Critical care air transportation of the severely injured: Does long distance transport adversely affect survival?

doi:10.1016/S0196-0644(05)81803-7

Annals of Emergency Medicine

Volume 19, Issue 2, February 1990, Pages 169-172

https://doi.org/10.1016/S0196-0644(05)81803-7 Get rights and content

Civilian aeromedical transportation systems, both fixed and rotary wing, have proliferated since the middle 1970s. However, outcome data substantiating the benefit of these services have been slow in coming. From February 22, 1982, through March 5, 1984, Airlift Northwest transported 118 trauma patients (aged 15 years and older) an average distance of 340 miles (range, 100 to 800 miles) with fixed-wing aircraft. The in-hospital mortality for this group was 19% compared with 18% for a comparable group of trauma patients who were ground-transported from within the city limits of Seattle, Washington. The two groups did not differ significantly in age, Injury Severity Score, or Glasgow Coma Score. These results suggest that some part of the clinical benefit of a regional trauma center may be extended up to 800 miles with no increase in transport-related mortality.

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Cited by (27)

The soft skills emergency management that matters at the hardest time: A phenomenology study of healthcare worker's experiences during Kelantan flood 2014
2022, International Journal of Disaster Risk Reduction
Citation Excerpt :
The challenges begin at the point of making the decision via triaging and choosing the most critical patient but safe to be transported. Even in a normal circumstance, any critically ill patient is subjected to increased risk of mortality and morbidity during the transport [5,6] and the risk was much greater during a flood disaster. Furthermore, it was highlighted in one study that accompanying personnel is warranted and should at least be a physician or paramedics [5] yet in these circumstances this study clearly had shown that every healthcare worker, especially medical officers were much more needed at the affected hospital instead.
The monsoon flood was inevitable for Malaysia. Nevertheless, no one expected that it would be as severe as the Kelantan Flood 2014. Total collapse of communication disruption had made it difficult for centric top-down emergency management to reach out to the healthcare workers. Not only the public were severely affected yet even healthcare workers and their families felt the impact of that disaster. This study aims to explore the challenges faced by the healthcare workers and look into the management that really helped them survive this crisis. Nine (9) healthcare workers under the ministry of health working at hospitals and affected clinics narrated their experience and their transcriptions were coded by a panel of experts. It was found that the common challenge occurred when they had to deal with patients and emergency circumstances with total cut down of necessities like electric supply, food and most of these healthcare workers were burned out when there were limited human resources during that critical phase. They also had to deal with their own inner turmoil and psychological concerns while mending the needs of their patient and the other staff. Breakdowns of communication and handling emergency cases really put them to the test. In handling most of these challenges, all agreed on the importance of having a leader to coordinate and motivate them, to form a crisis management centre as the core place for communication to be synchronized and the importance of soft skills in getting help from locals and the Non-Governmental Organizations (NGOs). This study has affirmed the importance for emergency management to focus on creating proactive response in empowering the bottom-up kind of management as a complement to the existing preparedness system. Hence there is no better way to do that than to pay heed on the soft skills aspect of an emergency management plan in the future.
Total Mission Time and Mortality in a Regional Interhospital Critical Care Transport System: A Retrospective Observational Study
2021, Air Medical Journal
We assessed the mortality risk related to the time for intensive care unit transport in a geographically large regional health care system.
Patient-level data from critical care ambulance missions were analyzed for 2,067 cases, mission time, and relevant patient factors. Mission time was used as a surrogate for the “distance” to tertiary care, and mortality at 7 days and other intervals was assessed.
Results: No increased mortality risk was found at 7 days in an unadjusted regression analysis (odds ratio = 1.00; range, 0.999-1.002; P = .66). In a secondary analysis, an increased mortality risk was observed in longer mission time subgroups and at later mortality assessment intervals (> 375 mission minutes and 90-day mortality; adjusted hazard ratio = 1.56; range, 1.07-2.28; P = .02). Negative changes in oxygenation and hemodynamic status and transport-related adverse events were associated with the longest flight times. Measurable but small changes during flight were noted for mean arterial pressure and oxygenation.
The main finding was that there was no overall difference in mortality risk based on mission time. We conclude that transport distances or accessibility to critical care in the tertiary care center in a geographically large but sparsely populated region is not clearly associated with mortality risk.
Impact of physician-less pediatric critical care transport: Making a decision on team composition
2018, Journal of Critical Care
Citation Excerpt :
Our cohort did not capture and include those patients that the PICU transport team did not transport, e.g., patients who died before or without referral calls, or were transported by a non-PICU transport team such as an ALS team (paramedics). There is also a possibility that patients from hospitals that are a shorter distance from the STOL might have been transported more often by the ALS team, particularly when the transport time was critical (e.g., trauma cases) [29-31]. Second, the distance or the transport time could also have been a factor in the decision-making of upper airway security (transport with or without endotracheal intubation) for a given transport.
To explore the impact of a physician non-accompanying pediatric critical care transport program, and to identify factors associated with the selection of specific transport team compositions.
Children transported to a Canadian academic children's hospital were included. Two eras (Physician-accompanying Transport (PT)-era: 2000–07 when physicians commonly accompanied the transport team; and Physician-Less Transport (PLT)-era: 2010–15 when a physician non-accompanying team was increasingly used) were compared with respect to transport and PICU outcomes. Transport and patient characteristics for the PLT-era cohort were examined to identify factors associated with the selection of a physician accompanying team, with multivariable logistic regression with triage physicians as random effects.
