Aeromedical Research Articles

Prehospital point of care ultrasound in Helicopter Emergency Medical Services: a 5-year experience study in Belgium

IntroductionThe utilization of Clinical Ultrasound (CUS) in Helicopter Emergency Medical Services (HEMS) has become increasingly prevalent, reflecting its significant role in emergency care.MethodsThis descriptive, monocentric study, conducted at the Helicopter Medical Center (CMH) of Bra-sur-Lienne, Belgium, aimed to describe the use of CUS within HEMS and evaluate its potential impact on diagnostic accuracy, therapeutic interventions, and hospital destination decisions.ResultsOver a 5-year period, from January 2018 to December 2022, our retrospective analysis included 6,126 HEMS interventions, with CUS performed in 29.55% of cases. The study demonstrated that CUS led to therapeutic changes in 30.88% of instances and affected the hospital destination in 9% of cases, despite a potential bias toward directing patients to the University Hospital Center of Liège (CHU of Liège) due to operational constraints. The agreement between prehospital CUS findings and hospital imaging was substantial, with an 80.39% concordance rate, underscoring CUS's utility in enhancing prehospital diagnostic accuracy. We found no significant increase in on-scene time due to CUS usage, with most exams completed in <5 min.DiscussionOur findings highlight the interesting role of CUS in HEMS, facilitating more informed and confident medical decision-making in prehospital emergency care. However, variability in CUS application emphasize the need for standardized guidelines to optimize its use. The study's limitations include its retrospective, monocentric design and the focus on on-scene ultrasound evaluations. Future research should aim at a more extensive, prospective analysis to further validate the benefits of CUS in emergency medical services.

Coffee and Cases (C&C) - Enhancing knowledge creation and sharing for organizational learning from clinical debriefs in a helicopter emergency medical service: A quality improvement study

ABSTRACT OBJECTIVES The objective of this quality improvement (QI) study was to improve organizational learning from clinical debriefs known as ‘Coffee and Cases' (C&C) in a helicopter emergency medical service (HEMS) by increasing weekly learning summaries (LS) and documented learning points (DLP) as well as the dissemination thereof by at least 50% from baseline. METHODS The problem analysis for sub-optimal organizational learning from C&C identified several factors, including lack of responsibility, poor documentation quality, and limited sharing of learning points. Using the Model for Improvement (MFI), interventions enhanced the learning environment, and improved documentation and dissemination. Changes included dedicated computers, introducing standardized processes, a newsletter and searchable DLP database. Statistical process control (SPC) charts were used to assess the effectiveness of interventions. RESULTS Prior to interventions (August 2022 to January 2023), baseline mean counts of weekly DLPs, LSs, DLPs internally disseminated, and DLPs openly disseminated were 3.18, 2.67, 3.18, and 2.96, respectively. Plan-Do-Study-Act (PDSA) cycles included declaring C&C as a non-clinical portfolio, redesigning documentation processes, initiating monthly newsletters, developing a DLP repository, and designing a C&C visual brand. Signals of special cause variation showed improvements, with mean counts increasing. Weekly DLPs increased to 14.92, LSs to 5.2, internally disseminated C&C Snippets to 11.88, and openly disseminated C&C Snippets to 8.64. CONCLUSIONS Recognizing barriers to effective knowledge creation and sharing, our QI study aimed to increase weekly DLPs and LSs by 50% from baseline. It aligned with the relationship between knowledge management and organizational learning, emphasizing the importance of utilizing knowledge for improved performance. Our interventions enhanced the learning environment, ensured robust capturing of learning points and effective communication thereof, ultimately contributing towards improving organizational dissemination of learning from clinical debriefs. Our QI study demonstrates how enhanced knowledge creation and sharing can widen the benefits of learning from clinical team debriefs.

