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.

Comparing Intubation Success Between Flight Nurses and Flight Paramedics in Helicopter Emergency Medical Services.

OBJECTIVE: Intubation is a vital skill performed by flight nurses and paramedics. Before flight training, nurses do not routinely intubate and must be trained in proper techniques. Flight paramedics universally train in intubation before flight training and are the primary managers of in-flight airways. The aim of this study was to determine if a difference exists in intubation attempts and success rates between flight nurses and flight paramedics. METHODS: A 5-year retrospective chart review was performed from a regional helicopter emergency medical service. Intubation attempts and the success of flight nurses compared with flight paramedics were the primary outcomes. RESULTS: Three hundred three of 322 cases in which intubation was attempted were successful. Three hundred forty-four total intubation attempts were made. Two hundred seventy-one (88.9%) patients were intubated by paramedics, and 32 (10.5%) were intubated by nurses. Of the 19 unsuccessfully intubated patients, 14 (73.7%) were attempted by a paramedic and 5 (26.3%) by a nurse. Two hundred seventy-seven intubations were successful on the first attempt, 250 (90.3%) of which were performed by a paramedic and 27 (9.7%) by a nurse. CONCLUSION: Flight paramedics performed more intubations with greater success than flight nurses.

Out-of-pocket payments made by patients transported by Helicopter Emergency Medical Services (HEMS).

OBJECTIVE: Recent news media have reported that Helicopter Emergency Medical Service (HEMS) programs use the practice of balanced billing, resulting in exorbitant charges not covered by insurance companies and financially burdening patients. To date, no study has described the billing practices of HEMS programs. We look to provide transparent billing practices and average patient payment of one midwestern non-profit HEMS program and report the reimbursement data of both federal and private insurance policies for transports. METHODS: Collated billing data were obtained from a HEMS program for two time periods from January 2017 through June 2018 (P1) and July 2018 through December 2019 (P2). From P1 to P2 the base charge per transport was increased. All transports that generated a bill during the periods were included and descriptive statistics were used to depict the findings. RESULTS: Per flight, base charge was $19,158 in P1 and $33,023 in P2. On average, patients paid $158.09 and $178.99 out-of-pocket, respectively. Reimbursement practices of insurance companies varied widely across time periods and among each other. CONCLUSION: The amount charged by this HEMS program and amount patients paid on average for flights was less than has been commonly reported in recent news media. More transparency in costs and payments between non-profit and for-profit HEMS agencies should occur.

Determining a Need for Point-of-Care Ultrasound in Helicopter Emergency Medical Services Transport.

OBJECTIVE: Point-of care-ultrasound (PoCUS) is useful in evaluating unstable emergency department patients. The portability of this technology increases its potential use in prehospital settings, including helicopter emergency medical services (HEMS) programs. Identifying useful applications may support implementing a PoCUS program that develops sonography skills for prehospital providers. The aim of this study was to determine the HEMS patient population that would benefit from prehospital PoCUS for hypotension and how commonly the extended focused assessment with sonography in trauma (E-FAST) for trauma patients or the rapid ultrasound in shock (RUSH) for medical patients could be used by HEMS. METHODS: A retrospective chart review was performed over a 1-year period of adult patients transported by a midwestern HEMS system. Charts were reviewed for episodes of hypotension. RESULTS: The chart review included 216 charts, of which 3 were excluded. Of the 213 cases, 100 were trauma patients, and 113 were medical patients. Of the trauma patients, 51% experienced hypotension, as did 73 of 113 medical patients. CONCLUSION: Fifty percent of HEMS patients may benefit from PoCUS to evaluate for hypotension in flight.

The Safety and Utility of Ground Transport of Traumatic Cardiopulmonary Arrest Patients by Helicopter Emergency Medical Services Crews.

OBJECTIVE: Patients suffering from traumatic cardiopulmonary arrest (TCPA) typically demonstrate dismal survival rates. Some helicopter emergency medical services (HEMS) systems transport TCPA patients via ground with a referring agency when cardiopulmonary pulmonary resuscitation is in progress. With expanding research on the inherent risk of ground emergency medical services (GEMS) transport with the use of lights and sirens to both crew and the general public, the benefits may not outweigh the risks of transporting these patients by GEMS. The aim of this study was to determine the number of TCPA patients transported by GEMS with HEMS crews on board who survived to hospital discharge. METHODS: A retrospective chart review was performed of approximately 10 years of data from a regional Midwest HEMS service. Survival to hospital discharge was the primary outcome. RESULTS: Flight crews transported 54 patients via ambulance with GEMS crews; 31 patients met all inclusion and exclusion criteria. Of the 31 patients transported, 0 survived to hospital discharge. CONCLUSION: Based on our 0% survival rate and the inherent risk of injury and death to emergency medical services crews and the general public, the risk of transporting adult TCPA patients by GEMS using lights and sirens outweighs the benefit.

