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.

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.

Aeromedical Transport for Critically Ill Patients.

Aeromedical transport (AMT) is an integral part of healthcare systems worldwide. In this article, the personnel and equipment required, associated safety considerations, and evidence supporting the use of AMT is reviewed, with an emphasis on helicopter emergency medical services (HEMS). Indications for HEMS as guideded by the Air Medical Prehospital Triage Score are presented. Lastly, physiologic considerations, which are important to both AMT crews and receiving clinicians, are reviewed.

A Descriptive Analysis of Air Medical Pediatric Rapid Sequence Intubation: Successes and Opportunities.

OBJECTIVE: Advanced airway management, including the use of rapid sequence intubation (RSI), is fundamental in resuscitation. However, the reported experience with pediatric airway management is limited because of the relatively low number of emergency RSI procedures in children. The aim of this study was to document the experience with pediatric RSI in a large air medical database and explore opportunities for improvement. METHODS: All pediatric patients (age < 18 years) undergoing RSI by air medical crews between 2015 and 2019 were included in this analysis. Subjects were divided a priori into 3 age subgroups (0-2 years, 3-8 years, and 9-17 years). The primary variables of interest included overall intubation success, first-attempt intubation success, and first-attempt intubation success without desaturation. The rates of positive-pressure ventilation (PPV) use for preoxygenation and oxygen desaturation were also explored. RESULTS: A total of 1,091 pediatric RSI patients were included. The overall intubation success rate was 98% (0-2 years = 96%, 3-8 years = 97%, and 9-17 years = 98%), with 91% intubated on the first attempt (0-2 years = 86%, 3-8 years = 90%, and 9-17 years = 92%) and 87% intubated on the first attempt without oxygen desaturation (0-2 years = 80%, 3-8 years = 88%, and 9-17 years = 90%). A sharp decline in intubation success was observed with preoxygenation SpO2 values < 97% across all patients. Younger patients (0-2 years) had lower initial SpO2 values and decreased first-attempt success rates with and without desaturation. These patients were less likely to receive PPV during preoxygenation attempts and had lower use of video laryngoscopy or a bougie on the initial intubation attempt. CONCLUSION: In this study, we documented high success rates for air medical pediatric RSI. Higher target SpO2 values may be justified during preoxygenation. Intubation success, PPV use for preoxygenation, video laryngoscopy, and the use of a bougie were lower for younger patients.

Using NEMSIS to report annual air medical transport statistics.

OBJECTIVE: The objective of this study was to use the National Emergency Medical Services Information System (NEMSIS) dataset to generate national air medical transport statistics. METHODS: Retrospective review of the 2021 NEMSIS dataset to identify all air medical transfers, both fixed- and rotor-wing. Transfers where then subcategorized into interfacility and scene responses. Frequencies for each category were generated and reported. RESULTS: A total of 317,267 air medical transfers were completed in 2021. These included 19,421 (6 %) with missing incident location code data. Of the 297,706 transfers with valid location codes, 208,689 (70%) were interfacility transfers, and 89,016 (30%) were scene responses. CONCLUSION: These preliminary results are consistent with other national estimates and achieve representation of all states and territories. Future work will include longitudinal analysis of NEMSIS datasets and direct survey of transport programs to establish long-term reliability.

The Estimated Cost-Effectiveness of Physician-Staffed Helicopter Emergency Medical Services Compared to Ground-Based Emergency Medical Services in Finland.

OBJECTIVE: Because the unit cost of helicopter emergency medical services (HEMS) is higher than traditional ground-based emergency medical services (EMS), it is important to further investigate the impact of HEMS. The aim of this study was to evaluate the cost-effectiveness of physician-staffed HEMS compared with ground-based EMS in Finland under current practices. METHODS: The incremental cost-effectiveness ratio was evaluated using the differences in outcomes and costs between HEMS and ground-based EMS. The estimated mortality within 30 days and quality-adjusted life years (QALYs) were used to measure health benefits. Quality of life was estimated according to the EuroQoL scale, and a 1-way sensitivity analysis was conducted on the QALY indexes ranging from 0.6 to 0.8. Survival rates were calculated according to the national HEMS database, and the cost structure was estimated at 48 million euros based on financial statements. RESULTS: HEMS prevented the 30-day mortality of 68.1 patients annually, with an incremental cost-effectiveness ratio of €43,688 to €56,918/QALY. Fixed costs accounted for 93% of HEMS expenses because of 24/7 operations, making the capacity utilization rate a major determinant of total costs. CONCLUSION: HEMS intervention is cost-effective compared with ground-based EMS and is acceptable from a societal willingness-to-pay perspective. These findings contribute valuable insights for health care management decision making and highlight the need for future research for service optimization.

A Description of Medications and Intravenous Fluids Used During Neonatal Transport by a Regional Pediatric Critical Care Team.

