AREU was born in 2008: state of HEMS in Lombardy

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3 AREU was born in 2008: state of HEMS in Lombardy Milano and Como: round-the-clock (24H) Sondrio, Bergamo and Brescia: ephemeris Crew composition: flyght crews (Pilots), doctor, nurse and Hems Technician (HT) always present, even at night Night activity: flight to and from helipads always authorized with full crew, including HT Average: about 1 mission every 3 nights (only secondary).

4 2008 Helipads authorized for night flyghts: half of them were for hospital services ELISUPERFICI NOTTURNE 1 Base Hems Bergamo 2 Spedali Civili (BS) 3 Base Hems Como 4 Aeroporto Bresso (MI) 5 Caiolo (SO) 6 Ospedale di Treviglio 7 Spedali Civili (BS) 8 Fondazione Poliambulanza (BS) 9 Ospedale di Lecco (LC) 10 Osp. Varese Fond.ne Macchi (VA) 11 Osp. Niguarda Cà Granda (MI) 12 Ospedale Policlinico San Donato (MI) 13 S.Raffaele (MI) I.R.C.C.S. 14 Ospedale di Sondrio (SO) 15 Ospedale di Sondalo (SO) 16 Ospedale di Menaggio (CO) 17 Ospedale Gravedona (CO) 18 Luino (VA) 19 Casa della Sanità Livigno (SO) 20 Ospedale S. Carlo (MI) 21 Ospedale San Gerardo - Monza 22 Porlezza (CO) 23 Bellagio (CO) 24 Civenna (CO) 25 Zelbio (CO) 26 Vilminore di Scalve (BG) 27 Aeroclub Cremona (CR) 28 Centro protezione civile di Mese (SO) 29 Diga Del Truzzo (SO) 30 Lanzo d'intelvi (CO) 31 Lario HS (LC) 32 Erba (CO)

5 First reorganizations Reduction of HT presence at night (in Milan) The helicopters of Milan and Como begin to alternate missions during the night, 6 months for each helicopter (just one HEMS at night) In 2014 an experimental project begins to use more sites in the territory of the Como HEMS; other sites are identified, still in limited numbers; The project does not modify the activity. No changes in nighttime activity; mission numbers are always quite small.

6 Orography orography

7 The HEMS characteristics of "AREU Lombardia" Integration between tire and rotating wing rescue vehicles Regional operational standardization (operating instructions, etc.) Medicalization and centralization of severe patients Round-the-clock operations (NVG, Hems places and, in the future, PBN): no longer remotely illuminated soccer fields Specific and homogeneous training of the rescue system personnel Research and development activities on the Rescue Copters 7

8 The «AREU Model» Today Bergamo, at Pope Giovanni XXIII Hospital: performs ephemerisephemeris activities, with an operating time of 12 Hours. Brescia, at Spedali Civili of Brescia Hospital: since June 13th 2017 it carries out round-the-clock activities Sondrio, Helipad in Caiolo Airport: performs 12 Hour activities throughout the year Como, Helipad in Villaguardia base: carries out round-the-clock activities Milan, Helipad in Bresso Airport: performs ephemeris-ephemeris activities, with an operating time of 12 Hours.

9 The «AREU Model» Today The team, according to the complexity of the missions, is composed of : Pilot/Pilots Copter Technician (CT) Medical Staff (Doctor + Nurse) HEMS Technician(HT) Avalanche Dog Unit

10 Steps Leading to full Operation of the «AREU model» Increasing the possibilities of landing: today more than 400 specific places/sites that allow landing in Lombardy Developing new ways to fly and land more easily at night: use of Night Vision, HOIST operations (with Eli Como), "off-field" landings with both night carriers Increasing the availability of carriers: two 24H copters Re-assessing the number of vehicles on wheel: how many vehicles, which professionals, which integration Establishing a regional technical-logistics console for helicopter rescue: C.R.ELI was born!

11 Regional Control Center for HEMS (C.R.ELI) 1 single console for the coordination of 5 helicopters choice of mission helicopter based on competitiveness and on the equipment (example: sequence of activation of the bases, NVG, etc.)

12 SEQUENZA ATTIVAZIONE BASI

13 CRELI HEMS Regional Control Center NVG OPERATIONAL INTEGRATION OF ALL VEHICLES RENDEZ VOUS HEMS SITES PBN

14 The Setting Primary Rescue URBAN Setting HOUSE - ROAD BUILDING SITE COMPANY RURAL Setting MOTORWAY - VIADUCT - GALLERY ESCARPMENT MEDIA MOUNTAIN MOUNTAIN SETTING: WOOD - PASTURE - CHALET - DIRT ROADS - EXCURSION TRAILS HIGH MOUNTAIN WALL AND RIDGE- STEEP GORGE CHANNEL - VIA FERRATA - ICE WALL RIDGE and MIXED GLACIER - NATURAL CLIMBING WINTER MOUNTAIN GORGE - WALL - ICE FALL, AVALANCHE- SKI AREA - SKI TRACK - OFF TRACK - SNOWMOBILES - ROPE SYSTEMS On TOP: Secondary INTERHOSPITAL Transfer

