HEMS vs GEMSby ground or by air: which is the best way to take care of traumatized patients

Narrative review by Mario RugnaPhysician GEMS and HEMS Florence, Italy

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References

On line literature search

You can find the original articles mentioned in the presentation at:

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Cost-Effectivness

Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States

M. Kit Delgado, MD, Kristan L. Staudenmayer, MD, N. Ewen Wang Ann Emerg Med. 2013 October ; 62(4): 351–364.e19.

Conclusions Compared to ground EMS transport, helicopter scene

transport is cost-effective if it results in a reduction in the relative risk of death for seriously injured trauma patients of at least 17% given our model assumptions. This translates into the need to save at least 1.6 lives per 100 patients transported with serious injury. Given current uncertainties, helicopter EMS

Given current evidence, it is not clear that HEMS achieves this mortality or disability reduction.

Reducing over-triage of minor injury patients to HEMS would improve its cost-effectiveness.

Benefit of HEMS

Galvagno Critical Care 2013, 17:169

Speed

HEMS missionTime to reach the targetOn scene timeTransport time to Trauma Center

Speed

HEMS to target Dispatch Take off Landing

On the target Nearby area/rendez-vous with ground EMS No safe landing space (Winch, hovering )

Dispatch

Take-off

Landing

Speed

Time to reach the targetHEMS vs GEMS

Marco A. Diaz, et al. J Trauma. 2005;58:148–153.

Speed

On scene timeSurvival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients

Andruszkow et al. Critical Care 2013, 17:R124

The extent of medical treatment on-scene which involved intubation, chest and treatment with vasopressors was more extensive in HEMS (p<0.001) resulting in prolonged on-scene time (39.5 62 vs. 28.9 minutes, p<0.001).

Impact of prehospital mode of transport after severe injury: A multicenter evaluation from the Resuscitation Outcomes Consortium

Eileen M. Bulger, Danielle Guffey. J Trauma Acute Care Surg. 2012 March ; 72(3): 567–803

Patients transported by air had higher rates of prehospital intubation (81% vs. 36%;) received more intravenous fluids (mean 1.3 L vs. 0.8 L; p< 0.001), and had longer prehospital times (mean 76.1 minutes vs. 43.5 minutes; p<0.001).

Speed

When Is the Helicopter Faster? A Comparison of Helicopterand Ground Ambulance Transport TimesMarco A. Diaz, Gregory W. Hendey, and Herbert G. Bivins, J Trauma. 2005;58:148 –153.

Time from 911 call to hospital arrival versus distance from hospital,

for ground, non simultaneously

dispatched (NSD), and simultaneously dispatched (SD)

helicopter transports. Each bar rep-resents the mean time from 911 call

to hospital arrival, in minutes, with 95%

confidence intervals.

Speed

When Is the Helicopter Faster? A Comparison of Helicopter and Ground Ambulance Transport Times Marco A. Diaz, Gregory W. J Trauma. 2005;58:148 –153.

Results: Ground trans-ports were significantly faster than non simultaneously dispatched ( NSD) helicopter transports at distances under 20 miles. Between 20 and 44 miles, there was no significant difference, and at distances greater than 45 miles, NSD helicopter transport was significantly faster than ground transport

Simultaneously dispatched (SD) helicopter transports became significantly faster than ground transport at distances greater than 10miles from the hospital.

Speed

When Is the Helicopter Faster? A Comparison of Helicopter and Ground Ambulance Transport Times Marco A. Diaz, Gregory W. J Trauma. 2005;58:148 –153.

Conclusions: Ground ambulance transport provided the shortest 911-hospi-tal arrival interval at distances less than 10 miles from the hospital. At distances greater than 10 miles, simultaneously dispatched air transport was faster.

Non simultaneous dispatched helicopter transport was faster than ground if greater than 45 miles from the hospital.

Severity

Dennis Den Hartog et al. Injury, Int. J. Care Injured (2015)

Patients in the HEMS group were more severely injured (ISS 26 versus 22; p < 0.001) and had more disturbed vital parameters (lower GCS and RTS; p < 0.001).

Andruszkow et al. Critical Care 2013, 17:R124

Patients treated by HEMS were more seriously injured compared to GEMS (ISS 26.0 vs. 23.7, P < 0.001) with more severe chest and abdominal injuries.

Bulger et al. J Trauma Acute Care Surg 2012 March

Patients transported by air were more severely injured (mean Injury Severity Score, 30.3 vs. 22.8; p<0.001)

Severity

Helicopter Scene Transport of Trauma Patients with Nonlife Threatening Injuries: A Meta-Analysis

Bryan E. Bledsoe, DO, FACEP, A. Keith Wesley, MD, FACEP, Marc Eckstein, MD, FACEP, Thomas M. Dunn, PhD, Michael F. O’Keefe, MS J Trauma. 2006;60:1257–1266.

