Emergency Medical Retrieval Service Research Articles

Pre-hospital and retrieval medicine in Scotland: a retrospective cohort study of the workload and outcomes of the emergency medical retrieval service in the first decade of national coverage

BackgroundThe Emergency Medical Retrieval Service (EMRS) has provided national pre-hospital critical care and aeromedical retrieval in Scotland since 2010. This study investigates trends in the service and patients attended over the last decade; and factors associated with clinical deterioration and pre-hospital death.MethodsA retrospective cohort study was conducted of all service taskings over ten years (2011–2020 inclusive). The EMRS electronic database provided data on location, sociodemographic factors, diagnoses, physiological measurements, clinical management, and pre-hospital deaths. Binary logistic regression models were used to determine change in physiology in pre-hospital care, and factors associated with pre-hospital death. Geospatial modelling, using road and air travel time models, was used to explore transfer times.ResultsEMRS received 8,069 taskings over the study period, of which 2,748 retrieval and 3,633 pre-hospital critical care missions resulted in patient contact. EMRS was more commonly dispatched to socioeconomically deprived areas for pre-hospital critical care incidents (Spearman’s rank correlation, r(8)=-0.75, p = 0.01). In multivariate analysis, systolic blood pressure < 90mmHg, respiratory rate < 6/min or > 30/min, and Glasgow Coma Score ≤ 14 were associated with pre-hospital mortality independent of demographic factors. Geospatial modelling suggested that aeromedical retrieval reduced the mean time to a critical care unit by 1 h 46 min compared with road/ferry transportation.ConclusionEMRS continues to develop, delivering Pre-Hospital and Retrieval Medicine across Scotland and may have a role in addressing health inequalities, including socioeconomic deprivation and geographic isolation. Age, specific distances from care, and abnormal physiology are associated with death in pre-hospital critical care.

Failure to initiate trauma team activation for patients who meet the criteria in a level 1 paediatric trauma centre: which patients are missing out?

Trauma team activation (TTA) is paramount in the early hospital management of trauma patients. This study aimed to evaluate factors which contribute to failure to activate the Trauma team for management of paediatric trauma. A retrospective cohort study of Emergency Department (ED) presentations at the paediatric major trauma hospital in Adelaide, South Australia was conducted over a 16-month period. Data from the hospital's trauma registry, individual case files and digital medical records were evaluated to determine factors that were associated with no TTA. During the study period, 617 trauma patients who met Level 1 or Level 2 TTA criteria attended the trauma centre. For 29 (4.7%) of these patients, there was no TTA. Predictors of no TTA included sustaining abdomen and/or pelvis injuries compared to limb injuries (unadjusted odds ratio [OR]=10.59, 95% confidence interval [CI] 1.98-56.69, P=0.006), sustaining non-accidental injury (NAI) versus an injury with vehicle involvement (OR=30.13, 95% CI 6.43-141.21, P < 0.001), and arriving via emergency medical retrieval service compared to private vehicle (OR=14.23, 95% CI 3.94-51.36, P < 0.001). No patients transferred directly to Paediatric Intensive Care Unit (PICU), or High Dependency Unit (HDU) received an appropriate TTA. Multiple factors were associated with no TTA in paediatric trauma patients. The results highlight that even in PICU and HDU admissions and transfer patients, vigilant clarification of mechanism of injury and potential for occult injuries should be undertaken to ensure appropriate TTA and improve patient outcome.

Telehealth training: Interprofessional mixed reality simulation in a retrieval service setting.

The use of Telehealth is well established in Australian retrieval service settings to aid assessment and management of patients requiring aeromedical transportation and to provide support to clinicians at remote facilities. Telehealth ensures prompt advice and treatment for critically ill and injured patients and can facilitate a resuscitation until the retrieval team arrives. There is scant information regarding the knowledge, skills and abilities required of Telehealth professionals, despite the universal recognition of it requiring a complex skill set, comprehensive understanding of technology and mastery of retrieval medicine. We share the experiences of the South Australia Ambulance Service MedSTAR Emergency Medical Retrieval Service preparing an education programme focussed on the psychometric skills in Telehealth. Our programme realistically simulates Telehealth and coordination systems in use across South Australia, provides in-depth hands-on practice for medical and nursing staff that incorporates teamwork, communication, technical and critical thinking skills and culminates with a mixed-reality simulation scenario and formal debrief.

