Cost-effectiveness and quality-of-life analysis of physician-staffed helicopter emergency medical services.

BACKGROUND: The long-term health outcomes and costs of helicopter emergency medical services (HEMS) assistance remain uncertain. The aim of this study was to investigate the cost-effectiveness of HEMS assistance compared with emergency medical services (EMS). METHODS: A prospective cohort study was performed at a level I trauma centre. Quality-of-life measurements were obtained at 2 years after trauma, using the EuroQol-Five Dimensions (EQ-5D) as generic measure to determine health status. Health outcomes and costs were combined into costs per quality-adjusted life year (QALY). RESULTS: The study population receiving HEMS assistance was more severely injured than that receiving EMS assistance only. Over the 4-year study interval, HEMS assistance saved a total of 29 additional lives. No statistically significant differences in quality of life were found between assistance with HEMS or with EMS. Two years after trauma the mean EQ-5D utility score was 0.70 versus 0.71 respectively. The incremental cost-effectiveness ratio for HEMS versus EMS was 28,327 Euro per QALY. The sensitivity analysis showed a cost-effectiveness ratio between 16,000 and 62,000 Euro. CONCLUSION: In the Netherlands, the costs of HEMS assistance per QALY remain below the acceptance threshold. HEMS should therefore be considered as cost effective.

Prehospital interventions: time wasted or time saved? An observational cohort study of management in initial trauma care.

OBJECTIVE: Preclinical actions in the primary assessment of victims of blunt trauma may prolong the time to definitive clinical care. The aim of this study was to examine the duration of performed interventions and to study the effect of on-scene time (OST) and interventions performed before admission to hospital on hospital resuscitation time. METHODS: 147 consecutive patients with high-energy blunt trauma aged >/=15 years were studied prospectively. Prehospital time intervals and interventions were documented and compared with hospital data collected from continuous digital video registration. Analyses were performed with correction for injury severity and type of prehospital medical assistance (emergency medical services (EMS) versus physician-staffed helicopter emergency medical services (HEMS)). RESULTS: Primary survey and initial treatment were initiated and completed within 1 h of arrival of the EMS. 83% of this "golden hour" elapsed out of hospital and 81% (n = 224) of all interventions (n = 275) were carried out before admission to hospital. An increase in the number of prehospital interventions was associated with an increased OST (p<0.001). Subanalyses showed no such correlation in the HEMS group. The HEMS group had a longer mean OST than the EMS group (p<0.001) with relatively more prehospital interventions (p<0.001) and a shorter mean in-hospital primary survey time with fewer in-hospital interventions. Overall, OST and the number of prehospital interventions were not related to in-hospital primary survey time and interventions. CONCLUSION: For most trauma patients the initial life- and limb-saving care is achieved within the "golden hour". Prehospital treatment occupies most of the golden hour. More prehospital interventions were performed with HEMS than with EMS only, but the higher number of interventions did not result in a longer OST with HEMS. Although the numbers of subsequent in-hospital interventions may be lower, no reduction in time in hospital may be expected from the interventions performed before hospital admission.

Prehospital chest tube thoracostomy: effective treatment or additional trauma?

BACKGROUND: The use of prehospital chest tube thoracostomy (TT) remains controversial because of presumed increased complication risks. This study analyzed infectious complication rates for physician-performed prehospital and emergency department (ED) TT. METHODS: Over a 40-month period, all consecutive trauma patients with TT performed by the flight physician at the accident scene were compared with all patients with TT performed in the emergency department. Bacterial cultures, blood samples, and thoracic radiographs were reviewed for TT-related infections. RESULTS: Twenty-two patients received prehospital TTs and 101 patients received ED TTs. Infected hemithoraces related to TTs were found in 9% of those performed in the prehospital setting and 12% of ED-performed TTs (not significant). CONCLUSION: The prehospital chest tube thoracostomy is a safe and lifesaving intervention, providing added value to prehospital trauma care when performed by a qualified physician. The infection rate for prehospital TT does not differ from ED TT.

Beneficial effect of helicopter emergency medical services on survival of severely injured patients.

BACKGROUND: In Rotterdam, the Netherlands, a helicopter-transported medical team (HMT), staffed with a trauma physician, provides additional therapeutic options at the scene of injury. This study evaluated the influence of the HMT on the chance of survival of severely injured trauma victims. METHODS: This was a 2-year prospective observational study of consecutive adults who suffered multiple trauma (Injury Severity Score (ISS) 16 or more) and presented to the Erasmus Medical Centre emergency ward. The effect of the HMT was quantified by an odds ratio (OR), adjusted for confounding variables in logistic regression models. RESULTS: Complete data for a total of 346 patients were available for analysis. Two hundred and thirty-nine patients were treated by ambulance personnel alone and 107 received additional HMT assistance. Patients in the HMT group had significantly lower Glasgow Coma Scale scores (mean 8.9 versus 10.6; P = 0.001) and a higher ISS (mean 30.9 versus 25.3; P < 0.001). The unadjusted OR for death was 1.7 in favour of the group treated by ambulance staff only (OR for survival 0.61 (95 per cent confidence interval (c.i.) 0.37 to 1.0, P = 0.048)). After adjustment, however, patients in the HMT group had an approximately twofold better chance of survival (all injuries: OR 2.2 (95 per cent c.i. 0.92 to 5.9), P = 0.076; blunt injuries: OR 2.8 (95 per cent c.i. 1.07 to 7.52), P = 0.036). CONCLUSION: The presence of the HMT may increase chances of survival for patients suffering multiple trauma, especially for those with blunt trauma.