In the PLT-era (N = 1177), compared to the PT-era (N = 1490) the probability of PICU admission was significantly lower, and patient outcomes including mortality were not significantly different. Associations were noted between the selection of a physician non-accompanying team and specific transport characteristics. There was appreciable variability among the triage physicians for the selection of a physician non-accompanying team.
No significant differences were observed with increasing use of a physician non-accompanying team. Selection of transport team compositions was influenced by clinical and system factors, but appreciable variation still remained among triage physicians.
Golden hour or golden opportunity: Early management of pediatric trauma
2010, Clinical Pediatric Emergency Medicine
The concept of a “golden hour” is a fixture in trauma care. There is a dearth of scientific proof for this concept but an abundance of controversy around how this concept should be interpreted, especially for pediatric trauma patients. Health care providers should instead focus on the “golden opportunity,” different for each patient, to provide the best care in the most appropriate environment for all injured children.
Aeromedical Retrieval for Critical Clinical Conditions: 12 Years of Experience with the Royal Flying Doctor Service, Queensland, Australia
2009, Journal of Emergency Medicine
Citation Excerpt :
For example, the US military utilizes fixed-wing aeromedical retrieval for intercontinental transport to definitive care (5,6). A 1990 study found that in-hospital mortality for fixed-wing aeromedical retrieval of trauma up to 800 miles was found to be not statistically different to in-city ground transport of clinically similar patients (7). However, there are few objective studies that detail the full spectrum of fixed-wing aeromedical retrieval, although there are studies that focus on specific patient populations such as Obstetrics, Pediatrics, or only one aspect of these transports, such as repatriation (8–10).
Background: The Royal Flying Doctor Service (RFDS) has been providing emergency aeromedical retrieval services in Queensland, Australia since 1928. Study Objectives: This article details service and delivery structure plus a description of 12 years of experience managing patients with critical clinical conditions. Methods: This study is a retrospective longitudinal analysis of the demographics and diagnostic classification of all cases of critical clinical severity conducted March 1, 1994 through February 28, 2006. Results: There were a total of 72,054 retrievals, with trauma the single most common clinical diagnosis. There were 4259 retrievals for patients with critical clinical conditions (6%). The most common categories of clinical diagnosis were: trauma with 1493 (35.1%), respiratory diseases 1386 (32.5%), and circulatory diseases 908 (21.3%). Trauma accounted for 69 of the 90 (77%) primary retrievals from locations without health care facilities. The death rate in transport was 1%, with most of these involving males from locations with minimal health facilities. Conclusion: The RFDS in Queensland is an effective provider of fixed-wing aeromedical retrieval services, operating in an unusual environment with vast distances, low population density, and a high number of Indigenous people.
The role of transport intervals in outcomes for critically ill patients who are transferred to referral centers
2008, Journal of Critical Care
Citation Excerpt :
Interestingly, this effect influences ICU/CCU length of stay but not hospital length of stay. Although reports of successful transportation of critically ill and injured patients over long distances and for prolonged periods [20,22] have been published, other studies have found longer distance traveled to be an independent prognostic factor for adverse outcome [9]. Another possible explanation for this association may be that more time is required to arrange for air transport from referral ICUs back to hospitals in their home communities when these communities are further away from the receiving hospital.
The aim of this study was to determine the association between transport intervals (including time from call to arrival of transport team at the sending hospital, time spent by the transport team in the sending hospital, and transport time between the sending and receiving hospital) and intensive care unit (ICU) and hospital length of stay and hospital mortality at the receiving hospital.
This was a retrospective, stratified cohort study involving all patients 15 years and older who were transferred from one hospital to another of equal or larger size in British Columbia, Canada, and who spent at least 1 day in an ICU or coronary care unit (CCU) at the receiving hospital during 1999 (n = 1930). Data were obtained from 6 administrative databases and linked using generalized software.
After adjustment for age, sex, comorbidity, and diagnostic group, longer time from call to arrival of paramedics at the sending hospital was associated with a shorter length of ICU/CCU stay (rate ratio [RR], 0.91; 95% confidence interval [CI], 0.86-0.97) for survivors and a longer length of hospital (RR, 1.12; 95% CI, 1.05-1.21) and ICU/CCU (RR, 1.14; 95% CI, 1.04-1.25) stay for nonsurvivors in the higher-priority air transport group, and with a slightly shorter length of hospital stay (RR, 0.97; 95% CI, 0.95-0.99) for all patients in the lower-priority air transport group. Longer time spent by paramedics at the sending hospital was associated with a shorter length of hospital stay (RR, 0.79; 95% CI, 0.65-0.96) for survivors in the higher-priority air transport group. Longer time for transport between the sending and receiving hospitals was associated with a longer length of ICU/CCU stay (RR, 1.69; 95% CI, 1.26-2.27) for survivors in the higher-priority air transport group but a slightly shorter length of ICU/CCU stay (RR, 0.97; 95% CI, 0.95-0.99) for all patients in the ground transport group. There were no associations between transport times and hospital mortality.
Transport intervals are independently associated with ICU/CCU and hospital lengths of stay at the receiving hospital for critically ill adults transferred to referral centers.

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Original contributionCritical care air transportation of the severely injured: Does long distance transport adversely affect survival?

Ann Emerg Med

Lancet

Ann Emerg Med

JACEP

Bad publicity forces evaluation of EMS services

Hospitals

Army acromedical evacuation procedures in Viet Nam

JAMA

The impact of rotocraft aeromedical emergency care service on trauma mortality

JAMA

Air transport of pediatric emergency medical cases

N Engl J Med

Original contribution
Critical care air transportation of the severely injured: Does long distance transport adversely affect survival?