The costs and benefits of helicopter emergency ambulance services in England and Wales

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1 Jural f Public Health Medicie Vl. 8, N., pp Prited i Great Britai The csts ad beefits f helicpter eergecy abulace services i Eglad ad Wales H. A. Sks, J. P. Nichll, J. E. Brazier ad S. Lees-Mlaga Abstract Backgrud Fllwig the itrducti f Helicpter Eergecy Abulace Services (HEAS) i the Uited Kigd i the last te years this paper exaies the csts ad beefits f three ctrastig services i Crwall, Ld ad Sussex. Methds Pre-hspital prcesses f care were cpared betwee helicpter atteded patiets ad lad abulace patiets i all three studies, ad health utces were cpared betwee helicpter ad lad abulace patiets i the Crwall ad Ld studies. A review f the literature the beefits f H EAS has als bee udertake. Resu/tsThere were iprveets i respse ties ad the tie scee was lger fr helicpter atteded patiets. Survival f traua r cardiac patiets atteded by helicpter was t iprved. I Ld there was se evidece f wrse residual disability i helicpter atteded survivrs, but i Crwall residual disability was better i helicpter atteded patiets. There was iprveet i geeral health status r aspects f daily livig i the helicpter atteded patiets. The verall ttal peratial csts fr these services were 55 p.a. i Sussex, 6 i Crwall ad - illi i Ld. Cclusi The aalysis suggests that Helicpter Eergecy Abulace Services are cstly, the health beefits are sall, ad there are liited circustaces i which the pre-hspital perfrace f a abulace service i Eglad ad Wales ca be iprved. Keywrds: Helicpter Eergecy Abulace Services, health utce, csts, beefits, abulace, traua Itrducti Helicpters were first used fr aeredical casualty evacuati i the ctext f wars fught i the secd half f this cetury, ad fllwig their perceived success i the battlefield, civilia services i the Uited States bega t csider their use fr trasprt f the critically ijured. Fllwig pilt studies cducted i the Uited States i the late 96s, the US Departet f Trasprt ccluded that the use f the helicpter as a eergecy abulace culd prvide ly liited edical beefits ad ight be t cstly. - Despite this reprt, civilia Helicpter Eergecy Abulace Services (HEAS) bega t develp i the Uited States i the early 97s, icreasig i uber fr just tw dedicated HEAS peratig i the Uited States i 976 t 8 i 99. These develpets were clsely paralleled i Geray. I the last te years at least te HEAS have bee set up i the Uited Kigd, plus ther services prvidig iter-hspital trasfers. These HEAS fllw differet dels i ters f the aircraft used (Blkw 5, Squirrel, Dauphi); their wership (leased, bught); crews (paraedical, edical); fudig (public subscripti, cetral fudig); peratrs (health authrity, abulace services, plice authrities, hspital trust); peratial basis (fr traua ly, r all eergecies); ad peratig eviret (etrplita, urba, rural). With such a array f cfiguratis, ad little evidece abut effectiveess i settigs i Eglad ad Wales, the Departet f Health cissied the Medical Care Research Uit at the Uiversity f Sheffield t udertake evaluatis f the csts ad effectiveess f three ctrastig services: the paraedically crewed helicpter service i Crwall, a rural ad sparsely ppulated suer hliday destiati; 3 the edically crewed service i the etrplita eviret f Ld; ad the jit plice ad abulace service veture i Sussex. 3 A suary f the results fr these three evaluative studies is Medical Care Research Uit, Uiversity f Sheffield, Reget Curt, 3 Reget Street, Sheffield SI DA. H. A. SNKS, Research Assciate J. P. NTCHLL, Directr J. E. BRAZIER, Seir Lecturer, Health Ecics S. LEES-MLANGA, Research Assciate Address crrespdece t Prfessr J. P. NichU. xfrd Uiversity Press 996

