Journal of Transportation Safety & Security

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/utss20

Impacts of augmenting heliports with school

playgrounds on air medical transport time

Soyoung Jung & Xiao Qin

To cite this article: Soyoung Jung & Xiao Qin (2020): Impacts of augmenting heliports with school
playgrounds on air medical transport time, Journal of Transportation Safety & Security, DOI:
10.1080/19439962.2020.1838680

To link to this article: https://doi.org/10.1080/19439962.2020.1838680

Published online: 04 Nov 2020.

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JOURNAL OF TRANSPORTATION SAFETY & SECURITY
https://doi.org/10.1080/19439962.2020.1838680

Impacts of augmenting heliports with school

playgrounds on air medical transport time
Soyoung Junga and Xiao Qinb
a
School of Safety Engineering, Dongyang University, Yeongju, South Korea; bDepartment of Civil
and Environmental Engineering, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA

ABSTRACT KEYWORDS
Air ambulance has a huge advantage over the ground trans- air ambulance; emergency
port in providing rapid medical access to remote areas, short- medical services; heliport;
ening transport time, and improving survival rate. However, policy; school playground;
transport time
one of the hurdles to expanding air service coverage is the
limited heliports for landing. This study aims to quantitatively
assess the impact of adding school playgrounds as sub-heli-
ports to reduce air medical transport time. To achieve this
goal, the existing air medical transport infrastructure and traf-
fic crash injury data were collected and analyzed to establish
the relationship between transport time and injury severities.
Then, air medical transport time with and without the aug-
mentation of school playgrounds were estimated, respectively.
Additionally, air medical service coverage maps were created
to show the impact of fatal injury reduction and the estimated
transport times. The findings have shown promising results of
using school playgrounds to reduce air medical transport
time, which is an encouraging sign for converting school play-
grounds to potential heliports. Our research provides the
quantitative evidence to the policy makers on expanding air
medical capacity with existing infrastructure to improve the
emergency medical services in South Korea.

1. Introduction
An air ambulance is a helicopter that is exclusively used for emergency
medical service (EMS). The effects of air ambulance transport have been
still explored in favor of the service (Brown et al., 2010; Chang et al., 2017;
Galvagno, Haut, & Zafar, 2012; Meyer et al., 2016). Many previous studies
found that prolonged scene of emergency event to a definitive hospital
interval cause severe outcome. The previous studies also identified that air
ambulance has advantages to provide medical access to remote areas,
shorten transport time, and improve survival rate of patient (Brown et al.,
2016; Chen et al., 2018; Floccare et al., 2013; Hesselfeldt et al., 2013; Lee,
Abdel-Aty, Cai, & Wang, 2018). Due to these advantages, the air

CONTACT Soyoung Jung jung2@dyu.ac.kr School of Safety Engineering, Dongyang University, Yeongju,
South Korea
ß 2020 Taylor & Francis Group, LLC and The University of Tennessee
2 S. JUNG AND X. QIN

ambulance is common to transport patients with heart attack, respiratory

arrest or massive bleeding from severe injuries in many countries
(Campbell, 2018; Garner, 2004; Taylor et al., 2011).
In South Korea (called Korea hereafter), approximately 33% of severe
injuries come from traffic crashes, which is the highest rate among all
causes of severe injuries in 2017 (Seoul National Database, 2017).
According to the Korea Road Traffic Authority, the cost to treat a single
traffic crash fatality in 2017 was 430,000 dollars, which is more than
seven times the cost required for a severe injury. To reduce fatalities in
post-crash phase by speedy transport to a definitive hospital, efforts to
expand helicopter emergency medical transport infrastructures have
started since 2011. Six hospitals currently operate their own air ambulan-
ces to provide speedy and acute medical care in Korea. One another hos-
pital will begin operation of its air ambulance in 2020. For air
ambulance helicopter landing, there are a total of 649 heliports pre-
specified throughout Korea. Note that the pre-specified heliport for the
air ambulance is called heliport hereafter.
However, the heliports are distributed only in five provinces out of a
total nine provinces in Korea where the air ambulance base hospitals are
located. Local governments in Korea are responsible for constructing
and managing heliports in their administrative areas. Additionally,
most of Korean local governments confront with budgetary deficit
and residents’ complaints about noise of turning helicopter rotor. These
circumstances mean that air ambulance should move to a heliport to
pick up patients from ground EMS unit even though there are vacant
spaces available for helicopter landing that are closer to the scene of a
crash than the heliport. The ground EMS unit also needs to transport
patients to the heliports. Since transport time is the time between leaving
the scene of a crash and reaching a definitive hospital (Jung, Qin, &
Oh, 2016), heliports have contributed to longer transport time
than necessary.
To deal with these problems, the capital province of Korea recently
signed a memorandum of understanding (MOU) on utilizing school
playgrounds as sub-heliports with air ambulance base hospitals. If the
use of school playgrounds produces positive impact on reducing trans-
port time, it is worth the consideration to take advantage of the existing
facilities for timely air medical transport (AMT). This MOU may have
the potential to be expanded to a nationwide agreement. Hence, this
study provides the data-driven evidence to quantify the air medical
transport time if the school playground is used as alternative heliport;
and to inform decision-making on the consideration of school play-
grounds for AMT.
 JOURNAL OF TRANSPORTATION SAFETY & SECURITY 3

Figure 1. Air ambulance dispatch system in Korea (National Emergency Medical Center, 2016).

