SD) NACA score was 3.3 (1.3). A potential or actual life-threatening diagnosis (NACA score: 4-6) was reported among 15 patients. The main interventions were intravenous lines (19 patients), analgesics (17), and oxygen treatment (14). Four patients were intubated, and 1 thoracostomy was performed. CONCLUSIONS: Static rope operations are rarely performed. The quality indicators suggest that the service is safe, available, and equitable. Its main benefit seems to be evacuation and the maintenance of readiness before rapid transport of the physician to the scene or the patient to the hospital.

Mortality rates in Norwegian HEMS-a retrospective analysis from Central Norway.

BACKGROUND: Helicopter Emergency Medical Services (HEMS) provide rapid and specialized care to critically ill or injured patients. Norwegian HEMS in Central Norway serves an important role in pre-hospital emergency medical care. To grade the severity of patients, HEMS uses the National Advisory Committee for Aeronautics' (NACA) severity score. The objective of this study was to describe the short- and long term mortality overall and in each NACA-group for patients transported by HEMS Trondheim using linkage of HEMS and hospital data. METHODS: The study used a retrospective cohort design, aligning with the STROBE recommendations. Patient data from Trondheim HEMS between 01.01.2017 and 31.12.2019 was linked to mortality data from a hospital database and analyzed. Kaplan Meier plots and cumulative mortality rates were calculated for each NACA group at day one, day 30, and one year and three years after the incident. RESULTS: Trondheim HEMS responded to 2224 alarms in the included time period, with 1431 patients meeting inclusion criteria for the study. Overall mortality rates at respective time points were 10.1% at day one, 13.4% at 30 days, 18.5% at one year, and 22.3% at three years. The one-year cumulative mortality rates for each NACA group were as follows: 0% for NACA 1 and 2, 2.9% for NACA 3, 10.1% for NACA 4, 24.7% for NACA 5 and 49.5% for NACA 6. Statistical analysis with a global log-rank test indicated a significant difference in survival outcomes among the groups (p < 2⋅10- 16). CONCLUSION: Among patients transported by Trondheim HEMS, we observed an incremental rise in mortality rates with increasing NACA scores. The study further suggests that a one-year follow-up may be sufficient for future investigations into HEMS outcomes.

Using machine learning to assess the extent of busy ambulances and its impact on ambulance response times: A retrospective observational study.

BACKGROUND: Ambulance response times are considered important. Busy ambulances are common, but little is known about their effect on response times. OBJECTIVE: To assess the extent of busy ambulances in Central Norway and their impact on ambulance response times. DESIGN: This was a retrospective observational study. We used machine learning on data from nearby incidents to assess the probability of up to five different ambulances being candidates to respond to a medical emergency incident. For each incident, the probability of a busy ambulance was estimated by summing the probabilities of candidate ambulances being busy at the time of the incident. The difference in response time that may be attributable to busy ambulances was estimated by comparing groups of nearby incidents with different estimated busy probabilities. SETTING: Medical emergency incidents with ambulance response in Central Norway from 2013 to 2022. MAIN OUTCOME MEASURES: Prevalence of busy ambulances and differences in response times associated with busy ambulances. RESULTS: The estimated probability of busy ambulances for all 216,787 acute incidents with ambulance response was 26.7% (95% confidence interval (CI) 26.6 to 26.9). Comparing nearby incidents, each 10-percentage point increase in the probability of a busy ambulance was associated with a delay of 0.60 minutes (95% CI 0.58 to 0.62). For incidents in rural and urban areas, the probability of a busy ambulance was 21.6% (95% CI 21.5 to 21.8) and 35.0% (95% CI 34.8 to 35.2), respectively. The delay associated with a 10-percentage point increase in busy probability was 0.81 minutes (95% CI 0.78 to 0.84) and 0.30 minutes (95% CI 0.28 to 0.32), respectively. CONCLUSION: Ambulances were often busy, which was associated with delayed ambulance response times. In rural areas, the probability of busy ambulances was lower, although the potentially longer delays when ambulances were busy made these areas more vulnerable.