Factors That Contribute to Provider Decision Between Direct and Video Laryngoscopy in a Helicopter Emergency Medical Services System: A Survey.

OBJECTIVE: In caring for critically ill patients in the prehospital setting, rapid, definitive airway management is a high-risk, crucial procedure. All helicopter emergency medical services (HEMS) providers must proficiently and safely perform this procedure. Little information is available about the preference and efficacy of video laryngoscopy (VL) compared with direct laryngoscopy (DL). Additionally, there is a paucity of research investigating which method of intubation is more successful in the HEMS setting. The objective of this study was to delineate factors that contribute to provider decision regarding the method of orotracheal intubation and compare the frequency of use for each method. METHODS: An anonymous online survey was distributed to all providers in a single HEMS program. The survey results were deidentified and blinded to the researchers. RESULTS: The survey was sent to 40 HEMS providers; 29 responded, and 119 total intubations were reported. Method familiarity and patient condition were the most commonly cited reasons for choosing both DL and VL for intubation. DL accounted for 15 intubation attempts, whereas 104 attempts were completed by VL. CONCLUSION: For both laryngoscopy techniques, the top reasons cited for selecting an intubation technique were being comfortable with that technique and patient presentation. Further investigation with chart review would help confirm the reported data.

Effectiveness of Manual Ventilation in Intubated Helicopter Emergency Services-Transported Trauma Patients.

BACKGROUND: Helicopter Emergency Medical Services agencies frequently transport intubated patients to definitive care. No evidence exists to determine the type of ventilation in this population. Practice varies amongst programs from bag-valve-mask to mechanical ventilation. STUDY OBJECTIVE: Evaluate the effectiveness of bag-valve ventilation in intubated trauma patients. We hypothesized manual ventilation provides adequate support to maintain physiologic ETCO2. METHODS: From June to December 2015, twenty patients were enrolled in this prospective, observational study. Included were endotracheally intubated trauma patients transported by this HEMS program. Excluded were interfacility transports, non-scene calls, and patients with supraglottic devices. ETCO2 was recorded every 30 seconds during the flight. As a descriptive pilot study, power was not considered. RESULTS: 20 patients provided over 500 cumulative minutes of manual ventilation data. The percentage of cumulative time spent with adequate oxygen saturations was 83.6%. The percentage of cumulative time spent with adequate ETCO2 was 48.7%, with 34.6% of time spent under and 16.7% above this range. CONCLUSION: Manual ventilation maintained a physiologic ETCO2 only 16.7% of the time. Significant variability existed, resulting in intermittent hypoxia and hyperventilation. Prior research linked such events to increased morbidity and mortality. Further studies are warranted to compare manual against mechanically ventilated patients.

Helicopter Emergency Medical Services Utilization.

BACKGROUND: The decision to utilize HEMS is a complex process that involves many considerations. Professional associations and agencies have published guidelines to assist providers with decision making for the utilization of helicopter transport. STUDY OBJECTIVE: Determine if requests for HEMS align with recently published utilization guidelines. STUDY DESIGN: A retrospective chart review was performed during a six-month period. Reviewers versed in Wisconsin HEMS Utilization, NAEMSP, and CAMTS guidelines determined if transport criteria were met. Charts were categorized according to whether or not criteria for each set of recommendations were followed. RESULTS: 514 charts were reviewed; 439 consisted of completed patient transports. CAMTS, NAEMSP, and WI HEMS guidelines satisfied 85.4%, 83.4%, and 53.1% of requests, respectively. Statistically significant differences existed when comparing rates meeting criteria between WI HEMS and CAMTS and between WI HEMS and NAEMSP guidelines (p-value <0.0001). This was true in all subgroups except STEMI, which did not show significant difference. No difference existed between rates for CAMTS and NAEMSP guidelines in any group. CONCLUSION: Significant difference between Wisconsin HEMS utilization versus NAEMSP guidelines, and between Wisconsin HEMS utilization and CAMTS guidelines in all subgroups except STEMI patients exist. No statistically significant difference existed between NAEMSP and CAMTS guidelines.