2. Data
2.1. Existing AMT infrastructure in Korea
Primary targets for AMT include symptoms that need rapid medical treat-
ment such as cardiovascular disease or severe external injuries. Figure 1
depicts the system of air ambulance dispatch in Korea.
According to Figure 1, AMT time includes the transport time of the
ground EMS unit from the scene of a crash to arrival at a heliport (t1),
and the transport time of the air ambulance from the heliport to arrival at
a definitive hospital (t2). Therefore, the main facilities for AMT are as fol-
lows: air ambulance base (hospital), definitive hospitals, and heliports. The
current status of the AMT facilities in Korea is described in detail in the
subheadings below.

2.1.1. Air ambulance base

Air ambulance base is the hospital where the air ambulance helicopter is
assigned. There are seven air ambulance bases in Korea. The air ambulance
bases are located in five provinces of Korea: two in the Capital province
(Gyeonggi), and one each in the northern province (Gangwon), northeast
province (Gyeongbuk), northwestern province (Jeonbuk), and southwestern
province (Jeonnam). The air ambulance bases are shown in Figure 2. Three
4 S. JUNG AND X. QIN

Figure 2. AMT facilities in the vicinity of Chungbuk province (study area).

provinces including central province (Chungbuk), southeastern province

(Gyeongnam), and southernmost island (Jeju) do not have air ambu-
lance bases.
Technical data for air ambulance helicopter assigned in air ambulance
bases are provided in Table 1 (Airbus Corporation, 2019; Leonardo
Corporation, 2019).

2.1.2. Definitive hospital

In Korea, the air ambulance transports patients to a definitive hospital
nearest to the scene of a crash within the province where the AMT calls
occur. When the AMT calls occur within the province of air ambulance
base, the definitive hospital for the AMT is the air ambulance base hospital.
Table 1. Technical data for air ambulance helicopter in Korea.
Rotor Overall length, Max. Available
Base province Model diameter rotors turning Cruise speed cruise speed Max range passengers Night
(city) (manufacturer) (m) (m) (km/h) (km/h) (km) (persons) operation
Chungnam AW109 11.00 11.45 285 311 785 6
7 N/A
(Cheonan) (Leonardo)
Jeonbuk AW109 11.00 11.45 285 311 785 6
7 N/A
(Iksan) (Leonardo)
Gyeongbuk AW109 11.00 11.45 285 311 785 6
7 N/A
(Andong) (Leonardo)
Gangwon AW109 11.00 11.45 285 311 785 6
7 N/A
(Wonju) (Leonardo)
Jeonnam AW169 12.12 14.65 268 306 820 10 N/A
(Mokpo) (Leonardo)
Gyeonggi AW169 12.12 14.65 268 306 820 10 N/A
(Incheon) (Leonardo)
Gyeonggi H225 16.20　 19.50 262 324 838 22 Applicable
(Suwon) (Airbus)
Note. N/A indicates daytime operation only; Model H225 will start AMT service in 2020.
JOURNAL OF TRANSPORTATION SAFETY & SECURITY
5
6 S. JUNG AND X. QIN

For proper medical treatment of severe injuries, the definitive hospital should
contain high-level medical equipments and professionals. The high-level grade
hospital for the EMS is called the EMS center in Korea. Note that all of the
air ambulance bases in Korea are EMS center-level hospitals. There are a total
of 149 EMS centers in Korea, and their locations and medical scales data can
be collected by Korea Emergency Medical Service Portal (2019).
All EMS centers are definitive hospital candidates where the air ambu-
lance can transport patients. Each of nine provinces in Korea has on aver-
age 16 EMS centers in their administrative territory. The capital province
of Korea (Gyeonggi) contains 71 EMS centers, which is the maximum
number of EMS centers, while the central province of Korea (Chungbuk)
has four EMS centers, which is the minimum number of EMS centers. All
EMS centers are shown in Figure 2.

