Three emergency physicians from all six HEMS units in Finland participated in the study (n = 18). The results section presents the findings of the inductive content analysis, capturing the perspectives of the HEMS physicians interviewed.
Factors influencing the creation and implementation of medical SOPs for Finnish HEMS units
In answer to the first research question, “What factors influence the creation and implementation of medical SOPs for Finnish HEMS units?” three main categories were identified in the interview data: Background to developing medical SOPs and CLs, the creation of medical SOPs in Finnish HEMS units, and the implementation of medical SOPs and CLs. The main categories were divided into eight upper and twelve subcategories (Table 2).
Main category: Background to developing medical SOPs and CLs
Upper category: The need to develop
HEMS physicians described that their units’ internal needs for SOPs arise when procedures do not function optimally in the field. The need also arises in response to complex issues, rare and critical procedures, and frequent hyperacute situations. Furthermore, the introduction of new equipment, efforts to enhance team operations, or problematic variations in physician practices from the crew’s perspective, often necessitate the development of SOPs.
The need to develop SOPs and CLs can be driven by external factors such as adverse events, near misses, new research evidence, or national treatment recommendations that require simplification for HEMS use. Units where SOPs and CLs were already in common usage created pressure for those who had not implemented standard procedures.
“We started getting some pressure from there [the emergency medical field] as these were already in use in other parts of Finland.” (Interviewee 10).
The interviewees described that the need for SOPs and CLs may also arise from their use as tools for learning, teaching, and memory aids.
Underlying factors
Scientific knowledge was seen as providing the basis for SOPs, in addition to national treatment recommendations. Experiences working with similar HEMS units in Finland and abroad, taking into consideration aviation regulations, have also influenced the use of SOPs and CLs.
Work experience in various hospitals and HEMS units, variations between units in the guidance accuracy of different issues, regional differences, and geographical landscape have contributed to the need to create SOPs and CLs. The difference in equipment might necessitate the development of a specific SOP or the modification of another unit’s SOP. Ready-made procedures were sometimes modified due to a desire to create their own version.
“One thing might just be that you don’t want to take the same [procedure] as somewhere else. You want to make your own. I don’t know if it’s like some kind of pride or what it’s about. But it may be that you think that if something over there [XX] is done like that, then yes, we will do better, or yes, we’ll handle it a little differently […] it’s probably also human, you want to make it your own, that it has been made by you. Not directly taken from somewhere else […] I don’t know if pride is the right word or not.” (Interviewee 14).
The interviewees recognised that hospitals play a significant role in different specialties. The regional operating practices, the hospital resources in the HEMS units’ operating areas, and the working cultures and individuals in local hospitals were seen as important to consider when developing SOPs.
Intended effects
The positive effects would be the reasons for developing SOPs and CLs. Quality of care, reduced errors, and appropriate functioning of equipment achieved through SOPs and CLs were seen as improving patient safety. However, it was also noted that a potential risk to patient safety exists if SOPs are followed too rigidly or if the procedures do not take into consideration the patient’s needs or the time window.
It was described that the use of SOPs and CLs could make decision-making easier, reduce deviations, and potentially prevent things from being forgotten. These, in turn, could lead to a reduced workload, enhanced occupational safety, a greater sense of security, and the feeling that their work is meaningful.
SOPs and CLs could improve the operations of the entire HEMS team. When using SOPs, the team’s composition would not matter because all members know how to act. The structure of SOPs improves and speeds up operations as all team members can identify potential errors and respond in an expected way.
Using SOPs has brought about an overall positive development in the EMS. Operations become standardised and more predictable, even when working with an external or different team.
Creation of medical SOPs in Finnish HEMS units
Responsible party
There is no designated person responsible for SOPs and CLs in the units. However, the responsibility is usually assigned to someone due to their qualifications or in relation to their other duties. It was seen as necessary that the person responsible for drafting SOPs and CLs had worked full-time in the HEMS unit to be sufficiently familiar with EMS and its requirements. Usually, other HEMS physicians would also review the draft SOP or CL at some point in the process.
“Well, maybe something smaller like that, so some people become responsible for developing SOPs, and then it begins with them gathering information and research for that unit and then making some kind of operating model. Then these are discussed in our unit meetings, and then we try to refine it a bit more” (Interviewee 2).
Informational sharing regarding different SOPs and CLs in use among HEMS units has increased, and the cooperation between units has improved. However, cooperation was seen as mainly taking place between the physicians in charge, and the interviews revealed differing opinions on whether this cooperation was adequate or not.
It was seen that the expertise of the HEMS physicians, crew members, pilots and specialists working in hospitals should be extensively utilised when developing SOPs and CLs. Multiprofessional and participatory development was also seen as mitigating resistance to change in implementing procedures.
Unstructured development process
The process for developing SOPs and CLs often lacks clarity. The time allocated to standardise a method ranges from a few hours to several months, depending on the unit. Development methods and timing can differ greatly between and within units, depending on the procedure type and scope. Effective early communication and a precise implementation timetable were seen as critical, yet often challenging to achieve in practice.
The EMS physicians emphasised the importance of collecting feedback and testing SOPs and CLs before implementation, using methods like simulation training, skill workshops, and pilot phases to assess and refine the procedures. After implementing an SOP or CL, its functionality should be assessed during regularly scheduled unit days for potential further development. While some procedures are reviewed annually and have a designated responsible person, not all SOPs or CLs are consistently monitored. It was seen as crucial to measure the outcomes of newly implemented procedures or CLs to identify potential benefits and assess HEMS crew members’ adherence to them.
