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.

Amplitude-Integrated EEG in Infants at Risk of Hypoxic-Ischemic Encephalopathy: A Feasibility Study in Road and Air Transport in Western Australia.

Infants at risk of HIE require early identification and initiation of therapeutic hypothermia (TH). Earlier treatment with TH is associated with better outcomes. aEEG is frequently used when making the decision whether to commence TH. As this is often limited to tertiary centers, TH may be delayed if the infant requires transport to a center that provides it. We aimed to provide a method for the application of amplitude-integrated electroencephalogram (aEEG) and to determine the feasibility of acquiring clinically meaningful information during transport. All infants ≥35 weeks, at risk of HIE at referral, were eligible for inclusion. Scalp electrodes were placed in the C3-C4; P3-P4 position on the infant's scalp and connected to the aEEG amplifier. The aEEG amplifier was, in turn, connected to a clinical tablet computer with EEG software to collect and analyze aEEG information. Recordings were reviewed by the chief principal investigator and two independent reviewers (blinded) for background trace and artifact. Predefined criteria for data quality were set to movement artifacts and software impedance notifications. Surveys were completed by healthcare staff and parents for acceptability and ease of use.

Parallel activation of helicopter and ground transportation after dispatcher identification of suspected anterior large vessel occlusion stroke in rural areas: a proof-of-concept case with modeling from the LESTOR trial.

BACKGROUND: When stroke patients with suspected anterior large vessel occlusion (aLVO) happen to live in rural areas, two main options exist for prehospital transport: (i) the drip-and-ship (DnS) strategy, which ensures rapid access to intravenous thrombolysis (IVT) at the nearest primary stroke center but requires time-consuming interhospital transfer for endovascular thrombectomy (EVT) because the latter is only available at comprehensive stroke centers (CSC); and (ii) the mothership (MS) strategy, which entails direct transport to a CSC and allows for faster access to EVT but carries the risk of IVT being delayed or even the time window being missed completely. The use of a helicopter might shorten the transport time to the CSC in rural areas. However, if the aLVO stroke is only recognized by the emergency service on site, the helicopter must be requested in addition, which extends the prehospital time and partially negates the time advantage. We hypothesized that parallel activation of ground and helicopter transportation in case of aLVO suspicion by the dispatcher (aLVO-guided dispatch strategy) could shorten the prehospital time in rural areas and enable faster treatment with IVT and EVT. METHODS: As a proof-of-concept, we report a case from the LESTOR trial where the dispatcher suspected an aLVO stroke during the emergency call and dispatched EMS and HEMS in parallel. Based on this case, we compare the provided aLVO-guided dispatch strategy to the DnS and MS strategies regarding the times to IVT and EVT using a highly realistic modeling approach. RESULTS: With the aLVO-guided dispatch strategy, the patient received IVT and EVT faster than with the DnS or MS strategies. IVT was administered 6 min faster than in the DnS strategy and 22 min faster than in the MS strategy, and EVT was started 47 min earlier than in the DnS strategy and 22 min earlier than in the MS strategy. CONCLUSION: In rural areas, parallel activation of ground and helicopter emergency services following dispatcher identification of stroke patients with suspected aLVO could provide rapid access to both IVT and EVT, thereby overcoming the limitations of the DnS and MS strategies.

Implementation of a point-of-care ultrasound archiving system and governance framework in a UK physician-paramedic staffed helicopter emergency medical service.