2.1.3. Air ambulance heliport

Based on the Korea Air Ambulance Operation Guidelines, a ground EMS
unit can transfer patients to the air ambulance only in the heliport during
AMT (National Emergency Medical Center, 2016). There are a total of 649
pre-specified heliports distributed throughout inland areas, expressways,
and island areas within five provinces of Korea. Particularly, five heliports
are located along freeway network in Chungbuk province (central province
of Korea), even though the province does not have air ambulance base.
The Korea Air Ambulance Operation Guidelines provide location and
landing pad size data for all heliports (National Emergency Medical Center,
2016). The size of landing pad in heliports ranges from 15 m X 15 m to
200 m X 200 m. The three provinces including Jeonbuk, Gyeongnam, and
Jeju Island provinces do not have heliports for AMT. Gyeongnam province
and Jeju Island do not have an air ambulance base in their administrative
areas. Jeonbuk province contains one air ambulance base, but the heliports
have not been pre-specified in the province because the AMT service
recently started there.

2.2. Data processing

One of the study goals is to examine impacts of the use of exiting school
playgrounds as sub-heliports on reducing the AMT time. The main target of
AMT in this study is severe injuries involved in traffic crashes resulting in
death in the post-crash phase. Correspondingly, transport time is of primary
interest in this study. For AMT, transport time is consist of the time from
leaving scene of a crash by a ground EMS unit to reaching the nearest heli-
port and the time from leaving the heliport by air ambulance to reaching
the nearest definitive hospital. The study framework is shown in Figure 3.
 JOURNAL OF TRANSPORTATION SAFETY & SECURITY 7

Figure 3. Study framework.

In Task 1, crash victim injury data were collected from Korean In-depth
Traffic Collision Database (KITCD). The KITCD recorded by four EMS
centers contains particularly patients’ injury severity score (ISS), medical
treatment, treatment result, EMS unit response, on-scene, and transport
times as well as conventional traffic crash-related data. Task 2 is to identify
the effects of significant factors, especially transport time, on victim
(patient) injury severities using an ordered response model. Based on the
resultant findings in Task 2, Task 3 is to estimate the sum of ground EMS
unit transport time and air ambulance transport time assuming patients
(resulting in death) are transported by AMT with the use of heliports only
versus school playgrounds as sub-heliports. The final task is to assess the
effectiveness of the use of school playgrounds as sub-heliports for AMT.
For Tasks 3 and 4, air ambulance base, heliports, availability of school play-
grounds and EMS centers were collected.

2.2.1. Crash victim injury

This study utilized patient data collected by KITCD between 2011 and
2016. The KITCD contains in-depth data fields from traffic crash victims
8 S. JUNG AND X. QIN

Table 2. Variables used in ordered response model.

Class Variable (unit) Description Variable category (coding)
Response Injury Severity ISS  15 Minor injuries (0, base)
ISS > 15 & survival Severe injuries (1)
ISS > 15 & death within 30 Fatal injuries (2)
days after a crash
Patient Age (yrs) Child Less than 14 (1) vs. others (0)
Adolescence 15 to 24 (1) vs. others (0)
Adult 25 to 64 (1) vs. others (0)
Senior 65 or more than 65 (1) vs. others (0)
Gender Patient’s gender Female (1) vs. male (0)
Seating position The position seated by patient Driver seat (1) vs. others (0)
in a vehicle Front passenger seat (1) vs. others (0)
Back seat (1) vs. others (0)
Seatbelt Seatbelt not worn (1) vs. seatbelt
worn (0)
Vehicle Airbag Airbag equipped in front area Operated (1) vs. not operated or not
of vehicle exist (0)
Side airbag Airbag equipped in side area Operated (1) vs. not operated or not
of vehicle exist (0)
Vehicle type The size of vehicle involved in Sedan (1) vs. others (0)
a crash SUV or Van (1) vs. others
Bus or Truck (1) vs. others
Crush extent The extent of external damage Continuous from 1 (min) to 9 (max)
in vehicle
　Pre-hostpial Response time (min) The time between the incident Less than 5 or 5 (1) vs. others (0)
EMS being reported and the arrival 6 to 10 (1) vs. others (0)
time of the first responder at the 11 to 15 (1) vs. others (0)
scene taken by ground 16 to 20 (1) vs. others (0)
EMS unit 21 to 25 (1) vs. others (0)
26 to 30 (1) vs. others (0)
More than 30 vs. others (0)
On-scent time (min) Time between the ground EMS Less than 5 or 5 (1) vs. others (0)
unit arrival at the scene of 6 to 10 (1) vs. others (0)
crash and leaving the scene of 11 to 15 (1) vs. others (0)
the crash by ground EMS unit More than 15 vs. others (0)
Transport time (min) The time between leaving the Less than 5 or 5 (1) vs. others (0)
scene of a crash and reaching a 6 to 10 (1) vs. others (0)
definitive hospital taken by 11 to 15 (1) vs. others (0)
ground EMS unit 16 to 20 (1) vs. others (0)
21 to 25 (1) vs. others (0)
26 to 30 (1) vs. others (0)
More than 30 vs. others (0)
Crash Road type Functional hierarchy of road Freeway (1) vs. others (0)
　 National highway (1) vs. others (0)
　 Rural trunk arterial (1) vs. others (0)
　 Local road (1) vs. others (0)
Weather Crash occurred in fog, rain, Adverse (1) vs. others
and snow.
Night Whether crash occurred Night (1) vs. Daytime (0)
after sunset
Collision type Pattern of collision by vehicles Head-on (1) vs. others (0)
involved in a crash Rear-end (1) vs. others (0)
Sideswipes (1) vs. others (0)
Day of the week Whether crash occurred Weekdays (1) vs. weekend (0)
on weekdays
Note. Sample size in each variable category is 30 or greater than 30.