2 68 JURNAL F PUBLIC HEALTH MEDICINE preseted here tgether with ther available ifrati draw fr the iteratial published literature ccerig the csts ad effectiveess f HEAS. 6 Methds Studies i Eglad ad Wales The three studies i Eglad ad Wales cpared chrts f helicpter atteded patiets with grups f siilar patiets atteded by paraedically crewed lad abulaces. Pre-hspital prcesses f care were cpared i the tw grups f patiets i all three studies, ad health utces were cpared fr the tw chrts i the Crwall ad Ld studies. HEAS ad grud abulace patiets were idetified fr abulace service, HEAS ad plice recrds fr iclusi i the three prspective studies fr a perid f tw years, ths ad e year i the Crwall, Ld ad Sussex studies, respectively. Helicpter ad lad abulace patiets were ly icluded i the studies if they et cliical criteria idicatig ijuries severe eugh t ptetially beefit fr the attedace f the helicpter abulace, ad peratial criteria were applied t the lad abulace ctrls t atch the characteristics f the HEAS cases. Fr exaple, lad abulace patiets were ly icluded i the studies if they were atteded by paraedics durig the daytie; ad i Ld if they were take t the sae hspitals as used by the Ld Helicpter Eergecy Medical Service (HEMS); ad i Crwall if they were atteded by e f the grup f paraedics wh were part f the air abulace crewig rta. Fr all patiets, pre-hspital ifrati type f icidet, pre-hspital tiigs fr bth grud abulace ad helicpter respse, ay treatets give scee, ad physilgical cditi f the patiet at the scee were recrded. The patiets i the Ld ad Crwall studies were fllwed up at the hspital t which they were take (ad ay subsequet hspital) ad data were recrded the physilgical cditi f the patiet i the A ad E departet; all ijuries recrded i hspital i-patiet tes (cded by Abbreviated Ijury Scre 7 ); ad legth f stay i Itesive Therapy Uit ad i hspital, r tie ad date f death. Accidetally ijured survivrs were fllwed up at six ths by iterview r pstal questiaire. This fllw-up icluded questis ccerig health service resurce use by patiets sice leavig hspital, residual disability easured usig the ffice f Ppulati Cesuses ad Surveys (PCS) disability questiaire 8, ad geeral health status easured by the Nttigha Health Prfile (NHP). 9 A cstig exercise was udertake fr each f the three studies, describig the pre-hspital capital ad peratig csts f the helicpter, special ladig ad patiet trasfer facilities where apprpriate, crewig csts, ad csequeces fr the abulace service ccered. The subsequet ipact hspital services, icludig special facilities built as a csequece f the helicpter, ad ther service csts were als icluded i this ecic aalysis. ther services A verview f the iteratial literature was carried ut by searchig the Medlie library database fr 966 wards fr relevat aterial, ad fllwig up all cited refereces fr withi the literature idetified. I additi, reprts were btaied fr ther research grups withi the Uited Kigd ver the perid f the studies. Thus the search was t exhaustive, but we believe that all ajr published studies were cllected ad have bee icluded i this review. Results Structure The three helicpter services studied varied csiderably i ters f equipet, crewig ad deplyet, as well as i ters f fiacial arrageets fr perati (Table ). The Ld HEAS uses a larger helicpter tha the ther tw services ad carries tw pilts i ctrast t the sigle pilts i Crwall ad Sussex. The Ld HEAS is differet i that a registrar grade dctr is carried i additi t a paraedic all issis. Call-ut is siilar i all three services, beig essetially thrugh the lcal abulace service ctrl r. Hwever, i Ld a paraedic is based i the ctrl r akig triage decisis, whereas i Crwall a despatcher judges the ccasis whe the helicpter shuld be activated. I Sussex, as the aircraft is dual purpse, the call-ut is perhaps ecessarily re flexible, with the plice HQ ad the helicpter tea als akig decisis abut attedace at icidets. The Ld HEAS is dedicated t priary traua eergecies, ad althugh it des carry ut se iter-hspital trasfers (IHTs), this is csidered as a secdary rle fr the helicpter tea. I Crwall the helicpter is als used fr se edical eergecies, pricipally crary eergecies, ad carries ut a csiderable uber f IHTs. The helicpter is see as ather abulace i that part f its rle is t help aitai abulace service respse tie stadards. The Ld helicpter tea is ly ever set i additi t a grud abulace respse. The Sussex helicpter's rle is re lsely defied,

