Emergency Medical Service at offshore sites: Exploring and
evaluating alternative network designs
Master Thesis
MSc Technology & Operations Management University of Groningen, Faculty of Economics and Business
23-06-2014
Martijn Vreekamp S2009153
Supervisor University: Dr. Ir. D.J. van der Zee
Co-assessor University: Dr. J.A.C. Bokhorst
Company supervisor: Drs. D. K. P. Kiewiet
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Abstract
Purpose: The EMS network contains all the transportation types that cover a geographic to treat out-of-hospital patients in need for urgent medical care. The objectives of this research were “develop an overview of EMS networks which meet the requirements of providing EMS at offshore sites” and “test and evaluate the designed EMS networks for cost effectiveness and timeliness.”
Method: This research is conducted at the Mobile Medic Team (MMT), which is a division of the University Medical Centrum Groningen (UMCG). First, a literature review is conducted. There are also interviews conducted with experts in the field of providing medical care at offshore sites. Based on literature and the conducted interviews is the current EMS network of the MMT described and analyzed, requirements for providing EMS at offshore sits are identified and alternative EMS networks are designed. The alternative EMS networks are evaluated based on timeliness and cost effectiveness. Findings: The current EMS network of the MMT does not meet the requirements. The requirements are categorized based on the number of people present at the offshore site and the wounds of the patient. Since the current EMS network does not meet the requirements, alternative EMS networks are designed to provide medical care at the offshore site in a timeliness and cost effective way. The designed alternative EMS networks are required to meet the identified requirements for providing EMS at an offshore site. The transportation types of the alternative EMS networks are the trauma helicopter of the MMT, the trauma helicopter of the hospital of Amsterdam, the ambulance, a regular helicopter owned by a third party and a catamaran.
The simulation study shows that the timeliness of the designed alternative EMS networks regarding patients at the offshore site and patients on land are comparable with each other. The effects on the remaining system when providing EMS at an offshore site are small. Some of the alternative designed EMS networks are not cost effective.
Conclusion: Some of the alternative EMS networks do not meet the requirements and some alternative EMS networks are cost ineffective. The following EMS network is proposed: The trauma helicopter of Groningen, trauma helicopter of Amsterdam, a catamaran, an ambulance and a nurse present at the offshore site.
Recommendation: Several recommendations are proposed but most important is that providing EMS at offshore sites requires an EMS network consisting of multiple transportation types. But since acquiring new transportation types is cost ineffective, we recommend to make use of already existing transportation types. The coordination between the company involved in the realization of the offshore asset and the hospital is paramount.
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Table of content
Preface 6
1. Introduction 7
2. Research objectives and design 9
2.1 Background 9
2.2 Research objectives 11
2.3 Research design 11
2.4 Information sources 13
3. EMS network system – A literature review 14
3.1 Design parameters for EMS network 15
3.2 Patient characteristics 16 3.2.1 Volume 16 3.2.2 Triage level 17 3.3 Performance measures 18 3.4 Transportation type 19 3.4.1 Air transport 20 3.4.2 Ground transport 20
3.4.3 Air versus ground transport 20
3.4.4 Telemedicine 21 3.5 Staff 22 3.6 Treatment 22 3.7 Dispatch criteria 23 3.8 Similar fields 24 3.9 Summary 24
4. Describe current EMS network 26
4.1 Input of the current EMS network 26
4.2 Current EMS network 26
4.3 Output 27
5. Analyze requirements 28
5.1 General requirements 28
5.1.1 Wind turbine park development phases 28
5.1.2 Patient groups 29
5.1.3 Patient demand categories 29
5.2 Triage level 1-3 29
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5.4 Analyze requirements 32
6. Design alternative EMS network s 33
6.1 Important sites 33
6.2 Overview EMS networks 34
6.3 Alternative EMS networks 36
6.3.1 EMS network “high volume, high urgency” 36 6.3.2 EMS network “low volume, high urgency” 39 6.3.3 EMS network “high volume, low urgency” 40 6.3.4 EMS network “low volume, low urgency” 41
6.4 Analyze alternative EMS networks 42
7. Evaluate performance 43
7.1 Experimental design 43
7.2 Simulation modeling 45
7.3 Performance current EMS network 46
7.4 Performance alternative EMS networks 47
7.5 Performance current EMS network and alternative EMS networks 48 7.5.1 Time before medical care for offshore patients 48 7.5.2 Time before medical care for regular patients 49
7.6 Costs 50
7.7 Redesign EMS network 52
7.7.1 Description redesigned EMS network 53
7.7.2 Performance redesigned EMS network 53
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Appendixes 64
Appendix I – Fatal incidents figure 64
Appendix II – Accidents table 65
Appendix III – Siemens Specifications of Rescue Preparedness 66
Appendix IV – Siemens Rescue Backup Requirements 67
Appendix V – Design parameters HEMS 68
Appendix VI – Design parameters regular helicopter at airport Eelde 69 Appendix VII – Design parameters additional HEMS at Airport Eelde 70
Appendix VIII – Design parameters HEMS at VUMC 71
Appendix IX – Design parameters regular helicopter at Gemini 72
Appendix X – Design parameters catamaran 73
Appendix XI – Design parameters ambulance (design 7) 74
Appendix XII – Design parameters ambulance (design 9) 75
Appendix XIII – Patient volume scenarios 76
Appendix XIV – Downtime 77
Appendix XV – Deterministic performance transportation types 78
Appendix XVI – Welch’s method 80
Appendix XVII – Deployments current EMS network 81
Appendix XVIII – Flight hours current EMS network 82
Appendix XIX – Cancel figure 83
Appendix XX – Utilization current EMS network 84
Appendix XXI – Tables offshore patients 85
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Preface
After I passed the bachelor Business Administration, I wanted to learn more about operations and therefore I have chosen the master Technology and Operations Management. This master thesis is my graduation project. I hope I have given insight about how to provide medical care at offshore sites, so that researchers at the UMCG can continue this research to improve the safety of employees working at offshore sites.
I would like to thank my supervisor Dr. Ir. D.J. van der Zee, for all his help. He organized meetings, read my thesis every time and gave feedback which really improved my thesis. Despite his busy schedule, he always had time for me to answer questions or help me if I was struggling with a problem regarding my thesis or my simulation model. Of the UMCG, I would like to thank Dr. Kiewiet for his help. Of the MMT, I would like to thank Mr. L. Doodkorte, Dr. G. de Rooij en Dr. B. Derkcsen. They have given me very useful information which helped me very much while writing my thesis. I also would like to thank Dr. Ir. Molenaar and Mr. E. Corver of Siemens. Mr. E. Corver has helped to get insight how a wind turbine park is realized and all of the information provided by Mr. E. Corver was very helpful for completing my thesis.
