Data collection in helicopter emergency medical services

Prehospital critical care, especially helicopter emergency medical services (HEMS), is a costly but vital part in the chain of survival for a critically deteriorated patient. The quality assessment and outcome measures of this service are important for targeting the limited resources accurately. Clinical registries are a key element of this system follow-up and quality assurance. In addition, they are a vast resource for scientific objectives. Therefore, the data reliability in these clinical registries needs to be assured. The aims of this thesis were to evaluate the accuracy and reliability of clinical data collection in a national HEMS service. In addition, to study the accuracy of prognostication based on prehospital patient classification and registry data. And finally, to revise a prehospital patient scoring system, the HEMS Benefit Score, to meet the modern standards of prehospital emergency medical services. This scoring is used in all Finnish HEMS units to evaluate the benefit of prehospital emergency medical services for patients treated on HEMS missions. Inter-rater reliability was evaluated among HEMS clinicians as they registered written mission scenarios into the FinnHEMS database. Furthermore, the accuracy of prognostication was evaluated in a retrospective patient population of 6219 HEMS patients. Finally, a revision for the HEMS Benefit Score was performed with Delphi method. The overall inter-rater reliability of data collected from the written mission scenarios was on an adequate level, however, vital signs documentation was shown to be poor. In addition, documentation of time-related parameters had a moderate inter-rater reliability. Patient scoring and classification indicated an overall poor inter-rater reliability among study participants. Prognostication in the HEMS setting had a moderate accuracy, and both futile and non-futile patients were treated with similar intensity. The revision of the HEMS Benefit Score resulted in a restructured and modernised version of a scoring for prehospital use, the EMS Benefit Score. As a conclusion, the reliability and accuracy of data collection among Finnish HEMS clinicians is on an adequate level. The reliability of a prehospitally set futile prognosis is at least questionable, therefore, decisions to limit treatment in a prehospital setting should be made with caution. Delphi method was established as a suitable process for implementation of a prehospital scoring system.Tiedon keruu ensihoidon helikopteritoiminnassa Lääkärijohtoiset ensihoidon helikopteriyksiköt (HEMS) ovat tärkeä osa kriittisesti sairastuneiden potilaiden hoitojärjestelmää. Jotta rajallisia resursseja voidaan kohdistaa oikealla tavalla, on tärkeää arvioida HEMS-toiminnan laatua ja vaikuttavuutta. Kliiniset laaturekisterit ovat olennainen osa toiminnan laadun arviointia, ja rekisterit toimivat myös tieteellisen tutkimuksen pohjana. Tästä syystä kliinisiin rekistereihin kerätyn tiedon luotettavuus tulee varmistaa. Tämän väitöskirjan tavoitteena oli tutkia kansallisissa HEMS-yksiköissä toimivien ensihoitolääkärien ja ensihoitajien kirjauskäytäntöjen luotettavuutta ja yhtenäisyyttä. Lisäksi tutkittiin potilaiden luokittelun ja ennustearvion osuvuutta HEMS-tehtävissä. Väitöskirjan viimeisenä osaprojektina päivitettiin kansallisten HEMS-yksiköiden käyttämä pisteytysjärjestelmä, HEMS Benefit Score, vastaamaan nykyaikaisia ensihoidon käytäntöjä. HEMS Benefit Score on ensihoidon yksittäiselle potilaalle tuottamaa hyötyä arvioiva pisteytysjärjestelmä, joka on käytössä kaikissa suomalaisissa HEMS-yksiköissä. Kirjausten luotettavuutta tutkittiin kuvitteellisten ensihoidon tehtävien avulla. Luotettavuutta arvioitiin erikseen sekä tehtäväkohtaisten muuttujien että potilasluokitus- ja pisteytysjärjestelmien osalta. Väitöskirjan kolmannessa osatyössä tutkittiin ennustearvion luotettavuutta 6219 potilaan retrospektiivisessä tutkimusasetelmassa. Viimeisessä osatyössä HEMS Benefit Score päivitettiin Delphimenetelmää käyttäen. Tulosten perusteella kirjaamisen luotettavuus oli kaiken kaikkiaan kohtalaisella, mutta peruselintoimintojen kirjaamisen osalta huonolla tasolla. Väitöskirjassa tutkittujen pisteytysjärjestelmien luotettavuus osoitettiin olevan vaihtelevaa vastaajien välillä. Ennustearvion teko onnistui kohtalaisen luotettavasti, ja sekä toivottomaksi arvioituja että todennäköisesti selviytyviksi arvioituja potilaita hoidettiin yhtä intensiivisesti. Väitöskirjan tulosten perusteella ensihoidossa asetetun toivottoman ennusteen osuvuus ei ole merkittävän korkea, joten päätöksiin rajoittaa hoitoa jo ensihoitotilanteessa tulisi suhtautua varovaisuudella. HEMS Benefit Score päivitettiin Delphi-menetelmällä vastaamaan nykyaikaisia hoitokäytäntöjä, ja nimettiin uudelleen EMS Benefit Scoreksi

