Medical Services Transport Research Articles

Keeping hope aloft: Mercy Flight Central, Inc.

Mercy Flight Central, Inc., or as it is affectionately called, MFC, is an air medical transport service that has served the people of New York State for over 15 years. At the beginning, I doubt anyone realized what an important role it would play in the New York state healthcare system.

The Effectiveness of Video-Telemedicine for Screening of Patients Requesting Emergency Air Medical Transport (EAMT)

Demand for emergency air medical transport (EAMT) services have increased in recent years. However, the high costs of these services have raised questions on the benefit to patient outcomes. In this study, we evaluate the effectiveness of video-telemedicine for the preflight screening of patients for air medical transports. A prospective cohort study. Medical records of patients transported from the Penghu Islands to Taiwan were retrospectively collected from November 1999 to October 2002 (stage 1). In addition, we collected medical records of patients who were preflight-screened by physicians using video Web cameras from November 1, 2002 through August 30, 2003 (stage 2). The intervention in stage 2 included a set of protocols and screening criteria for EAMT implemented by the National Aeromedical Consultation Center (NACC). In stage 1, there were no standardized protocols or screening guidelines for EAMT. The EAMT system before implementing preflight screening and telemedicine was mostly based on patient's requests and their health condition determined by the treating medical officers (TMO). A total of 822 transfers were included in this study. Patient demographic backgrounds in the two groups were similar on gender, age, disease classification, and types of illnesses. Patients in stage 2 were significantly older than those in stage 1. In a comparison of flight frequencies between the two stages, the results revealed a 36.2% reduction of EAMT applications in stage 2. The flight approval rate was 91.2%. The intervention in stage 2 also presented a significant reduction in cross-zone transport (16.1% to 0.1% to the northern Taiwan region). Within-zone transfers increased from 74.9% to 88.3%. Cost analysis showed that physician triage in stage 2 resulted in a total annual savings on EAMTs of US 448,986 dollars. This study demonstrates the physician-assisted preflight screening using video-telemedicine significantly reduced the frequency of unnecessary air medical transports and consequently led to reduced costs. Video-telemedicine can be an essential tool to support physicians in decision-making for patient screening.

Head injuries in adolescents in Taiwan: a comparison between urban and rural groups

Background Data pertaining to head injuries in adolescents in Taiwan are scarce. The purpose of this study was to investigate the trend and pattern of head injuries in adolescents in both urban and rural areas in Taiwan. Methods We collected data from major hospitals in the urban (20) and fsin the rural (4) areas of Taiwan for a period of 3 years. Data were obtained from the Head Injury Registry, a 10-year electronic database of head injury in Taiwan. The inpatient medical records of adolescents with head injury were thoroughly reviewed. Severity of head injury was classified by the GCS score, and patient outcome at discharge from hospital was measured by the Glasgow Outcome Scale. Differences and correlation between study groups (13-15 and 16-18 years old) in the urban and rural areas were examined using 2-tailed t and χ 2 tests. Results A total of 469 head injury cases in the urban area and 131 in the rural area were identified. Traffic accidents were the major cause of head injury, and motorcycles were the most predominant vehicles causing traffic accidents in both urban and rural areas. Intracranial hemorrhages were the most prevalent injury pattern in the study population. In both urban and rural areas, the severities of injury were not significantly different ( P = .184), but the outcomes at discharge were significantly better in urban areas ( P = .032). The correlation between the initial GCS and outcomes in both areas was significant ( P < .001). Craniotomy was performed more frequently in the rural area than in the urban area (15.3% vs 7.2%). The mean hospital stay was shorter in the latter than in the former ( P < .001). Education on helmet use, input of neurosurgical staff, and facility and emergency medical transportation service of head-injured patients following guidelines proposed by the WFNS are crucial for head injury and better control in rural areas. Conclusions The causes, patterns, and outcomes of head injury were statistically different between the 2 age groups of adolescents in urban and rural areas. Further studies on adolescent head injury are necessary.

