Медицина/3. Организация здравоохранения

Alibek K. Kossumov¹, Sergey V. Kim¹, Junko Tanaka²,

Kuat P. Oshakbayev³

¹Public Health Department #2, JSC “Astana Medical University”, 51, Beibitshilik Street, Astana, 010000, Republic of Kazakhstan

²Department of Epidemiology, Infectious Disease Control and Prevention, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan.

³Scientific Department, JSC “National (Republican) Scientific Centre for Emergency Medical Care”, 3, Khans of Kereyi and Zhanibek Str., Left bank, Astana, 010000, Republic of Kazakhstan

The use of air ambulance in the healthcare system of Kazakhstan at present time: justification

Abstract

The Republic of Kazakhstan has an economic potential to provide the healthcare system with small aircrafts. Small aircrafts in the country can play a special role due to low population density and great distances between settlements.

Due to the geographic spread and climatic conditions, most residents of Kazakhstan in need of medical emergency treatment in hospitals with provision of highly specialized medical care are unable to receive such quality assistance in a timely manner. Each year every third resident requires an emergency medical service. In 2010 5,781,241 emergency calls were served. More than 60 per cent were provided with emergency hospital care.

According to the order of the Minister of Health #793, issued on 26 November 2009, "On approval of the rules of provision of first aid and medical assistance in the form of air ambulance," provision of medical care by air ambulance is defined as provision of emergency medical care when there is lack of medical equipment or relevant professional qualified staff at a local medical organization where a patient is located [1]. Use of ambulance aircrafts is the best way to transport patients from the scene to any medical clinic in the world. According to Article 50 of the Code of the Republic of Kazakhstan "On health of the people and the health care system" issued on 18 September 2009 (#193-IV Law of the Republic of Kazakhstan), "air ambulance is a form of providing emergency medical care in cases of lack of medical equipment or professional qualified staff at a medical organization where a patient is located. Provision of medical care in the form of air ambulance shall be effected by delivery of skilled professionals to the scene or transport a patient to an appropriate medical organization by various means of transport. ... "[2].

The Minister of Health of the Republic of Kazakhstan in his speech in January 2008 noted that additional measures were taken to restore and develop air ambulance service to ensure availability of specialized medical care. Within the structure of primary health care, a special role is played by emergency medical care. An ambulance service should provide assistance in cases requiring urgent medical intervention (accidents, injuries, poisoning and other conditions and diseases). Deaths from injuries caused by accidents ranked second among causes of deaths in Kazakhstan. Often, death affects young males of working age.

Table 1 [3] presents the data on the number of requests for emergency ambulance services in Astana. As the table shows, the number of calls is increasing. The total number of calls in 2009 increased by 17 per cent compared to 2008. In 2010 the number increased by 35 per cent compared to 2008 and by 15 per cent compared to 2009. The increase in complaints in children by 26 per cent is recorded in 2009. The number increased by 56 per cent in 2010 compared to 2008 and by 16 per cent compared to 2009. Increase in cases involving adults is observed as well. The number of referrals increased in 2009 by 18per cent and in 2010 by 38 per cent if compared to 2008 and by 18 per cent if compared to 2009. An increase in the number of calls with regard to individual nosology, including traumas, has been recorded as well. The number of trauma related calls increased in 2009 by seven per cent and in 2010 by 24 per cent if compared to 2008 and by 16 per cent if compared to 2009.

Table 1 - The number of requests for emergency ambulance services in Astana in 2008-2010

Age based:	2008	2009	2010
Total	193,139	225,705	259,291
Gender: male	80,088	93,536	107,179
Gender: female	113,051	132,169	152,112
Age: children, total	57,804	78,264	90,196
Age: under one year	15,082	19,556	22,186
Age: 1-3	16,783	23,771	28,231
Age: 3-8	14,049	19,767	24,125
Age: 8-17	11,890	15,170	15,654
Age: adults, total	144,820	169,819	199,356
Age: 15-60	115,743	136,723	159,937
Age: 60 and above	29,077	33,096	39,419
Nosology based:
Infection	8,939	10,915	14,374
Endocrinology	578	687	733
Psychoneurology	14,277	15,516	17,838
Cardiovascular disease	25,316	31,282	34,658
ENT, ophthalmology, dentistry	961	883	1,124
Pulmonology	38,848	51,583	57,374
Surgery	19,379	21,380	25,099
Urology	9,277	9,766	11,084
Obstetric-gynecology	15,280	18,873	20,603
Oncology	1,559	1,643	1,862
Narcology	2,915	3,396	2,316
Allergology	3,166	4,635	5,691
Toxicology	2,065	1,868	2,956
Traumatology	23,013	24,600	28,413
Other	6,086	6,241	6,570

Methods

In this paper the research is based on the data reported by the ambulance station in the city of Astana and Akmola region which was recorded in their annual reports in 2003 - 2010. Both qualitative information analysis and quantitative statistical and mathematical analysis were applied in processing of the data.