transported to four EMS centers located in Chungbuk, Chungnam, Gangwon

and Gyeonggi provinces, which are related to: patients’ medical treatment,
personal information, boarding vehicle, crash environment/location, and
 JOURNAL OF TRANSPORTATION SAFETY & SECURITY 9

pre-hospital EMS times (ground EMS unit response time, on-scene time,
and transport time).
This study discriminated patients’ death within 30 days after transported
to a definitive hospital based on the treatment consequence data field.
Considering the study purpose, this study excluded patients’ death of
arrival (DOA) cases because DOA cases have nothing to do with transport-
ing time.
In KITCD, the patient’s injury severity level is recorded as the injury
severity score (ISS) data. ISS is an anatomical scoring system that is defined
by the sum of top three Abbreviated Injury Scale (AIS) score squared
(Baker, O’Neill, Haddon, & Long, 1974). Each injury in KITCD is assigned
by AIS scores ranged 1 (minor) to 6 (maximum) based on damages in
eight body areas including the head and face, neck, chest, abdomen, spine,
external (or skin) anatomical, legs and arms (Association for the
Advancement of Automotive Medicine (AAAM), 1998; Conroy et al., 2008;
Yang, 2014). In case of crash injuries, ISS that is greater than 15 is recog-
nized to severe injury (Kusano & Gabler, 2014; Niebuhr, Junge, &
Achmus, 2014).
In this study, therefore, injury severity levels were classified into the fol-
lowing categories: fatal (ISS is greater than 15 and medical treatment result
is death), severe (ISS is greater than 15 and medical treatment result is sur-
vival) and moderate/minor (ISS is 15 or less than 15). Consequently, this
study considered a total of 456 crash victim injury cases including 37 fatal,
71 severe, and 348 minor injuries for the ordered response model. Table 2
presents the response and explanatory variables used for the ordered
response model.
According to Table 2, pre-hospital EMS time in particular was consid-
ered as categorical variable because pre-hospital EMS time as continuous
variable was not significant to the response variable. The category classifica-
tion used in the current studies was based on previous studies. Two studies
found that an EMS response time within 4 minutes led to a significant sur-
vival benefit for patients (Blackwell & Kaufman, 2002; Pons, Haukoos, &
Bludworth, 2005). Similarly, many medical experts have shown that the
first 6 minutes after injury occurred are the most important for saving the
patient’s life (Carr, Caplan, Pryor, & Branas, 2006). A Fitch’s study stated
that the most common EMS performance measure is to respond to 90% of
life-threatening calls in fewer than 9 minutes of EMS response time.
Gonzalez, Cummings, Phelan, Mulekar, and Rodning (2009) found in their
study that the mean of EMS response time for rural crashes was
14.81 minutes with survivors and the mean was 18.87 minutes with fatal-
ities. It is well accepted that the response time from crash notification to
definitive care should be a maximum of 30 minutes, and the first hour after
10 S. JUNG AND X. QIN

injury on the scene for stabilization are called the “golden hour” (Rogers &
Rittenhouse, 2014; van Buuren & van der Mei, 2015). Considering the find-
ings in these past studies, the response time was classified until 30 minutes
by 5-minute interval as shown in Table 2. The same logic was utilized to
both on-scene time and transport time category classifications. Due to the
sample size, the categories of on-scene times with greater than 15 minutes
were aggregated.

2.2.2. School playgrounds as sub-heliports

In the current study, 456 crash cases were considered and all of them
occurred in central (Chungbuk) and northern (Gangwon) provinces of
Korea. For all schools located in the two provinces, data including schools’
name, educational institution level (primary/secondary/high), mailing
addresses (latitude/longitude), the number of students, playground avail-
ability were collected from Korean Educational Statistics Service (KESS)
website (2019). According to the standards of school facilities provided by
Korea Ministry of Law (2019), the minimum area of the school playground
is 3000 m2 and the length of one side is greater than 130 m if the total
number of students in a school is less than 600. Applying these standards,
the current study considered 1118 school playgrounds as sub-heliport can-
didates: 494 and 689 school playgrounds in Chungbuk and Gangwon prov-
inces, respectively. According to Table 1, the maximum overall length of
air ambulance helicopter is 19.5 m when the rotor is turning. Comparing
with the standards of school playgrounds, therefore, all ambulance helicop-
ters can land at all of 1118 school playgrounds in the two provinces
of Korea.

