Air ambulance: how an air ambulance brings a new heart.
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FROM the Western Isles to Renfrew; Southern General Hospital, Glasgow staff the air ambulances.
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The Red Cross (Western Cape Region) Air Ambulance Service.
The Air Ambulance Service completed 20 years of service to the people of southern Africa and particularly those of the Cape Province on 6 February 1986. This remarkable achievement by a voluntary organization supported by the community has been attained while maintaining an exceptionally high standard of patient care. Demands on the service have increased to the extent that there are now two aircraft in full-time use. The air ambulances are fully integrated with the overall emergency medical services in the Cape Province, co-ordinated by the hospitals department through its Metro control centre. There is every reason to believe that the number of patients transported by air in the future will increase and with improvements in landing facilities in the larger centres serious thought has to be given to the acquisition of a more sophisticated aircraft to serve these areas in particular.
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A nationwide survey of civilian air ambulance services.
To identify and characterize civilian air ambulance services, a questionnaire was mailed nationwide to 583 prospective air ambulance services, with 154 responding. Our survey identified differences between hospital, hospital-affiliated, and private air ambulance services as to aircraft ownership, availability, types of aircraft, types of patients being transported, types of medical personnel and equipment, aircraft retrofit, and their feelings regarding air ambulance regulations. We found that hospital air ambulances are better suited for transporting critically ill patients while many private air ambulances appear better suited to transport nonemergency patients. Hospital-affiliated air ambulance services, although not as consistent in providing the specialized care of hospital air ambulances, appear better able to provide critical care than private air ambulance services. Based upon this data, we recommend that air ambulance regulations be directed at levels of patient care. Such regulations and guidelines will assist patient safety during aeromedical transports without jeopardizing currently operating air ambulance services.
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An analysis of an air-ambulance program for children.
Air-ambulance services are extremely expensive to operate and maintain. The value of their existence has been questioned in this era of rationalization and downsizing. We examined the cost, safety, flight crew composition, types of trauma, and effectiveness of our air-ambulance program at the Children's Hospital of Eastern Ontario (CHEO) over a 3-year period, 1994-1997. During this time, 392 children were aeroevacuated to CHEO, 113 surgical (29%), 136 medical (35%), and 143 neonates (36%). Of the surgical cases, 43% were transferred for orthopaedic trauma, the commonest being fractured femur, 23% for general surgical cases, most common being thoracoabdominal trauma, and 22% for neurosurgical reasons, most commonly basilar skull fractures. The average response time (time from which the call was received to the time when the helicopter reached the patient site) for all of the cases was 46 min. The average travel time (time from departure of patient site to arrival at CHEO) for these same cases was 25.59 min. The air-ambulance program for children in the Ottawa-Carleton Eastern Ontario areas, was found to be safe, effective, and allowed earlier specialized medical care to be provided.
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A review of drug use during air medical transport to optimize an air ambulance formulary.
INTRODUCTION: The advent of air medical transport has pushed the delivery of critical care medicine into the prehospital arena. As a result, a wide variety of pharmacologic agents must be available in the air medical setting. PURPOSE: The purpose of this study was to conduct a retrospective review of drugs used during air medical transport to allow a streamlining of the air ambulance formulary. METHODS: All flights completed since the inception of the study's helicopter air ambulance program in 1985 through September 1991 were analyzed to determine which medications were used in flight. Drugs were counted if they were administered while in flight for either a scene or interhospital transport. RESULTS: Review of 2,694 flights showed that 45 individual drugs had been routinely carried during the study period. Many of these agents were administered fewer than five times during the six years, and 10 drugs were not used at all. CONCLUSION: As a result of this investigation, the formulary for our air medical transport service was modified. The authors recommend similar critical audits of drugs carried in flight be performed by other air ambulance services.
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Air ambulance regulations: a model.