Results

The main cause of traffic accidents related injuries are accidents involving motor vehicles on roads and highways. According to Table 2 [4], in Kazakhstan in 2007 15,942 accidents were recorded, in which the death toll was 4,365 people or 18.7 per cent of the total number of victims which was 23,316. 2008 saw 13,739 traffic accidents which involved the deaths of 3,351 people or 17 per cent of the total number of victims which was 19,751. In 2009 12,534 accidents resulted in the deaths of 2,898 people or 14 per cent of the total number of victims which was 20,584.

Table 2 – Traffic accidents in Kazakhstan

	2003	2004	2005	2006	2007	2008	2009
Number, total	14,013	15,302	14,517	16,038	15,942	13,739	12,534
Number of deaths	2,754	3,136	3,374	4,271	4,365	3,351	2,898
Number of wounded	16,951	18,794	17,422	19,389	18,951	16,400	17,686

Table 3 [3] presents data on the number of accidents on roads in the area of Akmola region of Astana. As the table shows, the number of accidents in 2009 decreased by 12 per cent, but in 2010 an increase of 2.5 per cent was observed. It should be noted that rates in 2010 did not stand above those of 2008.

Table 3 - Traffic accidents on highways in Akmola region

	Speedway	2008	2009	2010
1	Astrakhanskaya speedway	92	79	69
2	Karagandinskaya speedway	49	58	37
3	Kokshetauskaya speedway	15	9	14
4	Kurgaldjinskaya speedway	60	58	68
5	Pavlodarskaya speedway	7	0	1
6	Rojdestvenskaya speedway	21	19	15
7	Sofievskaya speedway	62	49	69
8	Shortandinskaya speedway	14	10	16
	Total:	320	282	289

Discussion

According to experts, 80 per cent of deaths take place in areas isolated from major centers of specialized trauma care. It is known that if aid is offered within the first two hours after an accident takes place, the mortality rate decreases to 15 per cent. Some of such patients could be saved if the structure of the emergency medical system would allow small capacity aircrafts, which could arrive to an accident site within two-three hours and save most of the victims.

In addition, small-scale aircrafts could be used if necessary for emergency delivery of patients from rural and central district hospitals to large regional trauma centers and other institutions of treatment of trauma. Small aircrafts could also be used for transfer of organs in cases of car accidents.

Effective organization of medical care at all stages of treatment is one of the priorities to alleviate effects of injuries. According to estimates of health workers, each twentieth victim from each hundred of deceased victims could be rescued: 20 per cent die before arrival at a hospital due to an injury incompatible with life and 80 per cent die due to imperfections of medical facilities and technology applied in the aftermath of an accident where no adequate medical care is provided. The importance of timely medical care is determined by the fact that 50 per cent of deaths in road accidents occur within a few minutes after accidents. During the first hour after an accident 61.1 per cent of victims die. In low and middle-income countries most affected die before admission to hospital. Among those brought to hospital 75.8 per cent die later on the first day. Assistance provided in the first 60 minutes after an accident takes place is the most effective. This period is called the "golden hour" [5]. Table 4 [3] provides the data on the proportion of calls with a delay of more than 15 minutes. The number of delays grew in 2010 by one per cent compared with 2008 whilst the number of calls increased by 37 per cent.

Table 4 - Data on calls and dispatch of services

№	Indicators	2008		2009		2010
		number	%	number	%	number	%
1	Calls, total	195,450		223,336		267,644
2	Up to five minutes between the time of a call and a service dispatch	187,445	95.9	218,101	97.7	259,630	97
3	Over 5-minute-delay by dispatchers	8,005	4.1	5,235	2.3	8,014	3
4	Up to 15 minutes after an ambulance dispatch and its arrival on the scene	186,384	95.4	211,583	94.7	252,667	94.4
5	Delayed arrivals (more than 15 minutes)	9,066	4.6	11,753	5.3	14,977	5.6

A review of research in Europe [6] showed that about 50 per cent of deaths in road accidents occur within a few minutes at the scene or on the way to hospital. 15 per cent die in hospital within four hours after an accident and 35 per cent die after four hours (see Table 5). A comparative study of deaths from road accidents in several countries [7] showed that the majority of deaths in low and middle-income countries occur before admission to hospital.