“That kind of retrospective systematic evaluation, in my opinion, occurs very rarely in the Finnish health care system, and it certainly does not occur very systematically in helicopter operations. I don’t know about other units, but for us to look and evaluate how this has gone, it’s not really done very systematically.” (Interviewee 13).
Implementation of medical SOPs and CLs
Unit-level implementation
The interviewees noted that the scope of the SOP and the available resources influence their implementation, leading to variation between and within units. Further, not all SOPs require an involved design and implementation process.
The need for well-planned communication was highlighted. Currently, the information on new SOPs and CLs is shared during unit or training days, via email and WhatsApp, followed by personnel training through videos, PowerPoint briefings, simulations, and animal or cadaver sessions. For some procedures, the training responsibility falls to individual HEMS physicians; however, there may not always be the possibility to train people adequately, often for valid reasons. HEMS physicians noted that insufficient training could affect the commitment to new procedures, which is why a slow and controlled introduction is often beneficial.
Integration into EMS
The training of other EMS professionals divided the interviewees’ opinions. On one hand, training was generally seen as important, and it was noted that other EMS fields already use SOPs. On the other hand, some SOPs were seen as specific to HEMS units, making broader EMS training unnecessary.
Challenges
A lack of commitment was identified as the biggest challenge in adopting SOPs. Implementation requires active discussion during the development process to identify and address obstacles. Moreover, insufficient training resources were seen as hindering commitment to the new practice(s). Poor implementation of CLs could result in a perceived increase in workload. Other identified challenges included the physical placement of SOPs/CLs, modifications by different physicians, and training part-time HEMS physicians.
Harmonising medical SOPs of HEMS units
In answer to the second research question, “What can be done to harmonise the medical SOPs of Finnish HEMS units?” four main categories were identified in interview data: Prerequisites for harmonising procedures, System-level changes needed, Integrating common medical SOPs into HEMS, and Cultural change. The main categories were divided into nine upper categories and nine subcategories (Table 3).
Prerequisites for harmonising procedures
Learning from the current situation
Interviewees emphasised the need for mapping and harmonising existing SOPs or selecting the most suitable common SOP to take into shared use. A shared system could make all SOPs visible to all units, acting as an instruction matrix. SOPs should be adaptable to any unit, irrespective of their operational area. Understanding the differences in current practices could be achieved, for example, by increasing cooperation at the individual level between different units and through physicians’ unit rotation.
“The practical division of duties has been agreed upon, it determines what a HEMS crew member does, what the doctor does, and so on, so on. It can also vary somewhat from unit to unit, as well as what those practices or notions are unless they are brainstormed and harmonised.” (Interviewee 8).
The need to strengthen competence in developing SOPs and CLs included understanding the hierarchical and stylistic structure of SOPs to meet operational needs.
National treatment recommendations for HEMS operations
As a basis for developing SOPs, the interviewees proposed creating separate treatment recommendations for HEMS operations, which would provide general guidelines for out-of-hospital treatment. Common SOPs should generally be universal and specific, including only the essential elements. Harmonisation should first concentrate on medical procedures, although it was also seen as necessary in matters related to care and transport.
System-level changes needed
Harmonising EMS
It was noted that harmonising SOPs would require a change in administrative management at the entire advanced care level. Regardless of the national emergency care system, transferring all medical activities under a single organisation would provide better support for the harmonisation of SOPs.
Allocated resources
According to the interviewees, the units would need enough full-time personnel to enable the development and harmonisation of SOPs. Common SOPs could require the standardisation of equipment between units.
Integrating common medical SOPs into HEMS
Increased collaboration
The interviewees wished for increased collaboration in the entire EMS field. Equal collaboration was also hoped for at the unit level so that some units would not monopolise the development of SOPs. It was felt that there was not enough collaboration at the individual level, as an attachment to one’s own ways of working could form a psychological obstacle to harmonisation and adaptation.
“Of course, it feels like, it’s always a bit like people have different ways of doing things, so how can we achieve this? Whose way is chosen [harmonised] without it always sparking discord.” (Interviewee 5).
Working groups
The interviewees described that harmonised HEMS SOPs would need to be developed in a working group with equal representation from each unit. There was no consensus on the composition of the working group, but the leadership responsibility was partly assigned to the physicians in charge. Otherwise, it was hoped that the members would be enthusiastic and focused and that all HEMS physicians could participate in the development of SOPs.
Training
Standardised and combined training between units was seen as important for SOPs to be adopted and used consistently nationwide. This could be implemented with a dedicated training organisation, by units organising training, or by involving emergency physicians from different units. Allocating sufficient resources to arrange training was emphasised.
Cultural change
Desire to harmonise medical SOPs
The need for everyone to be committed to the harmonisation of SOPs was emphasised. It was seen that units should operate uniformly nationwide, even if it requires individuals to deviate from their habits. However, some believe that SOPs should consider individual needs, such as equipment preferences.
Unit equality
HEMS units were felt to be in an unequal position, which caused friction and hindered the harmonisation of procedures. The interviewees explained that only a few HEMS physicians had worked in multiple Finnish HEMS units, resulting in a poor understanding of regional differences and individual unit needs. It was highlighted that HEMS physicians do not feel a wider sense of community, as each unit operates largely independently.
“What we don’t have between FinnHEMS units is, it’s that sense of togetherness, and even though we all strive for the best possible result in terms of patient care, we’re missing the feeling of everyone at FinnHEMS working together.” (Interviewee 15).
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