Establishing Outcome Parameters for Helicopter Emergency Medical Services Research in The Netherlands: Results of a Mixed-Methods Delphi Consensus Study

Objectives Physician staffed Helicopter Emergency Medical Services (P-HEMS) care in the Netherlands has transitioned from predominantly trauma management to handling a variety of medical conditions. Relevant outcome parameters for Dutch P-HEMS research have not been previously defined. National consensus was sought to identify relevant long term patient outcome parameters, process outcome parameters and performance outcome parameters for Dutch P-HEMS care. Methods This was a mixed methods Delphi consensus study. A list of potentially relevant outcome parameters was identified using a systematic literature review. These parameters were subsequently surveyed in a Delphi consensus study. Helicopter Emergency Medical Services physicians and relevant stakeholders were invited to participate in this Delphi survey, where they were allowed to suggest additional outcome parameters. Descriptive analysis was performed on all data sets. Results Forty-nine potential outcome parameters for Dutch P-HEMS care were surveyed. Of 71 invited participants, 53 (75%), 40 (56%), and 20 (28%) participated in the first, second, and third round of the Delphi study, respectively. Consensus was reached on 25 (51%) of 49 outcome parameters as being important. These consisted of seven long term patient related outcome parameters, four short term patient related outcome parameters, five process outcome parameters and nine performance outcome parameters. Conclusions In conclusion, this study identified 25 outcome parameters relevant for Dutch physician staffed HEMS care. These parameters should be considered when designing future studies and should be routinely collected for each dispatch if possible.

Helicopter Emergency Medical Services (HEMS) Transportation Utilization for Acute Ischemic Strokes at a Community-Based Hospital in South Florida

Background: A comprehensive stroke center (CSC) servicing remote areas in South Florida became HEMS direct-from-field capable on October 15, 2020. This analysis reviews the utilization of this service and compares it to ground EMS (GEMS). Methods: This is a retrospective cohort study from October 15, 2020, to July 31, 2021, that collected HEMS adult stroke alert data and compared it to the prior year's summary GEMS stroke alert data. Using HEMS transportation logs, presenting stroke symptoms and prehospital assessment were abstracted, in addition to initial NIHSS, downgrade rate, stroke diagnosis percentage, treatment rate, and times. Results: The analysis included a total of 52 direct transport HEMS stroke alerts. Assessment tools utilized by HEMS included the Cincinnati stroke scale (4%) and the FAST-ED (37%); most cases (59%) did not document a stroke assessment tool. The median NIHSS was 10, with 37% presenting a score <6. Cases were downgraded upon arrival in 27% and after CT imaging in 15% of cases. Significantly (p<.001), more HEMS cases were diagnosed as stroke (69%) compared to GEMS (57%). Stroke treatment rates remained similar (HEMS=23%; GEMS=24%). Median door-to-needle times were significantly faster for HEMS (15 min) than GEMS (25 min) (p<.05). Median door-to-puncture times were clinically faster for HEMS (61mins) than GEMS (66 mins). Conclusion: Prehospital triage could be improved to better detect the 77% of patients who are not eligible for acute stroke reperfusion treatments and may benefit from ground as opposed to air transportation. The current HEMS triage, although not consistently documented, appropriately selects stroke victims, but not necessarily those who need air transport to a higher care level. Patients arriving via HEMS receive similar access to stroke treatment and, if treated, significantly faster treatment times.

Effect of case identification changes on pre-hospital intubation performance indicators in an Australian helicopter emergency medical service.

A 45-min interval from injury to intubation has been proposed as a performance indicator for severe trauma patient management. In the Sydney pre-hospital system a previous change in case identification systems was associated with activation delay. We aimed to determine if this also decreased the proportion of patients intubated within this benchmark. Retrospective cohort study of patients intubated by a helicopter emergency medical service (HEMS) over two time periods. Period 1 dispatch was via HEMS crew directly screening the computerised dispatch system, and period 2 was via paramedics in a central control room. Times from emergency call to intubation were compared. In the HEMS crew screening period 46/58 (79.31%) intubations met the target, compared with 137/314 (43.6%) in the central control period (P < 0.001). The median (interquartile range) time to intubation in the direct crew screening period was 33 (25-41) min, versus the central control period at 47 (38-60) min (P < 0.001). On multivariate modelling, distance to the scene was related to time to intubation (P < 0.001; Incident Rate Ratio = 1.018, 95% confidence interval 1.015-1.020) as was dispatch system, entrapment/access difficulty and indication for intubation (all P < 0.001). Time from emergency call to intubation was significantly shorter in the HEMS screening period where all non-trapped cases less than 50 km distant were intubated within the 45-min benchmark. There was no distance where intubation within 45 min could be assured for non-trapped patients in the central control period due to dispatch delays.

