Lääkärihelikoptereiden hoitamien potilaiden pitkäaikaisennuste ja kuolleisuus

Väittelijä Johannes Björkman : Helsingin yliopisto, 2022

Shock index as a predictor for short-term mortality in helicopter emergency medical services : A registry study

Background The value of shock-index has been demonstrated in hospital triage, but few studies have evaluated its prehospital use. The aim of our study was to evaluate the association between shock-index in prehospital critical care and short-term mortality. Methods We analyzed data from the national helicopter emergency medical services database and the Population Register Centre. The shock-index was calculated from the patients' first measured parameters. The primary outcome measure was 1- and 30-day mortality. Results A total of 22 433 patients were included. The 1-day mortality was 7.5% and 30-day mortality was 16%. The median shock-index was 0.68 (0.55/0.84) for survivors and 0.67 (0.49/0.93) for non-survivors (P = .316) at 30-days. Association between shock-index and mortality followed a U-shaped curve in trauma (shock-index 1.3: odds ratio 4.4 [2.7-7.2] at 30 days). Patients with neurological emergencies with a low shock-index had an increased risk of mortality (shock-index 1.3: odds ratio 3.5 [2.3-5.4). The association was similar for all ages, but older patients had higher mortality in each shock-index category. Conclusion The shock-index is associated with short time mortality in most critical patient categories in the prehospital setting. However, the marked overlap of shock-index in survivors and non-survivors in all patient categories limits its predictive value.Peer reviewe

Predictive value of shock index variants on 30-day mortality of trauma patients in helicopter emergency medical services : a nationwide observational retrospective multicenter study

The original shock index (SI) has been further developed to increase its prognostic value. We aimed to evaluate the predictive value of different SI variants on 30-day mortality among severely injured trauma patients in pre-hospital critical care settings. Adult trauma patients in the national Helicopter Emergency Medical Services (HEMS) registry were evaluated based on the primary outcome of 30-day mortality. SI, SIA (SI multiplied by age), SI/G (SI divided by Glasgow Coma Scale (GCS)), SIA/G (SI multiplied by age and divided by GCS), and SS (SI divided by oxygen saturation) were calculated based on the first vital signs measured at the time of HEMS contact. The area under the receiver operating curve (AUROC) was calculated for each SI variant. In total 4108 patients were included in the study. The overall 30-day mortality was 13.5%. The SIA/G and SI/G had the highest predictive ability (AUROC 0.884 [95% CI 0.869-0.899] and 0.8000 [95% CI 0.7780-0.8239], respectively). The SIA/G yielded good predictive performance between 30-day survivors and non-survivors in the pre-hospital critical care setting.Peer reviewe

Effect of time intervals in critical care provided by helicopter emergency medical services on 30-day survival after trauma

Background: Trauma is the leading cause of death especially in children and young adults. Prehospital care following trauma emphasizes swift transport to a hospital following initial care. Previous studies have shown conflicting results regarding the effect of time on the survival following major trauma. In our study we investigated the effect of prehospital time-intervals on 30-day mortality on trauma patients that received prehospital critical care. Methods: We performed a retrospective study on all trauma patients encountered by helicopter emergency medical services in Finland from 2012 to 2018. Patients discharge diagnoses were classed into (1) trauma without traumatic brain injury, (2) isolated traumatic brain injury and (3) trauma with traumatic brain injury. Emergency medical services response time, helicopter emergency medical services response time, on-scene time and transport time were used as time-intervals and age, Glasgow coma scale, hypotension, need for prehospital airway intervention and ICD-10 based Injury Severity Score were used as variables in logistic regression analysis. Results: Mortality data was available for 4,803 trauma cases. The combined 30-day mortality was 12.1% (582/4,803). Patients with trauma without a traumatic brain injury had the lowest mortality, at 4.3% (111/2,605), whereas isolated traumatic brain injury had the highest, at 22.9% (435/1,903). Patients with both trauma and a traumatic brain injury had a mortality of 12.2% (36/295). Following adjustments, no association was observed between time intervals and 30-day mortality. Discussion: Our study revealed no significant association between different timespans and mortality following severe trauma in general. Trends in odds ratios can be interpreted to favor more expedited care, however, no statistical significance was observed. As trauma forms a heterogenous patient group, specific subgroups might require different approaches regarding the prehospital timeframes. Study type: prognostic/therapeutic/diagnostic test. (C) 2022 The Authors. Published by Elsevier Ltd.Peer reviewe