Prior attempts at establishing minimal federal air ambulance regulations and standards have been unsuccessful. However, reports of poor patient medical care during transport by some air ambulance services is now forcing many states to initiate air ambulance regulations. In 1984, the State of Utah Emergency Medical Services convened a special subcommittee to develop aeromedical regulations for the State of Utah. Using a three-level approach based upon the patient's requirements for basic, advanced, or specialized medical care and the urgency of transport, the subcommittee was able to derive medical categories necessary for the selection and utilization of air ambulance services. Minimum air ambulance regulations were then established for aircraft configuration, flight crew requirements, minimal equipment and medications, and the responsibilities of the medical director or designee for each of the three levels of medical care. We conclude that the application of a levels approach based upon the patient's medical requirements may be useful in assisting other states attempting to establish flexible but specific regulations directed at the safe transport of patients by aeromedical evacuation.
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Air ambulance trauma transport: a quality review.
OBJECTIVE: Provincial air ambulance transports of injured patients were quality reviewed prospectively to determine utilization and appropriateness of care. METHODS: All trauma air ambulance transports over a 2-month span were reviewed prospectively. Revised Trauma Score, Injury Severity Score, probability of survival, prehospital time, distance of transport, procedures performed, and outcome were determined. Quality control questions were asked of the sending and receiving physicians. RESULTS: The majority of air ambulance transports reviewed (N = 97) were indicated for mechanism and severity of injury. Economics and requirement for advanced medical care were indications in only 15%. Physicians tended to perform more advanced procedures, likely related to higher patient Injury Severity Score (23 vs. 15, p = NS). Four problems with air ambulance access were identified. The overtriage rate was 5%. Inappropriate patient care was documented in six (6%) cases; a physician was present for only one of these. CONCLUSIONS: A low overtriage rate was documented, raising concerns that the undertriage rate may be too high. Injured patients air transported without physician accompaniment more often received inappropriate care, suggesting that physician accompaniment is beneficial.
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Regulations and the air ambulance.
The recent biopolitical history of air ambulance development and the need for regulations is reviewed. There has been significant interaction between Aerospace Medical Association committees, the Federal Aviation Administration, and the Civil Aeronautics Board. The Federal Aviation Administration's Advanced Notice and Withdrawal of Proposed Rulemaking, the latter based on the FAA supposition that the "majority" of states had enacted regulations and guidelines, is compared to actual data that only seven states have regulations and two have guidelines. The precedence for FAA to act on regulations is established. The Aerospace Medical Association and the National Highway Traffic Safety Administration - not the FAA - have established and documented excellent guidelines. The FAA is providing a valuable service to aviation in general and air ambulance operations specifically through physiological training at military facilities which can provide information to promote patient protection in air ambulance operations.
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The effects of air ambulance admissions on orthopaedic trauma services in a single hospital.
UNLABELLED: Emergency air ambulance admissions to the authors' hospital have increased five-fold from 18 in 1992-1993 to 92 in 1998-1999. The service implications for hospitals receiving air ambulance admissions is unknown. AIM: An audit/analysis of all emergency air ambulance admissions to the authors' hospital between August 1998-July 1999. METHOD: Admissions identified from computer records. The case notes were then retrospectively analysed. Data was collected on accident location, admitting specialty, number of orthopaedic procedures and their operative time, and length of inpatient stay. RESULTS: There were 92 patients brought in by air ambulance. Hospital notes were available for 82 and a further 8 had A&E case notes only available for analysis. A total of 34 (38%) were admitted under the orthopaedic surgeons, 28 (31%) under the neurosurgeons, 10 (11%) under the plastic surgeons, 2 (2%) under the general surgeons and 2 (2%) under the physicians. Nine patients were discharged home from the A&E department, two died in A&E and five were transferred to other hospitals. Four of the neurosurgical patients needed orthopaedic input. The admitted patients required 122 orthopaedic procedures taking 120 h of theatre time. The total orthopaedic inpatient stay was 628 days, of which 145 days were in the intensive care or high dependency units. A total of 28 (80%) of the orthopaedic patients came from outside the hospital's catchment area. CONCLUSIONS: Admissions by air ambulance place a high demand on orthopaedic services and often originate from outside the hospital's catchment area. Additional resources may be required by hospitals receiving trauma patients by this route.