Elevating Prehospital Traumatic Brain Injury Care: A Comparative Analysis of Civilian and Military Air Transport Guidelines

ObjectiveTraumatic brain injuries (TBIs) are a leading cause of death and disability worldwide. Establishing TBI guidelines is crucial for prehospital management. Civilian medical practices are often influenced by military trauma guidelines. This study provides a comparative analysis of prehospital TBI management by a civilian air medical evacuation service using civilian guidelines and military clinical practice guidelines from the Joint Trauma System of the Department of Defense. MethodsA retrospective review of 100 deidentified patient transport logs from a prominent civilian air medical service was conducted. The logs were compared with the service's patient care guidelines and the 2023 Joint Trauma System Clinical Practice Guidelines. Data were analyzed for adherence to 14 metrics. ResultsPatients showed improvement in preflight and postflight Glasgow Coma Scale scores and were managed according to recommendations on head elevation, oxygenation, blood pressure, and temperature by both organizations. Discrepancies between guidelines included differences in the management of ventilator settings, blood pressure, oxygenation, temperature, serum glucose, intracranial hypertension, suspected brain herniation, serum sodium levels, and seizure prophylaxis. ConclusionComparing civilian and military guidelines highlights areas for potential improvements in TBI management, such as integrating advanced monitoring and the implementation of (i-STAT, Abbott Laboratories, Chicago, IL) testing in air transport to enhance patient care and outcomes.

Watercraft as Overwater Ambulance Exchange Points to Enhance Air Medical Evacuation

Ambulance exchange points are preidentified sites where patients are transferred between evacuation platforms while en route to enhanced medical care. We propose a new capability for maritime medical evacuation, which involves co-opting underway watercraft as overwater ambulance exchange points to transfer patients between medical evacuation aircraft. We partnered with the US Army's 25th Combat Aviation Brigade to demonstrate the use of Army watercraft as overwater ambulance exchange points. A manikin was transferred between 2 HH-60M medical evacuation Black Hawk helicopters conducting hoist operations over Army Logistics Support Vessel 3, which was traveling south of Honolulu, HI. The demonstration was enabled by a decision support system for dispatching aircraft, hoist stabilization technology, commercial satellite internet, military geospatial infrastructure applications, and digital medical documentation tools, the benefits of which are all discussed. Three extensions of the overwater ambulance exchange point are introduced, and civilian applications are considered.

Epidemiology and Expected Cost of International Medical Repatriation Into South Korea: 2019 to 2021

ObjectiveOverseas Koreans face challenges in accessing adequate medical care abroad. Understanding the epidemiology and costs of international medical repatriation is important. MethodsA retrospective analysis of overseas Korean patients who were repatriated to South Korea between 2019 and 2021 was conducted. The data collected from 121 countries included demographics, medical conditions, and costs. Variables from 9 continents (Southeast Asia, Northeast Asia, Southwest Asia–Pacific, Russia–Central Asia, North America, Central and South America, Europe, Middle East‒North Africa, and Sub-Saharan Africa) and the era of coronavirus disease 2019 (February 2020 and after) were analyzed and compared. Based on the available total cost data, stepwise extrapolation was conducted for the total cohort. ResultsA total of 428 overseas Korean patients who had undergone international medical repatriation via air transport were included in this study. The greatest number of repatriated patients were from Southeast Asia (108 patients), and 279 patients were transported within the coronavirus disease 2019 era. The average cost per patient exceeded $7,000, and the total cost estimated by extrapolation was over $8 million. ConclusionInternational medical repatriation is significant for overseas Koreans. Standardized guidelines and system development are essential for effective air medical services.

Air Transport Medicine: From the Field

Air Transport Medicine: From the Field

Ready to launch: a cross-sectional study of field trauma triage and air-ambulance policies across Canada.