3. Methodologies
3.1. Injury severity estimation
As shown in Figure 2, response variable considered in this study is injury
severity, which has three ordered levels: fatal injury (resulted in death
within 30 days after a crash), severe injury (but resulted in patient survival),
and minor injuries. To identify the impact of transport time on the injury
severity levels, this study develops an ordered response model, which is
generally used for ordered response. A traditional ordered response model
is performed under the assumption of proportional odds, and the probabil-
ity of an observed response outcome is specified as follows (Eluru, 2013):


Pr yi ¼ j j Xi ¼ Prðsj1 < yi  <sj j Xi Þ (1)
where, yi ¼ observed injury severity level; i ¼ sample case; j ¼ injury
severity levels (j ¼ 1, 2, 3); Xi ¼ a vector of explanatory variables; sj ¼
 JOURNAL OF TRANSPORTATION SAFETY & SECURITY 11

thresholds associated with injury severity levels; and yi ¼ underlying con-
tinuous latent variable for yi.
When yi replace Xib þ e, Equation (1) can be rewritten as:


Pr yi ¼ j j X ¼ Fðsj1 –Xi bÞ –Fðsj1 – Xi bÞ (2)
where, e ¼ random disturbance term; F ¼ cumulative function for e
(standard logistic and normal cumulative distributions for logit and probit
ordered models, respectively); and b ¼ a vector of unknown parameters to
be estimated.
The extent of the impact of certain variables on response is defined by
elasticity (Geedipally, Turner, & Patil, 2011). To evaluate the impacts of
changes in transport time on fatal injury, this study employs pseudo-elasti-
city. For binary indicator variable, pseudo-elasticity of the probability is
used because the use of standard elasticity gives misleading results, which
is defined by (Jung, Qin, & Yoon, 2013; Shankar & Mannering, 1996):
Ej ðXÞ ¼ ½Prij ðX ¼ 1Þ– Prij ðX ¼ 0Þ=Prij ðX ¼ 0Þ (3)
where, Ej(X) is the pseudo-elasticity indicating the percent change in the
probability of that injury severity levels j when a binary variable X for sam-
ple i is changed from 0 to 1.

3.2. Estimation of AMT time

Severe injury in this study is a case that resulted in survival after medical
aid in a definitive hospital, which was not of primary interest. Note that
minor injury is not the object of AMT. In targeting fatal injury cases, the
AMT time is estimated by separating cases with and without the use of
school playgrounds for Task 3 shown in Figure 3. In both cases, the EMS
station located nearest to the scene of a crash dispatches an EMS unit to
the scene, and the AMT time contains ground transport time and air
ambulance transport time.
For cases when heliports were only used in AMT, the ground transport
time (t1) is estimated by road network distance between the scene of crash
and the nearest heliport divided by the average vehicle speed of the EMS
unit. The air ambulance transport time (t2) is estimated by the straight-line
distance between the heliport and the nearest definitive EMS center divided
by the cruise speed of air ambulance helicopter. Consequently, the sum of
t1 and t2 is the estimation of the AMT time for cases with heliports only.
For cases with both heliports and school playgrounds, the heliport can
be replaced by a school playground nearest to the scene of a crash. In this
case, the AMT time estimate is the sum of the ground transport time from
the scene of a crash to the nearest school playground (t3) and air ambu-
lance transport time from the nearest school playground to a definitive
12 S. JUNG AND X. QIN

Table 3. Ordered logit model.

Full Data (456 cases transported by ground EMS units )
No. of cases with fatal injuries (ISS > 15 resulting in death) 37
No. cases with severe injuries (ISS > 15 resulting in survival) 71
No. cases with minor injuries (ISS  15 resulting in survival) 348 (base)
Proportional odd assumption
Log-likelihood ratio P-value > Chi-squared 0.119
Goodness-of-Fit
Global fit log-likelihood ratio P-value > Chi-squared <0.0001
Pseudo R2 (Nagelkerke) 0.217
Parameter Estimate
Variable Coefficient P-value Pseudo-elasticity/marginal
effect on fatal injury
Cut 1 3.419 <0.0001
Cut 2 4.953 <0.0001
Response time ranging 0.650 0.018 0.706
11 to 15
On-scene time ranging 11  0.834 0.048 1.303
to 15
Transport time ranging - 0.812 0.022 -0.500
11 to 15
Rural trunk arterial 0.688 0.025 0.497
Patient seated in 0.709 0.009 0.508
driver position
Patient not worn 0.720 0.006 0.513
by seatbelt
Crush extent 0.401 <0.0001 0.330
Note. Bold indicates the variable of primary interest in this study.