20: A Comparison of Endotracheal Intubation Success Rates Between Providers of a Metropolitan Air Medical Transport Service

20: A Comparison of Endotracheal Intubation Success Rates Between Providers of a Metropolitan Air Medical Transport Service

Influence of weather on emergency transport events coded as stroke: population-based study in Japan

Studying the relation between incidence of stroke and weather is difficult because it requires large-scale community-based data collection. Despite the lack of strong evidence that weather conditions influence stroke incidence, many clinicians feel that meteorological conditions influence the onset of stroke. This study examined whether emergency events related to stroke are influenced by meteorological factors and was based on computerized records of emergency medical transport services in a Japanese city during the period January 1992-December 2003. A total of 53,585 patients transported for an event coded as stroke were analyzed in relation to meteorological factors such as temperature, humidity, and barometric pressure. Poisson regression analysis was applied to clarify the influence of daily meteorological conditions on the daily incidence of emergency transport due to events coded as stroke. Ordinary least squares regression analysis was used to evaluate the influence of weather, defined as the combination of meteorological parameters, on the occurrence of emergency transport due to events coded as stroke. Daily mean ambient temperature and daily mean relative humidity showed a statistically significant negative effect on the incidence of the emergency transport events for both men and women (P<0.001). Daily mean barometric pressure was not significantly related to these events. The occurrence of a holiday was negatively related to the incidence (P<0.001). Dry weather and cool weather were likely to shift the circadian curve of the incidence upward. Thus, occurrence of emergency transport due to events coded as stroke is likely to be associated with weather conditions.

The value(s) of accreditation

The Commission on Accreditation for Medical Transport Systems (CAMTS) did a survey in 1998 to determine what motivated a service to apply for accreditation. Findings were surprising in that 77% of the participants chose “to demonstrate a level of quality” as their foremost motivating factor. In 2006, CAMTS will conduct a follow-up survey. We expect to find a larger number of programs applying for accreditation primarily because it is needed for state requirements or managed care contracts or because their competitors are accredited. There have been many changes in the way air medical transport services do business since 1998. There are fewer hospital-based and more independently owned services. In 1998, there were many single-based rotor-wing services. Today, we see many more rotor-wing services with multiple bases surrounding a coverage area like spokes on a wheel. Fixed-wing services are still primarily owned by aviation charter companies. In 1998, only two states required CAMTS accreditation (Rhode Island and Utah). Today six states (Rhode Island, Utah, Washington, Michigan, Colorado, and New Mexico) require CAMTS accreditation to obtain a state license. Several counties in California and Nevada require CAMTS accreditation, with several more states working on a CAMTS accreditation requirement as part of their licensing process. Massachusetts has started a trend of requiring CAMTS accreditation for licensing ground critical care services. CAMTS is also more recognized today than it was 8 years ago. For example, British Airways recently asked for a referral list of all the accredited services that provide long distance fixed-wing transport. They will no longer transport stretcher patients and will refer customers with that need to CAMTS-accredited services. No matter how the face of doing business has changed or what the motivating factor is, the benefits of going through the accreditation process remain fairly constant. For example, when a program is preparing for accreditation, the entire staff becomes involved. Often initial and continuing education is updated or introduced that had not previously been provided to medical personnel. Jonathan Godfrey tells how his program was preparing for accreditation and how the survival course they received was still fresh in his mind when he became the only survivor of a fatal crash in January 2005. After the LifeEvac EC135 helicopter crashed, Jonathan found himself ejected from the aircraft with traumatic injuries and still strapped into his seat, completely submerged in the Potomac River. Recalling the survival principles he was taught, Jonathan was able to save his own life. The value of an audit, such as that provided by CAMTS site surveyors, is also a benefit of accreditation that cannot be underestimated. As one program stated, “The site surveyors were very thorough in their inspection, and that is exactly what we wanted.” Whether the accreditation decision is favorable or not, the process of measuring a service against national standards is a positive learning experience. As another program stated, “Our survey was very in-depth, and it was a great learning experience. We thought we would be criticized if things weren't right, but instead we really learned a lot.” About 65% of the medical transport services that are site surveyed for the first time do not achieve full accreditation. Most of these services have worked hard to improve patient care and safety and often achieve accreditation after the second attempt. This is ultimately the value of accreditation and the main purpose of CAMTS—to improve safety and the quality of patient care and to be advocates for services with those same goals. As one program stated, “Achieving accreditation speaks volumes about the quality of our program. We are proud of the improvements we made while striving to achieve CAMTS accreditation.”