This study aimed to understand current prehospital trauma air-ambulance policies and triage guidelines across Canada. The research question centered on understanding the guidelines used by provinces and territories and identifying potential regional variations in air-ambulance triage. We conducted a cross-sectional survey from November 2022 to May 2023, involving trauma leaders from Canada's 13 provinces and territories. Participants were identified via the Trauma Association of Canada and professional networks. The survey, developed with expert input and pilot tested for clarity, focused on prehospital trauma-triage guidelines, level of adoption of Center for Disease Control and Prevention (CDC) triage guidelines, and auto-launch air-ambulance policies. Data were collected using an 18-item electronic survey. Potential response bias was considered, and confidentiality was maintained. A cross-sectional qualitative analysis was used to evaluate the guidelines' adoption and variations, with responses compared across regions. The analysis revealed a nationwide adoption (11 of 11 respondents) of the CDC guidelines, indicating a standardized approach to patient transportation. Notably, many provinces and territories (5 of 11) endorse auto-launch protocols for air ambulances in specific scenarios. These policies offer advantages in geographically vast regions weighed against the cost of over-triage and inefficient resource allocation. Each province and territory tailors its approach based on factors such as geographic areas served, and available resources. This study provides a snapshot of the current state of prehospital trauma-triage guidelines in Canada. With some differences in nomenclature, Canadian provinces and territories widely apply the CDC guidelines to serve their populations. There is some regional variation on how transport is initiated within their borders. The findings underscore the delicate balance required for optimizing air-ambulance policies, considering factors such as timely access, resource allocation, and the local application of guidelines.

Noncompressible Chest Wall in Critically Buried Avalanche Victims with Cardiac Arrest: A Case Series.

David Eidenbenz, Alexandre Kottmann, Ken Zafren, Pierre-Nicolas Carron, Roland Albrecht, and Mathieu Pasquier. Noncompressible chest wall in critically buried avalanche victims with cardiac arrest: a case series. High Alt Med Biol. 00:00-00, 2024. Introduction: In avalanche victims with cardiac arrest, a noncompressible chest wall or frozen body is a contraindication to initiating cardiopulmonary resuscitation. The evidence sustaining this recommendation is low. Objective: To describe the characteristics and prehospital management of critically buried avalanche victims declared dead on site, with and without noncompressible chest walls. Methods: Retrospective study including all critically buried avalanche victims declared dead on site by physicians of a helicopter emergency medical service in Switzerland, from 2010 to 2019. The primary outcome was the proportion of victims with a noncompressible chest wall reported in medical records. Secondary outcomes included victims' characteristics and the relevance of the criterion, noncompressible chest wall, for management. Results: Among the 53 included victims, 12 (23%) had noncompressible chest walls. Victims with noncompressible chest walls had significantly longer burial durations (median 1,125 vs. 45 minutes; p < 0.001) and lower core temperatures (median 14 vs. 32°C; p = 0.01). The criterion, noncompressible chest wall, assessed in six victims, was decisive for declaring death on site in four victims. Conclusion: The presence of a noncompressible chest wall does not appear to be a sufficient criterion to allow to declare the death of critically buried avalanche victims. Further clinical information should be sought.

The use of platelet-rich plasma in the treatment of patients with chronic dorsalgia

Background. The purpose of the study is to assess the clinical effectiveness of using platelet-rich plasma for functional recovery in patients with chronic back pain. Materials and methods. The research was carried out in the clinical units of the Ukrainian Research Institute of Transport Medicine and Petro Mohyla Black Sea National University in 2020–2023. Sixty patients with chronic dorsalgia were examined. Results. During the entire course of treatment, patients who received local platelet-rich plasma therapy did not experience any adverse reactions or intolerance, did not require adjustment or change of treatment regimen. After 2 weeks of therapy, compared to the initial level, a significant decrease in the severity of the pain syndrome according to the visual analog scale was found, by 2.1 ± 0.2 points in the main group and by 1.5 ± 0.3 points in the control group (p &lt; 0.05). Conclusions. After the treatment, the functional capabilities of patients in the main group improved significantly — Neck Disability Index decreased from 51.9 ± 2.2 % to 34.5 ± 1.3 % in the main group and from 53.3 ± 2.4 % to 45.8 ± 2.4 % in the controls, and Oswestry Disability Index — from 68.8 ± 2.3 % to 49.6 ± 1.8 % and from 66.7 ± 2.6 % to 55.8 ± 1.6 % (p &lt; 0.05), respectively.

