ORIGINAL PAPER. Background:

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1 ISSN DOI: /AOT Received: Accepted: Published: The Role of Medical Air Rescue Services in Medical Transport of Organ Recipients in Poland: Organizational Solutions Supporting Transplantation Medicine Authors Contribution: Study Design A Data Collection B Statistical Analysis C Data Interpretation D Manuscript Preparation E Literature Search F Funds Collection G ACDEG 1,2 Robert Gałązkowski BC 2 Agata Pawlak CE 2,3 Daniel Rabczenko DF 1 Grzegorz Michalak DF 4 Michał M. Farkowski DF 5,6 Roman Danielewicz CDEF 4 Maciej Sterliński 1 Department of Emergency Medical Service, Medical University of Warsaw, Warsaw, Poland 2 Department of Medical Logistic, Polish Medical Air Rescue, Warsaw, Poland 3 National Institute of Public Health, National Institute of Hygiene, Warsaw, Poland 4 II Departmant of Coronary Artery Disease, Heart Arrhythmia Ward, Institute of Cardiology, Warsaw, Poland 5 Department of Surgical and Transplant Nursing, Medical University of Warsaw, Warsaw, Poland 6 Polish Transplant Coordinating Center Poltransplant, Warsaw, Poland Corresponding Author: Source of support: Robert Gałązkowski, r.galazkowski@lpr.com.pl Departmental sources Background: Material/Methods: Results: Conclusions: MeSH Keywords: Full-text PDF: The aim of this study was to analyze the use of fixed-wing air ambulance (FWAA) services in Poland during the period , with particular emphasis on air transport of organ recipients to transplantation centers. This was a retrospective, cross-sectional analysis of data derived from standard FWAA medical documentation. In the years there were 500 emergency (52.7%) and 447 elective (47.3%) missions. Children who were 1 10 years old comprised the single largest group in both emergency (EM) and elective (EL) missions, accounting for 17% of all flights. EM transports carried mainly patients aged (18.5%), and 35.1% of all EM transports concerned patients with end-stage renal disease qualified as organ recipients who were transported to transplantation centers. With a total of 2278 kidney transplantations performed in Poland within the period analyzed, up to 7.8% recipients were transported by air medical services. For EL flights, the most numerous group were patients aged 1 10 (25.4%) and this group comprised mainly patients with congenital disorders (17.9%) and cardiovascular diseases (15.8%). The average flight duration was similar for both EM and EL groups (41.7±10.5 min vs. 40.4±8.7 min, respectively) (p=ns), as was the average distance covered (321.8±99.4 km vs ±87.4 km, respectively) (p=ns). In the case of patients with end-stage renal disease, the average distance and flight time were significantly longer than those for all other groups in total: 382.5±96.4 km vs ±87.3 km (p<0.001) and 74.9±10.2 min vs. 39.7±8.8 min (p<0.001), respectively. The most frequent clinical indication for FWAA transport was end-stage renal disease and most of those flights were carried out as EM. The FWAA service plays a vital role in the organization of pre-transplantation transport to referral centers in Poland. This analysis supports the data for evaluation and potential changes in the Polish distribution and allocation rules for kidney transplantation. Aircraft Kidney Transplantation

2 Gałązkowski R. et al.: Background Helicopter Emergency Medical Services (HEMS) are used mainly in emergency medicine and is above all dedicated to rapid access to scenes of accidents and immediate transport of victims or, more generally, transporting people who are suddenly ill to specialist hospital wards. The fixed-wing air ambulance (FWAA) is, on the other hand, devoted to the needs of hospitalized patients who require rapid medical transport to a remote higher referral center. Such a practice is well-grounded in world emergency and clinical medicine [1 5]. In Poland, the duties of FWAA are performed by a separate part of the Air Rescue Service. It is the only institution of this kind in Poland providing both medical care and specialist transport to patients. FWAA operations comprise emergency (ER) and elective (EL) flights. ER is intended for patients who suddenly experienced acute illness which requires intensive supervision during the flight and the situation arising is of the kind when postponing medical help can pose a threat to the patients health or life. EL is intended for patients who are not in a life-threatening state but require swift transport to a remote center and there are no contraindications for air transport. Due to the specifics of its operational possibilities and its significantly higher costs than those incurred by traditional means of transport, the FWAA [2] has to scrupulously monitor its services to optimize the utilization of its resources. As a part of the organization of the organ transplantation program, the FWAA attracts specific attention. Selected tasks within the transplantation medicine program in Poland are performed by the Polish Transplant Coordinating Center, Poltransplant. Needless to say, in many cases there is an urgent need to transfer organ recipients to a transplant center, taking into account