INTRODUCTION: There has been a rapid expansion in the use of point-of-care ultrasonography (POCUS) by emergency medical services (EMS). However, less than a third of UK EMS utilise imaging archiving for POCUS, and fewer review saved images as part of a clinical governance structure. This paper describes the implementation of a novel image archiving system and a robust clinical governance framework in our UK physician-paramedic staffed helicopter emergency medical service (HEMS). METHODS: A retrospective database review was conducted of all patients attended by East Anglian Air Ambulance (EAAA) between the introduction of a new POCUS device and image archiving system on 1 December 2020 to 31 January 2024. All patients with recorded POCUS examinations were included. Images from POCUS examinations at EAAA are archived on a cloud-based server, and retrospectively reviewed within 24 h by an EAAA POCUS supervisor. Image quality is graded using a 5-point Likert-type scale, agreement between reviewer and clinician is recorded and feedback is provided on scanning technique. T-tests were used to assess the difference in image quality between physicians and paramedics. Inter-rater reliability between reviewers and clinicians was assessed using Cohen's kappa (κ). RESULTS: During the study period, 5913 patients were attended by EAAA. Of these, 1097 patients had POCUS images recorded. The prevalence of POCUS during the study period was 18.6%. 1061 patient examinations underwent quality assurance (96.7%). The most common POCUS examination was echocardiography (60%), predominantly during cardiac arrest. The primary scanning clinician was a paramedic in 25.4% of POCUS examinations. Across all examination types; image quality was not significantly different between physicians and paramedics and agreement between reviewers and clinicians was strong (κ > 0.85). CONCLUSIONS: In this service evaluation study, we have described outcomes following the introduction of a new POCUS device, image archiving system and governance framework in our HEMS. Paramedics were the primary scanning clinician in a quarter of scans, with image quality comparable to physicians. Almost all scans underwent quality assurance and inter-rater reliability was strong between clinicians and reviewers. Further research is required to investigate the diagnostic accuracy of POCUS and to demonstrate the effect of utilising prehospital POCUS to refine diagnosis on clinical outcomes.

Safety and Risk in Airway Management During Bariatric Air Medical Retrieval.

OBJECTIVE: Bariatric anatomy and physiology present added clinical challenges to the provision of safe critical care and patient transport. LifeFlight Retrieval Medicine provides air medical retrieval services in Queensland, Australia, and performs over 6,000 retrieval missions annually using rotary wing, fixed wing, and ground ambulance platforms. METHODS: Bariatric patient retrievals were identified from the LifeFlight Retrieval Medicine electronic patient database. These cases were interrogated to quantify and describe adverse events during patient transport. RESULTS: Over the study period from July 2019 to December 2021 11,096 patient retrievals were completed. Of these patients, 816 (7.3%) had a body weight ≥ 120 kg (range, 120-246 kg; median = 146 kg). Bariatric patients were more likely to be male (70%) and to require critical care interventions than nonbariatric patients (25.9% vs. 19.9%). There was an absolute 1.5% increase of high-interest events during patient retrieval, corresponding to a 1.9-fold increased relative risk. Five hundred eleven of 11,096 patients were intubated by the retrieval team, and 61 of these weighed ≥ 120 kg. Bariatric patients undergoing intubation were of similar age and sex, weighed significantly more, had nonsignificant trends toward poorer airway visualization by Cormack-Lehane laryngoscopic grade, and tended toward reduced first-attempt success compared with nonbariatric patients. Rates of airway adverse events (AAEs) were significantly increased for the bariatric group (30/61, 49.2%) compared with the nonbariatric group (135/450, 30.0%) (χ2 likelihood ratio, P = .004). Postintubation desaturation was the most common AAE and was the only criterion significantly increased when comparing bariatric (26%) versus nonbariatric (12%) patients (χ2 likelihood ratio, P = .005). Using patient weight as a continuous variable, nominal logistic regression revealed a significant effect of increasing weight on AAEs (χ2 = 12.9, P = .0003) with a threshold of 105 kg providing an optimal 88% sensitivity for predicting AAEs. The odds of AAEs were increased significantly for those weighing 105 to 119 kg versus those weighing < 105 kg (odds ratio [OR] = 3.4; 95% confidence interval [CI], 1.6-7.5) and for those weighing ≥ 120 kg versus those weighing < 105 kg (OR = 2.5; 95% CI, 1.4-4.3). There was no difference between those weighing ≥ 120 kg versus those weighing 105 to 119 kg (OR = 0.73; 95% CI, 0.3-1.8). CONCLUSION: Air medical retrieval of bariatric patients is safe despite an increased risk of adverse events. Strategies to optimize emergency anesthesia should be used to maximize safe intubation in bariatric patients.