EMS center (t4). Two time periods, (t1 þ t2) and (t3 þ t4) were compared
to assess the effectiveness of school playground as sub-heliports on reduc-
ing AMT time.

4. Results and discussion

4.1. Optimal injury severity estimation model
Injury data for a total of 456 crash victims were used for the ordered
response model. All cases were transported by a ground EMS unit from the
scenes of crashes to two definitive hospitals (Chungju EMS center in
Chungbuk province and Wonju EMS center in Gangwon province).
Ordered logit and probit models were compared in this study. Even though
other performance measures were similarly identified in the two models,
the ordered logit model was selected as an optimal model under the
assumption of proportional odds. The resultant ordered logit model is
shown in Table 3.
Based on the study purpose, the following interpretation about the model
result is focused on the effect of transport time on the probability of fatal
injury occurrence. Table 3 shows good global goodness-of- fit based log-
likelihood ratio p-value (<0.0001) and pseudo R2 value (0.217), which
implies that explanatory variables significantly affected injury severity levels.
 JOURNAL OF TRANSPORTATION SAFETY & SECURITY 13

According to pseudo-elasticities, transport time ranging from 11 to

15 minutes, rural trunk arterial, driver seat, seat belt unfastened, and crash
extent were likely to significantly reduce the probabilities of fatalities .
Some categories of pre-hospital EMS time (including response, on-scene,
and transport times) were also statistically significant to injury severities,
but the impact of each time interval on fatal injury were found to be differ-
ent. The probability of fatal injury increased as the response or on-scene
time ranged from 11 to 15 minutes. On the contrary, the probability of fatal
injury decreased by 50% as the transport time ranged from 11 to
15 minutes. According to the golden hour principle, the effect of this trans-
port time interval on fatal injury is reasonable because 50% and 0% death
rates for respiratory arrest and massive bleeding are observed in the time
interval ranging from 11 to 15 minutes after a symptom occurs (Campbell,
2018). Any other time intervals in pre-hospital EMS time provided in
Table 2 were not significantly identified to affect injury severity levels.
The resultant finding implies that transport time ranging from 11 to
15 minutes is significantly effective in decreasing the probability of fatal
injury, which is used as the threshold of transport time for the following
AMT time estimation.

4.2. AMT time estimation

For AMT time estimation, patients involved in 37 fatal crash cases were
assumed to be transported from the scene of crash to a definitive EMS cen-
ter by a ground EMS unit and air ambulance. Those cases with the use of
school playgrounds were compared with cases that used heliports only. The
distribution of the fatal injury observations and surrounding current AMT
infrastructure in the study area are shown in Figure 2.
The average vehicle speeds of the ground EMS units were 55 km/h and
53 km/h in Chungbuk and Gangwon provinces, respectively (National Fire
Agency, 2018). To estimate AMT times in both provinces, road network dis-
tance from the scene of crash to a heliport or school playground was divided
by the average EMS unit speed for ground transport time, while straight-line
flight distance from the heliport or school playground to a definitive EMS
center was divided by air ambulance helicopter cruise speed for air ambu-
lance transport time. Considering the proximity to fatal injury occurrences,
the air ambulances in Chungnam, Gangwon, and Jeonbuk provinces were
assumed to be available in the study area in the daytime. The cruise speed
of air ambulance from all three bases was 285 km/h as provided in Table 1.
For fatal injury cases occurring in Chungbuk province in the daytime,
one of four EMS centers was determined as a definitive hospital based on
the proximity to the heliport or school playground. For fatal injury cases
14 S. JUNG AND X. QIN

Table 4. AMT time estimates targeting fatal injury cases.

With heliports
Hour of the day Data item With heliports only & school playgrounds
Daytime No. of cases 24 24
Ground transport time estimated (t1) 31.1 3.3
Air ambulance transport time estimated (t2) 4.8 3.9
AMT time estimated (t ¼ t1 þ t2) 35.9 7.2
No. of cases satisfying 11  t  15 0 7
Nighttime No. of cases 13 13
Ground transport time estimated (t1) 41.2 7.9
Air ambulance transport time estimated (t2) 10.9 9.7
AMT time estimated (t ¼ t1þ t2) 52.1 15.2
No. of cases satisfying 11  t  15 0 3
Note. Values in all time data are averaged over cases.

