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Department of Paramedicine, Monash University, Melbourne, AustraliaDepartment of Epidemiology and Preventive Medicine, Monash University, Melbourne, AustraliaAmbulance Victoria, Melbourne, Australia
Helicopter emergency medical services (HEMS) have formed an integral component of the Irish health care system for the past decade; yet, the factors leading their commencement, their evolutions over this time, and the current model of service delivery have not been widely published. Aeromedical service provision may vary significantly from country to country and may also vary regionally within countries. A health system's necessities; capacity and maturity; the level of state, corporate, private, or community investment; and the capacity of the contracted service provider are all factors that influence the service provision. This research article describes the historic factors leading to a military and health system collaboration to HEMS during an era of health care reform. Over the past decade, the Irish health system has undergone significant reconfiguration and centralization of services, leading to increased demands on emergency medical ground and air medical services. Future advancements in aeromedical service provision require an innate understanding of the current model. This article adds to the knowledge base, informs policy makers, and supports decision making surrounding HEMS provision and the potential to explore military and health system collaborations and enhanced overall service provision.
The “centralization of complexity” is a philosophy of health care delivery globally and requires that the right patient gets brought to the right place in the right time so lives can be saved and disability reduced. Aeromedical services are critical enablers of effective complex care delivery to patients, particularly in remote or rural areas, bringing clinical teams who provide specialist time-critical expert care directly to the scene and supporting the efficient use of ground resources by expediting patient transport to specialist health care facilities such as major trauma, stroke, or ST-segment elevation myocardial infarction (STEMI) centers while sustaining emergency response capacity in the community.
Models of aeromedical service provision and emergency response can be broadly divided into the following:
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Search and rescue (SAR): technical search and specialist rescue both in the offshore and onshore environment, often focusing on mountain and coastal areas
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Aeromedical retrievals: preplanned critical care transfers between health care facilities, bringing the patient to a facility with enhanced or specialist services
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Helicopter emergency medical services (HEMS): the delivery of expert care to the scene of an unanticipated event to provide essential care and/or transport to a specialist center for stabilization and further treatment
Some health care systems combine these distinct operational models in part or full through a combination of fixed wing or rotary wing assets.
Over the past decade, the Irish health system has undergone significant reconfiguration and centralization of services. These changes have implications for aeromedical service development in the Irish state. Changes include the reform of smaller hospitals
This will provide 2 trauma networks, each with a major trauma centre (MTC) at the hub.
The aim of this study is to describe the implementation and evolution to date of HEMS in Ireland. This study highlights the cooperation between Irish military aviation and civilian emergency medical services (EMS) that combined state assets to achieve a cost-effective way to initiate an aeromedical service for the benefit of patients.
Background
The harsh winter of 1962 was the catalyst for the introduction of helicopters by the Irish Air Corps (IAC), initially for SAR and later for roles such as troop transport, reconnaissance, aeromedicall retrievals, and island relief. In the early 2000s, SAR functions transitioned from the military to the Irish Coast Guard (IRCG). In 2004, an Irish government report examined the feasibility of introducing HEMS to Ireland; the report disputed the cost-effectiveness of such a service.
The Irish Health Service Executive was formally established in 2005, which heralded the start of significant structural change and the centralization of health services.
caused significant public reaction. The perceived loss of emergency services in predominantly rural areas and the associated longer transportation times by road ambulance led to public protests.
At this time, aeromedical assets were made available to the health service by the IAC or IRCG on an ad hoc basis. In the majority of situations, a request for a scene-landing helicopter was instigated when patients were inaccessible by ground crews or required some land- or water-based technical rescue element and was completed by IRCG SAR aircraft. Requests for national and international air ambulance transfers of patients were chiefly coordinated by 1 of 10 regional ambulance control centers or by individual hospitals in conjunction with the IAC. Decisions to use fixed wing or rotary wing assets were made according to the clinical needs of the patient, aircraft availability, and hospital requests.
In 2011, the Health Information and Quality Authority, an independent statutory body set up to safeguard people and improve the safety and quality of health services in Ireland, reported on an inquiry into the care of a child awaiting a liver transplant who failed to reach King's College Hospital in time to receive a transplant when an organ became available.