their health status, as well as the need to reduce the time of organ ischemia. With distances of up to 600 kilometers, the use of the FWAA is fully justified. This paper indicates the importance of the cooperation and interface between 2 different organizations the Polish Air Rescue Service (which is part of the state emergency medicine system) and the organizational system of transplantation medicine. It is also an example of supporting transplantation medicine by specialized air transport units. The aim of this paper was to analyze how efficiently air transport resources were used within the 24 months during the period of in Poland, with particular emphasis on FWAA missions for the transport of organ recipients to transplantation centers. Material and Methods The research was a retrospective, cross-sectional analysis of data from the medical histories routinely taken and recorded during the missions performed by the FWAA services from 2012 to The flights analyzed were carried out by the Piaggio P.180 Avanti plane and covered distances of up to 1000 km (the airbase was at the Warsaw Okęcie airport in central Poland). The crew comprised 2 pilots, a paramedic, and a physician. It had at its disposal standard medical equipment making it possible to carry out advanced resuscitation procedures, a transport monitor, and a transport incubator [6 8]. We analyzed data on the basic characteristics of the patients, the reason for transport defined as a diagnosis according to ICD-10 (the International Classification of Diseases and Related Health Problems), the place from which the FWAA plane took off and where it landed, flight duration, and the distance between the take-off and landing locations. Flights which took off or finished abroad were excluded. Data in aggregate form for ER and EL flights The categorical variables described are shown as frequencies and percentages of patients in each category analyzed. The distance and duration of transporting the patient (from the time of take-off to landing with the patient at the point of destination) were presented using descriptive statistics (the frequency of available observation, mean, and standard deviation). The significance of the differences was assessed using the t test. All of the calculations were made by using the R statistics program for Windows by GNU General Public License v2.0. Results From 1 January 2012 to 31 December 2013, FWAA carried out 947 flights: 500 ER missions (52.7%) and 447 EL (47.3%) missions. In both cases more men were transported (62.5%; p=ns for ER vs. EL). The age distribution of the patients by type of transport is presented in Figure 1; the most numerous group of patients transported was the 1 10 age group, which accounted for over 17% of all the patients. Flights with children under 1 year old accounted for 7.3% of the total number of flights in that period. In 78% of those cases, an incubator was used for transport. Most such missions were conducted as EL flights. For ER flights, the most numerous subgroup was patients in the age group (18.5%). The distribution of age sub-groups in ER and EL air ambulance transport missions is shown in Figure 1. Indications for using the FWAA The distribution of all ICD-10 diagnosis codes in groups of patients transported in ER and EL air ambulance missions and in 628

3 Gałązkowski R. et al.: ORIGINAL PAPER % Age interval ER EL Figure 1. Distribution by age sub-groups in emergency (ER) and elective (EL) air ambulance transport missions all FWAA flights is shown in Table 1. Over 19% of the missions (ER and EL combined) comprised 184 patients who suffered from diseases of the urogenital system (group N according to the ICD-10 code). The main diagnosis for this group was N18 chronic kidney disease. It was present in 170/175 of the whole N group (97%) of ER flight patients and in 7/9 (78%) EL flight patients, and 95% of the transport missions of this kind were carried out by ER flights. Out of the total number of ER transport cases, the N18 group accounted for 35.1% of all flights. The patients were almost exclusively organ recipients requiring rapid transport to a transplantation center. With a total of 2278 kidney transplantations performed in Poland within the period analyzed, up to 7.8% recipients were transported by air medical services. The age group accounted for 27% of these missions; the second most numerous age group was (20%), and the third most numerous was (16%). The second most numerous group of patients transported were those in the T group, according to the ICD-10 coding system, which refers to injury, poisoning, and certain other consequences of external causes: among ER flights, this group accounted for 15.8%. Almost 25% of all the transport cases of this kind were patients in the age group, the second most numerous group being patients were (18.2% of the total number), and the next 2 groups were and 59 69, each of which accounted for 14.3% of the patients overall. Another significant group (6.8%) was patients categorized as T29 in the ICD-10 system (thermal and chemical burns of multiple regions). In this kind of transport, 84% of the cases were carried out as ER, which