Focus on accidents provides opportunities

It is no secret that air medical transport services have been popular with the press recently. Although some reporters only want to print the sensational, negative news, even bad press has its advantages. It has provided the air medical community with the opportunity to identify a course of action with a stronger resolve to collaborate, lower the accident rate, and put the emphasis back on safe, quality transport for our patients and peers. Over the past several months, I have attended and represented the Commission on Accreditation of Medical Transport Systems (CAMTS) at several national meetings, starting with the HAI EMS Committee Meeting in Anaheim, Calif., in February. In the past, this meeting was usually attended by no more than 35 people. But this year—probably in response to the FAA's Notice 8000.293, issued on January 28, 2005—more than 100 attended. The FAA and the NTSB were well represented at this meeting, along with many aviation operators and air medical program managers. FAA officials Matt Rigsby and John Cox explained the study they did on air medical accidents and their findings, which resulted in Notice 8000.293. The Notice makes many recommendations, not mandates, to the air medical community that include training and equipment. Training in decision-making skills is emphasized for all disciplines within an air medical service, including managers. More management oversight also was discussed by Dick Healing from the NTSB, who strongly encourages the use of risk-assessment tools, such as those developed by the military and off-shore pilots. These risk-assessment tools provide the line pilot with a checklist to assist in decision making so that when a number of conditions—such as marginal weather, night conditions, and new pilot situations—occur, a manager is consulted. Several programs' risk-assessment tools are featured in the CAMTS Best Practices publication, but the FAA also announced they are collecting risk-assessment tools to make available to the air medical community. In March, several of our board members and I attended the AAMS Mid-Year conference in Washington, DC. The safety portion of this conference was very informative and involved not only air medical providers and organizations but also government officials from the FAA and the NTSB. James Ballough, FAA director of flight standards, spoke about air medical accidents and agency recommendations. He emphasized that creating tighter regulations would not be the answer to lower the accident rate and encouraged participants to enhance training and safety. He suggested that we police ourselves with auditing processes, such as CAMTS. The CAMTS board members had scheduled meetings while in Washington DC with Ballough and Healing. Again, the spirit of collaboration was evident, and we now have a hyperlink from the faasafety.gov Web site to the CAMTS page. The CAMTS board also met with Indian Health Services (IHS) while in Washington. The IHS requires CAMTS accreditation in order to award a service with a business operating agreement for air medical transport. Because of the remote location of many Native Americans, the CAMTS board wanted to bring to IHS' attention the need for paved runways, electricity, running water, and weather-reporting systems at these locations. We also agreed to provide a presentation for their emergency department physicians and nurses who request air transport to address “shopping” for air transport by emergency department personnel when weather conditions are unfavorable. Finally, Tom Judge, president of AAMS, announced a new initiative called Vision Zero during his talk at the Mid-Year conference. There is no downside to a heightened awareness about safety. Looking back at the mid-1980s rise in air medical accidents and resulting bad press, we drew together and developed standards. In 1990, the Commission on Accreditation of Air Medical Systems was incorporated as a voluntary accreditation process to address many of these safety issues. In that same year, there was only 1 air medical accident because we worked together and focused on setting a new course. That is what Vision Zero is about. None of us is naive enough to think we can prevent all air medical accidents, but an accident is something that could not have been predicted. What we want to stop are crashes caused by careless practices or bad choices. And we certainly do not want to lose any more patients or peers. As we move toward a new year, we all need to look for opportunities to make air medical transport safer and share our ideas in a spirit of enthusiasm for a brighter and safer future.

