Elsevier

Injury

Volume 42, Issue 10, October 2011, Pages 1088-1094
Injury

An investigation into the cost, coverage and activities of Helicopter Emergency Medical Services in the state of New South Wales, Australia

https://doi.org/10.1016/j.injury.2011.02.013Get rights and content

Abstract

Background and context

Helicopter Emergency Medical Services (HEMS) have been incorporated into modern health systems for their speed and coverage. In the state of New South Wales (NSW), nine HEMS operate from various locations around the state and currently there is no clear picture of their resource implications. The aim of this study was to assess the cost of HEMS in NSW and investigate the factors linked with the variation in the costs, coverage and activities of HEMS.

Methods

We undertook a survey of HEMS costs, structures and operations in NSW for the 2008/2009 financial year. Costs were estimated from annual reports and contractual agreements. Data related to the structure and operation of services was obtained by face-to-face interviews, from operational data extracted from individual HEMS, from the NSW Ambulance Computer Aided Despatch system and from the Aeromedical Operations Centre database. In order to estimate population coverage for each HEMS, we used GIS mapping techniques with Australian Bureau of Statistics census information.

Results

Across HEMS, cost per mission estimates ranged between $9300 and $19,000 and cost per engine hour estimates ranged between $5343 and $15,743. Regarding structural aspects, six HEMS were run by charities or not-for-profit companies (with partial government funding) and three HEMS were run (and fully funded) by the state government through NSW Ambulance. Two HEMS operated as ‘hub’ services in conjunction with three associated ‘satellite’ services and in contrast, four services operated independently. Variation also existed between the HEMS in the type of helicopter used, the clinical staffing and the hours of operation. The majority of services undertook both primary scene responses and secondary inter-facility transfers, although the proportion of each type of transport contributing to total operations varied across the services.

Interpretation

This investigation highlighted the cost of HEMS operations in NSW which in total equated to over $50 million per annum. Across services, we found large variation in the cost estimates which was underscored by variation in the structure and operations of HEMS.

Introduction

Since their introduction in the Korean and Vietnam wars,7 Helicopter Emergency Medical Services (HEMS) have become a widely utilized modality as part of centralized hospital networks. In many jurisdictions, HEMS have dual roles which include scene response to major trauma, termed ‘primary scene responses’, as well as the transport of trauma and other critically ill patient populations between hospitals, termed ‘secondary inter-facility transfers’.

For patients who have sustained major trauma, a HEMS provides three potential advantages over road transport systems through primary scene responses. These include increased access to isolated areas, a reduction in the time to definitive care, and a reduced time to patients receiving advanced clinical skills and judgement, as HEMS often transport specialist physicians or highly trained paramedics to the trauma scene. Despite such advantages, studies comparing HEMS and road transport systems in primary scene responses have failed to provide a consensus as to the number of additional lives saved by HEMS.29, 30, 31

In contrast, the use of HEMS to transport critically ill patients between hospitals through secondary inter-facility transfers is less controversial. In this role, the advantage of HEMS stems from its ability to provide a fast, stable and efficient transfer service with high quality medical staff that link hospitals together as part of a network.

As a healthcare resource and an intervention, HEMS have many potential advantages to a health system including reducing transport time and providing health service equity in rural areas. However, the magnitude of these advantages is heavily dependent on local geography as well as the functionality of HEMS within specific health systems. Between countries and jurisdictions, emergency medical service design varies 27 as does the function and utilisation of HEMS.14 Whilst HEMS is characterized as an expensive resource, the cost of HEMS remains unknown in many areas.

In NSW, nine HEMS operate from diverse locations around the state, complementing fixed-wing and ground transport as part of the state trauma plan 23 and critical care networks.22 Despite their established role, there is currently no comprehensive evaluation of HEMS in NSW with respect to their costs, coverage and activities. Understanding the role of HEMS within the local environment is a key first step in order to evaluate the benefit of HEMS and how this relates to the cost. Further, given the number of HEMS in operation, it is important to understand the range of costs associated with HEMS operations as well as the variation in functional aspects that impact on the cost and benefit of HEMS such as clinical staffing, type of transports undertaken and geographic coverage. The aim of the present study was to assess the cost of HEMS operations in NSW and investigate the factors linked with variation in the costs, coverage and activities of HEMS.

Section snippets

Methods

The state of NSW is situated on the east coast of Australia and is characterized by a large land mass (over 800,000 km2) and a population of approximately 6.8 million people, who predominantly reside near coastal areas. The capital city is Sydney which incorporates approximately two thirds of the population of NSW (approximately 4.5 million). The characteristics of the NSW emergency medical system, including the main provider of pre-hospital services, NSW Ambulance, has been described previously.

Results

Table 1 outlines the cost for each HEMS during the reference period (excluding services G and H which were unable to provide financial information). Across the HEMS, annual costs ranged from $2.7 m to $19.1 m per annum; a 7-fold variation. Dividing annual costs by the number of missions and engine hours undertaken during the 2008/2009 financial year led to a cost per engine hour which ranged from $5343 to $15,743 and a cost per mission ranging from $9300 to $19,000 across services. Cost per

Principal findings in relation to previous literature

In order to establish a business case for the use of HEMS in a health system, it is important to understand their cost in relation to the activities they undertake. This study highlights that NSW HEMS’ are an expensive resource, collectively costing the NSW community over $50 m per annum. Underscoring these costs, we found HEMS in NSW undertook over 4000 missions during a one year reference period which equates to an average of 12 missions per day. In terms of providing coverage, we found HEMS

Conclusion

The findings from this investigation show that HEMS are an expensive resource, estimated to cost between $9300 and $19,000 on a per mission basis or between $5343 and $15,743 per engine hour. Underscoring this variation, we found HEMS in NSW differed in terms of structural aspects such as how they are operated or how they are staffed as well as operational aspects such as the number and type of missions they undertake and the patients they carry. Whilst HEMS are expensive, the cost should be

Conflicts of interest

Two co-authors (Dr. Tall and A/Prof Middleton) are both employees of the Ambulance Service of NSW which partially funds Helicopter Emergency Medical Services. No other conflicts of interest are present.

Acknowledgments

The authors would like to acknowledge the following individuals who assisted with this investigation:

Dr. Alan GarnerMedical Director, NRMA CareFlight
Dr. Andrew BerryState Director, Newborn and paediatric Emergency Transport Service (NETS)
Dr. Chris GavaghanRetrieval Service Director, Northern Region Area Health Service
Dr. Chris TrewthewyDirector of Intensive Care Services, Tamworth Hospital
Dr. Damian MacMahonDirector of Shock Trauma Services, The Canberra Hospital
Mrs Fiona EllicottRetrieval

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