Scientific Papers

Overcoming distance: an exploration of current practices of government and charity-funded critical care transport and retrieval organizations | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

The literature search yielded 507 articles (Fig. 1). Following the removal of 334 duplicates, the titles, and abstracts of 173 articles were screened according to the inclusion and exclusion criteria. Twelve additional articles were identified through hand searching and backward chaining. After full-text reviews, 44 articles were included. The characteristics of included studies are shown in Table 2. Most studies were observational and conducted in Australasia or Northern Europe. Fourteen SMEs were interviewed from six different countries, 12 different services/systems, and seven operational roles. The characteristics of SMEs are shown in Table 3. Seven broad themes were identified including deployment, crew composition, selection and education, clinical governance, quality assurance and quality improvement, and research.

Fig. 1
figure 1

Flowchart of article selection for literature review

Table 2 Articles included in the literature review
Table 3 Characteristics of SMEs


Several studies described significant operational and logistical challenges associated with providing equity of care across vast access- and weather- challenged geography [20,21,22,23,24,25,26]. The Australian and New Zealand College of Anaesthetists (ANZCA) guideline for the transport of critically ill patients and the Intensive Care Society (ICS) and Faculty of Intensive Care Medicine (FICM) guidance on the transfer of the critically ill adult [27, 28] both described how the mode of transport should balance the nature of the illness, the urgency of transfer, distance, availability of transport, mobilization times, geography, traffic, weather conditions and cost. Furthermore, the ICS, FICM and ANZCA [27, 28] all identified the importance of central coordination of missions and real-time clinician support. Most SMEs describe central coordination with clinician (physician or paramedic) support.

An analysis of 1124 adult critical care transfers in the South West Critical Care Network in England found that ad-hoc transfers did not meet the standard for training, clinical experience, or timeliness compared to transfers with dedicated transport teams [29]. Furthermore, a study in Sweden found that transferring patients between ICUs transfers during periods of demand–supply mismatch was associated with an increased mortality rate [30]. A recent study from Norway explored the concept of introducing fairness in air ambulance base location planning and the importance of looking for optimal solutions [31].

All SMEs interviewed described clear mission statements, mission profiles and deployment priorities including 24/7/365 coverage. All SMEs identified varying abilities to transport special populations (neonatal, pediatric, obstetrical, bariatric, psychiatric, and extracorporeal life support [ECLS]) with bariatric, psychiatric and ECLS patients being the most challenging. Most SMEs described specialized hospital-based transport teams for neonatal and pediatric transports. Ornge utilized dedicated ground critical care and specialized mental health teams. Royal Flying Doctor Service (RFDS) Queensland used a specialized ambulance for all bariatric and ECLS patients, and the Norwegian Air Ambulance used on-call HEMS physicians with specialty training for all ECLS transports. FinnHEMS had limited special population capability, with most of these types of patients transported by ground using ad-hoc teams.

Common Theme(s): Clearly defined mission statements, mission profiles and deployment priorities with 24/7/365 response capacity. Central coordination with clinician support. Use of dedicated or specialized transport teams.

Crew composition

In 2011, Jashapara [32] proposed the optimal, most productive, and cost-effective solution to enhance prehospital critical care capacity in the United Kingdom was by using specialized (critical care) paramedics, with physicians providing medical support, clinical governance, and advice as part of a multi-professional team approach. This report has subsequently been criticized for drawing these conclusions from inappropriate or unsound methods and likely delayed the implementation of critical care paramedics in the United Kingdom by some years [33]. Several studies demonstrated that with extensive training, education, exposure to high-acuity patients and physician support, critical care or intensive care paramedics could successfully perform complex procedures in the prehospital and transport setting [21, 34, 35]. Similarly, Denton et al. [36] established that advanced critical care practitioners could provide an alternative care process for critically ill adults who require external transfer. Venter et al. [37] found that patient safety could be improved by using dedicated crew with additional training. Laverty et al. [38] found a trend toward decreased mortality in trauma patients treated by more experienced or advanced providers. Corfield et al. [39] concluded that the combined skills of a physician and paramedic retrieval team offer potentially life-saving benefits for patients with critical illness and injuries in rural and remote Scotland. Moors et al. [40] found that physician-based HEMS was associated with an additional 2.5 lives saved per 100 dispatches for severely injured pediatric patients. Smith et al. [41] demonstrate an additional 3.22 survivors per 100 severe trauma patients when treated by a physician and critical care paramedic team. Maddock et al. and Lyons et al. [42, 43] demonstrated that the physician and critical care practitioner model was associated with a reduction in 30-day mortality for patients with blunt traumatic injury compared with care provided by ground paramedics. Hesselfeldt et al. [44] observed a significant reduction in time to the trauma center for severely injured patients and reduced proportions of secondary transfers with physician-led HEMS. Conversely, Hepple et al. [45] found no significant evidence of survival benefit associated with physician-led HEMS and Masterson et al. [46] concluded that HEMS confers a patient benefit regardless of crew composition.