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

The development of emergency medical services benefit score : a European Delphi study

Publisher Copyright: © 2021. The Author(s).BACKGROUND: The helicopter emergency services (HEMS) Benefit Score (HBS) is a nine-level scoring system developed to evaluate the benefits of HEMS missions. The HBS has been in clinical use for two decades in its original form. Advances in prehospital care, however, have produced demand for a revision of the HBS. Therefore, we developed the emergency medical services (EMS) Benefit Score (EBS) based on the former HBS. As reflected by its name, the aim of the EBS is to measure the benefits produced by the whole EMS systems to patients. METHODS: This is a four-round, web-based, international Delphi consensus study with a consensus definition made by experts from seven countries. Participants reviewed items of the revised HBS on a 5-point Likert scale. A content validity index (CVI) was calculated, and agreement was defined as a 70% CVI. Study included experts from seven European countries. Of these, 18 were prehospital expert panellists and 11 were in-hospital commentary board members. RESULTS: The first Delphi round resulted in 1248 intervention examples divided into ten diagnostic categories. After removing overlapping examples, 413 interventions were included in the second Delphi round, which resulted in 38 examples divided into HBS categories 3-8. In the third Delphi round, these resulted in 37 prehospital interventions, examples of which were given revised version of the score. In the fourth and final Delphi round, the expert panel was given an opportunity to accept or comment on the revised scoring system. CONCLUSIONS: The former HBS was revised by a Delphi methodology and EBS developed to represent its structural purpose better. The EBS includes 37 exemplar prehospital interventions to guide its clinical use. Trial registration The study permission was requested and granted by Turku University Hospital (decision number TP2/010/18).Peer reviewe

The development of emergency medical services benefit score: a European Delphi study

BackgroundThe helicopter emergency services (HEMS) Benefit Score (HBS) is a nine-level scoring system developed to evaluate the benefits of HEMS missions. The HBS has been in clinical use for two decades in its original form. Advances in prehospital care, however, have produced demand for a revision of the HBS. Therefore, we developed the emergency medical services (EMS) Benefit Score (EBS) based on the former HBS. As reflected by its name, the aim of the EBS is to measure the benefits produced by the whole EMS systems to patients.MethodsThis is a four-round, web-based, international Delphi consensus study with a consensus definition made by experts from seven countries. Participants reviewed items of the revised HBS on a 5-point Likert scale. A content validity index (CVI) was calculated, and agreement was defined as a 70% CVI. Study included experts from seven European countries. Of these, 18 were prehospital expert panellists and 11 were in-hospital commentary board members.ResultsThe first Delphi round resulted in 1248 intervention examples divided into ten diagnostic categories. After removing overlapping examples, 413 interventions were included in the second Delphi round, which resulted in 38 examples divided into HBS categories 3–8. In the third Delphi round, these resulted in 37 prehospital interventions, examples of which were given revised version of the score. In the fourth and final Delphi round, the expert panel was given an opportunity to accept or comment on the revised scoring system.ConclusionsThe former HBS was revised by a Delphi methodology and EBS developed to represent its structural purpose better. The EBS includes 37 exemplar prehospital interventions to guide its clinical use.Trial registration The study permission was requested and granted by Turku University Hospital (decision number TP2/010/18).</p

