Air medical transport of trauma patients from the scene of injury plays a critical role in the delivery of severely injured patients to trauma centers. Over-triage of patients to trauma centers reduces the system efficiency and jeopardizes safety of air medical crews.

The objective of this study was to determine which triage factors utilized by Emergency Medical Services (EMS) providers are strong predictors of early discharge for trauma patients transported by helicopter to a trauma center.

A retrospective chart review over a two-year period was performed for trauma patients flown from the injury site into a Level I trauma center by an air medical transport program. Demographic and clinical data were collected on each patient. Prehospital factors such as Glasgow Coma Score (GCS), Revised Trauma Score (RTS), intubation status, mechanism of injury, anatomic injuries, physiologic parameters, and any combinations of these factors were investigated to determine which triage criteria accurately predicted early discharge. Hospital factors such as Injury Severity Score (ISS), length-of-stay (LOS), survival, and emergency department disposition were also collected. Early discharge was defined as a hospital stay of less than 24 hours in a patient who survives their injuries. A more stringent definition of appropriate triage was defined as a patient with in-hospital death, an ISS >15, those taken to the operating room (OR) or intensive care unit (ICU), or those receiving blood products. Those patients who failed to meet these criteria were also used to determine over-triage rates.

An overall early discharge rate of 35% was found among the study population. Furthermore, when the more stringent definition was applied, over-triage rates were as high as 85%. Positive predictive values indicated that patients who met at least one anatomic and physiologic criteria were appropriately transported by helicopter as 94% of these patients had stays longer than 24 hours. No other criteria or combination of criteria had a high predictive value for early discharge.

No individual triage criteria or combination of criteria examined demonstrated the ability to uniformly predict an early discharge. Although helicopter transport and subsequent hospital care is costly and resource consuming, it appears that a significant number of patients will be discharged within 24 hours of their transport to a trauma center. Future studies must determine the impact of eliminating “low-yield” triage criteria on under-triage of scene trauma patients.

Emergency Medical Services (EMS) preparedness and availability of essential medications are important to reduce morbidity and mortality from mass-casualty incidents (MCIs).

This study describes prehospital medication administration during MCIs by different EMS service levels.

The US National EMS Public-Release Research Dataset maintained by the National Emergency Medical Services Information System (NEMSIS) was used to carry out the study. Emergency Medical Services activations coded as MCI at dispatch, or by EMS personnel, were included. The Center for Medicare and Medicaid Services (CMS) service level was used for the level of service provided. A descriptive analysis of medication administration by EMS service level was carried out.

Among the 19,831,189 EMS activations, 53,334 activations had an MCI code, of which 26,110 activations were included. There were 8,179 (31.3%) Advanced Life Support (ALS), 5,811 (22.3%) Basic Life Support (BLS), 399 (1.5%) Air Medical Transport (AMT; fixed or rotary), and 38 (0.2%) Specialty Care Transport (SCT) activations. More than 80 different medications from 18 groups were reported. Seven thousand twenty-one activations (26.9%) had at least one medication administered. Oxygen was most common (16.3%), followed by crystalloids (6.9%), unknown (5.2%), analgesics (3.2%) mainly narcotics, antiemetics (1.5%), cardiac/vasopressors/inotropes (0.9%), bronchodilators (0.9%), sedatives (0.8%), and vasodilators/antihypertensives (0.7%). Overall, medication administration rates and frequencies of medications groups significantly varied between EMS service levels (P<.01) except for “Analgesia (other)” (P=.40) and “Pain medications (nonsteroidal anti-inflammatory drug; NSAID)” (P=.07).

Medications are administered frequently in MCIs, mainly Oxygen, crystalloids, and narcotic pain medications. Emergency Medical Services systems can use the findings of this study to better prepare their stockpiles for MCIs.

El SayedM , TamimH , MannNC . Description of Medication Administration by Emergency Medical Services during Mass-casualty Incidents in the United States. Prehosp Disaster Med. 2016;31(2):141–149.

This study was conducted to determine whether point-of-care testing, using the iSTAT Portable Clinical Analyzer, would reduce time at the referring hospital required to stabilize ventilated pediatric patients prior to interfacility, air-medical transport.

The following data were collected prospectively: (1) When a blood gas analysis was ordered; (2) If it was necessary to call in a technician; (3) Waiting time for blood to be drawn; and (4) Waiting time for results. The cost-efficacy of point-of-care testing was calculated based on: (1) Three minutes for a transport team member to draw a sample and obtain a result using the iSTAT (unit cost $CDN8,000); (2) Lab technician call-back (minimum two hours at $90); (3) Paramedic overtime (by the minute at $49/hour); and (4) Cost of charter aircraft wait time ($200 per hour) for every hour beyond four hours.

Data were collected on 46 ventilated patients over a three month period. A blood gas analysis was ordered on 35 patients. Laboratory technicians were called in for 17 (49%). For 12 (34%) patients, there was a wait for the sample to be drawn, and for 23 (66%), there was a wait for results to become available. Total time waiting to obtain laboratory gases was 526 minutes compared with a calculated 105 minutes using point-of-care testing. An iSTAT cartridge cost of $420 would not have been different from laboratory costs. Cost-saving on technician callback ($1,530), paramedic overtime ($690) and aircraft time waiting charges ($2,000) would have totaled ($4,220). From this study, the cost of point-of-care equipment could be recouped in 101 patients if aircraft charges apply or 192 patients if no aircraft costs are involved. For 11 cases, ventilator adjustments were made subsequently during transport, and for six patients, point-of-care testing, if in place, would have been used to optimize transport care.

The data from the present study indicate significant cost-efficacy from use of this technology to reduce stabilization times, and support the potential to improve quality of care during air medical interfacility transport.

To perform a review of the collective experience of all hospital-based helicopter ambulances in the state of North Carolina for compliance with utilization review criteria.

Flight records of the six members of the North Carolina Aeromedical Affiliation for the months of November and December 1989 were compared with utilization review criteria by an independent reviewer. A secondary review was performed by a staff member for each service. Scene responses and patients flown to a hospital other than the sponsor were evaluated.

All six hospital-based helicopter services in North Carolina.

All available flight records for November and December 1989.

None.

Of 756 transports, 747 flight records were available for review. Initial review demonstrated compliance with the criteria for 713 (95.4%) patients; secondary review showed compliance for 18 of 34 flights not meeting initial review, for an overall compliance rate of 97.9%. Compliance rates for scene responses and transports taken to a hospital other than the sponsoring facility were 96.6% and 94.1%, respectively.

Review of all flights over a period of two months by all six hospital-based helicopter services in North Carolina using utilization review criteria demonstrated a very high rate of compliance with the established criteria.