Health Information and Quality Authority. Report of the inquiry into the circumstances that led to the failed transportation of Meadhbh McGivern for transplant surgery and the existing inter-agency arrangements in place for people requiring emergency transportation for transplant surgery. Cork, Ireland: HIQA; 2011.Available at: https://www.hiqa.ie/sites/default/files/2017-01/Meadhbh-McGivern-Report.pdf. Accessed May 18, 2022.
This report recommended systematic changes and support required for the coordination, care, and transport of patients requiring specialist services or aeromedical transport.
The confluence of these systematic and case-specific factors provided a strong political platform for the establishment of HEMS in Ireland. In 2012, the minister for health, with the agreement of the minister for defense, initiated a trial emergency air medical service to assess the feasibility of HEMS for Ireland. Established as a pilot project between the National Ambulance Service (NAS) and the IAC with additional support from the IRCG on June 4, 2012, Ireland launched its first primary scene-landing rotary wing aircraft.
In 2019, a second HEMS was established in Southwest Ireland in collaboration with the Irish Community Air Ambulance (ICAA) charity and the NAS. Both services operate under a single governance structure and are dispatched by an air medical coordination center responding to in excess of 1,000 missions per year.
Methods
Geographic Setting and Population
Ireland has a population of 4.9 million. The population density (60/km2) is lower than the European average, with the lowest density to the west of the country (33/km2)
The rural and sparsely populated Atlantic coastline is rugged and shaped by intervals of steep cliffs with many islands, peninsulas, headlands, and bays, and the road networks in these regions are underdeveloped. The central plains, southeast, and eastern coast are more heavily populated with better road networks and improved access to larger towns and cities.
Ireland's extreme northerly position influences air medical service provision; the current HEMS model operates only during daylight hours, whereas SAR operates on a 24-hour basis. In summer, days can remain bright for 17 hours. However, during the winter months, daylight may only last for 8 hours.
NAS
The NAS is the statutory prehospital emergency and intermediate care provider for the Irish state; in the metropolitan Dublin area, EMS is provided by the Dublin Fire Brigade as well as the NAS. The NAS responds to approximately 350,000 ambulance calls each year and employs over 2,000 staff members across 102 ambulance stations, covering an area of 68,890 km2. It also operates an intermediate care service transporting 40,000 patients annually. The NAS Critical Care Retrieval Service performs approximately 300 adult, 150 pediatric, and 600 neonatal interhospital transfers annually. The NAS coordinates and dispatches approximately 1,000 aeromedical/air ambulance calls each year. (HEMS missions are coordinated via the National Emergency Operations Centre Aeromedical Desk.)
IAC
The IAC is the air component of the Defence Forces of Ireland. Through a fleet of fixed and rotary wing aircraft, it provides military support to the Army and Naval Service together with nonmilitary air services such as Garda Air Support, air ambulance, fisheries protection, and the Ministerial Air Transport Service. The IAC operates a combination of rotary wing aircraft, including AugustaWestland AW139s and Eurocopter EC-135s, and fixed wing aircraft, including CASA CN-235s, Pilatus PC9s and PC-12s, a Britten-Norman Defender, and a Learjet 45.
ICAA
The ICAA charity funds a national network of volunteer doctors and rapid response vehicles and, with its partners (ie, the NAS and Sloane Aviation), operates the second aeromedical platform, an AugustaWestland 109S, which operates out of a civilian airfield in Rathcoole, North Cork.
IRCG SAR
The IRCG SAR operate 4 S-92 medium-lift aircraft configured for offshore and onshore specialist SAR and are located strategically in Shannon (West), Sligo (Northwest), Dublin (East), and Waterford (Southeast).
Results
Operational Configuration
HEMS provision in Ireland commenced as a national service in 2012. The initial focus was on primarily serving the population on the western seaboard but with the capability to respond anywhere in the state. The location and response model for the initial pilot project was formulated through collaboration between the clinical director of the NAS and the wing commander of helicopter operations of the IAC. Initial HEMS operations commenced using a Eurocopter EC135 and later moved to an AugustaWestland AW139 aircraft.