Prehospital Care of Severely Intoxicated Patients by a Dutch Physician-Staffed Helicopter Emergency Medical Services: A Retrospective Study.

OBJECTIVE: Intoxicated patients are often encountered by emergency medical services (eg, in cases of recreational drug use, accidental ingestion, or inhalation of toxic substances or [attempted] suicide). Earlier research showed that a physician-staffed helicopter emergency medical service (P-HEMS) is regularly dispatched for intoxicated patients. However, it is still unclear if there is added value of P-HEMS compared with standard care provided by an ambulance crew. The aim of this study was to analyze the contribution of additional expertise and equipment that P-HEMS brings to the prehospital scene. METHODS: In this retrospective study, we searched the database of the helicopter emergency medical service Lifeliner 1 serving the northwestern quadrant of the Netherlands for cases that involved intoxications from January 2013 to July 2020. Patients were included in this study if the primary reason for P-HEMS dispatch was intoxication. The types of intoxication were categorized as (illicit/recreational) drug related, suicide attempt, or accidental. The agents were categorized as stimulants, depressants, hallucinogenic, cannabinoids, and other substances such as bleach or insulin. Patient characteristics, vital signs, and the therapeutic interventions performed were recorded for analysis. RESULTS: In our study period, P-HEMS was dispatched 23,878 times. Of these dispatches, a total of 259 cases were included for further analysis. The majority of patients were male (64.5%). Sixty-six patients (25.5%) had an intoxication of depressant agents alone, whereas 60 patients (23.2%) had an intoxication with a combination of agents. With 159 (61.4%) patients, the majority of cases involved recreational drug intoxications. Unintentional intoxications were treated in 27 (10.4%) patients, whereas 73 (28.2%) cases involved suicide attempts. In 159 patients (61.4%), prehospital endotracheal intubation was required; the vast majority was performed by the helicopter emergency medical service physician. Specific antidotes were administered in 56 (21.6%) of the cases. CONCLUSION: In this study, we found that P-HEMS crews might complement usual prehospital care by ambulance crews for patients with severe intoxications by bringing advanced skills (eg, airway management and specific antidotes) to the scene.

Air or Ground Transport to the Critical Care Resuscitation Unit: Does It Really Matter?

OBJECTIVE: Critically ill patients requiring urgent interventions or subspecialty care often require transport over significant distances to tertiary care centers. The optimal method of transportation (air vs. ground) is unknown. We investigated whether air transport was associated with lower mortality for patients being transferred to a specialized critical care resuscitation unit (CCRU). METHODS: This was a retrospective study of all adult patients transferred to the CCRU at the University of Maryland Medical Center in 2018. Our primary outcome was hospital mortality. The secondary outcomes included the length of stay and the time to the operating room (OR) for patients undergoing urgent procedures. We performed optimal 1:2 propensity score matching for each patient's need for air transport. RESULTS: We matched 198 patients transported by air to 382 patients transported by ground. There was no significant difference between demographics, the initial Sequential Organ Failure Assessment score, or hospital outcomes between groups. One hundred sixty-four (83%) of the patients transported via air survived to hospital discharge compared with 307 (80%) of those transported by ground (P = .46). Patients transported via air arrived at the CCRU more quickly (127 [100-178] vs. 223 [144-332] minutes, P < .001) and were more likely (60 patients, 30%) to undergo urgent surgical operation within 12 hours of CCRU arrival (30% vs. 17%, P < .001). For patients taken to the OR within 12 hours of arriving at the CCRU, patients transported by air were more likely to go to the OR after 200 minutes since the transfer request (P = .001). CONCLUSION: The transportation mode used to facilitate interfacility transfer was not significantly associated with hospital mortality or the length of stay for critically ill patients.