The CAMTS Web site

The 6th edition Accreditation Standards are now available on the Commission on Accreditation of Medical Transport Systems (CAMTS) Web site as a free download. A hard copy of the 2004 standards can also be ordered over the site (for $25 as before). The hard copy includes an index, a glossary, and an education matrix that are not part of the free download. The accreditation standards are the criteria used to measure a medical transport service's compliance. If the service is in significant compliance with the standards, accreditation will be awarded. For medical transport services that are distributing multiple copies to personnel while preparing for accreditation, the free download will be very useful. Also, medical transport services that just want to measure their program against the accreditation criteria will find the free download very helpful. The accreditation standards are widely accepted medical transport standards and are used for benchmarking and as a blueprint for organizational planning. Other publications and tools also are available for purchase on the site. Best Practices is a collection of outstanding programs and policies from accredited medical transport services. After 13 years of reviewing medical transport services, the board has identified many excellent examples. The third issue of Best Practices includes policies requested for accreditation, education and competency training programs, and quality management/performance improvement programs. This year we also include forms and reference tools for things like employee health screens, human factors training in maintenance, a safety analysis scorecard, and a rotor-wing risk analysis tool developed to help a pilot with weather decisions. We update Best Practices every 2 to 3 years. The current edition was published in October 2004. The Program Information Form (PIF) can also be purchased through the site without actually applying for accreditation. The PIF, a self-study document that asks a specific question about each accreditation standard, is a very useful tool in interpreting the accreditation standards and determining whether a medical transport service is prepared for accreditation. Along with specific questions comes a list of documents, policies, and education programs requested by CAMTS to be submitted when applying for accreditation. In the past, a medical transport service could acquire a PIF only if applying for accreditation. The CAMTS board of directors wanted to make the form available to everyone because it is a very useful tool in setting up a new medical transport service or determining whether a service is complying with national standards. CAMTS policies and procedures are also available as a free download. A policy manual is initially sent to each accreditation applicant. However, policies change, and it is the responsibility of accredited services to keep them updated by simply downloading the entire policy manual and new or revised policies as they are posted. The board of directors reviews policies on an annual basis but also revises and creates new policies as needed. In January 2005, we began to feature an accredited medical transport service with a picture and a brief description of the service. Air One in Tyler, Texas, was our first featured medical transport service with a picture of their American Eurocopter BO105 sitting in front of a huge American flag. Please enjoy these features and explore our site at www.camts.org.

Assessment of air medical coverage using the Atlas and database of air medical services and correlations with reduced highway fatality rates

Abstract The Atlas and Database of Air Medical Services (ADAMS) is a web-based, password-protected, geographic information system containing data on air medical service main and satellite base helipads, communication centers, rotor-wing aircraft, and major receiving hospitals for trauma in the United States. ADAMS initially was developed to provide the geographic information needed to support real-time, wireless routing of automatic crash notification (ACN) alerts from a crashed motor vehicle to the nearest air medical transport service and trauma center. This coupling of ADAMS and ACN technology to enhance emergency communications is expected to speed delivery of emergency medical care to crash victims and thereby reduce the deaths and disabilities caused each year. In addition to its planned use in ACN response, ADAMS is also a valuable data resource for trauma system research and homeland security applications. This article begins with an overview of ADAMS and briefly describes the features and rationale for its development. ADAMS is then used as a tool to assess the extent of air medical rotor-wing service coverage nationwide. Both geographic area and populations covered are determined for all 50 states. The correlation between increased air medical service coverage and reduced motor vehicle crash fatality rates is then examined.