The effect of time of measurement on the discriminant ability for mortality in trauma of a pre-hospital shock index multiplied by age and divided by the Glasgow Coma Score : a registry study

Peer reviewe

Accuracy of prehospital clinicians' perceived prognostication of long-term survival in critically ill patients : a nationwide retrospective cohort study on helicopter emergency service patients

Objectives Prehospital critical care physicians regularly attend to patients with poor prognosis and may limit the advanced therapies. The aim of this study was to evaluate the accuracy of poor prognosis given by prehospital critical care clinicians. Design Cohort study. Setting We performed a retrospective cohort study using the national helicopter emergency medical services (HEMS) quality database. Participants Patients classified by the HEMS clinician to have survived until hospital admission solely because of prehospital interventions but evaluated as having no long-term survival by prehospital clinician, were included. Primary and secondary outcome The survival of the study patients was examined at 30 days, 1 year and 3 years. Results Of 36 715 patients encountered by the HEMS during the study period, 2053 patients were classified as having no long-term survival and included. At 30 days, 713 (35%, 95% CI 33% to 37%) were still alive and 69 were lost to follow-up. Furthermore, at 1 year 524 (26%) and at 3 years 267 (13%) of the patients were still alive. The deceased patients received more often prehospital rapid sequence intubation and vasoactives, compared with patients alive at 30 days. Patients deceased at 30 days were older and had lower initial Glasgow Coma Scores. Otherwise, no clinically relevant difference was found in the prehospital vital parameters between the survivors and non-survivors. Conclusions The prognostication of long-term survival for critically ill patients by a prehospital critical care clinician seems to fulfil only moderately. A prognosis based on clinical judgement must be handled with a great degree of caution and decision on limitation of advanced care should be made cautiously.Peer reviewe

Standardised data collection in prehospital critical care : a comparison of medical problem categories and discharge diagnoses

Background Prehospital medical problem reporting is essential in the management of helicopter emergency medical services (HEMS) operations. The consensus-based template for reporting and documenting in physician-staffed prehospital services exists and the classification of medical problems presented in the template is widely used in research and quality improvement. However, validation of the reported prehospital medical problem is lacking. This study aimed to describe the in-hospital diagnoses, patient characteristics and medical interventions in different categories of medical problems. Methods This retrospective, observational registry study examined the 10 most common in-hospital International Statistical Classification of Disease (ICD-10) diagnoseswithin different prehospital medical problem categories, defined by the HEMS physician/paramedic immediately after the mission was completed. Data were gathered from a national HEMS quality registry and a national hospital discharge registry. Patient characteristics and medical interventions related to different medical problem categories are also described. Results A total of 33,844 patients were included in the analyses. All the medical problem categories included a broad spectrum of ICD-10 diagnoses (the number of diagnosis classes per medical problem category ranged from 73 to 403). The most frequent diagnoses were mainly consistent with the reported medical problems. Overlapping of ICD-10 diagnoses was mostly seen in two medical problem categories: stroke and acute neurology excluding stroke. Additionally, typical patient characteristics and disturbances in vital signs were related to adequate medical problem categories. Conclusions Medical problems reported by HEMS personnel have adequate correspondence to hospital discharge diagnoses. However, the classification of cerebrovascular accidents remains challenging.Peer reviewe

Accuracy of prehospital clinicians' perceived prognostication of long-term survival in critically ill patients: a nationwide retrospective cohort study on helicopter emergency service patients

Objectives Prehospital critical care physicians regularly attend to patients with poor prognosis and may limit the advanced therapies. The aim of this study was to evaluate the accuracy of poor prognosis given by prehospital critical care clinicians.Design Cohort study.Setting We performed a retrospective cohort study using the national helicopter emergency medical services (HEMS) quality database.Participants Patients classified by the HEMS clinician to have survived until hospital admission solely because of prehospital interventions but evaluated as having no long-term survival by prehospital clinician, were included.Primary and secondary outcome The survival of the study patients was examined at 30 days, 1 year and 3 years.Results Of 36 715 patients encountered by the HEMS during the study period, 2053 patients were classified as having no long-term survival and included. At 30 days, 713 (35%, 95% CI 33% to 37%) were still alive and 69 were lost to follow-up. Furthermore, at 1 year 524 (26%) and at 3 years 267 (13%) of the patients were still alive. The deceased patients received more often prehospital rapid sequence intubation and vasoactives, compared with patients alive at 30 days. Patients deceased at 30 days were older and had lower initial Glasgow Coma Scores. Otherwise, no clinically relevant difference was found in the prehospital vital parameters between the survivors and non-survivors.Conclusions The prognostication of long-term survival for critically ill patients by a prehospital critical care clinician seems to fulfil only moderately. A prognosis based on clinical judgement must be handled with a great degree of caution and decision on limitation of advanced care should be made cautiously.</p