3 TABLE Mdels f perati f the three UK HEAS studied CSTS Ld HEMS Crwall CASHU Helicpter used Aerspatiale Dauphi 365N Stretched Blkw 5 Sussex Plice Blkw 5 SPHU Crewig pilts edic paraedic pilt paraedics pilt plice bserver paraedic peratig characteristics Metrplita 7 days/week Daylight hurs Rural 7 days/week 8 hurs/day Rural/urba 7 days/week Daylight ad eveigs Call-ut prcedure Tasked thrugh Ld Abulace Service ly either by paraedic based i the ctrl r r request fr the scee Tasked thrugh Crwall abulace ctrl ly by despatchers Called ut by the lcal abulace services, by Sussex plice HQ, r by selfactivati Targetig Serius traua ly. Priary respse t scee, ad ifrequet iterhspital trasfers (IHTs) Traua ad se edical eergecies. The helicpter is als despatched t aitai cver f the abulace service area. Priary respse t scee ad frequet IHTs Pricipally traua. Priary respse t scee ly Fudig Pricipally Express Newspapers ad the Departet f Health Public subscripti Sussex Plice, except fr cst f prvidig the paraedic > D 3 Z " H C " r "3 r J ph a i > c r- Z C t J VIC t C

4 TABLE Patiets icluded i the studies i Eglad ad Wales Ldrl HEMS Crwall CASHU Sussex SPHU HEASi:hrt Ctrl chrt HEAS chrt Ctrl chrt HEASi;hrt Ctrl chrt Ttal cases Type f icidet Priary traua eergecies RTAs Falls Deliberate self har Assaults Fire-burs Drwig ther Crary eergecies-cllapse Iter-hspital trasfers Nt recrded _ c r 3 C C r- r- Age Nt recrded Sex Male Feale Nt recrded Ijury severity, priary traua eergecies ly t cllected t cllected ISS-5 ISS 6-75 (ajr traua) Nt scred

5 CSTS AND BENEFITS F HELICPTER EMERGENCY AMBULANCE SERVICES 7 with a ephasis traua, but with all ptetially serius icidets i difficult r rete lcatis csidered. Fiacial arrageets are differet fr each service studied. I Ld the helicpter is wed by Express Newspapers ad is la t the Ryal Ld Hspital, but all ther csts are et by the Departet f Health, cetrally r thrugh lcal Health Authrity fuds. The Crwall service is fuded etirely thrugh public subscripti, with ly the cst f the paraedic beig bre by the abulace service; ad the Sussex SPHU is paid fr etirely by the plice, ad agai ly the cst f prvidig the paraedic falls t the lcal abulace services. Patiets icluded i the studies The types f icidets i which patiets i the Ld study were ijured were prediatly rad traffic accidets (RTAs) (8 per cet), with substatial prprtis als f falls, assaults ad parasuicides (Table ). I Crwall, the fllw-up grup icluded traua IHTs, wh accuted fr 6 per cet f the patiets icluded, ad crary eergecies (5 per cet). Agst traua, falls were the ai cause f ijury, accutig fr 3 per cet f all cases. RTAs were als c, akig up 3 per cet f the chrt. Deliberate self-har, assault, fire ad ther icidets were cparatively rare. ver half the patiets i the Sussex study were ijured i RTAs. Falls were als fairly c (7 per cet). I all three studies, the HEAS atteded chrt was bradly siilar t the grud abulace ctrl chrt. Patiets i the Ld study were re severely ijured tha the traua patiets fllwed up i Crwall. I Ld, per cet f cases had a Ijury Severity Scre f >5, the geerally accepted cut-ff fr ajr traua; i Crwall the cparable figure was ly per cet, ad i the tw years f the study the helicpter atteded ly 7 ajr traua patiets. I bth studies, the helicpter atteded chrt was ade up f re severely ijured patiets tha the lad abulace ctrl chrt. Prcess f care Fr the studies carried ut i Eglad ad Wales there was evidece f ay iprveet i vehicle respse ties (fr call-ut t arrival scee) fr helicpter atteded patiets i cparis with grud abulace atteded patiets. I fact, the reverse was true i Crwall ad Ld (Table 3). I Crwall, the icreased respse tie was partly wig t lger distaces beig ivlved, althugh this did t explai all the