All SMEs described a more advanced scope of practice than ground paramedics with 24/7/365 online acute care physician support linked to standard operating procedures and clinical practice guidelines with regular and ad-hoc review points. Most SMEs reported considerable variation in crew composition as shown in Table 4.

Common Theme(s): Advanced scope of practice with 24/7/365 online acute care physician support linked to standard operating procedures and clinical practice guidelines.

Crew selection and education

Most prehospital or retrieval physicians are either senior registrars or consultants and typically come from anaesthesia, emergency medicine or intensive care backgrounds [42, 46] while paramedics typically undertake intensive multi-year process to become a critical or intensive care paramedic [21, 22, 47, 48]. Most SMEs outline a rigorous selection process including a minimum of five years’ experience at an advanced license level, knowledge-based and clinical performance assessments, and scenario-based interviews. Air Ambulance Victoria and Greater Sydney Area HEMS also described medical, physical, and psychological testing during their selection processes. While the Norwegian Air Ambulance mostly recruited paramedics from special operations forces.

Common Theme(s): Rigorous selection process of candidates.

A recent study identified many similarities among independently developed prehospital and retrieval medicine courses worldwide including the use of lectures, simulation and discussion groups but also noted some important differences including variations in content and delivery methods based on participant background and patient population [49]. Most SMEs described considerable variation in the length, structure, and delivery method of initial education, with a service-sponsored university-based graduate education model being the most common. Continuing medical education varied but was typically monthly, consisting of a combination of low- and high-fidelity simulations of clinical skills, case reviews, and quarterly education and training.

Common Theme(s): Service-sponsored university-based education model.

Clinical governance

Several studies described models of clinical governance. These models often included monthly clinical governance days, thorough case reviews and comprehensive registry audits [47, 48, 50,51,52]. Most SMEs reported the use of daily simulations, review of all recent patient transports, monthly case reviews, morbidity, and mortality rounds, and quarterly or yearly specialized education and recertification training. However, all systems without an advanced clinical governance model consider their lack to be a significant weakness.

Common Theme(s): Advanced clinical governance.

Quality assurance and quality improvement

There is paucity of literature describing quality assurance and quality improvement in CCT or retrieval medicine. In 2017, The EQUIPE-collaboration group reached consensus on 15 response specific and 11 system specific quality indicators for physician-staffed emergency medical services encompassing all six quality dimensions outlined by the Institutes of Medicine, although these still need to be prospectively tested for feasibility, validity and reliability in clinical datasets [53]. Similarly Ornge [51] outlined a framework of quality assurance and quality improvement initiatives for improving patient experience, clinical practice, and operational service delivery to meet the transport needs of residents in Ontario, Canada within a broader healthcare system. Another study established a benchmark for audit and quality improvement of advanced critical care practitioner-led interfacility transport [36]. Lastly, a recent scoping review by Edwards et al. [54] resulted in the development of a quality framework comprised of eight outcomes including: asset and team type, access to definitive interventions, prehospital factors, mortality, morbidity, the responsiveness of service, accessibility of service and patient disposition. If adopted, this framework could allow for better comparison between systems.

Researchers in Scandinavia have demonstrated the feasibility of gathering detailed and comprehensive data nation-wide on all HEMS missions and treated patients using centralized and bespoke databases and data entry templates [55,56,57]. They also indicated that a national database is an important data source for research and quality improvement and could provide valuable insights into where HEMS operations could be improved [55,56,57]. Similarly, Greater Sydney Area HEMS described the long-term effectiveness of their airway registry on the completeness of documentation of prehospital rapid sequence intubation [58]. They also highlighted the importance of collecting variables, as proposed in the literature, when establishing a registry. Furthermore, they emphasized that time should be invested in designing a data entry template to minimize free-text fields and unambiguous response options. Significant variables should be recorded through mandatory fields to ensure compliance [58].

Common Theme(s): Use of a comprehensive database to guide quality assurance and quality improvement.

Most SMEs describe advanced quality assurance and quality improvement programs, including equipment standardization, the use of checklists, regular case reviews and registry audits (Table 5). All systems without a robust quality assurance and quality improvement program viewed this lack as a significant weakness.

Table 5 Quality assurance and quality improvement

Common Theme(s): Equipment standardization including pre-packaged and sealed equipment, pre-drawn high-use medications, and the use of checklists.


There are well documented challenges associated with conducting prehospital and transport medicine research, including the extensive clinical, ethical, and logistical factors limiting clinical trials and accurate data collection and the inherent heterogeneity of the patient populations and systems that allow for generalization of results. [57, 59].

All SMEs reported varying degrees of research capacity, with the Norwegian Air Ambulance Foundation leading the way in out-of-hospital research with 31 doctoral candidates, 19 other researchers and six active randomized control trials. Air Ambulance Victoria, and Emergency Medical Retrieval and Transfer Service (EMRTS) Cymru both described a variety of ongoing base-specific research trials.

Common Theme(s): Organizational prioritization and support for research.

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