Management Considerations for Air Medical Transport Programs Transfusing RhD-Positive Red Blood Cell-Containing Products to Females of Childbearing Potential.

Recent years have seen increased discussion surrounding the benefits of damage control resuscitation, prehospital transfusion (PHT) of blood products, and the use of whole blood over component therapy. Concurrent shortages of blood products with the desire to provide PHT during air medical transport have prompted reconsideration of the traditional approach of administering RhD-negative red cell-containing blood products first-line to females of childbearing potential (FCPs). Given that only 7% of the US population has blood type O negative and 38% has O positive, some programs may be limited to offering RhD-positive blood products to FCPs. Adopting the practice of giving RhD-positive blood products first-line to FCPs extends the benefits of PHT to such patients, but this practice does incur the risk of future hemolytic disease of the fetus and newborn (HDFN). Although the risk of future fetal mortality after an RhD-incompatible transfusion is estimated to be low in the setting of acute hemorrhage, the number of FCPs who are affected by this disease will increase as more air medical transport programs adopt this practice. The process of monitoring and managing HDFN can also be time intensive and costly regardless of the rates of fetal mortality. Air medical transport programs planning on performing PHT of RhD-positive red cell-containing products to FCPs should have a basic understanding of the pathophysiology, prevention, and management of hemolytic disease of the newborn before introducing this practice. Programs should additionally ensure there is a reliable process to notify receiving centers of potentially RhD-incompatible PHT because alloimmunization prophylaxis is time sensitive. Facilities receiving patients who have had PHT must be prepared to identify, counsel, and offer alloimmunization prophylaxis to these patients. This review aims to provide air medical transport professionals with an understanding of the pathophysiology and management of HDFN and provide a template for the early management of FCPs who have received an RhD-positive red cell-containing PHT. This review also covers the initial workup and long-term anticipatory guidance that receiving trauma centers must provide to FCPs who have received RhD-positive red cell-containing PHT.

A Novel Technique for Temporally Securing a Chest Tube in a Resource-Limited Environment.

In the prehospital, transport, and resource-limited setting, patients with traumatic hemothorax, pneumothorax, or cardiac arrest require emergency tube thoracostomy for stabilization and transport. With the possibility of multiple patients, limited providers, and inability to commit a 1:1 provider-to-patient ratio for safe tubeless thoracostomies, a chest tube is often the safest option. Mercy Health Life Flight Air Medical program has developed practice over decades using towel clamps and tape to achieve securement rapidly and reliably. We report on this subject as an option for temporarily securing a chest tube in the disaster, resource-poor, prehospital, or critical care transport setting.

Flight to Recovery: Impact of a Rooftop Helipad Air Ambulance Service at the Emergency University Hospital of Bucharest-A Caseload Analysis of the First 3 Years After Its Implementation.

