RARARI Project 149 Arran Air Transport Study Summary A group of GPs provides medical and A&E services to the Isle of Arran, from a base at Arran War Memorial Hospital (AWMH). Patients requiring referral to facilities or specialists not available on the island are transferred to mainland hospitals either by ferry or by air ambulance (helicopter). Data for twelve years of helicopter evacuations (625 missions) was analysed, with a view to establishing how the Arran clinicians as a group make use of the option of air evacuation. Some recommendations are made for the future of this service.
Introduction Arran is an island some 2 miles long by 1 across, lying in the Firth of Clyde. Its main ferry link is to Ayrshire, and there is a daytime car ferry service with a journey time of approximately one hour. The permanent population of 5 lives in 12 villages on the coast, with the interior of the island being largely mountainous. There is little flat terrain, and consequently no access for fixed-wing aircraft. The island s main industry is tourism, though there is some farming and forestry activity, and the population rises in the summer months, possibly peaking at 15-2,. The island s resident population is predominantly elderly. Medical services are based on three traditional medical practices, with cooperation on various elements of work including an out of hours service. There is a 22-bed hospital at Lamlash (AWMH) which provides inpatient medical beds, an A&E service, and a low risk maternity service. Eight GPs participate in an out of hours rota with two being on call at any one time. A consultant surgeon and anaesthetist were based at Lamlash until this service was withdrawn in 21, following difficulties in recruiting to the surgical post. Limited use has been made recently of telemedicine and provision of emergency services by non-medical disciplines (eg emergency nurse practitioners and paramedics). The Scottish Ambulance Service (SAS) provides the only publicly funded air ambulance facility in the UK. A helicopter option was introduced in 1993 to serve locations not accessible by fixed wing aircraft, including accident sites and remote communities without airstrips. Prior to 1993, the Arran doctors made use of navy Sea King helicopters for occasional rescues in emergency. From 1993, initially the SAS service accessed Arran only in daylight, with Sea Kings being used at night. A fully lit helipad has been available more recently. The SAS offers the following guidelines for using an air ambulance: 1 In an emergency (immediate threat to life or limb) where use of air ambulance has demonstrable advantages over land resources in terms of speed or access; or 2 To facilitate a critical care retrieval; and 3 Where the use of land transport is inappropriate e.g. in remote and island communities These guidelines offer very little practical guidance to clinicians on the appropriate use of an expensive resource. On Arran it was believed that a pragmatic consensus had developed, though no written protocol exists. Clinicians attempt to take account of resource implications while considering each individual patient s situation and best interests. Once a decision has been made to transfer a patient, there is then a choice of transfer by ferry or by air. Various factors will be considered including the urgency of the transfer, the patient s clinical condition and comfort, 2
the ferry timetable, the availability of a suitable escort, and other current clinical demands on the doctor. The SAS has a current policy of not providing any escort for patients travelling by ferry and land ambulance from Arran to a mainland hospital. Following discussion involving Arran Local Health Care Cooperative (LHCC), Ayrshire and Arran Health Board, and the SAS, an approach was made to RARARI in 2 for support for this study. It was hoped that the outcomes might include recommendations which could be of general value throughout Scotland. Method Data on helicopter transfers from Arran was available from the start of the SAS helicopter service in 1993. Initially this was recorded in a handwritten logbook, and from 