Elsevier

Injury

Volume 45, Supplement 3, October 2014, Pages S53-S58
Injury

Ten years of helicopter emergency medical services in Germany: Do we still need the helicopter rescue in multiple traumatised patients?

https://doi.org/10.1016/j.injury.2014.08.018Get rights and content

Abstract

Background

Helicopter emergency medical service (HEMS) has been established in the preclinical treatment of multiple traumatised patients despite an ongoing controversy towards the potential benefit. Celebrating the 20th anniversary of TraumaRegister DGU® of the German Trauma Society (DGU) the presented study intended to provide an overview of HEMS rescue in Germany over the last 10 years analysing the potential beneficial impact of a nationwide helicopter rescue in multiple traumatised patients.

Patients and methods

We analysed TraumaRegister DGU® including multiple traumatised patients (ISS ≥16) between 2002 and 2012. In-hospital mortality was defined as main outcome. An adjusted, multivariate regression with 13 confounders was performed to evaluate the potential survival benefit.

Results

42,788 patients were included in the present study. 14,275 (33.4%) patients were rescued by HEMS and 28,513 (66.6%) by GEMS. Overall, 66.8% (n = 28,569) patients were transported to a level I trauma centre and 28.2% (n = 12,052) to a level II trauma centre. Patients rescued by HEMS sustained a higher injury severity compared to GEMS (ISS HEMS: 29.5 ± 12.6 vs. ISS GEMS: 27.5 ± 11.8). Helicopter rescue teams performed more on-scene interventions, and mission times were increased in HEMS rescue (HEMS: 77.2 ± 28.7 min. vs. GEMS: 60.9 ± 26.9 min.). Linear regression analysis revealed that the frequency of HEMS rescue has decreased significantly between 2002 and 2012. In case of transportation to level I trauma centres a decrease of 1.7% per year was noted (p < 0.001) while a decline of 1.6% per year (p < 0.001) was measured for level II trauma centre admissions. According to multivariate logistic regression HEMS was proven a positive independent survival predictor between 2002 and 2012 (OR 0.863; 95%-CI 0.800–0.930; Nagelkerkes-R2 0.539) with only little differences between each year.

Conclusions

This study was able to prove an independent survival benefit of HEMS in multiple traumatised patients during the last 10 years. Despite this fact, a constant decline of HEMS rescue missions was found in multiple trauma patients due to unknown reasons. We concluded that HEMS should be used more often in case of trauma in order to guarantee the proven benefit for multiple traumatised patients.

Introduction

Helicopter emergency medical service (HEMS) has become a significant component of preclinical treatment of traumatised patients in many countries [1], [2]. In Germany for example, HEMS is incorporated in a dense nationwide network of emergency medical services [1], [2], [3]. Since its introduction into the civilian rescue system, the effects of HEMS towards time and cost efficiency have been discussed controversially [1], [3], [4], [5]. In this context, diverse potential disadvantages of HEMS (e.g. high financial burden [6], availability of HEMS due to weather conditions, etc.) have been reported [1], [3], [7]. However, HEMS also seems to provide several presumable advantages compared to ground emergency medical services (GEMS). Firstly, HEMS is expected to facilitate rapid and wide ranged transport due to increased transportation velocity [8]. Secondly, HEMS medical crew members are supposed to be more experienced in trauma management improving preclinical treatment of traumatised patients [8], [9]. At least, improved triaging is suggested to result in transportation to a specialist trauma centre avoiding inter-hospital transfers [10].

Despite these expected beneficial aspects, the effects of HEMS transport on posttraumatic outcome also revealed varying results [5]. In this context, in some studies no significant effects of HEMS on mortality were found [9], [11], [12], whereas other studies reported contrary findings with a HEMS-associated decrease of mortality [1], [4], [13], [14], [15], [16], [17]. According to a current Cochrane Database analysis an accurate composite estimate of the benefit of HEMS could not be determined due to methodological weakness of the actually available literature, and the considerable heterogeneity of health care systems (e.g. physician-staffed HEMS) and study methodologies [5]. The authors stated that the benefit of HEMS has not been fully proven yet and that large, multicenter studies are warranted generating more robust estimates of treatment effects [5].

The presented study intended to provide an overview of HEMS rescue in Germany over the last decade. We aimed to evaluate potential changes in HEMS-associated pre-hospital trauma care over this period. We particularly investigated whether a nationwide, physician-staffed HEMS system has a beneficial impact on outcome in multiple traumatised patients.

Section snippets

The TraumaRegister DGU®

The TraumaRegister DGU® (TR-DGU) was established in 1993. In 2012 it prospectively collected data from more than 500 European trauma centres. About 90% of trauma patients are documented by German hospitals. Approximately 100 data elements are collected per patient structured in four sections corresponding to the consecutive phases of acute trauma care: A – preclinical phase: mechanism of injury, initial physiology, first therapy, neurological sign and rescue time; B – emergency room:

Demographic data

42,788 patients were included in the present study (Fig. 1). 14,275 (33.4%) patients were rescued by HEMS and 28,513 (66.6%) by GEMS. Overall, 66.8% (n = 28,569) patients were transported to a level I trauma centre, 28.2% (n = 12,052) to a level II trauma centre, and 5.1% (n = 2167) to a level III trauma centre. Mean age for all patients was 46.9 ± 21.5 years, and 72.4% were male. 3.7% of the included patients were children aged ≤15 years at time of injury. Patients transported by HEMS were younger

Discussion

Since its introduction 40 years ago, the outcome benefit of HEMS rescue in trauma patients has been discussed controversially. A current Cochrane Review concluded that on the basis of the currently available studies no definitive recommendation for the use of HEMS in preclinical trauma care can be given and emphasised the need for valid and large multicenter studies [5]. With this study we aimed to revisit this topic by presenting an overview of HEMS rescue in Germany over the last decade.

Conclusions

According to the results of the presented study, over the last decade a constant and independent survival benefit of HEMS in multiple trauma patients has been proven by adjusted multivariate regression analysis. Despite this fact, a steady decline of HEMS rescue trauma missions was found. We therefore conclude that HEMS rescue in Germany is advisable for the preclinical care of multiple trauma patients whenever possible and reasonable in order to allow the proven survival benefit for multiple

Conflict of interest

The authors declare no conflict of interests.

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