occurring in Gangwon province in the daytime, the air ambulance base

and definitive EMS center were equivalent because fatal injuries occurred
in the province where air ambulance base was located (National Emergency
Medical Center, 2016).
In the night time, however, the air ambulance helicopter from the Suwon
EMS center in Gyeonggi province was assumed to be dispatched to the
scene of a crash regardless of the proximity to the scene of the crash
because only the air ambulance is available for night operation. The cruise
speed of air ambulance helicopter in Suwon EMS center was 262 km/h,
which was employed to estimate the air ambulance transport time at night.
Applying the aforementioned assumptions to the 37 fatal injury cases,
Table 4 provides the resultant AMT time estimates.
In the daytime, the AMT times (t) were estimated by 35.9 and
7.2 minutes with heliports only and school playgrounds additions, respect-
ively. The estimated AMT time using heliports only was approximately five
times longer than that using school playground addition. Most fatal crashes
(33 out of a total 37 fatal injuries) occurred in Chungbuk province where
there is no air ambulance base hospital. There are few heliports pre-speci-
fied for air ambulance within Chungbuk province, and most of them are
located in the northern provincial boundary. That is, patients in Chungbuk
province would be transported to a heliport near the province boundary,
which resulted in long ground transport and AMT time estimate.
On the other hand, there were a greater number of school playgrounds
available to be used as sub-heliports than heliports in the study area as
shown in Figure 2. This resulted in short ground transport (t1) and the
relevant AMT time estimates.
In both conditions, with and without school playgrounds, the AMT time
estimate at night was found to be longer than that in the daytime. There
was only one air ambulance base (Suwon EMS center in Gyeonggi prov-
ince) available in Korea at night. It is impossible for any other air ambu-
lance base that is closer to the scene of crash to be operated at night. This
 JOURNAL OF TRANSPORTATION SAFETY & SECURITY 15

implies that air ambulance transport (t2) and AMT transport time esti-
mates become longer at night than in the daytime.
Applying the transport time threshold as provided in Table 3, seven cases
and three cases of a total of 37 fatal injury cases were fitted to the thresh-
old in the daytime and nighttime, respectively, if school playgrounds were
used as sub-heliports. Assuming AMT transport with using school play-
grounds as sub-heliports, approximately 27% of fatal injury cases (10 out of
37) could be transported to a definitive hospital within 11 to 15 transport
time threshold. This implies that the probability of fatal injury is expected
to be decreased and the medical treatment result could have an outcome of
survival and not death. In contrast, there were no cases that satisfied the 11
to 15 minute transport time with using existing heliports. The estimated
AMT times showed that the use of school playgrounds as sub-heliports
reduced the AMT transport time and the probability of fatal injury in the
post-crash phase.
Based on the 10 fatal injury cases that satisfied with the AMT time esti-
mates of 11 to 15 minutes, this study identified average straight-line dis-
tance coverage around a heliport or school playground for ground
transport and air ambulance transport. Note that the stretch of road net-
work from a heliport or school playground to the scene of a crash was
identified for every single fatal injury case and the stretch was converted to
the straight-line distance around the heliport or school playground as the
ground transport coverage.
Consequently, the straight-line distance coverages were 6 km and 37 km
for ground and air ambulance transport, respectively, for the 11- to 15-
minute AMT completion. These values in the straight-line distance cover-
age were employed to the following AMT coverage application test to verify
the positive impact of the use of school playgrounds on AMT.

4.3. AMT coverage test

The straight-line distance coverages (6 km around a heliport/school play-
ground for ground transport and 37 km around an EMS center for air
ambulance transport) were obtained from fatal injury cases that satisfied
with 11- to 15-minute AMT time threshold. The overlapped area of ground
straight-line distance coverage with the area of air ambulance straight-line
distance coverage implies the area that the relevant AMT can be success-
fully completed during 11 to 15 minutes. Applying the straight-line distance
coverages, the AMT coverage map was created to test how much area can
be covered with and without using school playgrounds. The map also pro-
vided the areas that need additional heliports. The test area was Chungbuk
province because there was no air ambulance base, and only five heliports
16 S. JUNG AND X. QIN

Figure 4. Area covered by the AMT time threshold in Chungbuk province.

exist near the northern provincial boundary. Figure 4 shows the areas cov-
ered by 11- to 15-minute AMT time threshold with and without school
playgrounds.
In Figure 4, the small orange ring buffer around each heliport or school
playground indicates the 11- to 15-minute ground EMS unit transport
coverage. The radius of the ring buffer was found to be 6 km. The 6 km
coverage for ground transport and 37 km coverage for air ambulance trans-
port were obtained from the average of AMT time estimates based on 10
fatal injury cases, which are relatively conservative but practical.
The radii of multiple ring buffers (presented in the blue circle) around
each EMS center in Chungbuk province (test area) indicates the 11- to 15-
minute air ambulance transport coverage levels: 37 km, 65 km, and 71 km
from the smallest to the largest one. In the test area, air ambulance base
can be Wonju (in Gangwon provice), Cheonan (in Chungnam province),
or Suwon (in Gyeonggi province) EMS centers and their air ambulance
cruise speeds are 285 km/h in the daytime and 262 km/h at night. The
65 km and 71 km coverage values were theoretically obtained from straight-
line distance from a heliport or school playground to an EMS center div-
ided by air ambulance cruise speed assuming the maximum 15-minute
transport time.
 JOURNAL OF TRANSPORTATION SAFETY & SECURITY 17

Figure 5. AMT coverage with/without the use of school playgrounds.