comprised 10.8% of all the ER flights. As for EL flights, the disease with which patients were most frequently transported were those from the Q group, which according to the ICD-10 code refers to congenital malformations, deformations and chromosomal abnormalities: these accounted for 17.9% of all the EL flights. The next significant group was patients from group I of the ICD-10 system, i.e. diseases of the circulatory system, which accounted for 15.8% of the flights. Transports carried out in the EL flight mode concerned patients with the A48 diagnosis according to ICD-10 (ie, other bacterial diseases, not elsewhere classified). This group accounted for 6.5% of the cases overall. The next most frequently transported group in the EL flight mode were patients in the Q20 category (i.e., congenital malformations of cardiac chambers and connections), which accounted for 3.8% of EL missions. In the most frequently transported group in EL missions (ie, those with the Q diagnosis), the oldest patients were in the up-to-29 age group. The most frequently transported patients (ie, patients aged 1 10) accounted for 55% of the cases, and the next most frequently transported group were children under 1 year old (33.8%). The next group in the order of the most frequent cases of EL transport were patients with the I diagnosis in the ICD-10 coding system. In this group nearly 27% of the patients were in the age group, followed by patients aged from (12.7%) those aged (9.9%). The number and percentage of missions for the most frequent ICD-10 diagnoses in groups of patients transported in overall, ER, and EL air ambulance missions are shown in Table 2. Routes and flight data An analysis of the places of take-off and landing with a breakdown by voievodeship (province) was performed for the most frequent reasons for ER and EL flights. Out of 947 flights, only 6 (0.6%) took place within the border of one voievodeship. The average distance covered by the plane with a patient on board was 316.3±93.9 km (range: km) and was comparable for ER and EL (p=ns). The average duration of the flights was similar in both groups: ER vs. EL, 41.7±10.5 min vs. 40.4±8.7 min, respectively (p=ns). Similarly, the average distance covered was comparable: 321.8±99.4 km vs ±87.4 km, respectively (p=ns). The situation was different for patients from the N18 group, and both the distance covered and 629

4 Gałązkowski R. et al.: Table 1. Distribution by International Classification of Diseases and Related Health Problem (ICD-10) diagnosis codes in groups of patients transported in emergency (ER), elective (EL) air ambulance missions, and overall. ICD-10 code ER EL Overall A 15 (3%) 38 (8.5%) 53 (5.6%) B 8 (1.6%) 2 (0.4%) 10 (1.1%) C 16 (3.2%) 24 (5.4%) 40 (4.2%) D 14 (2.8%) 24 (5.4%) 38 (4%) E 13 (2.6%) 16 (3.6%) 29 (3.1%) G 5 (1%) 22 (4.9%) 27 (2.9%) H 0 (0%) 2 (0.4%) 2 (0.2%) I 33 (6.6%) 71 (15.8%) 104 (11%) J 12 (2.4%) 34 (7.6%) 46 (4.9%) K 37 (7.4%) 43 (9.6%) 80 (8.4%) L 6 (1.2%) 2 (0.4%) 8 (0.8%) M 1 (0.2%) 2 (0.4%) 3 (0.3%) N 175 (35.1%) 9 (2%) 184 (19.4%) O 3 (0.6%) 1 (0.2%) 4 (0.4%) P 2 (0.4%) 9 (2%) 11 (1.2%) Q 16 (3.2%) 80 (17.9%) 96 (10.1%) R 7 (1.4%) 4 (0.9%) 11 (1.2%) S 46 (9.2%) 27 (6%) 73 (7.7%) T 79 (15.8%) 35 (7.8%) 114 (12%) Y 3 (0.6%) 3 (0.7%) 6 (0.6%) Z 8 (1.6%) 0 (0%) 8 (0.8%) Overall 499 (100%) 448 (100%) 947 (100%) Table 2. Numbers and percentages for missions carrying patients with the most frequent diagnoses according to the International Classification of Diseases and Related Health Problem (ICD-10) codes in groups of patients transported in emergency (ER), elective (EL) air ambulance missions and overall. ICD-10 code ER EL Overall A48 other bacterial diseases, not elsewhere classified 12 (2.4%) 29 (6.5%) 41 (4.3%) N18 chronic kidney disease 170 (34.1%) 7 (1.6%) 177 (18.7%) Q20 congenital malformations of cardiac chambers and connections 6 (1.2%) 17 (3.8%) 23 (2.4%) T29 thermal and chemical burns of multiple regions 54 (10.8%) 10 (2.2%) 64 (6.8%) the time of flight were longer than for all the other missions: 382.5±96.4 km vs ±87.3 km (p<0.001) and 74.9±10.2 min vs. 39.7±8.8 min (p<0.001), respectively. The length of ER and EL routes for the main groups with diagnoses that were the reason for transport did not exceed 1000 km. Patients with chronic kidney disease group N18 (n=177) were most frequently transported from the Slaskie Voievodship (province), which was followed by the Pomorskie, Dolnoslaskie, and Mazowieckie Voievodships. The most frequent destination voievodships were Pomorskie, Zachodniopomorskie, and Malopolskie. The routes of all the flights with patients with the N18 code are presented in Table

