A national survey of the air medical transport of high-risk obstetric patients

INTRODUCTION: Air medical transport of high-risk obstetric (HROB) patients can be accomplished and advantageous for neonate survival and maternal morbidity. A survey of U.S. helicopter air medical programs was conducted to determine the frequency and current practices of HROB transport. METHODS: Each program was contacted by telephone, and air medical personnel were asked to answer 12 questions based on personal experience and statistics compiled by their programs. RESULTS: Of the 203 programs surveyed, 133 (66%) provided responses. The mean number of HROB transports was 45.6 per year (4.6% of the mean 995 total transports). Although 83% of the responding programs used the standard flight crew during the HROB transport, only 52% required crew members to maintain neonatal resuscitation certification. Only 56% of the aircraft allow pelvic access in the normal patient configuration. While only 22% of programs have specific HROB launch (dispatch) protocols, 50% reported having obstetricians involved in dispatching flights, and 84% carry tocolytic agents in their drug kit. The greatest concerns included in-flight delivery (60%), inadequate fetal monitoring (6%), and inexperience (5%). CONCLUSION: While HROBs account for 5% of air medical flights, many programs appear to be poorly prepared for these patients.     

Presumption of death by air medical transport teams

BACKGROUND: The purpose of this study was to investigate nationwide trends and factors influencing the determination of death practice by rotor-wing air medical transport programs. METHODS: A survey was mailed to all Association of Air Medical Service members concerning demographics, crew configuration, team leader, patient population, field death determination protocols, and other possible associated factors. All rotor-wing air medical transport programs that carry out scene transports were included. RESULTS: The most common field presumption criteria were no response to advanced cardiac life support (77%), no signs of life on scene (65%), and asystole in 2 EKG monitor leads (61%). The most frequent reasons cited not to presume a patient dead in the field were political issues (71%) and signs of life on scene (56%). Criteria other than medical condition that were considered in the decision to presume death were ground personnel input (55%) and program policy/medical control (39%). The following factors did not significantly affect the presumption rate: crew configuration, team leader, transport time, billing, and type of medical control. CONCLUSION: Medical criteria appear to determine presumption of death in the field. Nonmedical factors, such as billing, response, and transport times, do not affect this process.     

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. 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.     

Air medical transport of severely head-injured patients undergoing paramedic rapid sequence intubation

INTRODUCTION: The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality with paramedic RSI of patients with severe traumatic brain injury. This analysis explores the impact of air medical transport of trial patients on outcome. METHODS: Adult trauma victims with severe traumatic brain injury (Glasgow Coma Scale score of 3 to 8) were prospectively enrolled. Paramedics performed RSI using midazolam and succinylcholine; air medical crews could be called at the discretion of ground paramedics, generally for anticipated prolonged transports. Patients were matched to historical controls using the following parameters: age, gender, mechanism, injury of severity score, and abbreviated injury scale scores for each body system. Patients transported by air and ground were compared with regard to demographics, clinical parameters, vital signs, arterial blood gas data, and outcome. RESULTS: A total of 336 patients were included (79 air medical and 257 ground transports). No significant differences arose between the groups with regard to demographic, clinical, vital sign, and arterial blood gas data. Air medical patients had decreased mortality (28% vs 31%, OR 0.9), and ground patients had increased mortality versus matched controls (33% vs 22%, OR 1.8). Discordant groups analysis revealed a statistically significant effect of transport personnel on outcome (P=.009). Neither advanced procedures nor the use of mannitol accounted for the improved outcomes; air medical crews used capnometry to guide ventilation on all study patients. CONCLUSION: Air medical transport of severely head-injured patients undergoing paramedic RSI was associated with improved outcomes. Improved ventilation by capnometry may account for part of these improvements.     

Training of flight nurses on fixed-wing air ambulance services

Introduction: The purpose of this study was to determine the background of fixed-wing air ambulance nurses, what level of training they receive before assignment as a flight nurse, and how closely supervised these fixed-wing air ambulance programs are by their medical directors.

Methods: In 1993, a retrospective statistical questionnaire was sent to 113 fixed-wing air ambulance programs. Chief flight nurses for all 113 fixed-wing air ambulance transport companies were requested to complete a written survey consisting of 17 multiple choice and fill-in-the-blank questions about previous experience, flight nurse qualifications, and content covered in their initial training program.

Results: Of 113 surveys, 72 (64%) responded. The majority (87%) of the flight crew were 30 to 39 years of age. The crew mix is RN/EMT-P in 49%, RN/RN in 25%, and RN/RT in 25%. Experience before flying showed emergency department/intensive care unit in 87% with 13% specialized to a specific type of patient care. The initial training in classroom hours was less than 21 hours in 50% of programs. Training programs were taught by the chief flight nurse in 75%, the medical directors in 74%, and outside organizations in 30%. Fifty-five percent of programs use pilots or other flight crew members to supplement initial training. Only eight of the programs did not have yearly refresher classes. Programs providing more extensive training appear to be affiliated with hospital-based services. Medical directors were involved with the everyday running of air medical transports in 35 of the pro grams (50%), 20 medical directors (28%) did monthly chart reviews only, and 12 (17%) were not involved with their programs. There were three responses to “Other” and two with no responses.

Conclusions: Although fixed-wing flight nurses appear to be medically experienced personnel with previous intensive care unit or emergency department experience, this survey would suggest that fixed-wing flight programs are variable in the amount of initial training, level of instructors, ongoing medical education, and involvement of the medical director. This survey indicates the need for increased standardization of continuing education, as well as increased involvement of medical directorship in fixed-wing air ambulance services.     

