Establishing a Consensus-Based Definition of Air Medical Transport Need for Rural Patients After Injury: Results from a Delphi Survey

Abstract

Objectives:

Air medical transport (AMT) improves survival for selected trauma patients. Improving AMT triage is limited by a lack of evidence and a standardized definition for which patients and circumstances may warrant AMT. Our objective was to develop a consensus-based definition of AMT need.

Methods:

We recruited a multidisciplinary, nationally representative panel with expertise in AMT from trauma surgery, anesthesiology, critical care, emergency medicine, and emergency medical services (EMS). Panelists were presented with criteria from the literature representing the potential for AMT need that included patient injuries, time-sensitive interventions, and system factors. Panelists voted over 4 rounds to refine and select (≥70% agreement) a final set of criteria using a web-based Delphi methodology, including potential criteria combinations.

Results:

A total of 32 of 45 (71.1%) invited panelists agreed to participate. From 66 initial criteria, panelists reached consensus on 18 patient factors, 6 time-sensitive interventions, 3 system factors, and 7 combinations of criteria. Two key themes emerged: the need for specialized care from air medical crews that may not be available from ground ambulance clinicians, as well as overall prehospital time-savings. After narrative feedback and refinement to eliminate redundant and overlapping criteria, an algorithm for AMT need was developed along with a decision flow diagram suitable for educational dissemination.

Conclusions:

We developed a consensus-based definition of AMT need for trauma patients that can be operationalized for AMT triage. Further validation of this concept with patient outcomes and identifying implementation barriers will contribute to field deployment of a useful AMT triage tool for EMS clinicians.

Introduction

Patients in rural America have worse outcomes after traumatic injury, with a 14% higher risk of death after injury than their urban counterparts (1). Trauma is a time sensitive condition; how long it takes to receive high-quality care can make the difference between life and death (2-4). Consequently, rural patients often rely on air medical transport (AMT) from the scene of injury for timely access to life-saving interventions and definitive trauma center care. Without AMT, up to 28% of Americans would be unable to reach a trauma center within an hour of injury (5). Air medical transport also brings to patients life-saving treatment capabilities that are otherwise often unavailable from ground emergency medical services (EMS). This can include more advanced and/or experienced airway management and blood transfusion, before reaching a trauma center (2,6-8). Air medical transport has been shown to improve the odds of survival after injury compared to ground EMS transport for selected patients (9-15).

Effective triage to identify the right patient for AMT is critical. Rural patients are 3.5-times more likely to be under-triaged to a non-trauma center than urban patients, which is associated with a nearly 20% increase in mortality in rural settings (1,16). Conversely, over-triage also clusters in rural areas, with a 3% increase in risk of over-triage per 10-mile increase from the nearest trauma center (17). Over-triage risks depleting a region’s AMT resources, with studies showing a resultant median delay of 100 min to definitive trauma care and ultimately 4% increase in loss of life-years when unavailable (18,19). Further, overuse of AMT assets contributes to increased risks inherent in aviation and financial burdens to patients and the health care system that are not justified when used unnecessarily (20,21).

A key barrier to improving air medical triage is the lack of a standardized definition of which patients and/or circumstances warrant the use of AMT after injury. Prior work demonstrates significant variation in measures for appropriate AMT (11,17, 22-26) and protocols for AMT use (27). Previous attempts to synthesize studies of air medical triage were hampered by low rigor and inconsistent definitions for which patients should undergo AMT after injury (28,29). Earlier work to develop and validate the Air Medical Prehospital Triage (AMPT) score did not consider important factors such as distance from the trauma center and availability of local ground EMS resources (30).

Therefore, our objective was to develop a consensus-based definition of AMT need for rural injured patients that considers patient, intervention, clinician, operational, and system factors holistically across the United States (U.S.). We hypothesized that an expert panel would reach consensus on several factors from these domains, define cases that potentially warrant AMT, and guide air medical triage decisions by EMS first responders.

Methods

Study Design

We conducted a modified Delphi consensus survey. The objective was to develop the definition of AMT need that was structured such that any one criterion is sufficient to warrant an air medical response similar to the American College of Surgeons National Field Triage Guidelines (31). However, a single criterion may represent a combination of multiple individual factors.