Table 5 - Proportion of deaths caused by traffic accidents in three cities

Place	Kumasi, Ghana (%)	Monterrey, Mexico (%)	Seattle, USA (%)
Before admission to hospital	81	72	59
Emergency care unit	5	21	18
Hospital department	14	7	23

The same study also showed that chances that a patient will die before delivery to hospital increases with decreasing socio-economic status of a patient. Studies around the world [8, 9] have shown that deaths can be prevented in many cases in which people died before admission to hospital. Many of the complications leading to disabilities can also be prevented before delivery to hospital.

The world experience of leading clinics providing emergency care points to two main factors which play a crucial role in the outcome of treatment:

1) quality of first medical care provided by pre-hospital emergency medical services;

2) time factor – time after an accident.

Late delivery of patients with urgent conditions is caused by various reasons: often these are anti-shock activities at the scene before transportation to hospital delivery. In many cases time to deliver a patient to hospital increases significantly because of large distances to the nearest regional hospital. In cities, an important role is played by traffic jams that occur during rush hours, obstructed access to houses by vehicles and lack of freight elevators in buildings.

The fastest way is to transport a patient to an emergency department by an ambulance or an emergency car [10]. The use of helicopter transport can reduce the time to hospital admission [11, 12] and increase availability of thrombolytic therapy in remote and rural areas [13]. In mixed areas (rural and urban areas) transfers of patients can be both air and by ground vehicles regulated by simple rules [14].

No studies have taken place to compare air and ground transportation of patients with stroke. One study which involved mostly trauma patients concluded that ground transportation provided faster delivery time over a distance to hospital less than 10 miles (about 16 km), whilst air transport was faster for distances over 45 miles (about 72 km) [15]. The study conducted by R. Silbergleit, P. Scott, M. Lowell demonstrated the cost-effectiveness of transporting patients with acute stroke, potentially suitable for thrombolysis, by helicopter transport [16].

In assessing the amount of time to evacuate a patient by land and by helicopter several important points should be considered [7, 16]. In a case of sparsely populated areas of Australia, the use of a medical helicopter is justified when a distance from the scene of an accident to the hospital is more than 50 km, or if an expected time of transportation exceeds 30-45 minutes. With regard to estimating the time required to evacuate the injured by helicopter, one should take into account technical delays in departure associated with time required to warm-up and conduct standard pre-flight checks of aircraft equipment, travel time to the scene of an accident, time required to search the scene of an accident and acceptable place for landing, takeoff, journey time to hospital, and time for landing. If the landing site is not located in close proximity to a hospital emergency department, time is lost by shifting the patient to ground ambulance transport with subsequent delivery to the emergency department of a hospital. According to some data, transfer of a patient from the cabin of a helicopter to a car or an emergency medical services vehicle requires an average of 20 minutes of extra time. In some cases, the cost of time spent on transferring the patient can take as much as the flight itself and from the accident scene to the landing area at a hospital. The most optimal option is when a helicopter landing area is located on the roof of a hospital and is connected to the relevant intensive care trauma unit by an elevator [18, 19].

Conclusions

In this case, attention should be drawn to the following features of transportation of victims of road accidents including those with polytraumas. This is restrictions of diagnostic and therapeutic options en-route. Access to a patient during transportation is limited. A number of health workers conducting remedial measures and monitoring the patient during transport is also limited. Available quantity of equipment also limits a range of diagnostic measures during transportation. As a result of transportation, a patient’s condition can be destabilized, especially that additional factors can play role in air transportation (acceleration, vibration, changes in atmospheric pressure) [19].

Delivery of patients by helicopter over delivery by ambulance has the following main advantages:

- Speed of service;

- Ability to service remote areas;

- More secure transportation of patients with certain types of injuries [20].