1995, in electronic form. A study Excel database was established which incorporated SAS Excel data, and data transferred from the logbook. Incomplete data was supplemented by reference to patient records at AWMH, where these were available. A specific pro forma relating to helicopter transfers was in use at AWMH, but many events were not recorded. Some data, especially diagnostic information was cross-referenced with AWMH medical records. The main investigator (MK) consulted with the Arran GPs regarding questions of interest to the group. Data collection, correction and analysis was undertaken by an AWMH administrator (AM). Results Flights per year (1993-24) Throughout the study period, flights per annum varied from 35 (in 2) to a peak of 67 (in 23), with a yearly average of 52 i.e. approximately one per week (charts p13 and pp14-17) Destination hospital (p18) A large majority of flights (424; 68%) were to Crosshouse Hospital in Kilmarnock, being the area s nearest District General Hospital. Smaller numbers were transferred to Ayrshire Central Hospital, Irvine (9%) where the area s maternity unit is situated, to another DGH, Ayr Hospital (8%), and to various Glasgow hospitals (8%). 3
Seasonal pattern As anticipated, more flights took place in the summer months when the island s base population is supplemented by large numbers of visitors. There were 82 and 75 flights respectively in July and August over the study period, with a second peak of 53 in January. Timing of flights through 24 hours On p19 the chart shows the distribution of flights, by time of request, over the 24 hour period. More flights took place during the hours of daylight, than at night. Age and gender of patient (charts pp21-22) In respect of patients ages, two peaks were observed, in the fourth and seventh decades of life. Females predominated in the fourth decade, suggesting use of helicopter evacuation in the management of maternity emergencies, and males in the sixth, seventh, and eighth decades, possibly reflecting increased cardiovascular risk in older males. There was a large preponderance of males in the first decade of life. Island residents and visitors (pp23-24) Island residents outnumbered visitors by a margin on 3 to1, where resident status could be established. It was impossible to identify the status of some 9% of patients due to gaps in records, especially in the early years of the study period. Resident and visitor flight numbers were similar only in July and August. The second peak noted in January was almost entirely due to resident patients. Less variation across the age groups was noted for the visitor cohort. Clinical conditions Clinical conditions were classified into nine groups, using the best available diagnosis, and an intuitive systematic classification. The system is described in more detail in Appendix 1. On p25 the chart gives an indication of the distribution of clinical diagnoses. Gastrointestinal problems accounted for almost one quarter of the requested flights, with fractures (including other orthopoedic emergencies) accounting for one fifth. Neurological, cardiac, and maternity emergencies led to 12%, 1% and 1% of flights respectively. 4
Fractures were more commonplace in the summer months (p26), reflecting the hazards of tourist activities. Analysis by clinician Flights were requested by a wide variety of clinicians, including GP principals, salaried GPs, locums, and the consultant surgeon. Four GP principals participated in an equitable emergency cover rota throughout the 12 year study period. The chart on p27 compares their request rates. Drs C, G, and T made similar use of the service (around 8 flights each), with Dr K requesting less than half this number. The pattern appeared to be sustained across three broad time categories (weekdays, weeknights, weekends) (p28). The requests of these four clinicians in relation to the nine clinical categories were examined (p29). The numbers involved may be too small to expect any pattern to emerge. It is noted, however, that Drs G and T, who had clinical roles supporting the consultant surgeon and anaesthetist, were involved in many