5 Gałązkowski R. et al.: ORIGINAL PAPER Table 3. Plane take-off and landing voivodeships for emergency and elective air ambulance transport missions in patients with the diagnosis of chronic kidney disease. Landing voievodeship Take-off voivodship Dolnoslaskie Kujawsko-Pomorskie Lubelskie Lubuskie Lodzkie Malopolskie Mazowieckie Opolskie Podkarpackie Podlaskie Pomorskie Slaskie Swietokrzyskie Warminsko- Mazurskie Wielkopolskie Zachodniopomorskie Total Dolnoslaskie Kujawsko-Pomorskie Lubelskie Lubuskie 2 2 Lodzkie Malopolskie Mazowieckie Opolskie Podkarpackie Podlaskie Pomorskie Slaskie Swietokrzyskie Warminsko- Mazurskie Wielkopolskie Zachodniopomorskie Total Patients with poisoning and certain other consequences of external causes group T according to ICD-10 (n=125) in the ER mode were most frequently transported from the Pomorskie Voievodship and almost half of the patients were taken to the Zachodniopomorskie Voievodship; other frequent destinations were also Slaskie, Wielkopolskie, and Dolnoslaskie. Patients with burns were most often transported to the Zachodniopomorskie and Slaskie Voievodeships. Patients with congenital malformations group Q according to ICD-10 (n=80) were most often transported from the Kujawsko-Pomorskie and Pomorskie Voivodeships, while the most frequent destinations were Mazowieckie, Lodzkie, Malopolskie, and Wielkopolskie. Discussion The present paper is the first analysis of the way fixed-wing air ambulance resources are used in Poland. It took into account the data derived from the original medical records of all the flights which took place in the 24 months of the years , which means the reliability of the results obtained is high. Over half of the indications for carrying out ER flights were urogenital diseases (first of all chronic kidney disease), as well as injuries and poisoning, and thermal and chemical burns of multiple body regions. The most frequent clinical situation in which ER transport was carried out was end-stage renal disease. The indication in such cases was urgent transport of the recipient to the kidney transplantation center when a donor was found (circa 35% of all ER missions). 631

6 Gałązkowski R. et al.: The main reason for EL flights were congenital diseases, mainly congenital heart defects. This is why almost one-fourth of all the patients transported were children under 10 years old. The indications for FWAA services in Poland were different from those described in Norway, where the main reasons for transport were cardio-vascular diseases (acute coronary syndromes) followed by injuries and neoplasms [5]. There can be different explanations for such a difference, but it seems that the main one is the now very well-developed network of catheterization laboratories in Poland, so that almost all the patients who are to have percutaneous transluminal coronary angioplasty are transported by land ambulances. Moreover, in the Norwegian analysis, air transport was predominately used in elective situations (61%), whereas EL transport in Poland constitutes a minority of the cases (47%). The analysis of the main reasons for transport in different age groups showed that it is hard to point out the dominant reason for rescue flights carrying younger patients, while when it comes to the older groups, they are above all undertaken due to diseases of the urogenital system and end-stage renal disease (as an indication in itself), as well as injuries and poisoning. In using a FWAA, the reasons for the transport of younger patients were usually congenital defects, and, after that, respiratory diseases. Some of the most frequent reasons for transporting older patients were cardiovascular diseases, and then digestive diseases, with infectious and parasitic diseases as third in order. In the largest group, cases of chronic kidney disease, patients were transported from virtually all the voievodeships and the destinations were mostly academic transplantation centers. It must be emphasized that over half of the patients transported with indications for kidney transplantation were admitted to these centers. In Poland the transplantation allocation model focuses on the recipient, while the model of organ (kidney) distribution is focused on the center. In practice this means that the recipients are taken from the national waiting list in Poltransplant in accordance with the national allocation rules published on the Poltransplant website [9]. According to the allocation rules, which are based on medical criteria (transplantation urgency, histocompatibility, the anatomic matching of the recipient and the donor, the age of the donor and the recipient, expected outcomes of the transplantation, and waiting time), the transplantation center chooses recipients and calls them to the center through their dialysis center. This model of organ distribution focused on the center requires that most recipients chosen from the waiting list must relatively frequently be transported to a distant transplant center. Due to the limited organ preservation time, in those cases it is justified to use air transport. It is also well-known that shortening the kidney preservation time has a significant impact on the short- and long-term transplant survival; the decision was therefore made to also include the geographical criterion in addition to the allocation factors mentioned above. This criterion gives extra points to patients listed for the transplant in the transplant center making the given allocation (the patient is from this voievodeship and lives close to the center). It is also important to notice the disadvantages of transporting patients to remote transplantation centers (e.g., longer preservation