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[State air ambulances and "physicians of the air"].
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The impact of a new regional air ambulance service on a large general hospital.
BACKGROUND: Helicopter air ambulance crews are influenced in their selection of the destination hospital for their patients by several factors including: distance from the scene; facilities, on site specialties, and senior cover of the receiving hospital; and the proximity of the helicopter landing area to the emergency department (ED). Only a limited number of hospitals have landing sites adjacent to the ED from which patients can be taken directly into the department (primary landing sites). Helicopter crews will often elect to over fly hospitals that do not have primary landing sites because secondary land transfers will add delays in delivering patients. Birmingham Heartlands Hospital has an elevated helideck adjacent to the ED. In October 2003, the Warwickshire and Northamptonshire Air Ambulance (WNAA) service was launched; the hospital sits on the western periphery of the area served by the service. METHODS: Prospective data was collated on all patients brought by WNAA to Heartlands Hospital between 1 October 2003 and 31 August 2004. RESULTS: In the 10 month period after the launch of the service, the helicopter delivered 83 patients to the ED; 74 of these were "off patch". This additional workload generated 163 ward days, 19 operative procedures, and 85 intensive care unit, high dependency unit, or coronary care unit days. The direct costs of this additional workload approached 160,000 pounds sterling. CONCLUSIONS: In future discussions on the cost effectiveness of air ambulances, it will be important to consider both the direct and indirect costs to the receiving hospitals arising from the redistribution of emergency workload.
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A computer-based simulator for air ambulance system analysis, design and optimization.
INTRODUCTION: Little is known about how best to quantitatively measure air medical system performance and optimally manage air medical emergency medical services start-up, operation and growth. Moreover, very little has been done to produce and distribute relevant tools for these critical tasks. SETTING: A hypothetical system modeled on the Ontario, Canada, air ambulance operation. METHODS: A user-friendly, high-performance computer simulation tool for air ambulance system design, quality management and optimization was developed. In this report, the authors describe the simulator's basic structure and method of operation and present the initial findings for application to the Ontario air ambulance system. The tool tested the hypothesis that if shorter patient transfer times positively influence patient survival and higher aircraft performance, as measured by block speed, has a positive correlation with aircraft direct operating costs, then there is a pattern of "best matching" between aircraft performance, flight economics and patient survival probability for the system. RESULTS: In the Ontario air ambulance system, an additional outlay in direct operating costs of $100 per flight yields an improvement in system quality, as measured by an improvement of 1% to 30% in the predicted patient survival probability, depending on the reference cohort and the efficacy of the life support procedures administered by the air crew. DISCUSSION: A notable feature of this model is that it separates the impact of air medical transport on patient survival from subsequent measures undertaken at the emergency department after delivery to the trauma center. The current needs of the air medical transport industry, combined with the progress to date, suggest that computer-based simulators can be a powerful, cost-effective means of extracting meaning from air medical data and applying the results to productive ends.
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The impact of an air ambulance system on an established trauma center.
Hospital competition for air ambulance business has resulted in implementation of a helicopter service before the medical staff can prepare for the increased patient load. We reviewed the effect of an air ambulance on an already established trauma center (TC) by analyzing the impact of the helicopter trauma patient load during the initial year of operation. The helicopter carried a three-member flight crew consisting of a pilot, paramedic, and critical care nurse. Admission data of all flights from February 1982 through February 1983 were reviewed. Of the 325 air missions launched, 192 (59%) were for the transport of trauma victims. One hundred forty (73.6%) patients were transported from local hospitals, the remaining 52 (26.4%) from the accident scene. Ninety per cent of the injuries were due to motor vehicle accidents. Forty-nine per cent of the flights occurred on weekends and 68.8% were launched between 7:00 P.M. and 3:00 A.M. The average flight times from hospital and accident scenes were 37 min 30 sec and 13 min 30 sec, respectively. Of all trauma missions flown, 126 (65.8%) were considered new or 'captured' by the air ambulance system and brought to the TC. Thirty-seven (19.3%) patients died in flight, were DOA, or died within 1 hour of TC arrival. Eighty per cent of the deaths were from massive head injuries. The average injury severity score was 35.58 (all patients), 32.9 (survivors), and 45.80 (deaths).(ABSTRACT TRUNCATED AT 250 WORDS)
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Changes in cardiac output during air ambulance repatriation.