Finally, most importantly I would like to thank my girlfriend, parents, family and friends for their support during my entire studentship! Thank you!
Martijn Vreekamp
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1. Introduction
The Dutch government stimulates the creation and exploitation of environmental friendly energy sources. In 2020, at least 14% of the energy in the Netherlands has to be obtained in an environmental friendly way.1 Offshore wind turbine parks are one of the solutions to achieve the goal set by the Dutch government. Unfortunately, despite the several advantages of obtaining environmental friendly energy, the construction and maintenance of wind turbine parks tend to go together with wounded or even killed people.3 This study aims to give an overview of Emergency Medical Service (EMS) networks that are able to provide EMS at offshore sites and to evaluate those EMS networks on cost effectiveness and timeliness.
Usually, wind turbine parks are built on land, but in the last years, the focus has been shifted towards offshore sites. Driven by the goal of the Dutch government, several wind turbine parks will be build at an offshore site near the coast of the Netherlands.2 These offshore sites are more useful than wind turbines built on land since offshore wind turbines have a higher wind-energy potential (Liserre, Cárdanas, Molinas & Rodríquez, 2011). In general, the potential of wind turbines is growing with a 5% annual increase in the energy yield of the turbines (Herbert, Iniyan, Sreevalsan & Rajapandian, 2007). Because of the higher yield of wind turbines at offshore sites is the realization of offshore wind turbine parks becoming an attractive solution to obtain environmental friendly energy and will most likely be used more often in the nearby future.
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Because of the expected casualties, the EMS network should be prepared to provide EMS at offshore sites. The EMS network contains all the transportation types that cover a geographic area (Daskin & Stern, 1981) to treat out-of-hospital patients in need for urgent medical care (Nichol, Stiell, Laupacis, Pham, De Maio & Wells, 1999). Until now, there is little known about the configuration of such an EMS networks, like the required transportation types and staff of the EMS network, needed to provide EMS on offshore sites. This is surprising since the EMS network has a great effect on the surviving rate of the patient, timeliness and cost efficiency of the EMS network (Aboueljinane, Sahin & Jemai, 2013; Willemain, 1975 & Savas, 1969). Only some research has been done in the field of EMS at offshore sites at British Antartic offshore expeditions, providing medical care on drilling rigs (Norman & Laws, 1988) and providing medical care in the Artic with the use of the HEMS in Norway (Norum & Elsbak, 2011). To extend the knowledge about the EMS networks needed to provide EMS on offshore sites, an explorative design study will be conducted at the Mobile Medical Team (MMT), which is a division of the University Medical Center Groningen (UMCG). The MMT is currently responsible for providing EMS on land, but the MMT will also be responsible for providing EMS at offshore sites.
This research contributes to literature by giving an overview of alternative EMS networks, which are able to provide EMS at offshore sites. These alternative EMS networks will be evaluated based cost effectiveness and timeliness. This research is a first step to a more in depth evaluation how to provide EMS at offshore sites.
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2. Research objectives and design
The research objectives clarify what this research aims to achieve and the research design makes clear what must be studied and how this research is done in order to achieve valid results (Karlsson, 2010). First, at section 2.1, a brief theoretical background will be provided and important definitions will be introduced. At section 2.2, the research questions will be explained. Section 2.3 contains the research design; how we have conducted this research and at last, section 2.4 contains an elaboration about the information sources of this research.
2.1 Background
Because of the aim of the Dutch governments to obtain a larger amount of energy in an environmentally friendly way, wind turbine parks will most likely be build more often in the nearby future. It can be expected that a large amount of these wind turbine parks are going to be build at an offshore site since offshore wind turbine parks have a higher wind-energy potential. Most likely, many of these wind turbine parks will be build near the coast of the Netherlands. To narrow the scope of this research, we aim to provide EMS networks which are able to provide EMS at offshore sites up to 100 kilometers off the coast. EMS networks like the MMT usually aim to provide EMS in a range of 100 kilometers. An example of an offshore wind turbine park is Gemini, which will be build 55 kilometers north of the coast of the Netherlands. Gemini will be part of the case study of this research. The site where Gemini will be build is displayed in figure 2.1.
Figure 2.1 – Site of Gemini
55 kilometers
UMCG 95 kilometers
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As mentioned above, casualties can be expected at a project like Gemini. In case of an accident, patients at Gemini must receive EMS and must be transported if necessary to the UMCG or another nearby hospital. The characteristics of patients can be different based on the volume of patients and their wounds. Patients can be categorized by their urgency for care with the use of a triage system. The categorization of patient ranges from 1 till 5. Patients with a triage level 1 must immediately receive medical care and patients with a triage level 5 do not require immediate medical care (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006).
Responsible for providing EMS at Gemini is the MMT. The MMT is a division of the UMCG located at Groningen. The MMT is the EMS network of the surrounding of Groningen on land. Usually, the MMT is responsible for providing EMS at patients with a triage level 1-3, who are the patients with serious injuries and those patients need immediate medical care. The MMT consists of a HEMS (Helicopter Emergency Medical Service) and a trauma car. The car is used when poor weather conditions make it impossible to use the HEMS. The HEMS is well equipped and it is possible to provide EMS at the accident scene. The staff of the MMT is well experienced and highly educated. The staff of the MMT has no experience or expertise in providing EMS at offshore sites. It is most likely that many other projects like Gemini will be realized in the nearby future. Therefore, the EMS network of the MMT must be prepared to provide EMS at offshore sites in a cost effective and timeliness way. If the EMS network of the MMT does not meet the requirements of providing EMS at Gemini, alternative EMS networks must be designed.
The performance of the current and alternative EMS networks will be evaluated with the use of performance measures. In literature, there are three types of performance measures identified, which are timeliness, cost and surviving rate of patient. Timeliness is the performance of the transportation type (Aboueljinane, Sahin & Jemai, 2013). The performance measure cost is regarding the cost of EMS network (Savas, 1969). The last performance measure is surviving rate, which is regarding the likelihood that a patient will survive an accident (Willemain, 1975).
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2.2 Research objectives
The MMT must be prepared to provide EMS at offshore sites but the problems concerning the provision of EMS at offshore sites are not yet taken into account. To be able to prepare the EMS network and to take the problems concerning the provision of EMS at offshore sites into account, we have set-up two research objectives:
1. “Develop an overview of EMS networks which meet the requirements of providing EMS at offshore sites.”
2. “Test and evaluate the designed EMS networks for cost effectiveness and timeliness.”