Impact of a physician - critical care practitioner pre-hospital service in Wales on trauma survival: a retrospective analysis of linked registry data.

The Emergency Medical Retrieval and Transfer Service for Wales launched in 2015. This service delivers senior pre-hospital doctors and advanced critical care practitioners to the scene of time-critical life- and limb-threatening incidents to provide advanced decision-making and pre-hospital clinical care. The impact of the service on 30-day mortality was evaluated retrospectively using a data linkage system. The study included patients who sustained moderate-to-severe blunt traumatic injuries (injury severity score≥9) between 27 April 2015 and 30 November 2018. The association between pre-hospital management by the Emergency Medical Retrieval and Transfer Service and 30-day mortality was assessed using multivariable logistic regression. In total, data from 4035 patients were analysed, of which 412 (10%) were treated by the Emergency Medical Retrieval and Transfer Service. A greater proportion of patients treated by the Emergency Medical Retrieval and Transfer Service had an injury severity score≥16 and Glasgow coma scale≤12 (288 (70%) vs. 1435 (40%) and 126 (31%) vs. 325 (9%), respectively). The unadjusted 30-day mortality rate was 11.7% for patients managed by the Emergency Medical Retrieval and Transfer Service compared with 9.6% for patients managed by standard pre-hospital care services. However, after adjustment for differences in case-mix, the 30-day mortality rate for patients treated by the Emergency Medical Retrieval and Transfer Service was 37% lower (adjusted odds ratio 0.63 (95%CI 0.41-0.97); p=0.037). The introduction of an emergency medical retrieval service was associated with a reduction in 30-day mortality for patients with blunt traumatic injury.

Responding to the COVID-19 pandemic: The experiences of South Australia's Rescue, Retrieval and Aviation Services.

COVID-19 poses significant challenges to pre-hospital and retrieval medicine (PHRM) clinicians - and many are unique to this area of clinical practice. We share the experiences of the South Australian Ambulance Service (SAAS) MedSTAR Emergency Medical Retrieval Service in preparing for the COVID-19 pandemic in the pre-hospital and retrieval setting - including the role of a multidisciplinary leadership team; challenges and potential approaches to screening for COVID-19; personal protective equipment for pre-hospital and aeromedical taskings; issues arising with interstate retrievals; and the role of telehealth. Although novel solutions allowed SAAS MedSTAR to continue to deliver high-quality care, considering the resource implications involved in undertaking the transfer of patients with COVID-19, it is clear that significant community disease transmission threatens to overwhelm any PHRM service. Should Australia face a significant future outbreak, it is conceivable that some PHRM operations may need to be reduced or suspended entirely.

Epidemiology and location of primary retrieval missions in a Scottish aeromedical service.

Prehospital critical care teams comprising an appropriately trained physician and paramedic or nurse have been associated with improved outcomes in selected trauma patients. These teams are a scarce and expensive resource, especially when delivered by rotary air assets. The optimal tasking of prehospital critical care teams is therefore vital and remains a subject of debate. Emergency Medical Retrieval Service (EMRS) provides a prehospital critical care response team to incidents over a large area of Scotland either by air or by road. A convenience sample of consecutive EMRS missions covering a period of 18 months from May 2013 to January 2015 was taken. These missions were matched with the ambulance service information on geographical location of the incident. In order to assess the appropriateness of tasking, interventions undertaken on each mission were analysed and divided into two subcategories: 'critical care interventions' and 'advanced medical interventions'. A tasking was deemed appropriate if it included either category of intervention or if a patient was pronounced life extinct at the scene. A total of 1279 primary missions were undertaken during the study period. Of these, 493 primary missions met the inclusion criteria and generated complete location data. The median distance to scene was calculated as 5.6 miles for land responses and 34.2 miles for air responses. Overall, critical care interventions were performed on 17% (84/493) of patients. A further 21% (102/493) of patients had an advanced medical intervention. Including those patients for whom life was pronounced extinct on scene by the EMRS team, a total of 42% (206/493) taskings were appropriate. Overall, our data show a wide geographical spread of tasking for our service, which is in keeping with other suburban/rural models of prehospital care. Tasking accuracy is also comparable to the accuracy shown by other similar services.