OBJECTIVE: This observational study provides an overview of the implementation and impact of the helipad at the Bucharest Emergency University Hospital, Romania. The helipad, established in April 2019, is the only rooftop medical helipad in Bucharest authorized for day and night flights. Its influence extends beyond the local region, enabling the hospital to receive patients from various cities across Romania. The helipad has particularly strengthened the hospital's capabilities in cardiology, neurovascular emergencies, and neonatal care. Patients with acute myocardial infarctions or strokes can now be swiftly transported to the hospital for immediate intervention, whereas critically ill newborns can receive specialized care at the earliest stages of their lives. The objective of this article was to present a comprehensive timeline of the helipad's implementation and to demonstrate its transformative role in improving patient transportation, enhancing medical interventions, and elevating the overall efficiency of the health care facility. METHODS: The study is a retrospective regional caseload analysis based on data gathered from the Emergency Department of the University Emergency Hospital of Bucharest database. We included all 215 air transfer missions registered between December 2019 and December 2022, exactly 3 years apart from the beginning of the program. RESULTS: The findings provide valuable insights into patient demographics, case distribution, and trends, highlighting the importance of specialized medical interventions at the University Emergency Hospital of Bucharest. In particular, the mean age of patients treated at the hospital was 55.9 years, with a higher representation of males (156) than females (59). The average duration of hospitalization was 10.68 days. The study also examined transportation statistics, showing a decrease in the average number of transports per month over the years. Cardiologic cases accounted for the highest frequency (62.8%) among the analyzed categories followed by neurosurgery (8.8%) and neurologic cases (8.4%). CONCLUSION: The analysis provides important insights into patient demographics, case distribution, and trends. The findings highlight the significance of specialized medical interventions, particularly in cardiology and neurosurgery, which accounted for the majority of the cases. The implementation of the helipad has greatly improved patient transportation and facilitated timely medical assistance.

REVA Air Ambulance and Seaplane Medevac Operations.

REVA, INC (Air Ambulance) is an Air Ambulance company headquartered in Fort Lauderdale, Florida. The company was formed in 2012 after the merger of two air ambulance companies, Aero Jet International and Air Ambulance Professionals. REVA completes around 1,300 medical transports a year, primarily international. It has always been a goal to provide more support to the Bahamas and hard to reach islands, which led to REVA launching its Seaplane Medevac Operation in December of 2022. The development of this program allows them to have a medical equipped seaplane available 365 days a year to service the Bahamas and hard to reach areas.

Perspectives from military neonatal transport: past, present, and future.

This article traces the historical development of neonatal transport, from ancient Greek mythology to the modern era, with a particular focus on the contributions of U.S. military aviation. The narrative begins with early efforts in thermoregulation through stationary incubators and progresses to the pivotal role of aerial hospitals during World War II. Post-WWII, the establishment of neonatal transport services in New York and advancements in incubator technology set the stage for further innovation. The U.S. military's involvement in neonatal transport, initiated in the 1970s, witnessed significant milestones, including the adaptation of ECMO technology for air transport. The narrative unfolds through the lens of U.S. military neonatology in the Western Pacific, particularly at Clark Air Base. The article concludes with insights into the U.S. Indo-Pacific Command's neonatal transport mission, highlighting challenges faced during the SARS-CoV-2/COVID-19 pandemic and the development of specialized infection containment transport systems.

Attributes of leadership skill development in high-performance pre-hospital medical teams: results of an international multi-service prospective study.

BACKGROUNDS: Team leadership skills of physicians working in high-performing medical teams are directly related to outcome. It is currently unclear how these skills can best be developed. Therefore, in this multi-national cross-sectional prospective study, we explored the development of these skills in relation to physician-, organization- and training characteristics of Helicopter Emergency Medicine Service (HEMS) physicians from services in Europe, the United States of America and Australia. METHODS: Physicians were asked to complete a survey regarding their HEMS service, training, and background as well as a full Leader Behavior Description Questionnaire (LBDQ). Primary outcomes were the 12 leadership subdomain scores as described in the LBDQ. Secondary outcome measures were the association of LBDQ subdomain scores with specific physician-, organization- or training characteristics and self-reported ways to improve leadership skills in HEMS physicians. RESULTS: In total, 120 HEMS physicians completed the questionnaire. Overall, leadership LBDQ subdomain scores were high (10 out of 12 subdomains exceeded 70% of the maximum score). Whereas physician characteristics such as experience or base-specialty were unrelated to leadership qualities, both organization- and training characteristics were important determinants of leadership skill development. Attention to leadership skills during service induction, ongoing leadership training, having standards in place to ensure (regular) scenario training and holding structured mission debriefs each correlated with multiple LBDQ subdomain scores. CONCLUSIONS: Ongoing training of leadership skills should be stimulated and facilitated by organizations as it contributes to higher levels of proficiency, which may translate into a positive effect on patient outcomes. TRIAL REGISTRATION: Not applicable.