Regarding the first objective, this research develops an overview of EMS networks which are able to provide EMS at offshore sites. Since an overview is lacking until now, the designed EMS networks contribute to literature by giving an overview of possible EMS networks. Regarding the second objective, the designed alternative EMS networks will be evaluated based on cost effectiveness and timeliness by means of a simulation study. Patient outcomes are hard to evaluate in the case of EMS, because of the difficulty of linking quantitative measures of survival rate to changes in the rescue process (Aboueljinane, Sahin & Jemai, 2013). Therefore, we consider timeliness as a proxy for patient outcomes. We assume if the patient receives earlier EMS, the likelihood of recovery is improved as well. So, the better the timeliness is of the EMS network, the better the patient outcome will be.
The case that will be researched is the MMT providing EMS at Gemini. The findings from this case will be generalized so that the findings can be applied to other offshore sites within a 100 kilometer range of the coast. To be able to meet both research objectives and to study the case of MMT providing EMS at Gemini, there are several research questions:
1. What are relevant design parameters for characterizing an EMS network? 2. What are the characteristics of the current EMS network of the MMT?
3. What are the requirements for the EMS network of the MMT when providing EMS at Gemini?
4. What are the characteristics of alternative EMS networks?
5. What is the performance of the designed EMS networks, evaluated by cost effectiveness and timeliness?
2.3 Research design
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the research design approach in figure 2.2 (Wieringa & Heerkens, 2007; Van Strien, 1997). Note how each step of the design-wise approach is related to a research question.
Figure 2.2 – Research design
Step 1 (design parameters):
The first step (chapter 3) consists of identifying and explaining relevant design parameters. The design parameters are identified by conducting a literature study. First, an EMS network system is proposed. The EMS network system contains all the factors which are of importance when designing an EMS network. Then, the design parameters are identified and explained. The design parameters consist of entities which describe the characteristics of an EMS network. The design parameters are used to describe the current EMS network and to design alternative EMS networks.
Step 2 (current design):
The second step (chapter 4) is characterizing the current EMS network of the MMT. The current EMS network of the MMT is characterized based on the design parameters. The characteristics of the current EMS network are determined by conducting interviews at the staff of the MMT.
Step 3 (analyze requirements):
The third step (chapter 5) consists of identifying and analyzing the requirements for the EMS networks when providing EMS at Gemini. The requirements are obtained by conducting qualitative interviews at Siemens. Siemens is one of the companies responsible for the realization of Gemini. After the requirements are identified, the current EMS network of the MMT will be analyzed if the current EMS network of the MMT meets the requirements for providing EMS at Gemini.
Step 4 (design alternative designs):
The fourth step (chapter 6) is designing alternative EMS networks. The alternative EMS networks are required to meet the requirements for providing EMS at Gemini. The alternative EMS networks are designed based on literature and conducted interviews at the MMT and Siemens.
Step 5 (evaluate current and alternative designs):
The fifth step (chapter 7) consists of evaluating the current EMS network of the MMT and alternative EMS networks based on cost effectiveness and timeliness when providing EMS at Gemini. This is achieved with the use of a simulation model with a random arrival of patients. A simulation model is chosen since a simulation model can cope with variability and it is a suitable option to evaluate multiple options (Robinson, 2004). The current and alternative EMS networks will be evaluated based on their performance at Gemini.
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According to Robinson (2004), it is important when conducting a simulation study to set up a conceptual model. An EMS network system is made at chapter 3, where the input, transformation process and output are displayed of an EMS network. The input, transformation process and output of every alternative EMS network are displayed at chapter 6, which will be used when setting up the simulation study. These transformation processes determine which data must be used.
2.4 Information sources
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3. EMS network system – A literature review
This section contains the first step of this research. The following research question is set up:
“What are relevant design parameters for describing an EMS network?”
The databases which are consulted are Google Scholar and Web of Science. Web of Science is related to the areas “management” and “operations research and management science”. Primary keywords are used and the primary keywords are used in combination with the secondary keywords to search for relevant articles in the field of EMS networks. The used keywords are displayed in table 3.1. A cross-reference analysis is conducted to evaluate if all the articles in the field of EMS networks are taken into account. Since there is little known in literature about providing EMS at offshore sites, it was a challenge to conduct a thorough literature review.
Primary keywords Secondary keywords
HEMS Pre-hospital care
EMS Rural
Offshore locations Urban
Wind turbines Air transport
Performance measures Ground transport
Water transport Cost-effectiveness Telemedicine Casualties
Table 3.1 – Keywords of literature review
At the literature review section, the aim is to give insight in the EMS network system and the design parameters of the EMS networks. The design parameters are the entities that describe and influence the EMS networks. The questions that will be answered at the literature review are:
What are key elements of the EMS network system? What are relevant design parameters?
What are the characteristics of the patients? How can the EMS networks be evaluated?
What are the characteristics of the design parameters?
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3.1 Design parameters for EMS network
In figure 3.1, the transformation process of the HEMS is displayed at the blue bar. The patients are the input of the transformation process; the EMS network is the transformation process and patients are the output of the transformation process, hopefully in better shape as they came in. As becomes clear in the EMS network system patients can be different based on the patient characteristics triage level and volume. The design parameters transportation type, staff, treatment and dispatch criteria describe the characteristics of the EMS network. The design parameters can also influence the EMS network. The requirements are described based on the design parameters and the requirements influence the EMS network when providing EMS at offshore sites. The EMS network will be evaluated based on cost. The output of the EMS network system will be evaluated based on timeliness. As we have already mentioned above, timeliness is considered as a proxy for patient outcomes since it is difficult to link quantitative measures of survival rate to changes in the rescue process (Aboueljinane, Sahin & Jemai, 2013).
Figure 3.1 – EMS network system
The design parameters that influence and describe the EMS networks are explained in table 3.2:
Design parameter Attributes Definition
Transportation type Response time The time it takes for the transportation type to reach the accident scene. Is depending on station of transportation type, the location of the accident scene (Brotcorne, Laporte & Semet, 2003) and the speed of the transportation type (Plevin & Evins, 2011)
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hospital (Brotcorne, Laporte & Semet, 2003) and the speed of the transportation type (Plevin & Evins, 2011)
Time before medical care
The waiting time of patients in need for medical care (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006). This is depending if the patient is treated at the accident scene or treated at the hospital (see design parameters treatment).
Distance capabilities Capability of the transportation type to travel over long distances (Plevin, 2011) and reach offshore sites (Laporte & Semet, 2003).
Capacity Number of patients that can be transported by the transportation type (Asplin, 2003).
Medical equipment Medical equipment present at the transportation type (Baxt, Moody, Cleveland, Fischer, Kyes, Leicht, & Wiest, 1985)
Staff Expertise The educational level of staff (Ponsonby, Mika & Irons, 2009; Bax, Moody & Cleveland, 1985).