differece. Furtherre, i all areas the tie take fr receivig the call t callig ut the helicpter was lger tha fr callig ut a lad abulace s that the differeces i ttal respse ties fr rigi f call util arrival scee were eve greater. The tie spet scee was als lger fr HEAS patiets tha grud abulace ctrls, ad patiets did t reach hspital ay re quickly whe atteded by the helicpter. Hwever, the destiati hspital was frequetly differet fr that which wuld have bee used if a grud abulace ly had atteded the patiet, particularly i Ld where the dctr scee culd triage patiets t hspitals with apprpriate specialist services. I ay istaces, this represeted a iprveet i the prcess f care, as the eed t ve the patiet fr the iitial receivig hspital t a specialist uit as a secdary trasfer was avided. The perfrace f helicpter abulace services i ters f -scee ties i Eglad ad Wales was wrse tha that f services i the Uited States ad ther cutries."~ Health utces I bth Crwall ad Ld, after takig it accut differeces i the ature ad severity f ijuries ad patiet characteristics, there was evidece f iprved survival i traua patiets atteded by helicpter i cparis with grud abulace ctrls. This was despite the fact that i Ld the HEAS has a dctr bard, wh was fud t frequetly carry ut ptetially life-savig prcedures (see Table ). There was se weak evidece i Ld that patiets with very severe ijuries ay have a iprved chace f survival if atteded by the helicpter, but that patiets with less severe ijuries ay d wrse. 5 This fidig irrrs results fr previus research carried ut i the Uited States. 6 It was estiated that there ay be e extra survivr each th agst patiets with very severe ijuries atteded by the Ld HEMS, but that verall there was iprveet i survival. There are csistet results fr ther studies t ctradict this cclusi (Table 5). Se previus studies have suggested that HEAS d iprve patiet rtality, ' 3-8 ' 6-8 whereas thers have fud survival advatage i patiets atteded by helicpter abulace. ' 5-9 " 3 Evidece ccerig rbidity fr the priary studies i Eglad ad Wales was equivcal ad difficult t iterpret. I Ld, after adjustig fr differeces i the ature ad severity f ijuries i the HEMS ad grud abulace chrts, there was se evidece that disability was wrse i HEMS survivrs, ad evidece f a differece i the six NHP

6 TABLE 3 Cparative perfrace ties fr HEAS respse Mea perfrace ties (iutes) Vehicle respse tie -scee tie Trasfer tie HEAS perati Ref. HEAS Ctrl HEAS Ctrl HEAS Ctrl Type f cases Crwall Sussex Ld Sa Dieg Stckhl Rchester, Miesta Isle f Ma Kxville, Teessee Haver Cecticut NE Pesylvaia Hust, Texas aha, Nebraska E. Pesylvaia E. Pesylvaia Ciciati ' T (983) 5-3(987) Traua ad crary eergecies Serius traua Serius traua Blut traua Blut traua Severe head ijuries Medical (57) ad traua (3) Medical ad traua scee flights Mtr cycle racers Multiply ijured traua Multiply ijured traua Multiply ijured RTA patiets Serius traua Blut (8) ad peetratig traua = 7 scee respses fr traua = 3 traua survivrs t hspital 558 traua patiets ver 5 years = 7 patiets i pst-trauatic cardiac arrest c > r " -a C B r r> H r a 5j Rage Media 'Media. tttal respse tie fr ijury t arrival at the scee.

7 CSTS AND BENEFITS F HELICPTER EMERGENCY AMBULANCE SERVICES 73 TABLE Dctr skills used i the aageet f HEMS patiets Maageet Drugs i.v. aitl Aaesthetics i.v. aalgesics Ati-eetics Cardiac drugs i.v. techiques Cut dw Cetral lie Paediatric itrasseus eedle i.v. ifusis >5 l Paediatric ifusis ther ivasive prcedure Thraccetesis Pericardicetesis Cricthyridty Iteral cardiac assage MAST suit ther All patiets with ay skill used All patiets ( = ) Nuber diesi scres, r f ay differece i the ea uber f prbles with aspects f daily livig such as lkig after the he, wrk ad hbbies. I Crwall, there was se evidece that residual disability was better i the helicpter atteded patiets tha i the grud abulace atteded ctrls after adjustig fr cfudig factrs such as age, ature ad severity f ijuries, ad distaces ivlved. There was