15 Operation Data HEMS: Missions with a regular result Base Hems Missions 2014 Missions 2015 Missions 2016 Missions 2017 Missions 2018 (11 months) Bergamo Como Brescia Milano Sondrio TOTALE Month Missions Excluding: interrupted missions, incomplete exercises and missions

16 Hems Base Night Missions Missions 2014 Missions 2015 Missions 2016 Missions 2017 Missions 2018 (11 months) Como Brescia Milano TOTALE Months Missions

17 Interventions by type of setting Helipad BG BS CO MI SO Plain Missions 2016 Missions 2017 Cities Cities partially mountain Totally mountain Total Plain partially mount Totally mountain TYPE PRIMARIO SECONDARIO TRAPIANTO Totale TIPO PRIMARIO SECONDARIO TRAPIANTO Totale TIPO PRIMARIO SECONDARIO TRAPIANTO Totale TIPO PRIMARIO SECONDARIO TRAPIANTO Totale TIPO PRIMARIO SECONDARIO Totale Total

18 Special activities Transport of organs and teams for explant/transplanting activities Neonatal transport also during night time (STEN with neonatologist on board) Maternal-fetal transport (STAM) Secondary transport of special patients (Intra-aortic balloon pump - IABP, mechanical chest compression CPR, ECMO)

19 Numerosity of the landing sites: in-depth and continuous study of AREU (Special Team - LAS) together with the Flight Companies

20 Esempio scheda sito HEMS

21 Use of Night Vision Googles (NVG)

22 On board Copter Night Vision by NVG

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24 Bases and Helipad of the Hospitals

25 Distribution of illuminated soccer fields, Helipads and NVG Sites

26 Mission example: Como - Stradella 20:20 20:38

27 Mission example: Landing according to predefined route

28 Mission Example: Centralization Policlinico - Pavia 21:24 21:30

29 HLS MINIMUM REQUIREMENTS REGULAR EVOLUTION COUPLED WITH OPERATIONAL EXPERIENCE Minimum size: 30 m. X 60 m. (2d x 4d) Landing ground: solid, flat Easy accessibility for rescuers / ambulance

30 HLS MINIMUM REQUIREMENTS REGULAR EVOLUTION COUPLED WITH OPERATIONAL EXPERIENCE Absence of pylons - power lines - cableways above the landing area within a radius of 300 meters Absence of obstacles higher than 20 meters within a radius of 120 meters

31 ca. 20 m 35m Obstacles to Report ca. 120 m 70m

32 THE AREU VISION FOR THE FUTURE At least 1 registered landing point in each municipality according to the new requirements

33 In Lombardy by December 1, 2018, AREU and NICU-ASST Lecco are transporting critical newborns from spokes to hub(s) on the whole regional area by helicopter ambulance, 24/24h.

34 Main indications for newborn transportation are pulmonary disease, congenital heart disease requiring cardiosurgery, need for ECMO and asphyxia requiring therapeutic hypothermia. Thank to this new collaborative service the neonatal networks of regional NICUs (and possibly also extra regional NICUs) are now more strictly interrelated with less time needed for transport and more comfort for newborn patients with critical, time-dependent disease.

35 Cost / activity analysis (EURO) Total Cost (EURO) Cost per hour Cost per Mission Over the years the absolute increase in costs has generated a relative reduction in both hourly and mission costs

36 HEMS IN LOMBARDY: YESTERDAY, TODAY and TOMORROW Significant financial and organizational investments; for example, from a single Hems H24 base (Como) to 2 H24 bases (Como and Brescia) with human resources development, both of AREU and of the pilots, etc. Real integration between helicopter rescue and road rescue without duplication and waste of professional and technological resources, C.R.ELI Necessary emergency helicopter development needed to ensure efficient integration with H24 road rescue: development of occasional sites, NVG. Maximum care devoted tostaff training: increased safety From the helicopter rescue development in Lombardy to the realization of an agreement for an interregional helicopter rescue project with neighboring regions

37 A strategic agreement was defined with the regional organizations of the Regions of Northern Italy (Piedmont, Lombardy, Veneto, Trentino, Alto Adige, Emilia Romagna, Liguria and Friuli Venezia Giulia), for the management of an integrated activity in the areas of interregional boundary both for daytime and nighttime flight.

38 2019 DEVELOPMENTS - Special night maneuvers: from 26 June 2018 by Eli COMO - Implementation of the possibility of using the spoke Hospitals sites - Evaluation of new developments of the operational organization (time bands and extra-regional areas of competence) - Collaboration with A.R.P.A. for Meteo

39 AREU Expectations The even more extensive use of helicopter rescue The possibility of even greater integration with road rescue The timeliness of medical interventions and centralization The use of HEMS in maxi emergencies and major scheduled events

40 Thank You for Your ATTENTION!