With using school playgrounds as sub-heliports, almost the entire area of

Chungbuk province were found to be common between ground transport
coverage (small orange ring buffer of 6 km radius) and air ambulance
coverage (blue ring buffer of 65 or 71 km radius) as shown in Figure 4.
This means that 11-to 15-minute AMT completion is possible with using
school playgrounds if the AMT call occurs in almost all provincial areas in
the daytime or nighttime. In the southernmost area of Chungbuk province,
however, there was no common area found between ground and air ambu-
lance transport distance coverages. This result implies that the southern-
most area in Chungbuk province needs additional heliports for successful
11- to 15- minute AMT completion.
Applying the conservative air ambulance transport coverage of 37 km
around EMS centers, two existing heliports near the northern provincial
border were found to be out of the air ambulance transport coverage as
shown in Figure 5.
In Figure 5, the size of common area between ground transport coverage
and air ambulance coverage with using school playgrounds (marked by
areas with dotted lines) was approximately 20 times larger than the area
without school playgrounds (marked by areas with blue lines). This finding
implies that 11- to 15- minute AMT with school playgrounds is practically
18 S. JUNG AND X. QIN

much more possible than with existing heliports only in the northern
county of Chungbuk province.
Thus, the aforementioned findings verify that the use of school play-
grounds is a cost-effective solution for timely AMT and fatal injury reduc-
tion, and suggests that it is worth expansion throughout Korea.

5. Conclusions
Air ambulance has been widely accepted in Korea, but the relevant infra-
structure is still not optimal. Typically, heliports for air ambulance landing
are pre-specified, which usually causes an increased patient transport time
in Korea. To address this issue, this study intended to quantitatively assess
the effect of the use of school playgrounds as sub-heliports on AMT time
and verify that it would be worthwhile to expand their use.
Correspondingly, the current AMT infrastructure and in-depth patient
injury data were collected, which was used to identify the significant impact
of transport time on increasing injury severity levels by the ordered logit
model. In addition, the AMT times with and without the use of school
playgrounds were comparatively estimated to examine the effectiveness of
school playgrounds on decreasing the AMT time, assuming patients with
fatal injuries are transported by air ambulance. Based on the estimated
AMT times, this study finally tested AMT coverage to verify the effective-
ness of school playgrounds on reducing fatal injuries. A summary of key
findings is as follows:

 The estimated AMT time using heliports only was approximately five
times more than that via the use of school playground additions.
 Transport time ranging from 11 to 15 minutes (timely AMT) was statis-
tically significant in decreasing the probability of fatal injury.
 The size of 11- to 15-minute AMT coverage area with the use of school
playgrounds was approximately 20 times larger than that without school
playgrounds.
 Timely AMT could be possible with using school playgrounds as sub-
heliports in study area if AMT call occurs in almost all study areas.
 The southernmost part of study area needs additional heliports for
timely AMT completion.

The key findings provide meaningful insights to further support the use
of school playgrounds as a cost-effective alternative to manage AMT time.
These findings are based on data from multiple sources, and a rigorous
process for examining the effectiveness of school playgrounds as sub-heli-
ports. Using the school playground as temporary take-off and landing point
 JOURNAL OF TRANSPORTATION SAFETY & SECURITY 19

of helicopter can improve the efficiency of first medical aid, especially in

the urban areas. As we know the massive challenges of redevelopment in
the dense areas, this research could inform the decision making on imple-
menting flexible strategies without significant capital investment, real estate
acquisition and new constructions of physical infrastructure, which could
be useful for other regions and countries world-wide with similar issues.
However, there are limitations in this study. First, only crash victim
injury data recorded by four EMS centers were considered. As a result,
only 37 fatal injury cases were used as the AMT target to estimate the
AMT time. Due to the small sample size of fatal injuries, the ground trans-
port distance coverage around a planned heliport was not separated by day-
time and nighttime. In addition, the time lapse between a crash occurred
and emergency call received (or crash notification time) was not available,
as a previous study shows that the crash notification system is an effective
mean to reduce the fatality risk (Noland & Quddus, 2004). For a more
comprehensive evaluation, future research could be performed by using
crash victim injury data recorded by all EMS centers in Korea and analyz-
ing the impacts of factors associated with crash notification and
EMS response.

Funding
This research was supported by Basic Science Research Program through the National
Research Foundation of Korea (NRF) funded by the Ministry of Education [NRF-
2018R1D1A1A09083905].

ORCID
Xiao Qin http://orcid.org/0000-0003-0073-3485

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