The first seven years of nationally organized helicopter emergency medical services in Finland - the data from quality registry

Background: Helicopter Emergency Medical Services (HEMS) play an important role in prehospital care of the critically ill. Differences in funding, crew composition, dispatch criteria and mission profile make comparison between systems challenging. Several systems incorporate databases for quality control, performance evaluation and scientific purposes. FinnHEMS database was incorporated for such purposes following the national organization of HEMS in Finland 2012. The aims of this study are to describe information recorded in the database, data collection, and operational characteristics of Finnish HEMS during 2012-2018. Methods: All dispatches of the six Finnish HEMS units recorded in the national database from 2012 to 2018 were included in this observational registry study. Five of the units are physician staffed, and all are on call 24/7. The database follows a template for uniform reporting in physician staffed pre-hospital services, exceeding the recommended variables of relevant guidelines. Results: The study included 100,482 dispatches, resulting in 33,844 (34%) patient contacts. Variables were recorded with little or no missing data. A total of 16,045 patients (16%) were escorted by HEMS to hospital, of which 2239 (2%) by helicopter. Of encountered patients 4195 (4%) were declared deceased on scene. The number of denied or cancelled dispatches was 66,638 (66%). The majority of patients were male (21,185, 63%), and the median age was 57.7 years. The median American Society of Anesthesiologists Physical Scale classification was 2 and Eastern Cooperative Oncology Group performance class 0. The most common reason for response was trauma representing 26% (8897) of the patients, followed by out-of-hospital cardiac arrest 20% (6900), acute neurological reason excluding stroke 13% (4366) and intoxication and related psychiatric conditions 10% (3318). Blunt trauma (86%, 7653) predominated in the trauma classification. Conclusions: Gathering detailed and comprehensive data nationally on all HEMS missions is feasible. A national database provides valuable insights into where the operation of HEMS could be improved. We observed a high number of cancelled or denied missions and a low percentage of patients transported by helicopter. The medical problem of encountered patients also differs from comparable systems.Peer reviewe

The first seven years of nationally organized helicopter emergency medical services in Finland - the data from quality registry

Background: Helicopter Emergency Medical Services (HEMS) play an important role in prehospital care of the critically ill. Differences in funding, crew composition, dispatch criteria and mission profile make comparison between systems challenging. Several systems incorporate databases for quality control, performance evaluation and scientific purposes. FinnHEMS database was incorporated for such purposes following the national organization of HEMS in Finland 2012. The aims of this study are to describe information recorded in the database, data collection, and operational characteristics of Finnish HEMS during 2012-2018.Methods: All dispatches of the six Finnish HEMS units recorded in the national database from 2012 to 2018 were included in this observational registry study. Five of the units are physician staffed, and all are on call 24/7. The database follows a template for uniform reporting in physician staffed pre-hospital services, exceeding the recommended variables of relevant guidelines.Results: The study included 100,482 dispatches, resulting in 33,844 (34%) patient contacts. Variables were recorded with little or no missing data. A total of 16,045 patients (16%) were escorted by HEMS to hospital, of which 2239 (2%) by helicopter. Of encountered patients 4195 (4%) were declared deceased on scene. The number of denied or cancelled dispatches was 66,638 (66%). The majority of patients were male (21,185, 63%), and the median age was 57.7 years. The median American Society of Anesthesiologists Physical Scale classification was 2 and Eastern Cooperative Oncology Group performance class 0. The most common reason for response was trauma representing 26% (8897) of the patients, followed by out-of-hospital cardiac arrest 20% (6900), acute neurological reason excluding stroke 13% (4366) and intoxication and related psychiatric conditions 10% (3318). Blunt trauma (86%, 7653) predominated in the trauma classification.Conclusions: Gathering detailed and comprehensive data nationally on all HEMS missions is feasible. A national database provides valuable insights into where the operation of HEMS could be improved. We observed a high number of cancelled or denied missions and a low percentage of patients transported by helicopter. The medical problem of encountered patients also differs from comparable systems