Background checks on programs applying for accreditation

When a medical transport service submits a Program Information Form (PIF), the work at the Commission on Accreditation of Medical Transport Systems (CAMTS) office truly begins. We complete certain background checks as we prepare for a site visit. We have always checked with emergency medical services (EMS) state offices regarding licensing by the state, formal or informal complaints about the service, involvement with regional or state disaster drills, and involvement on state committees by members of the medical transport service. Several states do not license air medical transport, but they may want to share their comments about interactions between air services and ground EMS services. Over the past few years, the business part of medical transport has become more complicated; therefore, we have added other resources to check on the overall history and status of a program applying for accreditation. In addition to the state EMS agencies, we also check with the state about incorporation issues. The program's articles of incorporation will designate ownership and include signatures, dates, and officers. At the same time, each state has a listing of corporations in good standing. Some states call them just that; other states issue a subsistence certificate, meaning the corporation is in good standing and has complied with all state regulations. Another resource to verify the status and safety record of the aviation certificate holder is Aviation Research Group US (ARGUS), an Internet service that provides a 10-year history of aviation companies and rates them according to their safety history. As a member of ARGUS, CAMTS has the capability to access a Charter Evaluation and Qualification System report on individual aviation companies. This instant, comprehensive report provides information on reports from the National Transportation Safety Board, Federal Aviation Administration accident and incident data, pilot experience and historic records with the Federal Aviation Administration, ownership and management of the company, and specific aircraft history. CAMTS will access a Charter Evaluation and Qualification System report whenever:•An aviation operator has not been reviewed in the recent past•An aviation operator undergoes changes that could affect the medical transport environment•A board member who is presenting to the board requests a report In addition to the ARGUS report, CAMTS keeps a database on National Transportation Safety Board accident reports and a file on CONCERN reports. Copies of these reports are sent to the board reviewer so that the member has this information while reviewing information in the PIF. The PIF also asks specific questions about judgments or litigation involving the medical transport service over the previous 5 years. Lawsuits are plentiful, unfortunately, and difficult to track down, but judgments are a matter of public record and can be accessed over the Internet. The information described above is not essential, but neither is it superfluous to the accreditation process. The medical transport community is so diverse today that we have found all this information to be helpful in understanding the dynamics of a service and improving our internal process of providing a comprehensive review.

The complexity of scheduling a site visit

The medical transport business is very complicated today compared with 10 years ago. The single type of business model is no more. The familiar single hospital-based helicopter program with 1 vendor supplying the aircraft, pilots, and maintenance is becoming a rare entity. This trend is understandable because many medical transport services attempt to survive with creative business and financial arrangements in a highly competitive environment. Several years ago, the Commission on Accreditation of Medical Transport Systems (CAMTS) changed its name to include the critical care ground transport services that were either stand-alone organizations or part of an air system. Adding a ground service is not the only change we are seeing lately, and it is a challenge to apply standards and procedures to models that no longer fit the mold.

CAMTS and the public

CAMTS and the public

The effect of etomidate on airway management practices of an air medical transport service

Objective The authors studied the effect of introducing etomidate on the airway management practices of their air transport crew and specifically considered the need for paralytic agents during rapid-sequence intubation. Methods A prospective observational review of the transport records for all patients aged greater than 10 years who required intubation transported by the air medical crew before (PRE) and after (POST) the introduction of etomidate into the authors' rapid-sequence induction protocol was conducted. Data were collected, including the method of intubation, indications for intubation, and complications from the procedure. The following outcomes were measured: the method used for intubation (nasotracheal or orotracheal), oral intubation success rate, number of attempts for oral intubation, need for paralytic agents, and complications with the procedure. Results Comparing the PRE and POST periods, nasotracheal intubation was performed in 27 of 70 (38.6%) versus 33 of 71 (46.4%; p = 0.237997). The overall success rate for intubation in the PRE period was 67 of 70 (95.7%), with 95.3% of orotracheal intubations being successful. In the POST period, the overall success rate was 65 of 71 (91.5%), with 94.7% of orotracheal intubations being successful. Complication rates were similar between the groups. Etomidate reduced the use of paralytic agents from 46 of 62 (74.6%) of patients receiving midazolam to 10 of 22 (45.5%) intubated with etomidate (p = 0.02). Conclusions Etomidate did not appear to have an impact on the selection of intubation methods by the air medical transport crew. Etomidate significantly reduced the need for administration of paralytic agents used in an RSI.

