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Investigating the barriers to air medical services in accidents and disasters in Iran and suggesting solutions: a qualitative study

BMC Research Notes volume 17, Article number: 365 (2024) Cite this article

Abstract

Objective

Today, air medical services play a key part in providing emergency medical services in accidents and disasters in many countries, including Iran. The present study aims to investigate the barriers to air medical services in accidents and disasters in Iran and suggest solutions to them.

Results

Analysis of the qualitative data resulted in extraction of 84 codes, which were classified into 13 subcategories and eventually into four themes, namely planning, management of resources, updating procedures, and empowerment of human resources. The findings also underscored the role of general policies, safety of flights and the scene of the accident, the cost and length of arriving at the scene of the accident, training programs designed to enhance the personnel’s preparation, and management of disasters and accidents. Senior medical emergency services managers can use the findings of the present study to identify the challenges which pre-hospital emergency care personnel are faced to air medical services in accidents and disasters and take the necessary measures to eliminate them toward improving the quality of pre-hospital care in air medical services in accidents and disasters.

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Introduction

In the past 30 years, disasters have doubled and the number of disaster victims has tripled worldwide [1, 2]. Iran is one of the ten highly hazard-prone countries in the world [3]. In this country, road accidents, which are four times more prevalent than in high-income countries, are the most common cause of injuries and the second leading cause of death [4, 5]. High-quality prehospital emergency services are an integral part of providing care to disaster victims [6]. Compared to ground emergency medical services (GEMS) which are time-consuming, helicopter emergency medical service (HEMS) reduce the time needed to transfer victims to hospitals at the time of a crisis and thus play a key part in providing emergency medical services (EMS) to disaster/accident victims in remote areas [7,8,9]. Air medical services are an essential part of planning a comprehensive national response to natural and man-made disasters and evacuating the victims in the shortest possible time [10, 11]. Air ambulances are an important factor in reaching and transporting victims from the scene of the accident and their survival rate [12,13,14,15]. In addition, by decreasing response time and the time required to transport victims and covering wid er areas, air ambulances allow for timely and quality emergency services [16, 17]. Air ambulances are among the fastest and most efficient ways of transporting victims or patients at the time of natural disasters or road accidents [7, 9]. Studies have shown that efficient expansion of air ambulance centers will reduce response time, cover larger populations, and lower mortalities [17,18,19].

Given the importance of the subject, and that few studies have been conducted in this area, it is recommended that the present study should be conducted in different countries to develop knowledge translation. Investigating the barriers to air medical services in accidents and disasters can help the policymakers and managers of the emergency medical services to eliminate barriers toward improving the quality of pre-hospital care in air medical services in accidents and disasters. Therefore, given that no study has been conducted in Iran in this field and that there are study gaps that need to be filled, the present study aims to investigate the barriers to air medical services in accidents and disasters in Iran and suggest solutions to them.

Main text

Study design

This is a qualitative study in Fars Province, Southern Iran, in which data were collected via semi-structured interviews.

Participants

The participants were key experts with academic knowledge or hands-on experience of air emergency services. The inclusion criteria were having at least three years’ experience of practice in air emergency services for the paramedics and nurses and having a PhD in disaster relief and experience of practice in pre-hospital emergency care and experience of disaster relief management and relevant research for the air emergency services administrators. The individuals who were not willing to participate in the study were eliminated. 24 pre-hospital emergency personnel were invited to participate in the study, but seven personnel refused due to busy schedules, intensive shifts and being infected with COVID-19. Therefore, 17 pre-hospital emergency services administrators and personnel employed by medical schools were recruited by purposeful sampling.

Data collection

Data were collected through semi-structured, in-depth interviews with open-ended questions about the current barriers to HEMS. The interviews were conducted by phone or in-person and lasted from 20 to 70 min (with an average of 40 min). The interviews were conducted from July 31 to September 15, 2022. Additional file 1: Interview Guide and Question.

Data analysis

The collected data were analyzed using Graneheim and Lundman’s method, which consists of six stages: 1. Becoming acquainted with the data 2. Generating the initial codes.3. Searching for themes: classifying the codes into potential themes and organizing all the data summaries into set themes 4. Checking the categories, subcategories, and themes: the codes of the categories and subcategories were compared against the data. 5. Defining and labeling the categories, subcategories, and themes: the identified categories and subcategories were analyzed again to determine which aspects of the data and subcategories were in each category; and 6. Generating a report: the final analysis was conducted and the results were made into a report [20, 21].

Trustworthiness (Rigors)

Lincoln and Guba's criteria were used to ensure the trustworthiness of the qualitative data [22]. For this purpose and for increasing the acceptability and accuracy of data, data collection was done using semi-structured interviews, prolonged engagement, and peer debriefing. For reducing bias in data collecting were used member and peer checking. To this end, the extracted themes were submitted to 5 participants and 7 peers, who stated that the results were consistent with their interpretations.