Interfacility Ambulance Versus Helicopter Transport of Traumatic Spinal Cord Injury Patients: Outcomes, Observations, and Utilization.

INTRODUCTION: Traumatic spinal cord injury (tSCI) is a devastating event that can cause permanent loss of function or disability. Time to surgical decompression of the spinal cord affects outcomes and is a critical principle in management of tSCI. One of the major determinants of time to decompression is transport time. To date, no study has compared the neurological outcomes of tSCI patients transported via ground/ambulance versus air/helicopter. OBJECTIVE: This retrospective cohort study sought to assess the association of the mode of transport on the neurological outcomes of tSCI patients. METHODS: Data from 46 ground transport and 29 air transport patients with tSCI requiring surgical decompression were collected. Outcomes were assessed by the change in American Spinal Injury Association Impairment Scale (AIS) grade from admission to discharge. Additionally, the utilization of air versus ground transport was assessed based on the distance from the admitting institution. RESULTS: Among the transport groups, there were no significant differences (PP < 0.05) in patient demographics. Helicopter transport patients demonstrated higher rates of AIS grade improvement (P = 0.004), especially among AIS grade A/grade B patients (P = 0.02; P = 0.02, respectively), compared to the ambulance transport group. Additionally, within the cohort of patients undergoing decompression within 0 to 12 hours, helicopter transport was associated with higher AIS grade improvement (P = 0.04) versus the ambulance transport group. Helicopter transport was used more frequently at distances greater than 80 miles from the admitting institution (P = 0.01). CONCLUSIONS: This study suggests that helicopter transport of tSCI patients requiring surgical decompression was associated with improved neurological outcomes compared to patients transported via ambulance.

Efficacy of endotracheal intubation in helicopter cabin vs. ground: a systematic review and meta-analysis.

BACKGROUND: Pre-hospital endotracheal intubation (ETI) is a sophisticated procedure with a comparatively high failure rate. Especially, ETI in confined spaces may result in higher difficulty, longer times, and a higher failure rate. This study analyses if Helicopter Emergency Medical Services (HEMS) intubation (time-to) success are influenced by noise, light, and restricted space in comparison to ground intubation. Available literature reporting these parameters was very limited, thus the reported differences between ETI in helicopter vs. ground by confronting parameters such as time to secure airway, first pass success rate and Cormack-Lehane Score were analysed. METHODS: A systematic review and meta-analysis were conducted using PUBMED, EMBASE, Cochrane Library, and Ovid on October 15th, 2022. The database search provided 2322 studies and 6 studies met inclusion and quality criteria. The research was registered with the International Prospective Register of Systematic Reviews (CRD42022361793). RESULTS: A total of six studies were selected and analysed as part of the systematic review and meta-analysis. The first pass success rate of ETI was more likely to fail in the helicopter setting as compared to the ground (82,4% vs. 87,3%), but the final success rate was similar between the two settings (96,8% vs. 97,8%). The success rate of intubation in literature was reported higher in physician-staffed HEMS than in paramedic-staffed HEMS. The impact of aircraft type and location inside the vehicle on intubation success rates was inconclusive across studies. The meta-analysis revealed inconsistent results for the mean duration of intubation, with one study reporting shorter intubation times in helicopters (13,0s vs.15,5s), another reporting no significant differences (16,5s vs. 16,8s), and a third reporting longer intubation times in helicopters (16,1s vs. 15,0s). CONCLUSION: Further research is needed to assess the impact of environmental factors on the quality of ETI on HEMS. While the success rate of endotracheal intubation in helicopters vs. on the ground is not significantly different, the duration and time to secure the airway, and Cormack-Lehane Score may be influenced by environmental factors. However, the limited number of studies reporting on these factors highlights the need for further research in this area.