Results: There were 22 studies comprising 37,350 patients that met the inclusion

criteria. According to the ISS, 60.0% [99% confidence interval (CI): 54.5–64.8] of

patients had minor injuries, According to the TS, 61.4% (99% CI: 60.8–62.0) of pa-tients had minor

injuries. According to TRISS methodology, 69.3% (99% CI: 58.5– 80.2) of patients

had a greater than 90% chance of survival and thus nonlife threatening injuries.

There were 25.8% (99% CI: 1.0–52.6) of patients discharged within 24 hours after arrival at the trauma center.

Conclusions: The majority of trauma patients transported from the scene by

helicopter have nonlife-threatening injuries. Efforts to more accurately identify those patients who would

benefit most from helicopter transport from the accident scene to the trauma center are needed to reduce helicopter overutilization.

Trauma Center Access

Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients

Andruszkow et al. Critical Care 2013, 17:R124

HEMS patients were more often transported to level I trauma centers compared to GEMS (HEMS: 90.1% vs. GEMS: 75.9%). Accordingly, GEMS transported their patients more frequently to level II (HEMS: 9.9% vs. GEMS: 24.1%).

Crew

Impact of prehospital mode of transport after severe injury: A multicenter evaluation from the Resuscitation Outcomes Consortium

Eileen M. Bulger, Danielle Guffey. J Trauma Acute Care Surg. 2012 March ; 72(3): 567–803

Results Patients transported by air had higher rates of prehospital intubation (81% vs. 36%; p < 0.001), received more intravenous fluids (mean 1.3 L vs. 0.8 L; p < 0.001), and had longer prehospital times (mean 76.1 minutes vs. 43.5 minutes; p<0.001).

Conclusions However, air medical transported more severely injured patients with more advanced life support procedures and longer prehospital time.

Crew

Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients

Andruszkow et al. Critical Care 2013, 17:R124

Methods: Traumatized patients (Injury Severity Score; ISS ≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2007 and 2009 were analyzed using the TraumaRegister DGU® of the German Society for Trauma Surgery.

Crew

Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients Andruszkow et al. Critical Care 2013, 17:R124

Results: More preclinical interventions were found in HEMS transported patients.

Crew

Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients Andruszkow et al. Critical Care 2013,

17:R124 Results: Sensitivity and specificity of preclinical diagnoses were not superior in HEMS compared to GEMS.

Survival

Helicopter emergency medical services for adults with major trauma (Review 2013)

Galvagno Jr SM, Thomas S, Stephens C, Haut ER, Hirshon JM, Floccare D, Pronovost P

Author Conclusions

An accurate composite estimate of the benefit of HEMS could not be determined.

Although five of the nine multivariate regression studies indicated improved survival associated with HEMS, the remainder did not.

All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their non-randomized design.

Survival

Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients Andruszkow et al. Critical Care 2013, 17:R124

Conclusions: Transportation by HEMS resulted in a significant survival benefit compared to GEMS patients despite increased injury severity and incidence of posttrau-matic complications (MODS, sepsis).

Survival

Survival benefit of physician-staffed Helicopter Emergency Medical Services (HEMS) assistance for severely injured patientsDennis Den Hartog,et al. Injury, Int. J. Care Injured (2015)

Conclusions:

The present study indicates an additional 5.33 lives saved per 100 dispatches of the physician-staffed HEMS. Given the excellent statistical power of this study (>90%), physician-staffed HEMS is confirmed to be an evidence-based valuable addition to the EMS systems in saving lives of severely injured patients.

Bottom line

SpeedMission Time In case of simultaneous activation HEMS is competitive for distance >10 miles

In case of non simultaneous activation HEMS is faster for distances >45 miles from Trauma Center

On scene time HEMS > GEMS

Bottom line

Severity HEMS patients are generally more severely injured than GEMS patients

Trauma Center Access HEMS transported patients have more chances to be referred to a level I Trauma Center

Bottom line

Crew More time on scene (beyond the golden hour)

More procedures performed The accuracy of prehospital documented diagnoses was not increased in HEMS compared to GEMS rescue

Bottom line

Survival No definitive evidences on HEMS benefits on survival rate

Recent literature points on a trend toward an increased chances of survival in some categories of trauma patients transported by HEMS

Safety

Series10

2

4

6

8

10

12

14

16

18

20

1

6

12 12

19

Airline

Commuter

Ground Ambulance

All Helicopters

Medical Helicopters

Fatal crashes per million of flight

Source: AMPA, A Safety Review and Risk Assessment in Air Medical Transport (2002)