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Re: Optimising deployment of air ambulances

Dear Editor,

The advantages of helicopter ambulance services are speed of response, access to remote areas, carriage of additional equipment (and personnel) and rapid transport to the nearest appropriate hospital. With an appropriately trained doctor on board, the air ambulance becomes a HEMS unit and offers hospital level immediate critical care at the scene. The challenge of course is to deploy this expensive resource effectively. One way of doing this is to wait for the land ambulance crew’s initial assessment of the scene prior to despatching the helicopter. However, this will incur a significant delay for critically injured and unwell patients and the window of opportunity for advanced interventions at the scene will often be lost. Therefore, the aircraft is usually launched as a primary response to the 999 call. While there are guidelines for helicopter launch, this will often be the subjective decision of the ambulance controller who will decide to launch the aircraft on the volume of calls from an incident or on the nature of the call. Certain key triggers will include mechanism (ejection, entrapment, mass casualties) or location (remote, difficult terrain, non-availability of land crew).

Many of the trauma cases flown to hospital and discharged the same day identified in our study, were isolated peripheral limb fractures in patients injured in remote locations (mainly equestrian injuries lying in fields). These were treated conservatively at hospital and followed up in fracture clinics. While it could be argued that they did not require the skills of a HEMS unit to save their life, many were retrieved quickly from terrain inaccessible to land ambulances, provided with optimum pre- hospital care and taken quickly to hospital. These ‘soft benefits’ of a helicopter unit have never been considered in any previous studies looking at the effectiveness of air ambulance units and we feel that they should.

Our bigger problem is that of ‘stop calls’. These are situations in which the aircraft is launched on the strength of 999 calls and then stood down before arriving at the scene. The reasons for this are many and include the receipt of further information from subsequent 999 calls or subsequent communication from other emergency service responders once they have arrived and assessed the scene. These ‘stop calls’ are expensive and render the aircraft unavailable for other more worthy calls. At present, stop calls represent approximately 20% of our activity and are a drain on our resource.

Send letter to journal:
Re: Delving deeper into the impacts of air ambulance services

Dear Editor,

In their study of the financial impact of a new Air Ambulance service on their institution, Jenkinson and colleagues identify 74 patients who were transported by helicopter from incident locations outside the usual catchment area of their hospital (1). Although the authors focused on the purely financial impact of this additional workload, they have highlighted an important issue for Air Ambulance services.

The decision to fly these 74 patients was made by a physician / paramedic crew on the Warwickshire and Northamptonshire Air Ambulance (WNAA). As I understand the results, 60 patients were categorized as trauma patients and, of these, 15 (25%) were discharged home from the ED on the same day. This implies that these patients did not have injuries that warranted hospital bypass or the risks and costs associated with air medical transfer (2,3). It would be useful to understand how these transport decisions were made.

This over-triage problem is not isolated to WNAA. A recent review of the literature on primary scene transport has identified that 446 of 1,850 patients (26%) were discharged from the ED within 24 hours of arriving by helicopter (4). Although some degree of over-triage is inevitable, these proportions seem too high.

Many of the UK Air Ambulance services, particularly those funded by charity, regard the transportation of patients as one measure of success. The number of patients conveyed is often regarded as a key performance indicator. Given the relative increase in risk and cost associated with unnecessary helicopter transfer compared to ground ambulance transfer, there is a need for much closer scrutiny of helicopter transport decisions. We will then be in a better position to focus Air Ambulance resources on those patients who can benefit.

References

1. Jenkinson E, Currie A, Bleetman A. The impact of a new regional air ambulance service on a large general hospital. Emerg Med J, 2006;23:368-371.

2. Nicholl J, Turner J, Stevens K, et al. A review of the costs and benefits of the helicopter emergency ambulance services in England and Wales. Final report to the Department of Health. University of Sheffield: Medical Care Research Unit, 2003.

3. Isakov AP. Souls on Board: Helicopter Emergency Medical Services and Safety. Ann Emerg Med 2006;47:357-360.