OBJECTIVES: To measure, with the use of suprasternal Doppler ultrasound, the hemodynamic changes in patients and volunteers during air ambulance repatriation. DESIGN: Unblinded prospective observational study. SETTING: Chartered air ambulances for the international repatriation of patients. PATIENTS AND PARTICIPANTS: Six medical crew members and seven patients transported back to hospitals in the UK. INTERVENTIONS: The measurement of non-invasive blood pressure, ECG, heart rate, oxygen saturation and hemodynamic variables with suprasternal Doppler. MEASUREMENTS AND RESULTS: There was a drop in systolic and mean arterial blood pressure in the patient's group once in the air. Oxygen saturation dropped in both groups once at cruising altitude. Heart rate remained unchanged. Stroke distance and minute distance increased significantly in the patient's group and non-significantly in the volunteers. Peak velocity increased significantly in the patient's group. There was an overall reduction of systemic vascular resistance during take off and once at cruising altitude. CONCLUSIONS: Hemodynamic changes happen during air ambulance transportation in fit and healthy volunteers and patients alike. These may be due to a combination of hypobaric hypoxia and gravitational forces. It is necessary to establish if these changes have short- or long-term effects in the critically ill.
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Civilian air ambulance services in Oregon.
To describe and evaluate the status of air ambulance service in Oregon, questionnaires were mailed to Oregon's 18 air ambulance operators; 16 operators responded with data on aircraft type and configuration, medical supplies and equipment aboard the aircraft, and training of inflight attendants. Records of 128 of the 152 patients transported by these services during September, 1985, were reviewed to estimate the extent to which patients had been appropriately selected. Findings were: trauma patients being transported to large specialized medical centers comprised the single largest patient category; failure to obtain an aeromedical assessment of every patient preflight resulted in some inappropriate transports, with airlift definitely contraindicated in at least 2% of the cases; most agencies met advanced life support standards for equipment; inflight documentation was inadequate; numerous aircraft lacked pressurization and adequate doorway size; many attendants received insufficient aeromedical training; and existing state regulations went unenforced. Measures to guide services and to remedy existing deficiencies are recommended.
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[Quality revision of air ambulance services].
The 14 anaesthesiologist-manned ambulance helicopters in Norway are administratively placed under the head of the nearest anaesthetic department. Routines for quality assurance vary considerably. In 1995, a total of 6,850 patients were treated by air ambulance anaesthesiologists. An enquiry to all 14 air ambulance services revealed that approximately two thirds of all medical records were reviewed for quality assurance purposes. Only half of the reviewers based their work on written treatment procedures in addition to their own sense of good clinical practice. A review of all 162 medical records for one year at one air ambulance base indicates that a thorough review of one third of all records would identify all major areas of improvement. The selection of records has to be based on local experience concerning both patients and personnel. When areas of improvement are identified, the quality assurance process can be simplified without increasing the risk of not addressing serious problems.
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Air ambulance services--integrated emergency care.
In the name of cost-conscious care, air ambulance program directors and service contractors are seeing the dawn of integrated networks as a boon to their business. As integrated networks form, facilities will become increasingly specialized in the types of services they provide. Patients will need to be moved around the system, resulting in more frequent patient transport and more points of transfer. Many programs are considering aircraft replacement and additions, rather than leasing. Financial benefits could come on depreciation and the high resale value of aircraft. Unless reimbursement levels increase, more program mergers and affiliations may take place to spread and reduce cost. Air ambulance services will increasingly become part of a facility's strategic plan.
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