To obtain a list of initial AMT triage criteria for panelists to consider, we first conducted a nonsystematic literature search by identifying positions statements on AMT by trauma, emergency medicine, and EMS organizations, systematic reviews, papers previously published by members of study team with review of bibliographies for relevant additional papers (28-30,32-35). We simultaneously reviewed trauma destination protocols for all 50 states and the District of Columbia for AMT triage criteria between October 2023 and December 2023. A full list of the initial criteria considered are included in the Supplemental File eTable 1. All identified potential criteria were collated, reviewed for redundancy, and organized into four domains: Patient Factors, Time-sensitive Interventions and Clinician Factors, System/Logistical/Operational Factors, and Combinations (two or more criteria necessary to warrant AMT). This study was approved by the University of Pittsburgh Institutional Review Board with consent for participation in the panel included in the Delphi web-based platform. The study protocol was not previously registered.

Participant Panel Recruitment

We identified and recruited a multidisciplinary nationally representative panel with expertise in AMT from the fields of trauma surgery, anesthesiology, critical care medicine, emergency medicine, and EMS, including both clinicians and researchers. Prospective panelists were identified as a convenience sample by the study steering committee (REC, LW, JB, MK, MO, CMG, FXG) and led by the study principal investigator (JBB) based on our professional knowledge and relationships as active researchers and clinicians in AMT to ensure expertise in this content area. Each prospective panelist received an email invitation that introduced the study and its objectives, described the asynchronous web-based Delphi platform, expectations for participation, and estimated time-commitment. Panelists then gained access to the platform, provided consent to participate, and viewed a video with detailed instructions on using the platform and the objectives of each Delphi round. Panelists were provided with a packet of reference literature pertaining to the collated criteria to review. At the end of the first round, panelists completed demographic and professional questions to document the composition and expertise of the panel.

We invited 45 panelists, expecting a sample size of 20–30 to participate and complete all rounds, which has been shown to be adequate to ensure generalizability of results and account for heterogeneity among a multidisciplinary panel and reach consensus on most items (36).

Asynchronous Web-Based Delphi Methodology

We used a modified Delphi approach to develop the definition. Delphi methodology is widely used to build consensus among expert or stakeholder groups through an iterative rating process structured in successive rounds. This methodology incorporates feedback to individual panel members about the aggregate responses from the group in real time and from prior rounds (36). Delphi approaches have been successful in developing expert consensus-based definitions in other areas involving injured patients (34,37,38). We used a web-based Delphi platform (Surveylet; Calibrum, Inc. St. George, UT) that allowed panelists to asynchronously view and complete the survey, giving us the ability to recruit a nationally representative panel from a variety of geographic locations (39). Each round was open to the panelists for approximately two weeks with several email reminders for non-respondents to complete the survey. A minimum of two-thirds of panelists were required to move to the subsequent round. Each round was piloted by the steering committee to ensure functionality and clarity.

The Delphi process was conducted in four rounds with two parts to Round 1. In the first part of Round 1, panelists were presented with the compiled list of potential criteria, organized into the four domains above, and then asked to suggest additional criteria to be considered. In the second part of Round 1, suggested criteria were added to the compiled list, and panelists were asked to consider removal or suggest modifications to make them better reflect the need for AMT after injury. Subsequent rounds allowed panelists to rate the criteria either on a Likert scale (1 to 9) or binary Yes/No for inclusion to develop consensus among which set of criteria were to be included in the final definition of AMT need. Given the complexity of some criteria, a two-step evaluation process was used. In these circumstances, panelists first rated the importance of a given conceptual criterion for AMT need (e.g., systolic blood pressure plus time saved), followed by rating specific thresholds that would indicate AMT need (e.g., <70 or <90mmHg, 15 or 30 min saved).

Criteria were included in the final definition if they reached ≥70% agreement as representing a need for AMT after injury. Criteria were removed from consideration if they reached ≥70% agreement as not representing a need for AMT after injury. Criteria that did not meet consensus criteria (either to be kept or removed) were carried forward into subsequent rounds. Criteria that did not reach the threshold of consensus for inclusion in the final round were ultimately not included in the definition of AMT need. Panelists could optionally submit comments on their rating rationale through the process, which could be viewed anonymously by other panelists in real-time within each round. All comments were reviewed individually by the steering committee for potential emerging themes among the panel as well as for potential modifications to the instructions or criteria for clarity.