Resuscitative endovascular balloon occlusion of the aorta in out-of-hospital cardiac arrest - A Delphi consensus study for uniform data collection.

Background: Evolving research on resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct treatment for out-of-hospital cardiac arrest mandates uniform recording and reporting of data. A consensus on which variables need to be collected may enable comparing and merging data from different studies. We aimed to establish a standard set of variables to be collected and reported in future REBOA studies in out-of-hospital cardiac arrest. Methods: A four-round stepwise Delphi consensus process first asked experts to propose without restraint variables for future REBOA research in out-of-hospital cardiac arrest. The experts then reviewed the variables on a 5-point Likert scale and ≥75% agreement was defined as consensus. First authors of published papers on REBOA in out-of-hospital cardiac arrest over the last five years were invited to join the expert panel. Results: The data were collected between May 2022 and December 2022. A total of 28 experts out of 34 primarily invited completed the Delphi process, which developed a set of 31 variables that might be considered as a supplement to the Utstein style reporting of research in out-of-hospital cardiac arrest. Conclusions: This Delphi consensus process suggested 31 variables that enable future uniform reporting of REBOA in out-of-hospital cardiac arrest.

Can video communication in the emergency medical communication centre improve dispatch precision? A before-after study in Norwegian helicopter emergency medical services.

OBJECTIVES: Dispatching helicopter emergency medical services (HEMS) to the patients with the greatest medical or logistical benefit remains challenging. The introduction of video calls (VC) in the emergency medical communication centres (EMCC) could provide additional information for EMCC operators and HEMS physicians when assessing the need for HEMS dispatch. The aim of this study was to evaluate the impact from VC in the EMCC on HEMS dispatch precision. DESIGN: An observational before-after study. SETTING: The regional EMCC and one HEMS base in Mid-Norway. PARTICIPANTS: EMCC operators and HEMS physicians at the EMCC and HEMS base in Trondheim, Norway. INTERVENTION: In January 2022, VC became available in emergency calls in Trondheim EMCC. Data were collected from 2020 2021 (pre-intervention) and 2022 (post-intervention). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the proportion of seriously ill or injured HEMS patients, defined as a National Advisory Committee for Aeronautics (NACA) score between 4 and 7. The secondary outcome was the proportion of inappropriate dispatches, defined as missions with neither provision of additional competence nor any logistical contribution based on quality indicators for physician-staffed emergency medical services. RESULTS: 811 and 402 HEMS missions with patient contact were included in the pre- and post-intervention group, respectively. The proportion of missions with NACA 4-7 was not significantly changed after the intervention (OR 1.21, 95% CI 0.92 to 1.61, p=0.17). There was no significant change in HEMS alarm times between the pre- and post-intervention groups (7.6 min vs 6.4 min, p=0.15). The proportion of missions with neither medical nor logistical benefit was significantly lower in the post-intervention group (28.4% vs 40.3%, p=0.007). CONCLUSION: The results from this study indicate that VC is a promising, feasible and safe tool for EMCC operators in the complex HEMS dispatch process.

Mortality and quality of care in Nordic physician-staffed emergency medical services.

BACKGROUND: Quality indicators (QI) for physician staffed emergency medical services (P-EMS) are necessary to improve service quality. Mortality can be considered the ultimate outcome QI. The process quality of care in P-EMS can be described by 15 response-specific QIs developed for these services. The most critical patients in P-EMS are presumably found among patients who die within 30 days after the P-EMS response. Securing high quality care for these patients should be a prioritized task in P-EMS quality improvement. Thus, the first aim of this study was to describe the 30-days survival in Nordic P-EMS as an expression of the outcome quality of care. The second aim was to describe the process quality of care as assessed by the 15 QIs, for patients who die within 30 days after the P-EMS response. METHODS: In this prospective observational study, P-EMSs in Finland, Sweden, Denmark, and Norway registered 30-days survival and scored the 15 QIs for their patients. The QI performance for patients who died within 30 days after the P-EMS response was assessed using established benchmarks for the applied QIs. Further, mean QI performance for the 30-days survivors and the 30-days non-survivors were compared using Chi-Square test for categorical variables and Mann-Whitney U test for continuous variables. RESULTS: We recorded 2808 responses in the study period. 30-days survival varied significantly between the four participating countries; from 89.0 to 76.1%. When assessing the quality of care for patients who die within 30 days after the P-EMS response, five out of 15 QIs met the established benchmarks. For nine out of 15 QIs, there was significant difference in mean scores between the 30 days survivors and non-survivors. CONCLUSION: In this study we have described 30-days survival as an outcome QI for P-EMS, and found significant differences between four Nordic countries. For patients who died within 30 days, the majority of the 15 QIs developed for P-EMS did not meet the benchmarks, indicating room for quality improvement. Finally, we found significant differences in QI performance between 30-days survivors and 30-days non-survivors which also might represent quality improvement opportunities.