Experience Years of experience of the staff (Baxt, Moody, Cleveland, Fischer, Kyes, Leicht, & Wiest, 1985)
Treatment Two options; “stay and play” or “scoop and run” (Smith & Conn, 2009).
Dispatch criteria Criteria based on patient characteristics before a transportation type will leave its station to provide EMS at an emergency situation (Svenson, O’Connor & Lindsay, 2006; Wigman, Van Lieshout, De Ronde, Patka & Scipper, 2010).
Table 3.2 – Design parameters
First, the input of figure 3.1 will be explained, which are the patient characteristics at section 3.2. Then, the performance measures that are used to evaluate the performance of the EMS network are explained in section 3.3. Then, the design parameters will be explained which are used to describe and to influence the design of the EMS network. The transportation type will be explained at section 3.4. The design parameter staff will be explained at section 3.5. Section 3.6 contains a literature overview about treatment. At section 3.7, dispatch criteria will be explained. Finally, section 3.8 contains a literature overview of findings in similar fields of wind turbine parks and section 3.9 contains a summary.
3.2 Patient characteristics
Patient characteristics are the input of the EMS network system displayed in figure 3.1, the patient characteristics influences the EMS networks needed to be able to provide EMS at offshore sites. If patient demand is a high volume of patients, the requirements are different then in the case of a low volume of patients. Although little is known about the volume and the triage level of patients on offshore sites, at the following section we will elaborate on the volume of the patients at offshore sites (section 3.2.1) and the triage level of their injuries (section 3.2.2).
3.2.1 Volume
17 0 20 40 60 80 100 120 140 160 180 NUMBER OF ACCIDENTS NUMBER OF ACCIDENTS Lineair (NUMBER OF ACCIDENTS)
3.2, we have displayed the graph of the known number of accidents from 1970 until 2013. As the graph shows, the trend is increasing, which is obvious because there are build more wind turbines every year.
Figure 3.2 – Number of accidents
In total, there were 1485 accidents over the last 25 years. In total, there were 146 fatalities directly related to wind turbines of which were 107 industry and direct support workers (see appendix I & II). Since at sea the likelihood of a fatal accident involving a bystander is small, the casualties involving industry and direct support workers are only taken into account. The most important reasons for accidents are blade failure, fire, structure failure or ice thrown as is concluded by the CWIF.
The data collected by the CWIF gives an excellent overview of the type of accidents that happened and the consequences of these accidents. However, this data is, according to the CWIF, by no means fully comprehensive and only a “tip of the ice berg”. They have collected the number of accidents (see figure 3.2 & appendix II). However, the CWIF estimates that they only have collected about 10 % of the real happened incidents, which means that these data are an underestimation of accidents actually happened. 4
3.2.2 Triage level
To categorize the patients, there are several triage systems developed for the emergency department of a hospital. About the precise triage level of patients at offshore sites is nothing known. With the use of a triage system, the patients entering an emergency department of a hospital can be categorized by their urgency of care (Baumann & Strout, 2005). This can be applied to categorize patients at offshore sites. One of the systems currently used is the Manchester Triage System (MTS). The MTS provides clarity about the maximum allowed waiting time for the different levels of urgency.
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The different levels of urgency are displayed in table 3.3 (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006).
Triage level Characteristics Time before medical care
1 Emergent Needs instantaneous evaluation
2 Very urgent Needs evaluation within 10 minutes
3 Urgent Needs evaluation within 60 minutes
4 Standard Needs evaluation within 120 minutes
5 Non-urgent Can wait up to 240 minutes
Table 3.3 – Triage levels
3.3 Performance measures
As is displayed in figure 3.1, the performance measures will be used to evaluate the performance of the EMS network and the output of the EMS networks system, which are the patients. There are three main types of performance measures used, namely those related to cost, survival rate and timeliness. The first type of performance measures relates to the financial aspect of the EMS network. The performance measure survival rate is related to the likelihood that the patient will survive an accident. The third performance measure timeliness is related to the performance of the EMS network.
Concerning the performance measure cost, it is important is to make a trade-off between cost effectiveness, the timeliness and surviving rate of the patient performance measures. Given the added expense of operating and maintaining HEMS in a health system, an important step in the justification for their continued use is to relate their costs to the benefits they provide (Taylor, Stevenson, Jan, Middleton, Fitzharris & Myburgh, 2010). We have based on literature identified the following costs performance measures:
1. The capital costs: The investment costs to obtain an EMS transportation type. 2. The operational costs: The costs of the EMS transportation type per year
3. The cost per deployment: Which is the total cost divided by the number of deployments of the transportation type (Savas, 1969).
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1. The mortality ratio: Refers to the ratio of patients who died despite of the EMS network. 2. The morbidity ratio: Refers to the ratio of patients who end with a disability of severe health
issues (Willemain, 1975).
Since very few papers used to link quantitative measures of survival rate to the changes in the rescue process (Aboueljinane, Sahin & Jemai, 2013), the performance measure survival rate of the patient is replaced with timeliness of transportation type. The assumption is made that the earlier the patient receives EMS, the better the survival rate of the patient will be. The performance measures concerning timeliness are listed below:
1. The response time: Defined as the period between the receipt of a call and the first arrival of a rescue team at the scene.
2. The transportation time: Defined as the period between the EMS transportation type leaving the scene with a patient and the arrival of the EMS transportation type at a hospital with a patient.
3. The round trip time: Defined as the period between the receipt of the call and the arrival of the rescue team with the patient to the destination hospital.
4. The service time: Defined as the time that a team spends on a rescue.
5. The vehicle utilization rate: The percentage of time the transportation type is occupied. This utilization should be low to ensure that an EMS team will be available for an urgent call. 6. The dispatching time: Defined as the time elapsed between the receipt of the call and the
allocation of the call to a vehicle.
7. The total mileage: Refers to the total distance traveled by an EMS transportation type. 8. The loss ratio: Defined as the total time of which an EMS unit has a breakdown or repair
time.