evidece f iprved geeral health status r aspects f daily livig assciated with helicpter attedace. The review f the iteratial literature idetified ly e study which cpared the rbidity f traua patiets atteded by helicpter with thse atteded by lad abulace. I this study, shrt-ter iprveets were reprted i Glasgw utce Scres fr severely brai-ijured patiets i the helicpter atteded chrt. 3 Csts The UK. studies fud that the ttal peratig csts f dedicated helicpter abulace services raged fr 6 p.a. fr the sall paraedically crewed helicpter peratig eight hurs a day i Crwall t - illi p.a. fr the larger edically crewed helicpter i Ld (Table 6). The shared service with the plice peratig i Sussex cst arud 55 p.a. This represets the cst f prvidig paraedic cver ly durig flyig tie. The full cst f the helicpter itself is bre by the plice service. Hwever, it is pssible that partly as a result f that fact, the tivati is lackig t ru the service t its full edical capability ad that the cst-effectiveess f the service culd be iprved. Thse services ru by public subscripti have shw that they ca aitai theselves ad that the public supprt the helicpter abulace as a wrth-while charity. Discussi ad recedatis Deplyet Size f peratial area I ters f deplyet, there are ay factrs which eed t be take it accut, icludig the gegraphy ad size f the peratig area, as well as the icidece, ad spatial ad tepral distributi f serius eergecies which culd beefit fr iprved prehspital perfrace ties ad the distributi f casualty departets. It has bee suggested that, fr successful perati, activity shuld be liited t abut 6 cpleted issis a th. 33 This is typical f the activity levels f bth f the helicpter services i Crwall ad Ld, but des t represet their capacity. Hwever, the Crwall helicpter was clearly liited by the vlue f ajr traua ad ther serius eergecies which ccur i the sall ppulati served. Furtherre, i Crwall the advatages i ters f eergecy respse ties were t as clear cut as had bee expected, partly because f the additial tie take t call ut the helicpter ad partly because the average distaces fr icidets ivlvig patiets with serius cditis t the earest abulace stati was just 7 iles by rad. I urba areas, i additi t the sae issues f prxiity t the earest abulace stati ad A ad E departets, there ay be ther factrs which eed t be take it accut, such as difficulties i fidig suitable ladig sites (i Ld, 7 per cet f ladigs are re tha fr the patiet), traffic bstructi ad assciated csts ad ise. It is suggested that a dedicated helicpter shuld serve a ppulati f at least e illi, ad perate i a area where a sigificat prprti f serius eergecy icidets have bee shw t ccur either re tha 5 iutes fr the earest lad abulace stati r re tha 5 iutes fr the earest hspital services. Hwever, the difficulty i clearly defiig areas i which ptetially successful HEAS

8 TABLE 5 Cparative studies assessig utces fllwig use f HEAS r grud abulaces (GA) i priary eergecies Place Ref. Methd Type f patiets Nuber Cclusi Ariza 9 Retrspective aalysis f GA ad HEAS patiets Nrway 3 Switzerlad 3 Sa Dieg, Califria Sa Dieg, 3 Califria Cecticut 8 Shrt-ter (+7 days) assesset f survival ad cplicatis Death ad cplicatis cpared i HEAS ad GA trasprted patiets Cparis f survival f GA ad HEAS patiets cpared with TRISS predictis Cparis f survival ad Glasgw utce Scres f urba GA ad rural HEAS patiets Cparis f survival with MTS rs fr GA ad HEAS patiets Crwall 3 Cparis f survival ad utce fr survivrs at 6 ths i HEAS ad GA chrts aaged by sae paraedics Ld 5 Cparis f survival ad utce fr survivrs at 6 ths t MTS criteria i dctr crewed HEAS ad paraedic staffed GAs Iwa Nrway USA Hust, Texas Retrspective review f HEAS patiets Assesset by expert paels Cparis f survival f patiets eetig MTS criteria with TRISS predictis Survival f patiets by traua scre Blut traua with < ISS < 39 Acute Mis trasprted by helicpter r grud abulace Multiple traua patiets Blut traua patiets survivig t hspital Severely brai ijured (GCS < 8) Multisyste ijured blut traua RTA patiets Patiets with severe ijuries (siilar t MTS criteria) r crary eergecies Patiets with severe ijuries siilar t MTS criteria Multisyste traua patiets: 7- fr scee All eergecy patiets trasprted by HEAS Blut traua e year chrt f traua scee flights HEAS = 37 GA = 59 HEAS = 9 GA = 58 HEAS = 7 GA = 3 HEAS = 5 GA = 5 HEAS = GA = 8 HEAS = 93 GA = 33 HEAS = 65 traua ad 55 craries GA = 7 traua ad 58 craries HEAS = 337 GA = 66 HEAS = 569 Cardivascular = 58 Traua = 69 ther = 3 HEAS = 73 HEAS = 577 [blut = 66 peetratig = ] with TS < N survival advatage with HEAS i a urba area with a sphisticated pre-hspital syste There was differece i utce N evidece f better utces i HEAS patiets Physicia staffed HEAS iprved patiet rtality Sigificat reducti i rtality assciated with HEAS ad iprveet i GS scres Helicpter patiets had survival better tha atial rs ad lad abulace patiets wrse tha atial rs N differece i survival, but se evidece f reduced disabilities at 6 ths i HEAS chrt verall, survival r utce advatage with HEAS, but se evidece that very severely ijured patiets did better with HEAS ad less severely ijured wrse HEAS essetial i care f 6-5 f patiets beefited fr HEAS Hspital based HEAS staffed by advaced edical persel ay have the ability t reduce rtality Advaced care by helicpter edical crews did t iprve survival fr patiets with very lw traua > < cj z> C D t- w ;> r H <-* z tfl

9 CSTS AND BENEFITS F HELICPTER EMERGENCY AMBULANCE SERVICES TABLE 6 peratig csts r charges f fur helicpter eergecy abulace services i Eglad ad Wales 75 Ttal peratig cst ( ) Successful issis* (uber) Cst per successful issi ( ) Ld HEMS (99-99) Crwall (99) Sussex (99-993) Wiltshiret (99) 'A 'successful' issi resulted i a patiet beig atteded. tbased a reprt prepared by RH (99). M culd perate eas that all prpsed peratis shuld be subjected t rigrus feasibility studies. Crewig The crewig arrageet ca vary csiderably depedig the type ad size f the aircraft, the rle f the service ad the itet f delivery f care. There ca be e pilt r tw, ad the edical tea ca be ade up f ay cbiati f dctr urseparaedic. There is a ctiuig debate abut the value f rutiely carryig a dctr as part f the edical crew, which is as yet ureslved. ' 9 ' 3 " 38 The beefits are see as the extra prcedural skills which the dctr ca brig t the scee f a eergecy ad the cliical judgeet ad decisi-akig the dctr ctributes t pre-hspital patiet aageet. If the decisi is take by a lcal purchaser t iitiate a HEAS, the it is receded that a sall helicpter with tw well-traied paraedical crew with advaced resuscitati skills shuld be csidered - particularly if there is a syste f BASICS dctrs r hspital based flyig squads s that dctrs ca easily be called t the scee i the case f specific eed, such as etrapet at the scee. If there is such schee i perati lcally, a edical crew ay be apprpriate. If the HEAS is t perate as a back-up facility r as a rapid trasfer vehicle the e edical r paraedical crew eber ay be sufficiet, i which case a shared service with the plice frce ay be a apprpriate arrageet. Types f patiets selected Althugh traua patiets are the ai target grup fr priary respse HEAS, there is csesus abut the idicatis fr apprpriate taskig f HEAS t traua patiets. Hwever, the priciple is clear: helicpter attedace shuld beefit se patiets. Thus patiets with relatively ir ijuries r lifeextiguishig ijuries which culd t be successfully treated i a respse exceedig abut te iutes (such as trauatic cardiac arrest) are usually iapprpriate fr HEAS taskig. The difficulty the beces e f crrectly idetifyig calls i abulace ctrl that are suitable cases fr the helicpter t atted. I the three UK helicpter services studied, ly the Crwall helicpter is regularly tasked t crary eergecies. N evidece was fud that these patiets had rtality ay differet fr that f patiets with crary eergecies atteded by lad abulaces, as has bee fud elsewhere. 