Testing quality indicators and proposing benchmarks for physician-staffed emergency medical services: a prospective Nordic multicentre study.

OBJECTIVES: A consensus study from 2017 developed 15 response-specific quality indicators (QIs) for physician-staffed emergency medical services (P-EMS). The aim of this study was to test these QIs for important characteristics in a real clinical setting. These characteristics were feasibility, rankability, variability, actionability and documentation. We further aimed to propose benchmarks for future quality measurements in P-EMS. DESIGN: In this prospective observational study, physician-staffed helicopter emergency services registered data for the 15 QIs. The feasibility of the QIs was assessed based on the comments of the recording physicians. The other four QI characteristics were assessed by the authors. Benchmarks were proposed based on the quartiles in the dataset. SETTING: Nordic physician-staffed helicopter emergency medical services. PARTICIPANTS: 16 physician-staffed helicopter emergency services in Finland, Sweden, Denmark and Norway. RESULTS: The dataset consists of 5638 requests to the participating P-EMSs. There were 2814 requests resulting in completed responses with patient contact. All QIs were feasible to obtain. The variability of 14 out of 15 QIs was adequate. Rankability was adequate for all QIs. Actionability was assessed as being adequate for 10 QIs. Documentation was adequate for 14 QIs. Benchmarks for all QIs were proposed. CONCLUSIONS: All 15 QIs seem possible to use in everyday quality measurement and improvement. However, it seems reasonable to not analyse the QI 'Adverse Events' with a strictly quantitative approach because of a low rate of adverse events. Rather, this QI should be used to identify adverse events so that they can be analysed as sentinel events. The actionability of the QIs 'Able to respond immediately when alarmed', 'Time to arrival of P-EMS', 'Time to preferred destination', 'Provision of advanced treatment' and 'Significant logistical contribution' was assessed as being poor. Benchmarks for the QIs and a total quality score are proposed for future quality measurements.

Developing quality indicators for physician-staffed emergency medical services: a consensus process.

BACKGROUND: There is increasing interest for quality measurement in health care services; pre-hospital emergency medical services (EMS) included. However, attempts of measuring the quality of physician-staffed EMS (P-EMS) are scarce. The aim of this study was to develop a set of quality indicators for international P-EMS to allow quality improvement initiatives. METHODS: A four-step modified nominal group technique process (expert panel method) was used. RESULTS: The expert panel reached consensus on 26 quality indicators for P-EMS. Fifteen quality indicators measure quality of P-EMS responses (response-specific quality indicators), whereas eleven quality indicators measure quality of P-EMS system structures (system-specific quality indicators). DISCUSSION: When measuring quality, the six quality dimensions defined by The Institute of Medicine should be appraised. We argue that this multidimensional approach to quality measurement seems particularly reasonable for services with a highly heterogenic patient population and complex operational contexts, like P-EMS. The quality indicators in this study were developed to represent a broad and comprehensive approach to quality measurement of P-EMS. CONCLUSIONS: The expert panel successfully developed a set of quality indicators for international P-EMS. The quality indicators should be prospectively tested for feasibility, validity and reliability in clinical datasets. The quality indicators should then allow for adjusted quality measurement across different P-EMS systems.