Cardiac transvenous pacing in the retrieval setting: A retrospective case series.

To report on the safety and efficacy of transvenous cardiac pacing wire insertion outside a tertiary hospital by a medical retrieval service. SAAS MedSTAR Emergency Medical Retrieval Service transports symptomatic bradycardic patients in rural South Australia to Adelaide on transvenous pacing for ongoing management. This is a retrospective case review of all transvenous cardiac pacing wires inserted by SAAS MedSTAR between January 2015 and October 2017. This study demonstrated successful insertion of cardiac transvenous pacing wires and cardiac capture in 10 of 11 cases (91%) by pre-hospital and retrieval doctors. There were no immediate or long-term complications from insertion. All of the patients were successfully transferred by helicopter or fixed wing to their receiving facility, with nine of the 11 patients (82%) surviving to hospital discharge. This paper demonstrates that transvenous cardiac pacing can be safely and successfully implemented for symptomatic patients by pre-hospital and retrieval physicians in the aeromedical retrieval setting.

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load

BackgroundWe examined the effect of advanced preparation and organisation of equipment and drugs for Pre-hospital Emergency Anaesthesia (PHEA) and tracheal intubation on procedural time, error rates, and cognitive load.MethodsThis study was a randomised, controlled experiment with a crossover design. Clinical teams (physician and paramedic) from the Emergency Medical Retrieval Service and the Scottish Air Ambulance Division were randomised to perform a standardised pre-hospital clinical simulation using either unprepared (standard practice) or pre-prepared (experimental method) PHEA equipment and drugs. Following a two-week washout period, each team performed the corresponding simulation. The primary outcome was intervention time. Secondary outcomes were safety-related incidents and errors, and degree of cognitive load.ResultsIn total 23 experiments were completed, 12 using experimental method and 11 using standard practice. Time required to perform PHEA using the experimental method was significantly shorter than with standard practice (11,45 versus 20:59) minutes: seconds; p = < 0.001). The experimental method also significantly reduced procedural errors (0 versus 9, p = 0.007) and the cognitive load experienced by the intubator assistant (41.9 versus 68.7 mm, p = 0.006).ConclusionsPre-preparation of PHEA equipment and drugs resulted in safer performance of PHEA and has the potential to reduce on-scene time by up to a third.

Paediatric workload of an adult retrieval service in Scotland.

The Emergency Medical Retrieval Service (EMRS) provides adults with life-threatening conditions in remote areas with timely interventions and rapid access to definitive medical care, including a primary response service. Paediatric patients are managed under a separate network. Despite this, there has been an increase in paediatric retrievals by EMRS. We aim to inform future service development and ascertain how EMRS can serve the needs of this cohort. This is a retrospective, observational study. Raw data were retrieved from the database of paediatric patients retrieved by EMRS for 9 years. A total of 112 paediatric patients were retrieved; 46% were primary retrievals. The most common injuries were head injuries (n=29) and orthopaedic injuries (n=16). Common interventions include fluid resuscitation (n=34), ventilation (n=22) and sedation/paralysis (n=22).This study describes the evolution of an adult retrieval service to cover paediatric patients in Scotland outside the remit of the paediatric retrieval service.

PELVIC FRACTURES IN TRAUMA PATIENTS ATTENDED TO BY THE EMERGENCY MEDICAL RETRIEVAL SERVICE

Objectives & BackgroundPre-hospital application of pelvic binders is recommended by the 2016 NICE guidelines for Major Trauma in any patient with blunt high-energy trauma and suspected active bleeding from a...

Challenges of postpartum haemorrhage: a case study in the aeromedical retrieval environment

Postpartum haemorrhage is one of the main causes of maternal deaths worldwide. The presentation of this aetiology in the remote and rural setting presents significant challenges to both referring and retrieval clinicians. A safe, timely and robust response to transferring these patients direct to definitive care is necessary. This article considers the case of a 36-year-old female who presented to the Emergency Medical Retrieval Service with a slow but worsening onset of abdominal pain and persistent vaginal bleeding. The patient was 16 days postpartum following the uncomplicated birth of her third child. Treatment delivered to the patient is included in the case example and discussion given to challenges faced in the areomedical retrieval environment. Considerations during treatment, such as communication, resuscitation, investigation and monitoring are also presented.