Protecting the integrity of accreditation

Medical transport services accredited by the Commission on Accreditation of Medical Transport Systems (CAMTS) know that they have worked hard to achieve and maintain that accreditation. Therefore, the ability to advertise as a CAMTS-accredited service and use the CAMTS logo is an exclusive privilege we must protect.

Consultation services

Several medical transport services have recently engaged the Commission on Accreditation of Medical Transport Systems' (CAMTS) consultation service to prepare for an accreditation site visit. The consultation service is offered to air medical and ground critical care services to measure the quality of service provided compared with the criteria listed in the accreditation standards. It is also available to provide specific assistance in preparing for an accreditation site visit through a review of documentation of policies without a site visit or an entire service by a consultant's on-site visit.

Why be accredited now?

Why be accredited now?

Statewide air medical transports for Massachusetts

In 1997, the Massachusetts Department of Public Health (MDPH) established a process to centralize air medical transport information. This database is one of the first statewide, population-based sources for civilian rotary-wing air medical transports (U.S. Coast Guard, police, and military missions are not included). The purpose of this database is to facilitate MDPH review of air medical transport service utilization, with input from a multidisciplinary committee. This article discusses the challenges in producing uniform data from multiple service submissions and presents aggregate “baseline” utilization information for 1996. These data served as a starting point for later studies using data linkage. This indexed article is the first to report statewide, population-based data for all types of air medical helicopter transports. The only other indexed “statewide air medical transport” paper focused on scene transports to trauma centers in Pennsylvania. 1 A previous article by the authors in the July-September 2000 Air Medical Journal provided an overview of air medical transports for fatal motor vehicle crashes for 1 region of the state. 2

Is there a neurologist on this flight?

To analyze the frequency of neurologic events during commercial airline flights and to assess whether onboard emergency medical kits are adequate for in-flight neurologic emergencies. Collaboration of the Mayo Clinic's Departments of Emergency Medicine and Medical Transportation Service and the Division of Aerospace Medicine to provide real-time in-flight consultation to a major US airline that flies approximately 10% of all US passengers. We analyzed all medical events reported from 1995 to 2000 in a database that catalogs the air-to-ground medical consultations. All cases with potential neurologic symptoms were reviewed and classified into various neurologic symptom categories. The cost of diversion for each neurologic symptom was calculated and then extrapolated to assess the cost of neurologic symptoms to the US airline industry. A total of 2,042 medical incidents led to 312 diversions. Neurologic symptoms were the single largest category of medical incidents, prompting 626 air-to-ground medical calls (31%). They caused 34% of all diversions. Dizziness/vertigo was the most common neurologic symptom followed by seizures, headaches, pain, and cerebrovascular symptoms. Whereas seizures and dizziness/vertigo were the most common reasons for diversion, loss of consciousness/syncope was the complaint most likely to lead to a diversion. The estimated annual cost of diversions due to neurologic events is almost 9,000,000 dollars. Neurologic symptoms are the most common medical complaint requiring air-to-ground medical support and are second only to cardiovascular problems for emergency diversions and their resultant costs to the US airline industry. Adding antiepileptic drugs to the onboard medical kit and greater emergency medical training for in-flight personnel could potentially reduce the number of diversions for in-flight neurologic incidents.

Use of the CAMTS logo

When a medical transport service achieves accreditation, it receives a certificate for public display, copies of the logo for use on stationery, and marketing materials and decals for aircraft and ground vehicles. Use of the logo is regarded as a well-earned privilege by the accredited service.

Changing times result in policy changes

The way air medical transport services are structured today is not as predictable as it was when the Commission on Accreditation of Medical Transport Systems (CAMTS) was initiated in 1990. Ten years ago at many hospital-based helicopter services, the hospital contracted for aviation services from a vendor and named its program Life Flight or Air Care or MedEvac, etc. Fixed-wing services were offered by private aviation providers based at local airports. A transport service usually had one owner, one name, and one mission.