Definition and Algorithm Development

After each round, agreement was calculated across the participating panelists. Criteria wording was refined where necessary to enhance clarity and prioritize simplicity and brevity for potential field use. At the conclusion of each round, redundancy was eliminated where possible from single and combination criteria, and when a patient or situation would simultaneously be captured by another criterion. Preference was given to less complex criteria. These modifications were made by the study principal investigator with input from the steering committee.

Once the final set of criteria was determined, the definition for AMT after injury was operationalized by structuring it into a flow-based yes-no decision algorithm. Criteria that contained a combination of factors were structured sequentially in the algorithm so all conditions would need to be present to suggest AMT. The overall objective was to develop an algorithm from the definition that could be applied to an individual patient scenario and quickly identify whether AMT is recommended or not. All panelists who participated were presented with the final set of criteria and the completed algorithm to provide input in a post-Delphi survey for final refinement of the definition.

Results

A total of 32 of 45 (71.1%) invited panelists provided responses in at least one round. The characteristics and experience of the panelists are included in Table 1. Of note, 8 (25%) panelists report currently practicing in a rural setting, and 11 (34%) make rural settings a focus of their research. Seventeen participants (53%) completed all five surveys. Seven (22%) completed four, two (6%) completed three, five (16%) completed two, and one (3%) completed one. Completion rates by round were: 100% for both parts of Round 1 (32 participants), 78% for Round 2 (25 participants), and 69% for Rounds 3 and 4 (22 participants each). The Delphi rounds were conducted between February 2024 and November 2024.

Table 1.

Characteristics of delphi panel participants.

Age, median (interquartile range)	49.5 (42.5, 57.5)
Sex (female)	6 (19%)
Race
White	28 (88%)
Asian	1 (3%)
More than one race	1 (3%)
Prefer not to answer	2 (6%)
Ethnicity
Hispanic, Latino, or Spanish	2 (6%)
Not Hispanic, Latino, or Spanish	28 (88%)
Prefer not to answer	2 (6%)
Clinical specialty
Emergency medicine physician	19 (59%)
Trauma surgeon	7 (22%)
Anesthesiologist	1 (3%)
Emergency medical services clinician	5 (16%)
Professional experience in years
5 to <10	2 (6%)
10 to <15	8 (25%)
15 to <20	5 (16%)
20 to <25	5 (16%)
≥25	12 (37%)
Current job/appointment primarily related to EMS	23 (72%)
Provides patient care in prehospital setting	23 (72%)
EMS agency medical director affiliation	23 (72%)
Geographic practice setting
Rural	8 (25%)
Suburban	6 (19%)
Urban	17 (53%)
Does not provide patient care	1 (3%)
Active in EMS research	28 (88%)
Rural setting a focus of research	11 (34%)

Continuous data are presented as median (interquartile range). Categorical data are presented as n (%).

In part 1 of Round 1, panelists suggested 14 additional Patient Factors, 1 additional Time-sensitive Intervention and Clinician Factor, 3 System/Logistical/Operational Factors; and 3 additional Combination criteria. This resulted in a total of 66 initial criteria for the panel to consider. After completion of the four Delphi rounds, consensus was reached for inclusion of 18 Patient Factors, 6 Time-sensitive Interventions and Clinician Factors, 3 System/Logistical/Operational Factors, and 7 Combination Factors (Table 2).

Table 2.

Final set of criteria that reached consensus for inclusion by the panelists.

Patient factors

• GCS motor component <6

• Systolic blood pressure <90mmHg + clinical suspicion or mechanism with high risk of hemorrhage

• Penetrating injury to the head, neck, torso, or proximal extremities

• Suspected unstable pelvic fracture

• Crushed, degloved, mangled, or pulseless extremity

• Amputation proximal to wrist or ankle

• Active bleeding requiring a tourniquet, wound packing, or continuous pressure

• Multisystem trauma (e.g., potential or suspected severe injuries to 2 or more anatomic body regions: head/face, neck, chest, abdomen, upper extremities, lower extremities as evidenced by suspected injury beyond superficial lacerations or abrasions e.g., potential underlying fractures, intra-abdominal or thoracic injuries, signs of closed head injury)

• Injured patient with other medical need that otherwise would be transported by Ground EMS to center without both trauma & specialized services (e.g., OB/neonatal for pregnant patient, Burn services for concomitant burn/traumatic injury, PCI center for a patient with STEMI criteria, Stroke center for a patient with stroke symptoms)