Comparison of factors associated with desaturation in prehospital emergency anaesthesia in primary and secondary retrievals

ObjectiveTo investigate the incidence and factors associated with desaturation related to emergency intubations within an aeromedical retrieval service pertaining to both primary prehospital and secondary interhospital missions.MethodsA retrospective analysis of...

The evolving role of the Emergency Medical Retrieval Service critical care practitioner

Journal of Paramedic PracticeVol. 6, No. 1 Career DevelopmentThe evolving role of the Emergency Medical Retrieval Service critical care practitionerNeil Sinclair, Lisa CuratoloNeil SinclairSearch for more papers by this author, Lisa CuratoloSearch for more papers by this authorNeil Sinclair; Lisa CuratoloPublished Online:18 Feb 2014https://doi.org/10.12968/jpar.2014.6.1.40AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferencesFindlay G, Martin C, Carter S, Smith N, Weyman W, Mason M (2007) Trauma care: Who cares? A report of the National Confidential Enquiry into Patient Death and Outcome. NCEPOD, London Google ScholarHearns S (2012) Diploma in Retrieval and Transfer Medicine syllabus. The Royal College of Surgeons of Edinburgh, Edinburgh Google ScholarSturgeon N (2008) Delivering for remote and rural healthcare: What it means for you. The Scottish government, Edinburgh Google Scholar FiguresReferencesRelatedDetailsCited by 1 January 2014Volume 6Issue 1ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 18 February 2014 Published in print 1 January 2014 Information© MA Healthcare LimitedPDF download

Use of prothrombin complex concentrates: 4-year experience of a national aeromedical retrieval service servicing remote and rural areas

IntroductionProthrombin complex concentrates (PCCs) are recommended as first-line treatment for acquired or congenital factor II, VII, IX and X deficiencies in situations of major haemorrhage. The Emergency Medical Retrieval Service...

Rural mobile phone coverage is an issue for the NHS

We read with great interest the editorial regarding the value of smartphones to anaesthetic practice in the developing world [1]. Many of the advantages noted, such as access to reference material, contact details, photography and education are also of considerable value in the UK, and particularly to colleagues in remote and rural areas. The Association of Anaesthetists of Great Britain and Ireland has developed standards for pre-hospital anaesthesia and inter-hospital transfer of patients [2, 3]. In both these circumstances, smartphone access can be highly relevant and offer significant improvements in quality of care and clinical governance. However, whilst mobile phone network coverage is generally ‘taken for granted’ in urban areas, many rural parts of the UK are still without cover (Table 1). In Scotland, the Emergency Medical Retrieval Service (EMRS) provides a critical care transfer service to remote and rural areas [5]. After repeated issues with network coverage, we surveyed the 66 sites covered by EMRS and found that 34 have no network providing ‘good’ 2G (phone and text) coverage, including five of the community hospitals (Arran, Barra, Portree, Golspie and Benbecula); 3G coverage was even poorer. Many rural staff and patients are subject to a digital divide that excludes them from the advantages outlined above. Comments from our rural colleagues are illuminating, some relying on carrying multiple mobile phones where single networks cover different parts of practices, others relying on pagers or innovatively using non-UK tariffs to permit ‘roaming’ of UK networks [6]. All these must inevitably increase NHS costs. Critical care skills, with the appropriate equipment, are transferrable to remote and rural environments. Although EMRS has developed a prize-winning app containing contact and logistics details, standard operating procedures and checklists for their service catchment area, the utility of this app is restricted by the poor availability of 3G service across rural areas. Whilst we fully agree with the editorial regarding the value of mobile phones in the developing world, we feel that the NHS should recognise the value of mobile communications in remote and rural areas and actively support improved coverage. The current position is detrimental to NHS service provision in terms of costs and quality of care, which should prompt a corporate response from the NHS to improve coverage for rural services in the UK.

016 Occurrence reporting and significant events during aeromedical transportation: a review of 18 months of retrievals by the Scottish Emergency Medical Retrieval Service (EMRS)

Objectives and BackgroundsHuman factors represent a substantial contribution to significant events in high-risk professions, including medicine and aviation. Aviation has acknowledged this and introduced confidential reporting systems to include human...