Feasibility of 10-Minute Arrival Time to Departure Time Metric for STEMI Patients

Objectives Delays in reperfusion treatment in ST-elevation myocardial infarction (STEMI) patients leads to higher morbidity and mortality. Previous reports for Helicopter Emergency Medical Services (HEMS) suggests a 10-minute skid-to-skid (arrival to departure) time to achieve appropriate reperfusion times. However, there is no published data on whether this goal is achievable for a HEMS service. This study aims to see if a midwestern critical care service can consistently achieve a 10-minute helicopter skid-to-skid time or ground critical care service arrival to departure time. Further, comparing this metric between ground and helicopter transportations will help evaluate the ideal transportation method to optimize time to percutaneous intervention (PCI). Methods This was a retrospective chart review utilizing 10 years of data from our ground and HEMS program to assess whether a 10-minute arrival to departure time for STEMI patients could be achieved. Patients included were at least 18 years of age and were transported from the referring facility for further STEMI management. Wilcoxon rank sum test and Chi-square tests were used to evaluate data between helicopter and ground services. Results Included in the study were 686 patients, 608 by helicopter transport and 78 by ground transport. The median arrival to departure time was 14 min (IQR = 5) for helicopter patients and 13 min (IQR = 6) for ground patients. There was not a statistically significant difference in this metric for STEMI patients transported by helicopter versus ground. A statistically significant difference, though, existed between helicopter and ground transports among percent with times less than or equal to 10 min versus percent times greater than 10 min, X2 = 5.46, df = 1, p = 0.02. Two referring facilities had statistically significant differences in median arrival to departure times. Conclusions Our study found that a median EMS arrival to departure time of 10 min to transport STEMI patients was not consistently achieved via either helicopter or ground transportation.

Characteristics of trauma patients treated by Helicopter Emergency Medical Service and transported to the hospital by helicopter or ambulance

IntroductionTrauma patients treated by the Helicopter Emergency Medical Services (HEMS) can be transported to the hospital either by helicopter or by ambulance, in both cases accompanied by the HEMS physician. The objectives of this study are first to compile an overview of patients treated and transported by the HEMS team with either the helicopter (patients transported by helicopter, PTH) or with the ambulance (patients transported by ambulance, PTA). In addition, to evaluate whether the existing information systems obtain relevant data for researching the decision-making process. The second objective is to identify potentially influencing factors that could be significant for further research.MethodsAll patients in the period from 1 January 2011 until 31 December 2020, treated by HEMS and subsequently transported to hospitals were included in the study. To avoid overrepresentation of the PTA group, a random sample was taken, creating two groups in a 1:2 ratio (PTH n = 724, PTA n = 1448). Differences in patient and treatment characteristics between PTH and PTA were compared using t-tests, Mann-Whitney U tests, and chi-square tests.ResultsPTH accounted for 12.2% of all transports. Approximately two-third of the patients were male and the mean age was around 40 years. PTH had lower iEMV (initial Eye opening, best Motor response, best Verbal response) and iRTS (initial Revised Trauma Score) scores, were more frequently transported to a level 1 trauma centre, underwent more prehospital treatments and were roughly twice as far from their hospital of arrival compared to PTA.ConclusionThe current dataset is, after some modifications, suitable to provide a comprehensive overview of patients treated by HEMS in the Netherlands. A predictive model could be developed using this dataset, which should include factors such as the patient’s location, age, distance to the hospital, physician on duty, mechanism of injury and overall injury severity.