more Gastrointestinal emergencies. In two distinct periods, pairs of salaried GPs were in post for comparable periods. Over three years, Dr J requested 1.8 flights pa, while Dr P requested 3.7 flights pa. Over a separate two year period, Dr S requested 6.3 flights pa, while Dr N requested 2.3 flights pa. Finally, two surgeons were compared, and had per annum request rates of 16.9 and 2.3 respectively. Some reflection of these results (pp3-31) is subsequently approached in the Discussion section. Following the loss of the resident consultant surgeon and anaesthetist, there is an impression that flights for gastrointestinal emergencies declined and that other categories were unaffected (p32). Discussion The first recorded use of air transportation for medical evacuations is believed to have taken place when the French used hot air balloons for the purpose during the Franco-Prussian War in 187 (1). Use of fixed wing aircraft was also initiated by the military, and then the first use of helicopters is usually attributed to the US Army during the Korean War. Anecdotal evidence, however, suggests that the first medical helicopter evacuation from Arran (a maternity emergency) took place in 1945 (2). 5
Although there is ample literature on air ambulance services in general, there is rather less on helicopter ambulance services. Services were described, however, from the late sixties, in rural South East Mississippi (3), and in Oregon (4). More recently, descriptions of helicopter services in rural Illinois (5), and Sweden (6) have been made. The advantages cited for helicopters include their ability to land very close to accident sites, and close to receiving hospitals. Many of Scotland s islands have no airstrip and can therefore only be accessed in emergency by helicopters. In Scotland, an air ambulance service (using fixed wing aircraft) was started in 1934, but withdrawn at the start of the Second World War, and not re-introduced again until 1967. A description of its use on Orkney (7) between 1974 and 1981 includes assessment of its value, and some of the associated risks, and a similar approach is taken to the Scottish service as a whole in a 1982 description (8). The latter paper describes the births and deaths of some patients during flight. Accidents involving injury and even fatality are not unknown, although the same reservation can be applied to land ambulances. The SAS employed assistance from the Ministry of Defence, which maintains Sea King helicopters principally for a search and rescue role, for occasions when the versatility of a helicopter was required. In 1993, the SAS introduced helicopters to their own Air Ambulance Service, though MOD resources are still employed as back-up. We have encountered no working protocols to support decision-making on the use of helicopters for medical evacuations. It is generally held that there are no standardised criteria for air versus ground transportation, and a decision is left to the discretion of the referring and receiving physicians (1). This is certainly the situation on Arran. Our results suggest that clinicians take differing approaches to the use of helicopters. Discussion among the Arran clinicians indicates that the factors taken into consideration prior to deciding to use a helicopter include: patient s condition, the disease process and/or mechanism of injury, the location of the patient, and distance from the receiving unit, availability of local resources (e.g. an escort), weather conditions, and putative cost. It is noted that the SAS alternately encourages and discourages use of its air ambulances. On occasions, the SAS control room has suggested the use of a helicopter where the clinician has not felt this necessary, and on other occasions, has resisted apparently appropriate requests, other than for reasons of immediate non-availability. It has been noted that once a helicopter service is available, the marginal cost of an additional mission is far lower than the average cost per mission (9). More information for clinicians on the economics of air ambulances would be welcome. 6