Critical care transfers

In his recent editorial, Handy raises interesting points regarding critical care transfers [1]. We endorse the view that only by collecting accurate data regarding transfer activity can we hope to ensure such transfers are undertaken to recognised standards. Only when armed with such data, including robust clinical governance and critical incident review, can we demonstrate the volume of work involved and the need for appropriate resources. We would suggest that the recent evaluation of the Emergency Medical Retrieval Service exemplifies this approach [2], and resulted in continuation of the service after an 18-month pilot, built on the strengths of an earlier voluntary model. A recent audit of inter-hospital transfers in Scotland again showed a reduced incidence of equipment failure when dedicated transfer teams were utilised, compared with ad hoc transfer arrangements (0.6% vs 9.2%) and a reduced incidence of unsecured medical equipment (1% vs 18%) [3]. One factor not discussed is that transfers are multi-agency tasks, involving both hospital and ambulance services. We suggest that an essential element when developing a critical care transfer network is to build closer working relationships. Greater understanding of the needs and priorities in a critical care transfer and the logistics and practical constraints on the ambulance service will improve the transfer process. As anaesthetists, we are familiar with paramedic airway skills training in the operating theatre, but to improve the critical care transfer process it is probably worth offering greater critical care exposure. We are concerned by the assertion that ‘retrieval teams will never be able to perform time-critical transfers as quickly as the referring hospital’ and the implication that neurosurgical emergencies are not time-critical. This assumes that the UK is wholly covered by district general hospitals and tertiary centres. Across much of remote and rural Scotland, initial emergency care is provided at general practioner-staffed community hospitals with no CT scanner and no staff able to institute advanced airway care. The Department of Health report ‘Comprehensive Critical Care’ stressed the importance of providing critical care beyond traditional unit boundaries [4]. Patients from these centres requiring critical care can be transferred more rapidly by an airborne critical care team to the most appropriate unit, rather than by local means. Local personnel have infrequent exposure to critical care and undertaking such a transfer stretches local services for a prolonged time, as the return journey is often protracted. It makes more sense to take critical care skills to the patient, then to resuscitate, stabilise and triage appropriately. We disagree with the suggestion that ‘if retrieval teams are to accommodate all transfers at all times of the year, they will need to incorporate significant built-in redundancy… a situation deemed intolerable in the current UK healthcare climate.’ Emergency care is an essential aspect of the NHS, and critical care transfers will often involve clinical emergencies at unsocial hours. A recent report from the Royal College of Surgeons highlights the issue of marginalisation of emergency surgery and similar considerations apply to critical care transfers [5]. This reinforces the need for accurate data and a clear appreciation of the urgency of cases and severity of illness involved. Audit will inform accurate deployment of resources, and a predictable seasonal variation in activity may allow a greater emphasis on teaching and training at times of reduced demand, with increased clinical availability at peak times. It is interesting to compare this editorial with one from 1994 [6]. Whilst progress has been made, increasing centralisation of the emergency specialities of trauma and interventional cardiology, and expansion of extracorporeal membrane oxygenation services, will place additional pressures on transfer services with an expectation that our specialty will be able to respond. A thorough appreciation of the current workload is essential.

010 ‘Time well spent?’: a correlation between total time on-scene (TOST) and interventions delivered for an Aero medical retrieval service

IntroductionThe Emergency Medical Retrieval Service (EMRS) provides a retrieval service to remote and rural communities (>70% of EMRS referrals are from isolated general practices or GP led community hospitals). These...

On-scene times and critical care interventions for an aeromedical retrieval service

BackgroundThe Emergency Medical Retrieval Service (EMRS) provides an aeromedical retrieval service to remote and rural communities. Most of these facilities are unable to deliver Critical Care Interventions (CCI). CCI are...

Scottish audit of interhospital transfers of acutely ill adults

The audit was commissioned by the Scottish Government Health Department to identify the number of acutely ill adults transported between hospitals by the Scottish Ambulance Service (SAS). Currently interhospital transfer (IHT) of acutely ill adults requiring medical escorts is undertaken by the SAS Accident and Emergency (A&E) ambulances or by dedicated transport teams (for example, Glasgow Shock Team and Emergency Medical Retrieval Service).