3 As cardi-pulary resuscitati ad defibrillati ay ly ake a differece t survival if prvided i thefirstfew iutes fllwig arrest, it fllws that helicpters with their geerally lger respse ties are ulikely t be able t iprve survival i these patiets. Call-ut The HEAS services i Crwall are called ut exclusively via the lcal abulace service ctrl, usually i respse t 999 calls fr the geeral public r requests fr assistace fr abulace persel r ccasially fr the plice r fire service already at the scee. I Sussex, althugh the plice helicpter uit is called ut by the abulace service it is als fte requested by plice services at the scee. I additi, the helicpter uit ca respd t icidets which ce t its atteti befre beig requested by eergecy persel. The echais fr call-ut i Geray is siilar t that i Eglad ad Wales, with all call-uts beig c-rdiated ad activati decisis ade i abulace ctrl. I ctrast, early all helicpter services i the Uited States are called ut by eergecy service persel at the scee. There is

10 76 JURNAL F PUBLIC HEALTH MEDICINE evidece f csiderable effrt beig ade t trai persel as t whe t request the helicpter. 38 Ufrtuately, there is evidece r cet i the published literature the cparative success f this type f idirect call-ut prcedure. Idirect call-ut ight, hwever, be particularly apprpriate if the pricipal fucti f the helicpter was rapid trasfer f patiets fr the scee t rete hspital facilities, such as i areas with regial traua services. If there is direct call-ut, it is receded that HEAS shuld be called ut via the lcal abulace service, which shuld be respsible fr develpig ad auditig separate call-ut prtcls fr respdig t 999 calls fr the public ad scee requests fr ther eergecy service persel. Recet develpets i cputer-aided pririty dispatch systes ay be useful fr this fucti, but util validati f curret systes is cpleted, it is receded that HEAS services shuld ly be perated i cjucti with a syste capable f fral audit. Cclusis There are liited circustaces i which a helicpter ca iprve the pre-hspital perfrace f abulace services i Eglad ad Wales, ad health beefits are sall if they exist at all. If, despite this evidece, a HEAS is csidered, rigrus feasibility studies shuld be cducted ad care shuld be take t use a apprpriately crewed helicpter, ad a large ppulati which is iadequately served by a lad abulace service shuld be cvered. I geeral, services are cstly, althugh there is a wide rage f csts, depedig aily the cfigurati f the service, ad i particular the helicpter used; the crewig; ad whether the helicpter is a dedicated eergecy air abulace ru by the abulace service r whether it is a jit veture with the plice r se ther agecy. Ackwledgeets The authrs wuld like t thak the edical ad adiistrative staff f the abulace services ad hspitals i Ld, Crwall ad Sussex. We are grateful t the Departet f Health, which cissied these studies ad supprts the MCRU. Refereces Thas F. The develpet f the ati's ldest peratig civilia hspital-spsred Aeredical Helicpter Service. Aviati, Space Evir Med 988(Jue); US Departet f Trasprtati. Helicpters i eergecy edical service. NHSTA experiece t date. DT HS 83. NHSTA. Washigt, DC: US Gveret Pritig ffice, Nichll JP, Beeby NR, Brazier JE. A cparis f the csts ad perfrace f a eergecy helicpter ad lad abulaces i a rural area. Ijury 99; 5(): * Nichll JP, Brazier JE, Sks HA, Lees-Mlaga S. The csts ad effectiveess f the Ld Helicpter Eergecy Medical Service. Sheffield: Medical Care Research Uit, Uiversity f Sheffield, Brazier J, Nichll J, Lees-Mlaga S, Beeby N. The csts ad perfrace f the edical activities f the Sussex Plice Helicpter Uit. Sheffield: Medical Care Research Uit, Uiversity f Sheffield, Nichll J, Sks H, Brazier J. The csts ad effectiveess f helicpter eergecy abulace services. Ifrati fr purchasers i Eglad ad Wales. Sheffield: Medical Care Research Uit, Assciati fr the Advaceet f Auttive Medicie. The Abbreviated Ijury Scale. Revisi. Des Plaies, IL: AAAM, Marti J, Meltzer H, Ellit J. The prevalece f disability