An Improved Iterated Greedy Algorithm for Solving Collaborative Helicopter Rescue Routing Problem with Time Window and Limited Survival Time

Research on helicopter dispatching has received considerable attention, particularly in relation to post-disaster rescue operations. The survival chances of individuals trapped in emergency situations decrease as time passes, making timely helicopter dispatch crucial for successful rescue missions. Therefore, this study investigates a collaborative helicopter rescue routing problem with time window and limited survival time constraints, solving it using an improved iterative greedy (IIG) algorithm. In the proposed algorithm, a heuristic initialization strategy is designed to generate an efficient and feasible initial solution. Then, a feasible-first destruction-construction strategy is applied to enhance the algorithm’s exploration ability. Next, a problem-specific local search strategy is developed to improve the algorithm’s local search effectiveness. In addition, the simulated annealing (SA) method is integrated as an acceptance criterion to avoid the algorithm from getting trapped in local optima. Finally, to evaluate the efficacy of the proposed IIG, 56 instances were generated based on Solomon instances and used for simulation tests. A comparative analysis was conducted against six efficient algorithms from the existing studies. The experimental results demonstrate that the proposed algorithm performs well in solving the post-disaster rescue helicopter routing problem.

Regional differences, repeated use, and costs of emergency medical services in Germany.

Little is known about regional differences regarding the utilization and costs of emergency medical services (EMS) in Germany. Evidence on characteristics of repeated use of EMS is also scarce. To compare German federal states regarding the utilization and costs of EMS and to analyze characteristics of repeated EMS use. We used BARMER health insurance data on more than 1.4million German EMS cases in 2022. We estimated EMS use rates (per 1000 inhabitants) and median reimbursements and costs by EMS type (ground transport with/without emergency physician (EP); helicopter emergency medical services), hospitalization status, and federal state. We applied Poisson regression to estimate incidence rate ratios (IRRs) with 95% confidence intervals (95% CI), capturing relationships between repeated use of EMS and individual characteristics, including care degree and income level. Ground transport EMS use rates varied between federal states by more than 2.6-fold without EP (Bavaria: 84.6; Berlin: 223.2) and 2.1-fold with EP (Bremen: 19.1; Saxony: 41.3). Median reimbursement of ground transport with EP was 132% higher in Schleswig-Holstein (€ 1530) compared with Berlin (€ 660). Approximately one-third of all persons used EMS more than once and accounted for two-thirds of all EMS cases. Repeated EMS use was strongly related to care degree (IRR of care degree5: 3084; 95% CI 3.012-3.158) and low income (IRR: 1.174; 95% CI 1.161-1.189). The substantial regional heterogeneity in terms of utilization and costs of EMS calls for anationwide, consistent regulation of EMS in Germany. Additionally, (outpatient) primary nursing care of persons with severe health impairments and health literacy should be strengthened.

Drones reduce the time to defibrillation in a highly visited non-urban area: A randomized simulation-based trial

IntroductionOut-of-hospital cardiac arrest (OHCA) has a high global incidence and mortality rate, with early defibrillation significantly improving survival. Our aim was to assess the feasibility of autonomous drone delivery of automated external defibrillators (AED) in a non-urban area with physical barriers and compare the time to defibrillate (TTD) with bystander retrieval from a public access defibrillator (PAD) point and helicopter emergency medical services (HEMS) physician performed defibrillation. MethodsThis randomized simulation-based trial with a cross-over design included bystanders performing AED retrievals either delivered by automated drone flight or on foot from a PAD point, and simulated HEMS interventions. The primary outcome was the time to defibrillation, with secondary outcomes comparing workload, perceived physical effort, and ease of use. ResultsThirty-six simulations were performed. Drone-delivered AED intervention had a significantly shorter TTD [2.2 (95 % CI 2.0–2.3) min] compared to PAD retrieval [12.4 (95 % CI 10.4–14.4) min] and HEMS [18.2 (95 % CI 17.1–19.2) min].The self-reported physical effort on a visual analogue scale for drone-delivered AED was significantly lower versus PAD [2.5 (1 – 22) mm vs. 81 (65–99) mm, p = 0.02]. The overall mean workload measured by NASA-TLX was also significantly lower for drone delivery compared to PAD [4.3 (1.2–11.7) vs. 11.9 (5.5–14.5), p = 0.018]. ConclusionThe use of drones for automated AED delivery in a non-urban area with physical barriers is feasible and leads to a shorter time to defibrillation. Drone-delivered AEDs also involve a lower workload and perceived physical effort than AED retrieval on foot.

