Reasons for Delays in Fixed-Wing Medical Evacuations from Remote and Rural Regions and Their Impact on Trauma Patient Outcomes: A Scoping review

Timely access to definitive care in remote and rural regions remains a persistent challenge due to geographic isolation, limited transport infrastructure, and variability in local healthcare capacity. In many of these settings, air medical evacuation serves as the primary pathway through which critically ill or injured patients reach higher levels of care, making the performance of aeromedical retrieval systems a key determinant of clinical outcomes. Delays in evacuation may arise from a range of operational factors, including adverse weather, aircraft or crew availability, infrastructural limitations, and system-level coordination processes. Despite their clear clinical significance, these contributors to delay are inconsistently described and have rarely been examined in a systematic manner across diverse settings. The experience in Nunavik, a remote region in northern Quebec, illustrates the broader challenges faced by aeromedical systems serving geographically isolated populations. Studies from this region have demonstrated that prolonged transport times are associated with increased risk of clinical deterioration and higher rates of ICU admission among transferred patients. Nunavik also experiences disproportionately high rates of trauma-related morbidity and mortality compared with the rest of Quebec, underscoring the consequences of delayed access to definitive care. However, comprehensive data on the operational causes of aeromedical evacuation delays remain limited, and many cases are not captured in provincial registries, contributing to persistent gaps in system-level understanding. These challenges can be conceptualized through the three delays framework, which describes barriers to timely care as delays in the decision to seek care, delays in reaching appropriate care facility, and delays in receiving definitive treatment. In remote and rural environments that depend on aeromedical transport, the delay in reaching care is particularly influenced by transport logistics, operational capacity, and interfacility coordination. Applying this framework to aeromedical systems offers a structured approach to understanding how operational factors contribute to evacuation delays and how such delays may affect downstream clinical outcomes. A scoping review is therefore warranted to systematically map and synthesize the literature on factors contributing to delays in air medical evacuation from remote and rural regions, and to examine how these delays are associated with clinical outcomes. By identifying and categorizing logistical, personnel, infrastructural, and system-level contributors to delay, this review aims to inform quality improvement initiatives, and support future research focused on optimizing aeromedical systems in geographically isolated settings. To this end, the aim of our study is to answer the following question: what factors contribute to delays in air medical evacuation of patients from remote and rural regions, and how are these delays associated with clinical outcomes?