Enhanced care team response to incidents involving major trauma at night: Are helicopters the answer?
Introduction
Regional Trauma Networks (RTNs) were formally launched in England in March 2011 [1]. Within the West Midlands Regional Trauma Network there are 3 adult Major Trauma Centre's (MTC), 1 children's MTC and 10 Trauma Units (TU) (Fig. 1). The MTCs in the north and south of the network also receive patients from TUs from outside the West Midlands. All potential Major Trauma patients are screened using a major trauma triage tool (Fig. 2). Patients triaged as having identified or suspected severe traumatic injuries should be transported preferentially to a MTC (bypassing TUs if necessary), if they fall within a 45-min travel window of the MTC. Support for triage decisions is available 24/7 via a Regional Trauma Desk in the Emergency Operations Centre (EOC) manned by a specialist trauma paramedic [2].
Triage bypass decisions can be overridden by the acuity of the patient's injuries. Such patients will usually have time critical airway, breathing or circulatory compromise which cannot be resolved or attenuated within the skill mix of the personnel at scene. These patients must be taken to the nearest TU unless personnel with advanced clinical care skills can be transported to scene.
Within the West Midlands network there is a 24/7 Medical Emergency Response Incident Team (MERIT). The MERIT team consists of a doctor competent in advanced airway management and immediate surgical intervention (normally a consultant in Emergency Medicine or Anaesthesia) and a specialist trauma paramedic [3]. The role of the MERIT service within the regional trauma network is twofold: to deliver enhanced care interventions to patients with time critical injuries and to facilitate expedient onward transfer to centres for definitive care.
Between the hours of 0700–1900 the MERIT team is deployed by helicopter based at RAF Cosford in Shropshire. The location of the airbase in the centre of the region ensures appropriate coverage of all areas within the network. In addition to their role as a tool for skills delivery, helicopters provide an additional advantage in incidents located in remote parts of the region as a platform for rapid transfer to definitive care.
The MERIT team is deployed by road utilising a Fast Response Vehicle (FRV) between the hours of 1900–0700. The night MERIT base is located in West Birmingham in close proximity to the regional motorway networks and the centre of the city. Additional regional enhanced care resources operating at night include voluntary organisations such as doctors from the British Association of Immediate Care Specialists (BASICS) and the West Midlands Central Accident Resuscitation and Emergency (CARE) Team. Although not formally integrated with MERIT service the regional voluntary schemes utilise common standard operating procedures, equipment and governance structures. Many personnel from the MERIT service also respond to incidents with voluntary schemes.
At night the 45 min travel isochrone becomes more important than during daylight hours due to the unavailability of helicopters for skill insertion to scene and onward transfer to an MTC. This increases the proportional area of the regional network classed as geographically “remote”. The current models of delivery of specialist pre-hospital care teams to such areas at night in the West Midlands are outlined in Box 1.
Box 1—description of the models for Enhanced Care Team delivery utilised in the West Midlands. Both ‘interception’ and ‘hyper-acute transfer’ are co-ordinated via the specialist trauma paramedic manning the regional trauma desk in close liaison with the ambulance crew conveying the patient; the Enhance Care Team and receiving hospitals.
The logistics of how best to deliver enhanced care to these remote trauma patients is a subject of debate [4]. Night flying of civilian air ambulance helicopters is common in North America and continental Europe [5], [6], [7]. Operation of HEMS aircraft at night are however associated with notable increases in the risk of accidents [7], [8], [9], [10] and costs [11]. Over the last two decades HEMS operations in England have had an exemplary safety record compared to other countries [12]. Funding for HEMS services in England is almost exclusively derived from charitable donations from the public [4] and much of the country currently lacks the appropriate infrastructure to support landing at hospital helipads during the hours of darkness [13], [14]. The costs associated with establishing a night HEMS service in England are estimated to be significant. The current annual operating costs for the HEMS platform utilised by the MERIT service in the West Midlands is in excess of £2 million [15]. Additional training and equipment costs would be associated with ensuring that a night HEMS service complies with Civil Aviation Authority guidelines [16].
Despite the identified risk and cost associated with such operations, some Helicopter Emergency Medical Service (HEMS) organisations in England have recently been launched night time services as a potential solution to the delivery of Enhanced Care Teams to incidents in geographically remote locations within regional trauma networks. Evaluation of the frequency of occurrence of critical incidents and their location within regions is strongly advised when designing the structure of the pre-hospital care systems within regional trauma networks [4]. To date no such analysis has been performed in an English regional trauma network.
This study describes this remote trauma workload at night in the West Midlands Regional Trauma Network in terms of incident location; injury profile; and the requirement for time critical interventions at scene. Potential solutions to the delivery of Enhanced Care Teams to such incidents are discussed, including whether the introduction of a night HEMS service is required.
Section snippets
Methods
The Trauma Audit and Research Network (TARN) [17] provided a dataset drawn from the TARN database of cases submitted by hospitals in the West Midlands RTN for a one year period (1st April 2012 until the 31st March 2013). Records included in the dataset were limited to those patients that had been conveyed to hospital by an ambulance/air ambulance. Patients who had presented by other means (e.g. self-presentation) were excluded. Inter-facility transfers between hospitals, in which patients were
Night time workload and enhanced care team utilisation
A total of 603 out of 1620 (37%) incidents involving Major Trauma that occurred within the regional network, were identified during night time hours. An ECT resource was dispatched to 224 out of the 603 incidents occurring within night time hours during the twelve months (37%) with 57 cancellations by WMAS personnel prior to arrival of the team at scene (25% of dispatches). Enhanced Care Teams therefore attended 167 incidents involving Major Trauma (28% of total at night). Fig. 3 maps the
Discussion
Major Trauma is common during ‘night time hours’ in the West Midlands Regional Trauma Network with approximately 40% of incidents occurring between 1900 and 0659. This study shows that a majority of incidents are heavily concentrated in, and immediately around, the large urban conurbations within the region. The existing road-based structure in the West Midlands performs well in delivering Enhanced Care Teams to incident scenes: with teams attending almost a third of all incidents, including
Limitations
This study is limited by its retrospective design and potential under-reporting of cases to the TARN database. During the period evaluated the number of cases reported to TARN by hospitals in the region was 100% of expected from MTCs and 60% from TUs [17]. This is consistent with the national average. Crudely accounting for an under reporting rate of 40% we estimate that there may have been 24 un-reported cases of Major Trauma during the period analysed that occurred at night in locations
Conclusions
There is limited evidence to support the need for night HEMS operations in the West Midlands regional trauma network. Expansion of the resource pool available to respond to incidents at night is required, specifically in remote areas. Augmentation of existing road based resources has the potential to provide a safer, more cost effective solution than night HEMS. Principal to this strategy is the development of improved dispatch criteria for Enhanced Care Teams that more accurately identify
Conflict of interest statement
The authors declare that there are no conflicts of interest.
Acknowledgements
CMcQ is the recipient of a National Institute for Health Research (NIHR) Doctoral Research Fellowship (Ref: DRF-2013-06-035). This paper presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. The authors also wish to acknowledge the support of the staff in the West Midlands Ambulance Service NHS Foundation Trust Emergency Operations
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