In the health care system of Kazakhstan, development of air ambulance service has a number of problems such as:

· Insufficiency / lack of specialized equipment (helicopters, airplanes, mobile systems);

· Insufficient funding for procurement, maintenance and operation;

· Remote distances between settlements and between health organizations, at various levels (central regional hospitals - provincial hospitals - national hospitals);

· The remoteness of medical facilities from the scene of an accident located on main highways;

· Inconsistent provision of equipment to medical institutions and staff shortages;

· Inconsistent density of population, internal migration, different consumption rates of medical services in the regions;

· Overloaded traffic on urban and suburban highways.

The solution to these problems will contribute to the development of air ambulance service and save lives.

Thus, there is a need to examine the feasibility and cost-effectiveness of the use of small aircrafts in the country’s health system.

It should be noted that a choice of an aircraft for medical evacuation of casualties in different road accidents is based on the performance characteristics of aircrafts. Today several types of medical aircrafts are used throughout the world: Lear Jet 55 marks, Hawker, Cessna, Global Express [21]. Modern helicopters, equipped with the necessary equipment for rescue, are used to transport patients directly from the scene: Eurocopter AS 350, Mi-8/Mi-17, Mi-2, Ka-226 Ka-32A11BC, et cetera (Table 6).

Table 6 - Comparative characteristics of helicopters

Aircraft performance	Ка-226	Мi-2	Мi-8	Eurocopter AS 350	Agusta AW 109	Agusta AW 139
Flight range, km	600	450	550	660	948	1061
Duration of flight, hour	4.5	2.45	6	4.1	4.51	5.12
Speed, km/h	210	190	225	246	285	291
Flight altitude, km	6.5	4	5	6.1	5.9	3.6
Passenger / seating capacity, persons	2+6	1+8	2+9	1+6	2+7	2+15
Height, m	4.15	3.7	4.73	3.34	3.5	4.95
Length, m	8.1	11.4	18.3	10.93	13.04	16.65
Cost of one flight hour, USD	950	1,300	1,950	1,600	750	750
Cost of one unit, USD	4,000,000	10,000,000	14,750,000	16,000,000	12,023,344	23,907,202
Maintenance costs per year, USD	570,000	570,000	570,000	500,000	450,000	450,000

A medical helicopter has a smaller size, which means that it has a better maneuverability and efficiency. A medical helicopter can reach even the most inaccessible areas where an accident may take place. A medical helicopter as a means of medical evacuation is invaluable in transporting patients from the scene of an accident to a specialized clinic or an appropriately equipped nearby medical center.

In his annual address to the people of Kazakhstan, the President noted that to facilitate the development of air ambulance service and emergency medical assistance to victims of road accidents on the highways of the country 16 helicopters will be purchased by 2015 [22].

In addition to the technical characteristics of aircrafts, distances between airports to the scenes of accidents must be considered. There is a need to examine the key road routes, where car accidents mainly occur.

Conventionally, the Republic of Kazakhstan was divided into six regions (coverage zones) for servicing air ambulance service by helicopters. Air bases were established in the following cities: Atyrau, Kostanay, Kyzylorda, Oskemen, Almaty, Astana. The National Air Ambulance Focal Point of the Ministry of Health of the Republic of Kazakhstan is located in Astana.

The purpose of medical assistance in the form of air ambulance transport is to transfer a patient to an appropriate medical facility in life-threatening events due to sudden illness, accident, complications during pregnancy and childbirth, and traumas and injuries in man-made accidents and natural disasters [18, 19].

Today two common modes of medical transportation (see figure #2) are used: ground transportation (special vehicles) and air (specialized aircrafts AN-2 and helicopters MI-8).

Figure 2 - The scheme of medical evacuation

*EV – Evacuation by vehicle

**AMS – Air medical service

According to the scheme of medical evacuation (transportation), health organizations can request air ambulance service through the duty dispatch unit of the National Air Ambulance Focal Point of the Ministry of Health of the Republic of Kazakhstan [23]. The dispatching service of the Focal Point regulates and classifies calls based on health conditions of patients and severity of cases. If a case requires urgent action, air ambulance medical transportation is provided to transport a patient from the place where a call was made (regional out-patients clinics, provincial hospitals or local medical centres) on condition that there are aircraft landing facilities. If a case does not require urgent action, patients are transferred by ground transport. Also, there are cases when specialized medical teams can be transported by air to the place of a call [24, 25].

Air ambulance service is developing in some regions of the country. The National Air Ambulance Focal Point of the Ministry of Health of the Republic of Kazakhstan And has already been established to ensure consistency of air ambulance services in regions, cities and the capital city in provision of emergency and urgent medical care to patients and accidents survivors [23].

References

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