ag adults. PCS Scial Survey Divisi. Ld: HMS, Hut SM, McEwa J, McKea SP. Measurig health status. Beckeha: Cr Hels, 986. Cpes WS, Chapi HR, Sacc WJ, et al. The Ijury Severity Scre revisited. J Traua 988; 8(): Baxt WG, Mdy P. The ipact f a rtrcraft aeredical eergecy care service traua rtality. J A MedAssc 983; 9(): Baxt WG, Mdy P. The ipact f a physicia as part f the aeredical prehspital tea i patiets with blut traua. JAMA 987; 57(3): Baxt WG, Mdy P. The ipact f advaced pre-hspital eergecy care the rtality f severely brai-ijured patiets. J Traua 987; 7(): Brisa B, AJveryd A. The abulace helicpter is a prerequisite fr cetralised eergecy care. Acta Chir Scad 986; 53: Farell MB, Sachs JL. May Cliic's hspital-based eergecy air edical trasprt service. May Cliic Prc 989; 6: Hackey RG, Varley G, Steves D, et al. Traua the Isle f Ma. Br J Sp Med 993; 7(): Schidt U, Frae SB, Nerlich ML, et al. -scee helicpter trasprt f patiets with ultiple ijuries - cparis f a Gera ad a Aerica syste. J Traua 99; 33(): Schwartz RJ, Jacbs LM, Juda RJ, et al. A cparis f grud paraedics ad aeredical treatet f severe blut traua patiets. Cecticut Med 99; 5(): Aders TE, Rse WD, Leicht MJ. Physicia-staffed helicpter scee respse fr a rural traua cetre. A Eergecy Med 987; 6: Fischer RP, Fly TC, Miller PW, et al. Urba helicpter respse t the scee f ijury. J Traua 98; (): Pult TJ, Gutierrez PJ, Schwabe DJ. Physicias' rle i aeredical trasprt questied. Crrespdece. A Eergecy Med 987; 6:. Rhdes M, Perlie R, Ars J, et al. Field triage fr

11 CSTS AND BENEFITS F HELICPTER EMERGENCY AMBULANCE SERVICES 77 -scee helicpter trasprt. J Traua 986; 6(): Rhdes M, Tikff G. A five-year experiece with scee helicpter trasprt. J Air Med Trasprt 989(ctber); 5. Wright SW, Dre SC, Cbs T, el al. Aeredical trasprt f patiets with pst-trauatic cardiac arrest. A Eergecy Med 989; 8: Nichll JP, Slcs H, Brazier JE. Effects f the Ld helicpter eergecy edical service survival after traua. Br Med J 995; 3: Baxt WG, Mdy P, Clevelad HC, el al. Hspital-based rtrcraft aeredical eergecy care services ad traua rtality: a ulticeter study. A Eergecy Med 985(Septeber); Urdaeta LF, Sadberg MK., Cra AE, et al. Evaluati f a eergecy air trasprt service as a cpet f a rural EMS syste. A Surg 98; 5: Kristiase IS, Ther J, Aldahl SM, et al. Csteffectiveess f a eergecy helicpter i a sparsely ppulated area f Nrway. Paper preseted t the Health Ecics Study Grup, Jauary Schiller WR, Kx R, Zierker H, et al. Effect f helicpter trasprt f traua victis survival i a urba traua ceter. / Traua 988; 8(8): Magus AK, Kristiase IS, Legehelikpter g Trasprt Av Pasieter Med Akutt Hjerteifarkt. Tidsskr Nr Legefre 99; : Graf M, Dearties N, Harder F, et al. Plytraua: Vergleich des Spitalverlaufes ach Luft- (it Ntarzt) versus Bdetrasprt (he Ntarzt). Helv Chir Ada 99; 59: Nichll JP, Brazier JE, Beeby NR. The csts ad effectiveess f the Crwall ad Isles f Scilly Abulace Service Helicpter Uit. Sheffield: Medical Care Research Uit, Uiversity f Sheffield, Jacbs LM, Schwartz RJ, Jacbs BB, et al. A three-year reprt f the edical helicpter trasprtati syste f Cecticut. Cecticut Med 989; 53(): Meschler, Refdii S, Hfliger C, el al. Difficult aeredical rescue situatis: experiece f a Swiss Pre- AJpie helicpter base. J Traua 99; 33(5): Rhee KJ, Strzeski M, Burey RE, et al. Is the flight physicia eeded fr helicpter eergecy edical services? A Eergecy Med 986; 5: Carraway RP, Brewer ME, Lewis RB, et al. Why a physicia?: aeredical trasprt f the traua victi. J Traua 98<July); Burey RE, Passii L, Hubert D, et al. Cparis f aeredical crew perfrace by patiet severity ad utce. A Eergecy Med 99; (): Haa BL, Jrge IC, Miller FB, et al. Helicpter trasprt f traua victis: des a physicia ake a differece? J Traua 99; 3(): peratial Research i Health Ltd. Abulace eergecy cver i Wiltshire. Evaluati f Air Supprt Uit. Fial Reprt. Readig: RH Ltd., 99. Accepted July 995

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