A number of key factors influenced the location and the response model, including the use of military facilities, the capabilities of the aircraft, the projected clinical requirements of the patients, and efficient access to patients who were not within close proximity to specialist medical and trauma facilities. The geographic and demographic challenges of the Atlantic seaboard informed the decision to establish the HEMS base in a military base in Athlone Town. This is a central location providing the timeliest access to the greatest majority of patients nationally while maintaining efficient access to the western seaboard (Fig. 2).
The AW139 is operated as a multicrew (2 pilots) operation with a military technical crewmember who is a qualified emergency medical technician (EMT) and an advanced paramedic (AP) provided by the NAS. Although operation is primarily restricted to daylight hours, the aircraft and crew are capable of operating under instrument flight rules and with night vision goggles when necessary (eg, a return to base in low-light situations; Fig. 3).
Figure 3A military AW139 based in Athlone, County Westmeath.
In 2019, the ICAA charity, in collaboration with Sloane Aviation and the NAS, established a charity-funded HEMS allowing greater geographic coverage and access to the southern region of the country. This second platform operates an AW109S (Fig. 4) from the base in Rathcoole in County Cork (Fig. 2). The hours of operation for the second platform also vary seasonally but remain compliant to visual flight rules with instrument flight rules capability.
Figure 4A Charity AW109S based in Rathcoole, County Cork.
The crewing model on the AW109S is a single pilot and 2 clinical crewmembers, an EMT and AP provided by the NAS, who both maintain European Aviation Safety Agency technical crewmember ratings and support the pilot with navigation, communication, and flight safety and flight monitoring. Clinical governance, clinical standards, and dispatch standards are identical across both services.
Dispatch and Coordination
A single aeromedical dispatch and coordination desk in the National Emergency Operations Centre now coordinates all air medical calls including the HEMS, IRCG, and air medical retrievals, both nationally and internationally. Aeromedical dispatch staff are nonclinical dispatchers and are guided by standardized tasking criteria, incorporating specific clinical conditions, the mechanism of injury, and optimal locations where HEMS response may be most beneficial. Aeromedical missions are categorized into 3 key streams (Table 1).
Table 1Air Medical Tasking
Primary tasking is classified as an aeromedical activation before ground resource at the scene and/or when limited information can be obtained, but the mechanism of injury, clinical disposition, or distance from definitive care predicts there may be a benefit from HEMS transport or treatment by HEMS clinical crew.
Secondary tasking is classified as an aeromedical activation from ground resources at the scene when the clinical disposition, clinical level of the practitioner, or distance from definitive care predicts there may be a benefit from HEMS transport or treatment by HEMS clinical crew.
Tertiary tasking is classified as an aeromedical activation from a hospital to facilitate the emergency transfer of a patient to a specialist facility/hospital. Examples of this are primary percutaneous coronary intervention for ST-elevation myocardial infarction patients and stroke thrombectomy for patients with confirmed large vessel occlusion.
The clinical staffing model is that of an AP and an EMT. The AP has a broad clinical skill set including the capacity to provide advanced life support and agents including ketamine, morphine, fentanyl, and midazolam; those who work on HEMS have an average of 15 to 20 years of clinical experience before HEMS recruitment. HEMS APs provide a limited number of enhanced care procedures beyond road-based APs, including procedural sedation and analgesia. These are provided largely for safety reasons in the context of helicopter transport.
Recruitment and Training of HEMS Clinical Crews
The selection/training of HEMS crews is a collaborative process between the aviation providers and the providers of clinical care. The fundamental training was broken into 3 key areas: aviation ground school, clinical ground school, and in-flight clinical simulations (Table 2).
Table 2Training for Helicopter Emergency Medical Service (HEMS) Clinical Crews
This article is the first to describe the implementation and evolution of HEMS in Ireland, the political forces involved, the benefits of interagency cooperation between military aviation and civilian emergency medical services, and the current models of HEMS in the Irish context. A health system's requirements; capacity and maturity; the level of state, corporate, private, or community investment; and the capacity of the contracted service provider are all factors that influence the model of aeromedical service provision. The implementation of aeromedical systems are complex and expensive and often rely on government, organizational, or community leadership. They are commonly established out of a desire to fulfill an unmet need in service provision and therefore focus on a single model of service provision or specific regional requirement.