• Suspected spinal injury with new motor or sensory loss

• Free abdominal or pericardial fluid on FAST ultrasound + clinical suspicion or mechanism with high risk of abdominal hemorrhage/cardiac injury

• Entrapped patient requiring active resuscitation, airway management, and/or amputation for extrication

• GCS < 13 with signs of head trauma if age ≥ 65

• CPR performed after trauma with ROSC (e.g., not in active arrest)

• Suspected thoracic injury + Respiratory distress (tachypnea, cyanosis, stridor/wheezing, retractions, diaphoresis, irregular breathing pattern or periodic apnea), or need for advanced respiratory support (need for suctioning/maneuvers to maintain open airway and/or need for ventilation)

• Suspected hemothorax or pneumothorax + Respiratory distress (tachypnea, cyanosis, stridor/wheezing, retractions, diaphoresis, irregular breathing pattern or periodic apnea), or need for advanced respiratory support (need for suctioning/maneuvers to maintain open airway and/or need for ventilation)

• Respiratory distress (tachypnea, cyanosis, stridor/wheezing, retractions, diaphoresis, irregular breathing pattern or periodic apnea), or need for advanced respiratory support (need for suctioning/maneuvers to maintain open airway and/or need for ventilation)

• Signs of head trauma + patient on anticoagulation/full dose antiplatelet therapy + GCS motor < 6

Time-sensitive Interventions + Clinician Factors

• Anticipated urgent need for specialized care not available by ground EMS in region that can be delivered by air medical crew

• Anticipated need for specialized care not available by ground EMS in region that can be delivered by air medical crew urgently (examples may include blood transfusion, drug assisted intubation, cricothyroidotomy or other advanced airway management, field amputation, vasopressor support, finger thoracostomy or chest tube placement, pelvic binder, resuscitative hysterotomy, etc.)

• Anticipated need for transfusion of blood or blood products urgently + not available from ground EMS

• Anticipated need for advanced airway management (endotracheal, drug assistant intubation, supraglottic airway, cricothyroidotomy) urgently + not available from ground EMS

• Anticipated need for vasopressors urgently + not available from ground EMS

• Potential need for surgical hemorrhage control urgently

System/Logistical/Operational Factors (Among injured patients with ACS NFTG or local triage criteria for transport to a trauma center)

• Difficult or inaccessible scene terrain/location that is safely accessible by helicopter

• Number of patients requiring trauma center care exceeds ground transport capabilities

• Anticipated total prehospital time savings of air medical transport over ground EMS ≥30 min

Combinations

• Patient with injury that is not definitely managed at closet trauma center and may benefit from transport to more distant specialized trauma center (e.g., severe TBI, spine injury, pelvic fractures based on knowledge of local system capabilities)

• Injured patient with STEMI criteria or acute stroke signs + air medical transport will reduce total prehospital time

• Anticipated total prehospital time savings of air medical transport over ground EMS ≥30 min + Patient has any ACS NFTG RED criteria

• Patient requires any of following interventions: advanced airway management, chest decompression, blood transfusion, vasopressor support, tourniquet placement, pelvic binder placement + air medical crew would arrive prior to ground EMS arriving at a trauma center in clinically significant time frame

• Anticipated need for specialized care not available by ground EMS in region that can be delivered by air medical crew (examples may include blood transfusion, drug assisted intubation, cricothyroidotomy or other advanced airway management, field amputation, vasopressor support, finger thoracostomy or chest tube placement, pelvic binder, resuscitative hysterotomy, etc.) + air medical crew would arrive prior to ground EMS arriving at a trauma center by 30 min

• Anticipated need for specialized care not available by ground EMS in region that can be delivered by air medical crew (examples may include blood transfusion, drug assisted intubation, cricothyroidotomy or other advanced airway management, field amputation, vasopressor support, finger thoracostomy or chest tube placement, pelvic binder, resuscitative hysterotomy, etc.) + air medical crew would arrive prior to ground EMS arriving at a trauma center in clinically significant time frame

• Ground EMS would only otherwise transport to a non-trauma center in patient that meets any ACS NFTG RED or YELLOW criteria or local triage criteria for transport to a trauma center

EMS, emergency medical services; ACS NFTG, American College of Surgeons National Field Triage Guidelines; GCS, Glasgow Coma Scale; CPR, cardiopulmonary resuscitation; ROSC, return of spontaneous circulation; OB, obstetrics; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.