9. The overtime: Refers to the additional working hours beyond the scheduled shift (Aboueljinane, Sahin & Jemai, 2013).
3.4 Transportation type
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3.4.1 Air transport
In the Netherlands, the HEMS is introduced approximately 15 years ago (Wigman, Van Lieshout, De Ronde, Patka & Scipper, 2010). The primary aim of the HEMS is to bring specialized medical care to trauma patients at the accident scene (Plevin & Evans, 2011). Since many studies struggle to assess if the HEMS improves patient outcome (Plevin & Evans, 2011) and because of the high cost of the HEMS (Wigman, Van Lieshout, De Ronde, Patka & Scipper, 2010), the HEMS is subject of a still ongoing debate. The costs are important to know, so that the consideration can be made if the investment is worth the possible improved surviving rate of trauma patients. The annual cost of the HEMS ranges from $115,777 to $5,571,578 per year (Taylor, Stevenson, Jan, Middleton, Fitzharris & Myburgh, 2010). These costs are a result of the resources necessary for a HEMS (Karanicolas, Bhatia, Williamson, Malthaner, Parry, Girotti & Gray, 2006), the staff with the advanced skills and trauma experience (Baxt, Moody, Cleveland, Fischer, Kyes, Leicht, & Wiest, 1985) and the investment costs (Taylor, Stevenson, Jan, Middleton, Fitzharris & Myburgh, 2010).
3.4.2 Ground transport
The most frequently used type of ground transport for trauma patients is the ambulance. The ambulance has equipment to provide medical care to the patient. Since time is vital in emergency situations (Brotcorne, Laporte & Semet, 2003), the standard rule in the Netherlands is that at least 97 % of the Dutch people of every region can be accessed within 15 minutes (Kommer & Zwakhals, 2008). Because of this standard rule, the Netherlands ensures an adequate coverage and a quick response time (Wisborg, Guttmorsen, Sørensen & Flaatten, 1994). The location of the ambulance is therefore always close to the accident scene.
3.4.3 Air versus ground transport
Delgado, Staudenmayer, Wang, Spain, Weir, Owens & Goldhaber-Fiebert (2013) have tried it, but many studies are still struggling to assess if HEMS improves patient outcomes in comparison with EMS transportation types like the ambulance (Plevin & Evans, 2011). Many researchers have been unable to demonstrate that the HEMS improves patient outcome in comparison with the traditional EMS like the ambulance (Taylor, Stevenson, Jan, Middleton, Fitzharris & Myburgh, 2010). Several studies have done attempts to compare the costs of the HEMS and the EMS. The annual costs of the HEMS ranges from $115,777 to $5,571,578. Potential savings in ground ambulance cost due to HEMS operations were estimated in one study at $210,221 per year (Taylor, Stevenson, Jan, Middleton, Fitzharris & Myburgh, 2010).
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HEMS has to deal with remote sites, long distances, rough weather and non-accessible sites by ground transport (Norum & Elsbak, 2011). The HEMS is faster than the ambulance, under the condition of perfect dispatch and transport conditions (Svenson, O’Connor & Lindsay, 2006). However, others concluded that variation between trauma system characteristics such as inconsistent presence of onsite helipads, geographic and weather differences and the limited number of HEMS make it impossible to pinpoint a distance beyond which the HEMS transports the trauma patients faster than ground transport (Karanicolas, Bhatia, Williamson, Malthaner, Parry, Girotti & Gray, 2006). An overview of literature regarding air versus ground transport is displayed in table 3.4
In favor of air transport Equal In favor of ground transport
Patient outcomes
Baxt, Moody,
Cleveland, Fischer, Kyes, Leicht, & Wiest (1985)
Delgado, Staudenmayer, Wang, Spain, Weir, Owens & Goldhaber-Fiebert (2013)
Taylor, Stevenson, Jan, Middleton, Fitzharris & Myburgh (2010) Plevin & evans (2011) Biewener,
Aschenbrenner, Rammelt, Grass & Zwipp (2004)
Distance Plevin & Evans (2011) Svenson, O’Connor & Lindsay (2006)
Karanicolas, Bhatia, Williamson, Malthaner, Pary, Girotti & Gray (2006)
Rural areas Plevin & Evans (2011) Norum & Elsbak (2011)
Cost Taylor, Stevenson,
Jan, Middleton, Fitzharris & Myburgh (2010)
Table 3.4 – Overview literature air versus ground transport
3.4.4 Telemedicine
In addition to air and ground transport, telemedicine can be considered as a supportive tool to the transportation type (figure 3.1) (Ponsonby, Mika & Irons, 2009). Telemedicine can be defined as the use of telecommunication technologies to provide medical information and services. Electronic signals are used to transfer information from the patient to the specialist and backwards (Perednia & Allen, 1995).
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unnecessary medical evacuations and economic benefits for the employee, the company that owns the offshore asset and the society (Stroetmann, Jones, Dobrev & Stroetmann, 2006; Hailey, Roine & Ohianmaa, 2002; Jannet, Affleck, Hailey, Roine & Ohianmaa, 2002). Most of disadvantages of telemedicine are related to anticipated problems with equipment, because of the high dependability on the equipment. Other disadvantages identified are a lack of ‘hands on’ opportunities, difficulties in communicating, lack of team-building environment and busier schedules (Khoja, Casebeer, & Young, 2005).
Ponsonby, Mika & Irons (2009) identified two scenarios in which telemedicine might be useful in providing care at offshore sites. First, real – time on distant monitoring of patients during their transport can reduce the time of initiating treatment and allow emergency crew waiting for the casualty to be better prepared for further management. This is especially useful when the transport time is longer because of the offshore site and so there is less time left to provide care. Second, telemedicine can facilitate monitoring the workers at the offshore site. For workers offshore with for example diabetes can this be the solution.
3.5 Staff
The second design parameter is staff. The staff is present on the transportation type and they are responsible for providing medical care and the transportation of the patient. In general, the staff of the HEMS is more experienced and has more expertise than the staff on a traditional EMS. Some authors suggest that the presence of the HEMS with medical staff with advanced skills and trauma experience is responsible for decreased mortality (Baxt, Moody, Cleveland, Fischer, Kyes, Leicht, & Wiest, 1985). Others disagree, they have found that the survival rate of patients transported to a trauma center by the skilled staff of the HEMS is identical in comparison with the survival rate of patients when transported by the less skilled staff of the ambulance (Biewener, Aschenbrenner, Rammelt, Grass & Zwipp, 2004).
3.6 Treatment
The third design parameter is the treatment of the patient. The staff of the transportation type has two options. The first option is “stay and play”, which is providing advanced levels of emergency care at the accident scene. Required is a staff with medical experience and expertise (Smith & Conn, 2009). The second option is “scoop and run”, then the goal is to minimize the time from the accident to definitive treatment at the hospital (Gold, 1987). At all times, the goal is to minimize the time from the accident to definitive treatment at the hospital but also to maximize the pre-hospital care that increases the probability of the patient arriving alive at the hospital. Between these two objectives, there is a conflict between “scoop and run” and “stay and play” (Gold, 1987).
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procedures delayed until hospital arrival. But, these recommendations are suggested for patients in close proximity to an urban environment (Seamon, Fisher, Gaughan, Lloyd, Bradley, Santora & Goldberg, 2007). This claim is supported by other authors, but there may be more need for “play and stay” in rural environments or where transportation times are prolonged (Smith & Conn, 2009).