Conclusions The study confirmed several expected findings regarding use of the air ambulance service by Arran clinicians, namely:?? The majority of transfers (two-thirds) were to the nearest District General Hospital (Crosshouse Hospital)?? Peak activity took place in July and August, reflecting the increase in summer workload brought about by tourists?? A preponderance of female transfers was observed in young and very elderly women?? Male transfers were more frequent in childhood and older men?? The most common reasons for emergency transfer by air were gastrointestinal conditions including the surgical acute abdomen, followed by fractures There were several unexpected findings:?? The use of the air ambulance by individual clinicians varied widely, possibly reflecting quite different presumptions regarding its purpose?? The loss of a consultant surgeon within the clinical team led, initially, to an overall reduction in air ambulance transfer requests, with this effect being particularly marked in the GI clinical category?? Transfers were much more prevalent during daylight hours (and on weekdays as against weekends), despite the fact that transfers by ferry and land ambulance were also available during this period?? No overall trend towards increasing use of the air ambulance during the 12 year study period was observed 7
Recommendations 1 Agreement is being sought from the SAS with regard to provision of data prospectively, possibly on a quarterly cycle to enable ongoing audit of Arran air ambulance use. 2 Arran Health Group intends to instigate systems to capture similar data, as well as information not collected by the SAS e.g. robust request to flight times, reasons for delays, aborted transfers, use of land based resources and ferry, etc. 3 Further discussion is to take place among the Arran clinicians with regard to the need for written guidelines and/or algorithms. The current understanding is that guidelines may be useful as a means of ensuring converging practice, but prescriptive protocols are probably unnecessary and unworkable. 4 It is intended to set up a prospective quarterly audit of Arran air ambulance activity, with this topic becoming a standing agenda item at the Arran GP Forum. 5 A wider debate should take place regarding the helicopter air ambulance and its place in current discussions about emergency and out of hours services on Arran. 6 The study should form the basis for development of a template to allow clinicians and managers in other regions to audit air ambulance activity. 7 Further work on cost-benefit and risk issues, outwith the scope of this study, would be valuable. 8
References (1) Wijngaarden M, et al. Air Ambulance Trauma Transport: a Quality Review. 1996. The Journal of Trauma: Injury, Infection and Critical Care. 41:1. 26-31. (2) Buchanan R. Personal communication. (3) Green B. Southeast Mississippi Air Ambulance District: Twenty-one years of service and safety. December 199. The Journal of Air Medical Transport. 14-6. (4) Hill M P. Helicopter Air Ambulance in a Rural Community. Emergency Medical Services. July/August 1979. 43-6. (5) Vasiljevich J, et al. Changing trends in use of helicopter transport for the sick and injured in rural Illinois. July 199. Emergency Care Quarterly. 6(2): 53-64. (6) Vesterbacka J, Eriksson A. A Rural Ambulance Helicopter System in Northern Sweden. May-June 21. Air Medical Journal. 2:3. 28-31. (7) Collacott R A. The air-ambulance: Orkney s experience. JRCGP. March 1984. 163-5. (8) Henderson M. Destination outer limits. 1982. Health and Social Services Journal. May 6 th : 554-5. (9) Zafren K. Outcome assessments and air ambulance services. The Lancet 1996; 347:1843. Letter, comment. 9
Acknowledgements The study was funded in its entirety by RARARI. I am particularly grateful to Alison McNicol for administrative assistance and the analysis of data, to Jim Kersse of the Scottish Ambulance Service for rapidly meeting repeated requests for data, and to Karen Bell of Ayrshire and Arran Community Health Division for help in the early stages of the work. Malcolm Kerr 28 th March 25 Communications Dr Malcolm Kerr, FRCPEdin, MRCGP Arran War Memorial Hospital Lamlash Isle of Arran KA27 8LP 177 32175 (office) 177 32651 (home) Malcolm.Kerr@aapct.scot.nhs.uk Or tuathair@aol.com 1