After eliminating redundant criteria, incorporating combination criteria, and optimizing for field use, an algorithm was developed that could be followed in individual patient scenarios to guide AMT decisions for injured patients. The algorithm considers the availability of specialized care or overall prehospital time-savings among patients with any one of 14 Patient Factors. It also considers six System/Operational criteria that do not fall under the considerations for specialized care or time-savings. The algorithm was further refined for simplicity and clarity based on final panelist feedback (Figure 1). Final panelist comments also informed the development of a flow diagram outlining the algorithm as a series of binary paths to the appropriate transport mode (Figure 2).

Figure 1. Consensus-based need for air medical transport for injured patients.

Among patients with any one of 14 clinical criteria (Box 1) who would either have an anticipated urgent need for specialized prehospital care not available from ground ambulance crews and the air medical crew would arrive before the ground ambulance could reach a trauma center or there would be an anticipated total prehospital time saving, warrants air medical transport. Patients or situations that meet any one of the six System/Operational criteria (Box 2) would also warrant air medical transport.

Figure 2. Flow diagram of binary decision paths of the consensus-based need for air medical transport for injured patients.

The flow algorithm also places the patient-factors in the context of the MARCH framework; a familiar approach emergency medical services clinicians use for trauma patient assessment

Discussion

We conducted a modified Delphi consensus process among a multidisciplinary panel of experts in air medical transport and triage, identifying several patient, intervention, and system/operational criteria that should warrant consideration of air medical transport to a trauma center for injured patient encountered in rural settings. We included several panelists that either practice in a rural setting or focus their research on rural settings to strengthen insights into this patient population.

Three key themes emerged from the Delphi panel that became a focal point for developing the consensus algorithm. First was the need for specialized interventions or care strategies that would otherwise be unavailable from ground-based EMS crews. Examples of such interventions included blood transfusion, advanced airway management, and vasopressor support. The highest rated interventions are listed in the call out box in Figure 1. Panelists noted significant regional variation in protocols and available interventions for both air and ground EMS. It is important to note that the quality and effectiveness of particular interventions and care may vary based on experience and volume (40), with lower volumes typical for rural ground EMS crews. A key aspect of this specialized care was the caveat that the air crew had to arrive at the scene to deliver this care prior to the estimated time it would take for ground EMS to transport by ambulance to the nearest trauma center to not delay access to definitive care.

Consistent with the priority of timely access to definitive care, the second major theme was that AMT should reduce total prehospital time. There was debate about how to best operationalize both the time advantage of air medical rendezvous with a ground crew before they could have otherwise driven to a trauma center and the expected reduction in total prehospital time. Panelists acknowledged the desire to allow for variability within local trauma and EMS system resources, while also providing practical guidance when setting timeframes. Criteria that included a flexible “clinically significant timeframe” for achieving the delivery of specialty care allowing for EMS clinician’s judgment, as well as ultimately reaching consensus on 30 min as a reasonable baseline timeframe for delivery of specialty care and total prehospital time reduction. Recent evidence suggests that a reduction in approximately 20 min or more of total prehospital time for AMT over ground transport would be expected to confer a survival benefit (41).

Systems components and operational considerations comprised the final core theme of AMT need. This included physical scene limitations, patients with injury plus other time-sensitive conditions that benefit from more distant specialized centers, and situations in which ground EMS did not have the resources to travel to a distant trauma center. Inclusion of these criteria aimed to prevent under-triage to a local non-trauma center hospital with resulting secondary transfer.

The Delphi consensus definition generally aligns with existing recommendations for trauma and EMS communities (29,35,42). In a joint position statement from the National Association of EMS Physicians (NAEMSP), American College of Emergency Physicians (ACEP), and Air Medical Physicians Association (AMPA), stakeholders also identified advanced specialty care available from air medical transport, expedited transport for time-sensitive interventions, and system or environmental conditions that limit ground EMS transport for traumatic conditions, but lacked specific patient criteria or time-savings thresholds (35). Doucet et al., representing the American College of Surgeons Committee on Trauma (ACS-COT) EMS Subcommittee, identified several priorities and system/policy level recommendations, but offered few granular recommendations amenable to implementation within EMS protocols for clinical decision support (42). Thomas and colleagues conducted a systematic review and GRADE assessment to identify literature relevant to development of an actionable algorithm for AMT triage. Based upon available evidence, the authors could only extrapolate the ACS-COT field triage criteria and recommended a significant time-savings, without a specific time threshold identified (29).