When the staff chooses to conduct the “stay and play” option, there is more time lost with providing EMS to the patient at the accident scene. In literature it is determined that the average time spent in the field when the staff chooses to “stay and play” was 17 minutes with a standard deviation of 6.7 minute (Ramenofsky, Luterman, Curreri & Talley, 1983). Other research states that the time on the scene when choosing the option “stay and play” was ranging from 10 minutes (Mexico) to 37 minutes (the UK). Because of lacking data, there is nothing known about the time at the accident scene in the Netherlands (Roudsari, Nathens, Arreola-Risa, Cameron, Civil, Grigoriou, & Rivara, 2007).
3.7 Dispatch criteria
The fourth design parameter is dispatch criteria. Dispatch criteria are systems that are used to help categorize and prioritize EMS resources for requests for assistance (Hettinger, Cushman, Shah & Noyes, 2012). Little research has been done about the dispatch criteria; however they are important from a cost-efficiency perspective and the effects on over-triage or under-triage. Either over-triage or under-triage of the trauma patient will lead to higher cost. Wigman, Van Lieshout, De Ronde, Patka & Scipper (2010) suggest that the balance between those two is very delicate. An over-triage rate up to 50% is expected in order to reduce the under-triage level to 10%.
Regarding dispatch criteria for the HEMS, there is in literature concluded that there is a lack of uniformity in the use of trauma-related dispatch criteria on a national and international level. In Europe, the most commonly used dispatch criteria for the HEMS are “fall from height”, “lengthy extrication and significant injury” and “multiple casualty incidents”. However, the activation of the HEMS is not only depending on dispatch criterion protocols, but is also influenced by organizational factors like the education of the dispatcher, the training of the HEMS staff, the familiarity with the dispatch criteria and the responses of bystanders (Wigman, Van Lieshout, De Ronde, Patka & Scipper, 2010).
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3.8 Similar fields
In contrary to the wind turbine park industry, the offshore oil industry has provided guidance for offshore medical care on their offshore sites like a drilling rig. The offshore oil industry at the North Sea has encountered the same problems like serious accidents and diving fatalities, these accidents emphasize necessary requirements for a higher standard of medical care (Norman & Laws, 1988). To mitigate this problem, some medical providers provide training for paramedics working offshore. Employees working at offshore sites have also supervision of doctors via radio or phone links. These methods of communication are now replaced with more sophisticated telemedicine solutions such as internet and live video links (Ponsonby, Mika & Irons, 2009).
Providing EMS in the Arctic of Norway can be considered as similar to providing EMS at offshore wind turbine parks because of the common characteristics. Whereas the geography of northern Norway makes it necessary to include the HEMS, the HEMS has several limitations. A problem the EMS network is facing in Norway is the limited access to well experienced and educated staff. Also the HEMS can suffer from weather conditions, which are a significant problem in the Arctic Norway. In the case of poor weather conditions, water transport may be seen as an alternative. The authors make another recommendation, namely passengers participating in polar adventure operations must have a declaration from their personal physician that they are fit for the journey. And to increase the timeliness in a cost effective way, an excellent fleet coordination system is mandatory (Norum & Elsbak, 2011).
3.9 Summary
At the literature section, the aim was to give insight the subject of EMS networks which are able to provide EMS on offshore sites. The research question was:
“What are relevant design parameters for describing an EMS network?”
The EMS network is displayed in figure 3.1 Important of the EMS network is the EMS transformation process, which is displayed in figure 3.3.
Figure 3.3 – EMS network transformation process
Before the literature review, there are several questions raised we tried to answer at the literature review section. The answers are displayed in table 3.5.
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What are key elements of the EMS network system?
Patients are the input of the transformation process. Transformation process is the EMS network. Patients are the output of the transformation process.
Can be evaluated by performance measures on timeliness of the EMS network, cost effectiveness of the EMS network and surviving rate of the patient.
Influenced and described by design parameters.
What are relevant design parameters?
Transportation type, staff, treatment and dispatch criteria
What are the characteristics of the patients?
Volume data about patients at offshore sites is lacking.
Data about the wounds or triage level of patients at offshore sites is lacking.
Patients can be categorized based on triage level. Level 1 are the most urgent patients, level 5 are patients with no urgency.
How can the EMS networks be evaluated?
The EMS network can be evaluated based on cost, timeliness and survival rate of patient.
Although survival rate performance measures reflect the ability of an EMS unit to meet its primary objective of saving lives, very few papers used it due to the difficulty of linking quantitative measures of survival rate to the changes in the rescue process (Aboueljinane, 2013).
We consider timeliness as a proxy for surviving rate. If an EMS transportation type arrives earlier at the accident scene, we assume that the surviving rate will be higher as well since the patient receives EMS sooner which improves most likely the health of the patient.
What are the characteristics of the design parameters?
Transportation type: Three possibilities, which are ground transport, air transport and water transport. Ground transport is the ambulance and air transport is the HEMS. In addition telemedicine is identified. Telemedicine can be used when providing EMS at offshore sites so that the triage level of the patient can be determined even though there is no doctor or anesthetist present at the offshore site.
Staff: Staff of the HEMS is more experienced and has higher expertise than the staff of the ambulance.
Treatment: Two possibilities, which are “play and stay” and “scoop and run”. “Play and stay” is considered to be more effective when the area is rural, “scoop and run” is effective when a hospital is nearby. Requirement for “play and stay” is a specialized medical staff.
Dispatch criteria: Commonly based on the wounds (triage level) of the patient. Either over-triage or under-triage of the trauma patient will lead to higher cost. Wigman, Van Lieshout, De Ronde, Patka & Scipper (2010) suggest that the balance between those two is very delicate. An over-triage rate up to 50% is expected in order to reduce the under-triage level to 10%.
What are findings in literature about providing EMS at offshore sites in general?
Concerning drilling rigs, medical providers provide training for paramedics working offshore. Employees working at offshore sites have also supervision of doctors via radio or phone links. These methods of communication are now replaced with more sophisticated telemedicine solutions such as internet and live video links.
Concerning providing EMS in the Arctic of Norway, in the case of poor weather conditions, water transport may be seen as an alternative. The authors make another recommendation, namely passengers participating in polar adventure operations must have a declaration from their personal physician that they are fit for the journey. And to increase the timeliness in a cost effective way, an excellent fleet coordination system is mandatory (Norum & Elsbak, 2011).