time, lack of family support at the time of the operation, difficulties with offering long-term post-operative care in the transplant center). Changes in the system of distributing kidneys for transplantation are now being considered. Following the proposal of the Minister of Health, members of the National Transplantation Council (NTC) and other experts agreed on the introductory criteria which should be fulfilled in order to implement a new model of kidney distribution which would focus on the recipient. This might mean transporting the organ to the center closest to the recipient s place of residence, instead of transporting the recipient. Such changes should certainly help to shorten the kidney preservation time and ensure continuity of care for the recipient. Obviously, the need for recipients using air transportation will be lower. As it is known from the materials of the above-mentioned team, in an analysis made in mid-2014, 30% of the recipients receiving the transplant in a given transplantation center come from the same voievodeship, while 20% come from neighboring voievodeships (under 200 km away). This means that 50% of the kidney recipients in a given center came from a voievodeship which is further away. A wider discussion of the threshold conditions to be met for the new principles of kidney distribution is beyond the objectives of the present paper. It seems indisputable, however, that the new principles will limit the need to transport recipients to remote transplantation centers, and it will be the organs that will require transportation which will be less demanding and less costly (sanitary road transport, the possibility to use rapid railway connections or a commercially available air carrier). The analysis of ER routes showed that in the case of injury patients, each voievodeship apart from the Lubuskie Voievodeship was the starting point of transport at least once, whereas for half of these patients the destination was the Zachodniopomorskie Voievodeship. At the same time, patients with burns were primarily sent to the West Pomeranian and Silesian Voievodeship, where centers experienced in the treatment of burns are located. Patients with congenital defects were most frequently taken to the Mazowieckie and Lodzkie Voievodeships, which have experienced pediatric centers. To sum up, on the basis of the medical records of almost 1000 flights in the years , it can be concluded that the way FWAA services were used in the period being evaluated had strong clinical grounds in the form of the need to rapidly 632

7 Gałązkowski R. et al.: ORIGINAL PAPER take patients to a specialized center, including transplantation centers. Maintaining the base of the sanitary transport team in central Poland seems optimal for the present allocation model in transplantology. Limitations of the research Our investigation is limited by the typical constraints of observational research, but its reliability is raised by using standard medical records as the source of data and analyzing all the flights that took place in the period under consideration. A detailed analysis of comorbidities, further treatment of patients, and outcome of therapeutic procedures is beyond the scope of the present analysis, since the medical records filled out during the missions do not include such data. Conclusions 1. I n the 24-month probe the most frequent clinical indication for fixed-wing air ambulance services was end-stage renal disease and a definite majority of the missions were carried out as emergency flights. 2. Using a fixed-wing air ambulance for the transport of organ recipients is an important support element of the organization of transplantation medicine in Poland. 3. The present analysis supports the relevance of the data submitted for evaluation and the necessity of implementing changes in the Polish distribution and allocation rules for kidney transplant. References: 1. Boyd CR, Corse KM, Campbell RC: Emergency interhospital transport of the major trauma patient: air versus ground. J Trauma, 1989; 29: ; discussion Brandstrom H, Winso O, Lindholm L, Haney M: Regional intensive care transports: a prospective analysis of distance, time and cost for road, helicopter and fixed-wing ambulances. Scand J Trauma Resusc Emerg Med, 2014; 22: Mann NC, Pinkney KA, Price DD et al: Injury mortality following the loss of air medical support for rural interhospital transport. Acad Emerg Med, 2002; 9: Mitchell AD, Tallon JM, Sealy B: Air versus ground transport of major trauma patients to a tertiary trauma centre: a province-wide comparison using TRISS analysis. Can J Surg, 2007; 50: Norum J, Elsbak TM: Air ambulance flights in northern Norway Increased number of secondary fixed wing (FW) operations and more use of rotor wing (RW) transports. Int J Emerg Med, 2011; 4: Deakin CD, Nolan JP, Soar J et al: European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation, 2010; 81: Nolan JP, Soar J, Zideman DA et al: European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation, 2010; 81: Warren J, Fromm RE Jr, Orr RA et al: Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med, 2004; 32: (19 th April 2015) [in Polish] 633