The Irish model commenced as a military aviation and civilian EMS collaboration. This collaboration provided a robust foundation for both services, improving the understanding and capability to continue to develop and enhance aeromedical service provision; military pilots and technical crewmembers gained experience in primary scene–landing HEMS operations and prehospital emergency care, whereas prehospital professionals gained experience in a well-structured aviation system with an evolved human factor infrastructure. This transferrable knowledge positively influenced both the wider health system and military services.
A maturing Irish health system with increasing centralization of care for time-critical patients with conditions including STEMI or stroke care, post–cardiac arrest care, and major trauma care increases the impetus to further develop the current aeromedical infrastructure. Although an immediate response and connectivity by road ambulance are available for the majority of the population within a clinically acceptable time frame, the delivery of senior experienced prehospital practitioners with an extended scope of practice to safely and efficiently transport critically ill or injured patients to specialist centers over long distances is yet to be established.
As a small island nation, some complex and specialized services will remain beyond the scope of the Irish system, requiring access to specialist centers in the United Kingdom and continental Europe. Future models of aeromedical service provision need to have the capacity to provide international intervention as required.
Internationally, HEMS tends to be associated with the delivery of and transport of a higher level of care than is available from ground EMS, with consistency emerging internationally regarding the need to provide neuroprotective anesthesia via drug-assisted advanced airway management, the use of prehospital blood products, and inotropic support in the HEMS setting.
In the Irish context, this was true during the establishment of the service nearly a decade ago. When HEMS was introduced in 2012, APs were not as widely available, so HEMS was a method of delivering advanced life support to a broader cohort of patients. As the prehospital system has developed so too has the access to ground advanced life support services; a large proportion of prehospital staff in Ireland are now trained to the AP level, therefore reducing the difference in the competencies of ground staff and HEMS staff. In Ireland, the statutory regulatory body for prehospital care in association with key stakeholders is developing the role of the specialist paramedic with defined roles in critical care to support the evolving aeromedical system.
Optimal location of HEMS bases is multifactorial and complex.
Use of geographic information systems to determine new helipad locations and improve timely response while mitigating risk of helicopter emergency medical services operations.
Current aircraft locations have been heavily influenced by the existing infrastructure and geography to support access to care for rural communities. Future air medical developments need to support maximizing the availability of HEMS so all citizens of the state have timely access to expert time-critical care. This will involve maximizing daylight flying and developing safe nighttime HEMS operations.
Further research is required to inform the optimal model of HEMS to meet the future needs of an evolving Irish health service. Geographic location, hours of operation, clinical competencies, clinical crewing models, projected levels of service delivery, and extended roles such as specialist retrieval and/or technical rescue all require further investigation to ensure cost-effective, sustainable, effective, and efficient HEMS for the Irish state.
Conclusion
HEMS are resource intensive, expensive, and complex. There is a confluence of national health policies, strategies, and service reconfigurations that requires the right patient is delivered in the right time by the right people with the right skills to the right hospital. Interagency cooperation and collaboration with broad political support has resulted in efficiencies, synergies, and improved patient access to specialist centers by HEMS in Ireland; however, further research in this area is required to inform future service development.
References
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Clinical pathway: helicopter scene STEMI protocol to facilitate long-distance transfer for primary PCI.
Health Information and Quality Authority. Report of the inquiry into the circumstances that led to the failed transportation of Meadhbh McGivern for transplant surgery and the existing inter-agency arrangements in place for people requiring emergency transportation for transplant surgery. Cork, Ireland: HIQA; 2011.Available at: https://www.hiqa.ie/sites/default/files/2017-01/Meadhbh-McGivern-Report.pdf. Accessed May 18, 2022.
Use of geographic information systems to determine new helipad locations and improve timely response while mitigating risk of helicopter emergency medical services operations.
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