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

Physician staffed emergency medical service for children: a retrospective population-based registry cohort study in Odense region, Southern Denmark

Objectives The aim of this study is to determine diagnostic patterns in the prehospital paediatric population, age distribution, the level of monitoring and the treatment initiated in the prehospital paediatric case. Hypothesis was that advanced prehospital interventions are rare in the paediatric patient population. Setting We performed a retrospective population-based registry cohort study of children attended by a physician-staffed emergency medical service (EMS) unit (P-EMS), in the Odense area of Denmark during a 10-year study period. Participants We screened 44 882 EMS contacts and included 5043 children. Patient characteristics, monitoring and interventions performed by the P-EMS crews were determined. Results We found that paediatric patients were a minority among patients attended by P-EMS units: 11.2% (10.9 to 11.5) (95% CI) of patients were children. The majority of the children were Conclusion Prehospital paediatric contacts are uncommon, more frequently involving smaller children. Monitoring or at least documentation of basic vital parameters is infrequent and may be an area for improvement. Advanced and potentially life-saving prehospital interventions provide a dilemma since these likely occur too infrequently to allow service providers to maintain their technical skills working solely in the prehospital environment.</div

Can fisheries-induced evolution shift reference points for fisheries management?

Heino, M., Baulier, L., Boukal, D. S., Ernande, B., Johnston, F. D., Mollet, F. M., Pardoe, H., Therkildsen, N. O., Uusi-Heikkilä, S., Vainikka, A., Arlinghaus, R., Dankel, D. J., Dunlop, E. S., Eikeset, A. M., Enberg, K., Engelhard G. H., Jørgensen, C., Laugen, A. T., Matsumura, S., Nusslé, S., Urbach, D., Whitlock, R., Rijnsdorp, A. D., and Dieckmann, U. 2013. Can fisheries-induced evolution shift reference points for fisheries management? - ICES Journal of Marine Science, 70: 707-721. Biological reference points are important tools for fisheries management. Reference points are not static, but may change when a population's environment or the population itself changes. Fisheries-induced evolution is one mechanism that can alter population characteristics, leading to "shifting” reference points by modifying the underlying biological processes or by changing the perception of a fishery system. The former causes changes in "true” reference points, whereas the latter is caused by changes in the yardsticks used to quantify a system's status. Unaccounted shifts of either kind imply that reference points gradually lose their intended meaning. This can lead to increased precaution, which is safe, but potentially costly. Shifts can also occur in more perilous directions, such that actual risks are greater than anticipated. Our qualitative analysis suggests that all commonly used reference points are susceptible to shifting through fisheries-induced evolution, including the limit and "precautionary” reference points for spawning-stock biomass, Blim and Bpa, and the target reference point for fishing mortality, F0.1. Our findings call for increased awareness of fisheries-induced changes and highlight the value of always basing reference points on adequately updated information, to capture all changes in the biological processes that drive fish population dynamic

Can fisheries-induced evolution shift reference points for fisheries management?

Biological reference points are important tools for fisheries management. Reference points are not static, butmay change when a population's environment or the population itself changes. Fisheries-induced evolution is one mechanism that can alter population characteristics, leading to "shifting" reference points by modifying the underlying biological processes or by changing the perception of a fishery system. The former causes changes in "true" reference points, whereas the latter is caused by changes in the yardsticks used to quantify a system's status. Unaccounted shifts of either kind imply that reference points gradually lose their intended meaning. This can lead to increased precaution, which is safe, but potentially costly. Shifts can also occur in more perilous directions, such that actual risks are greater than anticipated. Our qualitative analysis suggests that all commonly used reference points are susceptible to shifting through fisheries-induced evolution, including the limit and "precautionary" reference points for spawning-stock biomass, B-lim and B-pa, and the target reference point for fishing mortality, F-0.1. Our findings call for increased awareness of fisheries-induced changes and highlight the value of always basing reference points on adequately updated information, to capture all changes in the biological processes that drive fish population dynamics