Results

Of the 17 participants, 16 were male and one was female, with an average age of 41 years. 23.5% of the participants had a PhD. Table 1 shows the participants’ demographic characteristics. Analysis of the initial data resulted in 701 codes. After the repeated codes were eliminated, 84 codes remained. These codes addressed the barriers and solutions to air emergency services in Iran and fell into four categories and 13 subcategories. Table 2 shows the extracd codes, ategoies, and subcategories.

Table 1 The participants’ demographic characteristics
Full size table
Table 2 The extracd codes, ategoies, and subcategories
Full size table

Planning

Planning is the key to success. Preparation for accidents is essential to making a proper response when accidents happen. Effective and comprehensive planning improves preparation for accidents and disasters [23, 24].

Guidelines and policies

Guidelines and general policies on the national level is one of the most important subcategories in the present study. “We need to change our national strategies and promote the idea that helicopters are not only for military purposes, but can be used for emergency medical services” (P 1).

Security and safety

One of the barriers which puts the safety of the personnel and victims at risk as described by many of the participants is landing helicopters in open spaces, e.g. roads, parks, and stadiums, because there is a lack of helipads. Some of the participants mentioned that certain places, including main roads, should be equipped with helipads to increase safety (P 16). Another example of disregard for safety protocols is building high unmarked obstacles in the path of helicopters or near helipads in cities, roads, or hospitals without informing the authorities (P 9).

Management of resources in HEMS

Management of resources is one of the major aspects of air medical services. Limited resources and high costs adversely affect the quality of services in HEMS. A suitable infrastructure, modern equipment, and trained personnel can improve the quality of services provided by air ambulances.

Financial resources

The findings of the study showed that expenses and financial resources play a key part in determining the quality of HEMS. “One of the major barriers in our field is financial problems: air emergency services are expensive all over the world, but they cost much more in our country because of the sanctions” (P 11, P 14).

Performance of the personnel

The success of air emergency services depends on the readiness of the personnel for quick action, which entails their competence in making quick judgments and arriving at the scene of accidents in the shortest possible time (P 11).

Equipment

The participants mentioned that shortage of spare parts and equipment due to sanctions undermines their efficiency (P 2, P 8). “We can’t fly at night because we don’t have the necessary equipment for night flight” (P 10). Another problem is lack of smart equipment (P 3).

Structure

Faults in the national and local infrastructures was another issue referred to by many of the participants. “Air ambulances can be a good choice for 30- to 40-bed hospitals in Iran, which is a large country” (P 12). According to some of the participants, in many cases, ground ambulances arrive at the site of accidents sooner than air ambulances (P 8). “We can’t give effective care to the victims in helicopters. A large part of what we do for the victims has to be done on the ground, before they are transferred to the helicopter” (P 6).

Upgrading procedures

In all organizations, upgrading procedures is associated with greater productivity, less dissatisfaction, and reduction in costs. Some common ways of upgrading procedures are revising the current rules and regulations, revising operation forms, and clarifying duties.

Helicopters

Lack of helicopters specially designed for emergency services is one of the biggest barriers to providing emergency services by air. “Most of our helicopters are for military purposes and we need to purchase more non-military or medium-lift helicopters to overcome the current barriers and provide better services” (P 13).

Standards

The medical personnel’s poor knowledge can increase the number of unnecessary flights. Requests for air ambulances should be treated according to the relevant disaster protocols (P 8).

Influential factors in the quality of services

Limited access to accident victims is another factor with an adverse effect on the quality of emergency services. The participants referred to lack of access to all the accident and disaster victims due to lack of vehicles, lack of helipads in many inaccessible and mountainous areas, the high cost of air travel, and heavy traffic in big cities as barriers to emergency medical services (P 15, P17).

Empowerment of human resources

The key to an organization’s success is efficient and competent human resources. Empowerment of human resources is a modern approach which enhances self-confidence in the personnel and increases their willingness to cooperate [25].

Education

Air emergency services are expensive services with limited funds; therefore, they need well-trained and skillful personnel [26].

Training

Frequent drills and training allow managers to assess and revise policies before accidents and disasters occur [27]. The managers in emergency services should provide the equipment needed for regular training programs to empower the personnel in making quick and sfae responses to accidents and disasters (P 5).

Stress-inducing factors

A variety of factors, including bad weather, previous air incidents, and pilots’ experiences, can cause stress in air emergency services personnel. Landing is the most stressful stage in air medical services [28].

Promotion and retention of the personnel

Educating the personnel and updating their knowledge will improve the quality of services (P 1). The managers should also consider the personnel’s physical and emotional health and replace the caregivers who are not fit for a mission (P 17).

Discussion

The present study aims to investigate the barriers to air medical services in accidents and disasters in Iran. The findings also underscored the role of general policies, safety of flights and the scene of the accident, the cost and length of arriving at the scene of the accident, training programs designed to enhance the personnel’s preparation, and management of disasters and accidents.