Clinicians’ experience of barriers and facilitators to care delivery of an extracorporeal cardiopulmonary resuscitation service for out-of-hospital cardiac arrest: a qualitative survey

BackgroundOut-of-hospital cardiac arrest (OHCA) survival in the UK remains overall poor with fewer than 10% of patients surviving to hospital discharge. Extracorporeal cardiopulmonary resuscitation (ECPR) is a developing therapy option that can improve survival in select patients if treatment begins within an hour. Clinicians' perspectives are a pivotal consideration to the development of effective systems for OHCA ECPR, but they have been infrequently explored. This study investigates clinicians' views on the barriers and facilitators to establishing effective systems to facilitate transport of OHCA patients for in-hospital ECPR.MethodsIn January 2023, Thames Valley Air Ambulance (TVAA) and Harefield Hospital developed an ECPR partnership pathway for conveyance of OHCA patients for in-hospital ECPR. The authors of this study conducted a survey of clinicians across both services looking to identify clear barriers and positive contributors to the effective implementation of the programme. The survey included questions about technical and non-technical barriers and facilitators, with free-text responses analysed thematically.ResultsResponses were received from 14 pre-hospital TVAA critical care and 9 in-hospital clinicians’ representative of various roles and experiences. Data analysis revealed 10 key themes and 19 subthemes. The interconnected themes, identified by pre-hospital TVAA critical care clinicians as important barriers or facilitators in this ECPR system included educational programmes; collectiveness in effort and culture; teamwork; inter-service communication; concurrent activity; and clarity of procedures. Themes from in-hospital clinicians’ responses were distilled into key considerations focusing on learning and marginal gains, standardising and simplifying protocols, training and simulation; and nurturing effective teams.ConclusionThis study identified several clear themes and subthemes from clinical experience that should be considered when developing and modelling an ECPR system for OHCA. These insights may inform future development of ECPR programmes for OHCA in other centres. Key recommendations identified include prioritising education and training (including regular simulations), standardising a ‘pitstop style’ handover process, establishing clear roles during the cannulation process and developing standardised protocols and selection criteria. This study also provides insight into the feasibility of using pre-hospital critical care teams for intra-arrest patient retrieval in the pre-hospital arena.

The offload study: A prospective observational study of the time to offload a patient from an ambulance or helicopter into an emergency department or percutaneous coronary intervention centre

Introduction Providing an accurate estimated time for patient handover in the emergency department (ED) can be difficult from the scene. The time taken to offload a patient from a conveying ambulance and transfer into the resuscitation room is often not considered within the estimated time of arrival (ETA). The aim of this study was to assess offload times for pre-alerted patients conveyed by a UK Helicopter Emergency Medical Service (HEMS) by air and road ambulance. Methods A prospective observational study was conducted at The Air Ambulance Service (TAAS) from August 2022 to February 2023. Consecutive emergency patients who were pre-alerted to hospital and arrived at an ED or Percutaneous Coronary Intervention (PCI) centre with an escorting air ambulance crew member were included. The offload time (time between hospital arrival and handover of the patient) was measured using a stopwatch. Results Data was available for 228 patients arriving at 18 hospitals and 6 helipads. The median offload time by road ambulance was 2 min 34 s. The range of helicopter offload times was from 4 min 20 s to 21 min 37 s, which mainly depended on the location of the helipad. Conclusion An additional 2–3 min should be added to the ETA by road ambulance. There is large variation in helicopter offload times depending on the helipad location (secondary/offsite helipad taking longer than a primary rooftop helipad or primary same-level helipads). HEMS services should review their own offload times at local sites to be able to provide a more accurate ETA.

Quality and safety in prehospital airway management – retrospective analysis of 18,000 cases from an air rescue database in Germany

BackgroundPrehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective.MethodsThis was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0.ResultsOut of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11).ConclusionsPrehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety.Trial registrationThe study was registered in the German Register for Clinical Studies (number DRKS00028068).