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4. Describe current EMS network
As is displayed in figure 3.1, the EMS network is the key part of providing EMS and transporting patients. The current EMS network is located at the UMCG in Groningen, displayed in figure 2.1. At chapter 4, the current EMS network of the MMT will be described. The research question we have set up is:
“What are the characteristics of the current EMS network of the MMT?”
At the moment, the MMT of the UMCG consists of a car and a HEMS. In anticipation of the requirements at chapter 5, the capacity of the transportation type should be at least 1. It has become clear during the interviews at the MMT that the car of the MMT is not able to transport patients; therefore we exclude the car from this research. Only the HEMS will be taken into account at this research.
The transformation process of the current EMS network of the MMT is displayed in figure 4.1 and is based on the EMS network system of figure 3.1. Patients are the input of the EMS network system (section 4.1). The transportation type used at the current EMS network of the MMT is the HEMS (section 4.2). Patients are the output of the current EMS network (section 4.3).
Figure 4.1 – HEMS transformation process
4.1 Input of the current EMS network
The patients are input of the current EMS network. The current EMS network mainly provides EMS to patients with triage level 1-3. These are regular patients who are wounded at land. In total the EMS network processes 1322 regular patients during 2013, 942 by day and 380 by night.
4.2 Current EMS network
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Design parameter Attributes Definition
Transportation type Response time The response time is depending on the location of the accident scene.
Transportation time The transportation time is depending on the location of the accident scene and the location of the hospital if the patients must receive treatment at the hospital.
Time before medical care Since the staff treats the patient at the accident scene (see design parameters treatment), the time before the patient receives medical care is equal to the response time.
Distance capabilities The HEMS is able to fly 400 kilometers. Capacity The capacity of the HEMS is 1 patient.
Medical equipment The equipment is very specialized and developed. The medical equipment is suitable for ABC situations, which are wounded patients with problems on their (A) airway, (B) breathing and (C) circulation of blood.
Staff Expertise The staff consists of an anesthetist or a doctor, nurse and pilot. The anesthetist is required to be graduated from the university; the nurse supports the anesthetist or doctor and must be graduated from the university of applied sciences. Moreover, the nurse must have passed the trauma care specialization. The pilot is responsible for transportation and must have a pilot’s license. Experience The anesthetist is required to have an experience of 10 years. The
nurse is required to have at least 15 years of experience at the intensive care department. The pilot must have experience of 4000 flight hours, usually pilots fly 200 hours a year and therefore the required experience is approximately 20 years.
Treatment The staff treats the patient on the scene before transportation,
which is “stay and play”.
Dispatch criteria The dispatch criteria for the HEMS are depending on the wounds
of the patient, the cause of the accident or regional agreements. In general, the HEMS is used when the location is hard to reach or when the triage level of the patient is approximately 1-3.
Table 4.1 – Design parameters HEMS
4.3 Output
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5. Analyze requirements
At chapter 5 are the requirements identified. The requirements are identified based on the design parameters. The design parameters influence the EMS network, as is displayed in figure 3.1 After the identification of the requirements, the current EMS network of the MMT is analyzed if it meets the requirements for providing EMS at Gemini. The following research question is set up:
“What are the requirements for the EMS network of the MMT when providing EMS at Gemini?”
At section 5.1 the general requirements are explained and the patient demand categories are identified. At section 5.2, the requirements when providing EMS to patients with triage level 1-3 are explained. Section 5.3 contains an elaboration about the requirements when providing EMS to patients with triage level 4-5. Section 5.4 analyses if the current EMS network meets the requirements for providing EMS at Gemini.
5.1 General requirements
Soon the wind turbine parks will be guided by the same rules applicable for the offshore oil industry, so there can be worked at Gemini 7 days a week and 24 hours a day. But since Gemini is a near coast wind turbine park, the transportation times are considered to be short and employees will be transported to and from the wind turbine park every morning and evening. Therefore, the MMT does not have to provide EMS during the night.
At section 5.1.1, there are explained different development phases during the realization of Gemini. This is important to take into account since the number of employees working during each phase is different. At section 5.1.2, there are different groups of patients identified based on their triage level, because the requirements are different when providing EMS to patients with triage level 1 than when providing EMS to patients with triage level 4. At section 5.1.3 are the patient demand categories proposed.
5.1.1 Wind turbine park development phases
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there is a lot of interaction between industrial equipment and employees.5 The maintenance phase is the phase at which maintenance (both preventive as corrective) is conducted. There are at least 2 employees (appendix III) present at the offshore location to conduct preventive or corrective maintenance. The main difference between the construction phase and the maintenance phase is the number of employees present at the offshore site.
5.1.2 Patient groups
Another distinction is made between the requirements for the EMS networks based on the triage level of the patient. Employees must pass the “advanced rescue” training (appendix IV), so they have gained basic medical knowledge. Employees working at offshore locations always work in teams (appendix III). Because of the training and cooperative way of working we assume that an employee is able to determine the triage level of a wounded colleague with the help of telemedicine. With the use of telemedicine the colleague of the patient can communicate with a doctor and in coordination with the doctor the triage level of the patient can be determined. By making this assumption, a distinction can be made between the requirements for the EMS networks in the case of a patient with triage level 1-3 and a triage level of 4-5. This distinction is made since the current EMS network of the MMT provides EMS to patients with triage level 1-3. Although triage levels are meant to categorize patients at the intensive care department of a hospital, it gives an indication how quick the patient must receive medical care. The time before each triage level must receive medical care is displayed in table 3.3.
5.1.3 Patient demand categories
Gemini has two development phases, which are the construction phase and the maintenance phase. The patient groups can be divided based on triage level, so patients with triage level 1-3 and patients with triage level 4-5. Based on the distinction between development phase and patient groups, the following patient demand categories are displayed in figure 5.1.
Triage level 1-3 “High volume, high urgency” “Low volume, high urgency”
Triage level 4-5 “High volume, low urgency” “Low volume, low urgency”
Construction phase Maintenance phase
Figure 5.1 – Patient demand categories
5.2 Triage level 1-3
The requirements for the EMS networks in the case of patients diagnosed with a triage level 1-3 are displayed in table 5.1. The requirements are based on the worst case scenario, which are patients with triage level 1.
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Design parameter Attributes Definition
Transportation type Response time In the worst case, the patients has triage level 1 which means a response time of 0 (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006).
Transportation time The time to transport the patient to a nearby hospital should be minimal because of triage level 1 (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006).
Time before medical care The time between the accident and that the patient receives medical care should be minimal (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006).
Distance capabilities Transportation type should be able to at least travel two times the distance of 55 kilometers, which is the distance from Gemini to the coast.