On the other hand, planning and management of resources, upgrading procedures, and empowerment of human resources can help alleviate the adverse effect of these barriers. Planning is essential to making optimal use of all the possibilities in air medical services. By setting general policies, updating protocols, increasing capacities, creating a safe environment, and predicting the progress of disasters, managers can cope with the existing barriers. Planning involves setting the right path toward achieving objectives, efficient management of resources, risk management, and creating a systematic approach to performing tasks [29]. In most countries, HEMS is an integral part of disaster management and planning [30]. An established set of guidelines for coping with disasters makes it easier to address key issues [31]. To ensure a safe, coordinated, and effective response to accidents and disasters, air emergency services teams need clear and up to date plans which should be incorporated into general disaster policies and local healthcare [32]. Developing and implementing safety education standards is one way to reduce hazards in HEMS [33]. The National Transportation Safety Board suggests safety and disaster preparation workshops for medical professionals [34]. The Iranian organization of emergency services has banned night air rescue missions. The purpose of most of the safety precautions for flights is to avoid incidents [35].

Management of resources is another important factor in air emergency services. In financial reports, the high costs and unknown efficacy of HEMS compared to ground ambulances raise questions about the effectiveness of air ambulances [36]. There are many controversies about the costs, effectiveness, and safety of air ambulances compared to ground ambulances [36]. Responsible use of financial resources can increase the tendency to rely on cheap means of transportation (ground as opposed to air) to meet victims’ clinical needs [37]. In one study in Iran, the cost of HEMS missions was estimated to be 40 times the cost of using ground ambulances [38]. In management of human resources, triage plays a key part in identifying victims or patients who need air transport: overtriage can limit the possibility of using this costly way of transporting patients [39, 40]. Personal protective equipment makes it possible to work safely in a large accident scene with common risks. When the scene of an acciddetn is too far or ground routes are too dangerous, helicopters are the only way to transport first responders and equipment to the scene of the accident [41, 42].

Upgrading procedures is another way to improve the quality of air medical emergency services. Inability to fly due to bad weather [43] and lack of predetermined areas for landing are among the operational hazards in HEMS [42]. Before each flight, the risks for the victims and the personnel should be carefully weighed against the medical benefits of being transported by an air ambulance for the patients [44]. To ensure the optimal function of HEMS, the agencies which use the services of air ambulances should act in coordination and use these resources in a safe, clinically justified, and professional way [35].

Empowerment of human resources through regular drills is essential to enhancing the level of preparation of the personnel in HEMS. A study in Norway stresses the significance of educating air ambulance crew using common scenarios about road accidents and severe weather conditions. Workshops can contribute to identifying and overcoming these barriers [45,46,47]. Accordig to a study in Malysia, education improves air ambulance pesonnel’s teamwork and group decision making skills [39]. As HEMS is a limited resource with high costs, it is essential that the personnel should be very well-trained and skillful. One of the ways to empower the human resources is emotional support: all the memebrs of HEMS personnel should have access to effective counsel and emotional support [32].

Limitations

For some reasons, including work overload, some experts were not available for an interview. Another limitation of the study is that data were collected solely through individual interviews. It is suggested that future studies use other methods of data collection, including focus group interviews, to obtain richer qualitative data.

Conclusion

Senior medical emergency services managers can use the findings of the present study to identify the challenges which pre-hospital emergency care personnel are faced to air medical services in accidents and disasters and take the necessary measures to eliminate them toward improving the quality of pre-hospital care in air medical services in accidents and disasters.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

HEMS:

Helicopter Emergency Medical Service

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Acknowledgements

The authors acknowledge and thank all the participants in this study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

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Authors and Affiliations

  1. Department of Health in Disasters and Emergencies, School of Health Management and Information Sciences, Health Human Resources Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

    Mahmoudreza Peyravi & Milad Ahmadi Marzaleh

  2. Student Research Committee, Department of Health in Disasters and Emergencies, School of Health Management and Information Sciences, Health Human Resources Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

    Mahmoud Hatami

  3. Department of Medical Surgical Nursing, School of Nursing, Fasa University of Medical Sciences, Fasa, Iran

    Mostafa Bijani

  4. Prehospital Emergency Research Center (PERC), Tehran, Iran

    Mostafa Bijani

  5. Department of Management, Shiraz University, Shiraz, Iran

    Payam Shojaei

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Contributions

MP, MH and MB was involved in the conception and organization of the study. MAM, MH and PS were involved in the execution and data collection of the study; MB, MH, and PS participated in statistical analysis design and/or execution. All authors contributed to the preparation, critical review and all of them approved the final manuscript.

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Correspondence to Mahmoud Hatami or Mostafa Bijani.

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Ethics approval and consent to participate

All the participants gave written informed consent to participate in the study. This study was conducted based on the principles of the revised Declaration of Helsinki, which is a statement of ethical principles used to guide medical researchers who investigate human subjects. The participants were assured about their anonymity and confidentiality of their information. Moreover, the proposal of this study was approved by the Ethics Committee affiliated with Shiraz University of Medical Sciences (SUMS), Shiraz, Iran with the code of (IRSUMS.NUMIMG.REC1402.009).

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Peyravi, M., Marzaleh, M.A., Hatami, M. et al. Investigating the barriers to air medical services in accidents and disasters in Iran and suggesting solutions: a qualitative study. BMC Res Notes 17, 365 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13104-024-07018-w

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