OBJECTIVE: This study aimed to describe the type and frequency of enteral and parenteral fluids and medications used during the transport of neonates by a regional pediatric critical care transport team. METHODS: We performed a retrospective analysis of neonates transported by a regional neonatal transport team affiliated with a level IV neonatal intensive care unit within a large care network between 2020 and 2021. Demographic and clinical data were collected from the electronic medical record. Standard frequency tabulation and summary statistics were used to report demographics, transport characteristics, and fluid and medication use; results were then stratified by preterm (37 weeks) and term births. RESULTS: In the 628 included transports, more term than preterm infants received at least 1 fluid or medication (53% vs. 43%, respectively). The most commonly administered medications were antibiotics (ampicillin and gentamicin), prostaglandin, and opiates (morphine sulfate and fentanyl). In addition, term infants received more analgesic medications, antimicrobials, and prostaglandin, whereas preterm infants received total parenteral nutrition more often. There were over 38 different medications provided on the transports studied. CONCLUSION: This study of a single transport team revealed that a wide variety of medications and fluids were used in the transport of neonates, with term infants receiving more medications than preterm infants. These data could be used by transport teams in making or updating their standardized medication lists or in creating simulations.

Survival of Out-of-Hospital Pediatric Blunt Traumatic Arrest With Full Neurologic Recovery: Case Report.

We present the case of a 10-year-old previously healthy male who suffered an out-of-hospital cardiac arrest because of abdominal trauma and survived with excellent neurologic outcomes and near complete return to baseline functional status at hospital discharge. The rapid response and efficient mobilization of resources led to an excellent patient outcome despite the severity of injuries, including intra-abdominal injuries with expected mortality, out-of-hospital traumatic arrest, coagulopathy, and an extended pediatric intensive care unit stay. This case underscores the significance of timely advanced trauma life support interventions, especially early blood product administration, efficient transport, and airway management, while sharing a remarkable case of out-of-hospital pediatric traumatic arrest with near full recovery.

The Effect of Coronavirus Disease 2019 on Adverse Events in Health Care: A Retrospective Study in Ground and Helicopter Emergency Medical Services.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has proven to be a significant hardship for the entire world. Health care systems and their workers have been stretched to their limits. Research regarding whether this increased strain has affected patient safety has not been sufficient, especially in emergency medical services. The aim of this study was to determine if there has been an increased rate of adverse events in ground and helicopter emergency medical services since the onset of the COVID-19 pandemic. METHODS: A 2-year retrospective review was performed at a Midwest regional critical care transport service. The rate of adverse events for 1-year periods before and after March 13, 2020, was the primary outcome. All adverse events that generated a quality improvement incident report form (QIRF) were included, except those generated for non-clinical-related incidents. Additionally, a smaller time frame between May 1st and August 31st of both years was included containing all flagged adverse events from peer reviewers; not all of these generated a QIRF. RESULTS: In the time period between March 13, 2019, and March 12, 2020, 5 of 3,154 (0.16%) calls generated a QIRF versus 21 of 3,185 (0.66%) calls between March 13, 2020, and March 12, 2021. There was a significant relationship showing an adverse event was more likely to happen after the onset of COVID-19 compared with before (χ21 [N = 6,339] = 8.643, P ≤ .001). Additionally, from May 1st to August 31st, the total adverse event rates were 16.86% (143/848 calls) and 24.46% (387/1,582 calls) for 2019 and 2020, respectively. Similarly, statistical significance existed for adverse events occurring after onset of the pandemic versus before (χ21 [N = 2,430] = 18.253, P ≤ .001). CONCLUSION: A higher rate of adverse events for the year after the onset of COVID-19 existed. Additional studies looking at the causes of adverse events and patient outcomes should be undertaken to further understand this increase.

Implementation of a Rapid Sequence Intubation Checklist Improves First-Pass Success and Reduces Peri-Intubation Hypoxia in Air Medical Transport.

OBJECTIVE: Rapid sequence intubation (RSI) is a critical skill commonly performed by air medical teams in the United States. To improve safety and reduce potential patient harm, checklists have been implemented by various institutions in intensive care units, emergency departments, and even prehospital air medical programs. However, the literature suggests that checklist use before RSI has not shown improvement in clinically important outcomes in the hospital. It is unclear if RSI checklist use by air medical crews in prehospital environments confers any clinically important benefit. METHODS: This institutional review board-approved project is a before-and-after observational study conducted within a large helicopter ambulance company. The RSI checklist was used by flight crewmembers (flight paramedic/nurse) for over 3 years. Data were evaluated for 8 quarters before and 8 quarters after checklist implementation, spanning December 2014 to March 2019. Data were collected, including the self-reported use of the checklist during intubation attempts, the reason for intubation, and correlation with difficult airway predictors (HEAVEN [Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurologic injury] criteria), and compared with airway management before the implementation of the checklist. The primary outcome was improved first-pass success (FPS) when compared among those who received RSI before the checklist versus those who received RSI with the checklist. The secondary outcome was a definitive airway sans hypoxia improvement noted on the first pass among adult patients as measured before and after RSI checklist implementation. Post-RSI outcome scenarios were recorded to analyze and validate the effectiveness of the checklist. RESULTS: Ten thousand four hundred five intubations were attempted during the study. FPS was achieved in 90.9% of patients before RSI checklist implementation, and 93.3% achieved FPS postimplementation of the RSI checklist (P ≤ .001). In the preimplementation epoch, 36.2% of patients had no HEAVEN predictors versus 31.5% after RSI checklist implementation. These data showed that before RSI checklist implementation, airways were defined as less difficult than after implementation. CONCLUSION: The implementation of a standardized RSI checklist provided a better identification of deterring factors, affording efficient and accurate actions promoting FPS. Our data suggest that when a difficult airway is identified, using the RSI checklist improves FPS, thereby reducing adverse events.