Capacity During the construction phase, there are sometimes 450 employees present.6 Therefore, the EMS network should be able to transport multiple casualties; we assume that a capacity of 2 is sufficient. During the maintenance phase, the required capacity should be 1 because of the lower number of employees working at Gemini.
Medical equipment Because patients with triage level 1 should receive medical care, the requirement for medical equipment present at the transportation type is high (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006).
Staff Expertise Because of the remoteness from land and specialized care which
makes providing EMS harder (Norman & Laws, 1988) and because the patients with triage level 1 (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006), the staff must have a high educational level since patients must be treated immediately at the accident scene to increase the surviving chance of the patient.
Experience Because of the remoteness from land and specialized care which makes providing EMS harder (Norman & Laws, 1988) and because of the patients with triage level 1 (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006), the staff must have a lot of experience since the patients must be treated immediately.
Treatment Since patients with triage level 1 should receive immediately EMS
(Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006) and the accident scene is rural (Norman & Laws, 1988), the best option is to “play and stay” (Smith & Conn, 2009).
Dispatch criteria Is based on triage level, the criterion is patients with triage level 1-3 (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006). Telemedicine is required to estimate the triage level of the patient (Perednia & Allen, 1995). Employees should be able to determine the triage level of a patient in coordination with a specialized doctor because of their medical training (appendix IV).
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There is a key role for the coordinator, which has to decide based on the triage level of the patient and the development phase of the wind turbine park which EMS network must be used.
Table 5.1– Requirements triage level 1-3
5.3 Triage level 4-5
The requirements in the case of patients with a triage level 4-5 are displayed in table 5.2. The requirements are based on the worst case scenario, which are patients with triage level 4.
Design parameter Attributes Definition
Transportation type Response time In case of triage level 4, the response time and the transportation together should be at most 120 minutes (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006).
Transportation time In case of triage level 4, the response time and the transportation together should be at most 120 minutes (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006).
Time before medical care The time between the accident and that the patient receives medical care should be at most 120 minutes (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006). Distance capabilities Transportation type should be able to at least travel two times the
distance of 55 kilometers, which is the distance from Gemini to the coast (Norman & Laws, 1988).
Capacity During the construction phase, there are sometimes 450 employees present.7 Therefore, the EMS network should be able to transport multiple casualties; we assume that a capacity is required of 2. During the maintenance phase, the required capacity should be 1 because of the lower volume of employees working at Gemini.
Medical equipment Patients with triage level 4-5 do not require immediate medical care (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006), therefore the required equipment on the transportation type is low and only basic medical equipment is sufficient since patients do not have to be treated immediately.
Staff Expertise Since the triage level is 4-5, the response time is 120 minutes (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006) patients do not have to be treated during transport. The main objective is to transport the patients within 120 minutes to a nearby hospital and therefore the required expertise is low. Experience The main objective is to transport the patients within 120 minutes
to medical care; therefore there is no need for experienced staff.
Treatment Because of the low expertise and experience of the staff, “stay
and play” is not an option and therefore “scoop and run” is sufficient (Smith & Conn, 2009) under the restriction that the patient reaches a hospital within 120 minutes.
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32 Dispatch criteria Is based on triage level, the criterion is patients with triage level
4-5 (Roukema, Steyerberg, van Meurs, Ruige, van der Lei & Moll, 2006). Telemedicine is required to estimate the triage level of the patient (Perednia & Allen, 1995). Employees should be able to determine the triage level of a patient in coordination with a specialized doctor because of their medical training (appendix IV). There is a key role for the coordinator, which has to decide based on the triage level of the patient and the development phase of the wind turbine park which EMS network must be used.
Table 5.2 – Requirements triage level 4-5
5.4 Analyze requirements
The current EMS network of the MMT must be able to provide EMS at Gemini. The transformation process of the current EMS network when providing EMS at Gemini is displayed in figure 5.2.Input are both regular patients and offshore patients. The transformation process is the HEMS and patients are the output of the transformation process.
Figure 5.2 – Transformation process current EMS network providing EMS at Gemini
The analysis if the current EMS network meets the requirements is listed below:
During “high volume, high urgency”: Capacity is too low, the capacity should be 2. During “low volume, high urgency”: Current EMS network meets requirements.
During “high volume, low urgency”: Capacity is too low, the capacity should be 2. The time before the patient receives medical care is too short, which leads to cost ineffectiveness. Staff is too experienced, has too high expertise and the transportation types has too much medical equipment for patients with triage level 4-5. This leads to cost ineffectiveness as well.
During “low volume, low urgency”: The time before the patients receives medical care is too short, which leads to cost ineffectiveness. Staff is too experienced, has too high expertise and the transportation types have too much medical equipment for patients with triage level 4-5. This leads to cost ineffectiveness as well.
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6. Design alternative EMS networks
The current EMS network does not meet the requirements for providing EMS at Gemini. Therefore, alternative EMS networks have to be designed based on the design parameters. The following research question is set up:
“What are the characteristics of the EMS network of the MMT and what are the characteristics of alternative EMS networks?”
At section 6.1, the most important sites are explained anticipating the alternative EMS networks. At section 6.2 is displayed an overview of the designed alternative EMS networks. At section 6.3 are the designed alternative EMS networks explained. At section 6.4 are the alternative EMS networks analyzed based on the requirements for providing EMS at Gemini.
6.1 Important sites
The locations of important sites are displayed in figure 6.1. The relevance of the sites will become clear later this chapter. The distance between the sites are displayed in table 6.1.
Figure 6.1 – Relevant sites
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From To Distance (kilometers)
UMCG Gemini 95
Harbor Eemshaven Gemini 75
Airport Eelde Gemini 105
VUMC Gemini 200
Harbor Eemshaven UMCG 34
Table 6.1 – Distances between relevant sites
To be able to calculate the round trip time, the destination hospital must be known. Usually, to which hospital a patient is brought is depending on the wounds of the patient. At the moment, around 50 % of the patients of the HEMS are brought to the UMCG, but these are patients with triage level 1-3 since the UMCG has specialized intensive care department. Patients with triage level 4-5 can be treated at a nearby hospital which is less specialized, like the hospital of Delfzijl. The reasoning why hospital Delfzijl is chosen will become clear later this chapter. The location of the UMCG and the hospital of Delfzijl are displayed in figure 6.2. Other hospitals are displayed as a blue dot.
Figure 6.2 – Location hospitals
6.2 Overview EMS networks
During the patient demand categories “high volume, high urgency” and “low volume, high urgency”, the time before the patient receives medical care should be as low as possible, the staff should be specialized and the staff should have access to medical equipment. For these two patient demand categories, the aim was to develop EMS networks that have a minimal round trip time. During the patient demand categories “high volume, low urgency” and “low volume, low urgency” the time
UMCG