We started with the unique objective of developing a definition that was usable in the prehospital environment by EMS clinicians to support AMT triage decision-making. Many of the included patient factors represent patients with significant hemorrhage, head injury, severe chest injury, or potential need for time-sensitive surgical intervention at a trauma center. The addition of system and operational considerations is a step forward compared to prior work on the clinically focused AMPT score, a prediction tool to identify which patients will have a survival benefit from AMT. The AMPT score was included in the original criteria presented to the panelists. However, panelists ultimately chose to remove the AMPT score due to concerns about increasing complexity and ease of use within this novel triage tool. The calculation of a score did not align with the criterion-based field trauma triage guidelines from the American College of Surgeons. Notably, most individual criteria from the AMPT score are represented in the current consensus definition and algorithm.

We developed two visual aids for the algorithm after completing the Delphi panel. We believe that the flow diagram in Figure 2 would be most useful for initial education about the algorithm as it is the easiest to follow logically and understand the decision points to determine transport mode. The more compact version of the algorithm in Figure 1 originally developed and reviewed by the Delphi panel would be well suited to “just in time” reminders as badge cards, posters, or viewed on mobile devices. These complementary visual displays may help with dissemination and implementation efforts in a variety of settings in the future.

We acknowledge that it is important to gather validation evidence for the consensus definition prior to widespread adoption. Surveys among EMS clinicians as potential end-users are underway to evaluate perceived validity and input for further refinement focused on field usability. We are also in the process of operationalizing the definition components for application to patient-level data sources to evaluate whether patients who meet or do not meet the algorithm criteria have differences in mortality or other clinical outcomes based on actual transport mode. Lastly, it is important to note that any meaningful adoption will require buy-in and incentives to change current practice and system pressures.

Limitations

This study has several limitations. First, we assembled a representative panel of experts across relevant domains with significant proportions of clinicians providing prehospital care, involved in research, and representing rural locations. An alternative panel composition may have reached consensus on different criteria. The steering committee identified specific potential panelists as a convenience sample; however, this was done to ensure the panel had the requisite expertise in AMT. Further, we designed the potential sample of panelists to ensure geographic representation from across all regions of the U.S.; however, panelists that agreed to participate led to some regions being over or underrepresented in the final panel. Finally, given varying potential EMS system consideration in other countries, panelists were identified for knowledge of U.S.-based EMS and trauma systems.

While this definition is intended to be used in rural locations where AMT is predominantly used, only a quarter of the panel practices in a rural setting. This may be due to academic practices often being in urban settings, and academic clinicians were more likely to accept the invitation to join the panel. Further, rural settings were a research focus for a greater proportion of panelists, albeit still a minority. The drop out from the panel limited our ability to explore potential differences in consensus around specific criteria based on expertise and clinical backgrounds. Of note, six of eight panelists practicing in a rural setting completed all rounds with the other two missing only one round each, giving this group a higher completion rate than non-rural panelists.

These criteria may not be generalizable to all cases across all trauma and EMS systems but should be viewed as a potential starting point that can be adapted to individual systems. These criteria only consider adult trauma patients; pediatric patients may warrant a separate set of criteria though some overlap in criteria would likely apply. Similarly, this panel had a narrow focus on AMT from the scene for traumatic injury; separate considerations would be warranted for other mechanisms such as thermal injury as well as interfacility transport of trauma patients.

Conclusions

We developed a consensus-based definition and algorithm for AMT need after injury in rural settings. This definition recommends AMT after injury among patients meeting specific criteria who may benefit from either specialized care available from air but not ground EMS, clinically significant savings in total prehospital time, or system/operational factors that prohibit ground transport to an appropriate hospital. This algorithm is structured to be used by EMS clinicians to support decision-making about individual trauma patients. Further study is warranted to evaluate the ability of this definition to predict patients most likely to benefit from air medical transport.

Supplementary Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10903127.2026.2632975.

Data Availablity Statement

De-identified data and results from the Delphi panel have been deposited in openICPSR data repository and is available at https://doi.org/10.3886/E241983V1