Appendix 1 System of Clinical Categorisation: 1 Neurological: stroke, subarachnoid haemorrhage, convulsions (including febrile), meningitis, eye injuries, unspecified collapse 2 Respiratory: pneumothorax, chest injury, pulmonary embolus, near-drowning, neonatal RDS 3 Gastrointestinal: all GI bleeding, pancreatitis, hernia, liver conditions, ruptured spleen 4 Metabolic: diabetes, poisoning, snake bite, allergies, dehydration, burns, diving accidents, septic shock 5 Cardiac: acute myocardial infarction, arrhythmias 6 Other cardiovascular: aneurysm, peripheral embolism, haematology, anaemia, epistaxis, vascular trauma, amputation 7 Urology/renal: including some gynaecological emergencies 8 Maternity: obstetric, including miscarriage 9 Fractures/orthopoedic: road traffic accidents, septic arthritis, facial injuries, ruptured tendon, other severe trauma e.g. lacerations 11
Appendix 2 Bar Charts Pages 13 to 32 12
NO OF EVACUATIONS PER YEAR 8 7 6 5 4 39 6 65 52 55 58 53 35 5 4 67 51 3 2 1 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 13
EVACUATIONS JAN-MAR 3 25 2 15 1 5 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 14
EVACUATIONS APR-JUN 3 25 2 15 1 5 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 15
EVACUATIONS JUL-SEPT 3 25 2 15 1 5 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 16
EVACUATIONS OCT-DEC 3 25 2 15 1 5 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 17
HOSPITAL PATIENT FLOWN TO 45 4 35 3 25 2 15 1 5 CROSSHOUSE THE AYR HOSP ACH GLASGOW OTHER TO AWMH 18
EVACUATIONS OVER 24 HOURS 7 6 5 4 3 2 1 TIME.~.59 TIME 1.~1.59 TIME 2.~2.59 TIME 3.~3.59 TIME 4.~4.59 TIME 5.~5.59 TIME 6.~6.59 TIME 7.~7.59 TIME 8.~8.59 TIME 9.~9.59 TIME 1.~1.59 TIME 11.~11.59 TIME 12.~12.59 TIME 13.~13.59 TIME 14.~14.59 TIME 15.~15.59 TIME 16.~16.59 TIME 17.~17.59 TIME 18.~18.59 TIME 19.~19.59 TIME 2.~2.59 TIME 21.~21.59 TIME 22.~22.59 TIME 23.~23.59 19
WEIGHTED TIME EVACUATION WAS REQUESTED 1993-24 7 6 5 4 3 2 1 MON - FRI 8. - 18. MON - THURS 18. - 8. FRI 18. - MON 8. 2
AGE OF PATIENT 1 9 8 7 NO. EVACUATED 6 5 4 3 2 1 ~9 1~19 2~29 3~39 4~49 5~59 6~69 7~79 8~89 9~99 AGE 21
AGE & GENDER OF PATIENT 6 5 NO. EVACUATED 4 3 FEMALE MALE UNKNOWN 2 1 ~9 1~19 2~29 3~39 4~49 5~59 6~69 7~79 8~89 9~99 AGE 22
RESIDENTS v VISITORS 5 45 4 35 3 25 2 RESIDENTS VISITORS UNKNOWN 15 1 5 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 23
MONTHLY DISTRIBUTION RESIDENT v VISITOR 6 5 4 3 RESIDENT VISITOR UNKNOWN 2 1 JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC 24
EVACUATIONS CATEGORISED BY MEDICAL CONDITION 1993-24 16 14 12 1 8 6 4 2 NEUROLOGICAL RESPIRATORY GI METABOLIC (INC DIABETES) CARDIAC OTHER CARDIOVASCULAR UROLOGY/RENAL MATERNITY FRACTURE/ORTHOPAEDIC 25
MONTHLY DISTRIBUTION OF FRACTURE/ORTHOPAEDIC EVACUATIONS 25 2 15 1 5 JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC 26
EVACUATIONS 1993-24 9 8 7 6 5 4 3 2 1 DR CAMPBELL DR GRASSIE DR KERR DR TINTO 27
TIME EVACUATION REQUESTED 1993-24 6 5 4 3 2 1 MON - FRI 8. - 18. MON - THURS 18. - 8. FRI 18. - MON 8. DR CAMPBELL DR GRASSIE DR KERR DR TINTO 28
GP EVACUATIONS BY CLINICAL CATEGORY 3 25 2 15 1 5 NEUROLOGICAL RESPIRATORY GI METABOLIC (INC DIABETES) CARDIAC OTHER CARDIOVASCULAR UROLOGY/RENAL MATERNITY FRACTURE/ORTHOPAEDIC DR CAMPBELL DR GRASSIE DR KERR DR TINTO 29
DR REQUESTING EVACUATION 1993-24 12 1 8 6 4 2 DR CAMPBELL DR GRASSIE DR KERR DR TINTO DR E GRASSIE DR GUTHRIE DR HAMILL DR JOHNSON DR MCINTYRE DR NOGUERA DR PRESTWICH DR SALCEDA DR THOMPSON DR WHITLA LOCUM GP DR MACLEOD MS BUSWELL MR O'DONOVAN (LOCUM) SURGEON OTHER AYR CONTROL 3
DR REQUESTING EVACUATION - REQUESTS PER YEAR 18. 16. 14. 12. 1. 8. 6. 4. 2.. DR CAMPBELL DR GRASSIE DR KERR DR TINTO DR JOHNSTON DR PRESTWICH DR NOGUERA DR SALCEDA MS BUSWELL MR O'DONOVAN 31
EVACUATIONS WITH / WITHOUT SURGEON (WEIGHTED PER YEAR) 25 2 15 1 5 NEUROLOGICAL RESPIRATORY GI METABOLIC (INC DIABETES) CARDIAC OTHER CARDIOVASCULAR UROLOGY/RENAL MATERNITY FRACTURE/ORTHOPAEDIC WITH SURGEON (WEIGHTED PER YEAR) WITHOUT SURGEON (WEIGHTED PER YEAR) 32