Analysis of patients discharged from receiving hospitals within 24 hours of air medical transport

Introduction: Use review has become increasingly important in the current atmosphere of cost justification for air medical transport. One criterion for use review is patient discharge from receiving hospitals within 24 hours of transport. The objective of this study was to determine the frequency and characteristics of patients discharged within 24 hours of air transport; the goal was to identify particular patient types likely to be discharged soon after air transport.Methods: Flight records from November 1994 to September 1995 were reviewed. Follow-up identified patients who were discharged within 24 hours of air medical transport; these were designated the “24-hour group.” Other patients were designated the “overall group.” Comparisons between groups were made using the t test, Wilcoxon rank sum, and chi-square analysis (α = 0.05) for the following factors: age, vital signs, Glasgow coma score, percentage of intubated patients, and percentage of trauma and scene transports.Results: Of the 945 flights analyzed, 42 (4.4%) transported patients who were discharged within 24 hours of air transport. Patients in the 24-hour group were younger, less likely to be intubated, and more likely to be scene-trauma transports compared with the overall group.Conclusion: This study demonstrates that air medical transports meet currently accepted criteria for helicopter transport. This study suggests that inappropriate air medical transport is rare, even in patients discharged from receiving hospitals within 24 hours of air transport.     

Impact of a triage tool on air versus ground transport of cardiac patients to a tertiary center

INTRODUCTION: The optimum method of transport for acute cardiac patients remains controversial. We proposed a physician-developed triage scheme for appropriate use of air versus mobile intensive care unit (ICU) in the transfer of cardiac patients and sought to determine the impact on the distribution of transport mode for cardiac patients in areas of personal characteristics and clinical factors and whether the triage scheme would be a valuable decision-making tool for physicians referring cardiac patients to tertiary centers. METHODS: This was a prospective, observational study of transport mode for cardiac patients transported to a tertiary care facility. A comparison was conducted with historical controls. The intervention studied was an educational program designed to teach a triage decision tool developed by a receiving cardiologist with input from the critical care transport team. Short-distance (less than 30 minutes) and long-distance transports were examined. A follow-up survey of referring hospitals was conducted. RESULTS: Short-distance transports enjoyed excellent compliance with 41 of 42 patients being transported by mobile ICU. Long-distance transports by mobile ICU increased from 55% to 65% during the study period. However, a third of the mobile ICU patients actually met air transport criteria. Long-distance patients transported by air had significantly higher transport costs, total hospital charges, and direct admission to the catheterization lab. Five of the 10 surveyed emergency department directors found the triage instrument useful in making transport decisions. CONCLUSIONS: A physician-developed triage instrument to select an appropriate mode of transport for acute cardiac transfers was effectively used. Further studies must validate the cardiac triage criteria against clinical outcomes, and more effective dissemination of the triage instrument must be sought. Furthermore, this information must be perceived as useful by referring physicians to gain wider acceptance.     

Reverse transport of children from a tertiary pediatric hospital

INTRODUCTION: The purpose of this study was to determine the epidemiology and resources used and to study the potential savings of pediatric reverse transport patients. METHODS: A case control study was performed with patients undergoing a reverse or outbound transport from a large, pediatric hospital. Twenty-five children undergoing reverse transport were compared with matched controls. Lengths of stay and costs were compared between the reverse transport and matched control patients. RESULTS: Fifty-two percent of the reverse transport patients returned home, whereas 32% went home for end-of-life care and 16% went to other facilities. The average reverse transport was more than 400 miles and cost $6,064. The reverse transport of these patients did not save pediatric intensive care unit (PICU) days but did result in a shorter hospital stay compared with the matched controls (10 vs. 19 days, P = .03). Decreased utilization of bed days came from less use of intermediate care unit resources. CONCLUSIONS: Pediatric patients undergo reverse transports for a variety of reasons, often for end-of-life care. The ability to reverse transport pediatric patients may not save PICU bed days but may offer pediatric tertiary care hospitals a means to provide more intermediate care bed availability.     

A regional review of air medical transports for fatal motor vehicle crashes

This article presents study results from an assessment of the performance of the air medical (and advanced life support) components of the EMS system in response to fatal motor vehicle crashes. Results are presented for one of Massachusetts' five EMS regions, including the finding that air medical transports are involved in 20% of the fatal crashes for the region and transport 11% of the involved individuals. Although the study focused on air medical utilization, it also identified issues related to the future implementation of motor vehicle automatic crash notification (ACN) and telematics that could relay crash severity data from onboard computers (e.g., event data recorders) to auto manufacturers' help centers or state emergency call centers. This technology will place new demands on state EMS systems. To meet the challenges posed by these technological changes, states will need to assess the type and number of EMS services required to respond to ACN motor vehicle crashes and develop methods to determine what level of service to deploy based on the information relayed from the vehicles. An initial step in this evaluation process is to determine the current use of EMS resources to place planned system changes and demand into context.     

The Air Medical Leadership Congress: setting the health care agenda for the air medical community

BACKGROUND: Emergency air medical transport provides the means for critically ill or injured patients to rapidly access sophisticated medical flight teams and medical centers. However, issues such as surging emergency medical services helicopter accidents, expected pilot and nurse shortages, falling reimbursements, and new compliance regulations are now threatening these important but expensive transport services. Unless an industry strategy can be developed to address these and other threats, many medical flight programs may be forced to curtail the availability of these lifesaving services. PURPOSE: On September 4-6, 2003, air medical leaders, experts, program managers, providers, and users of emergency air medical services gathered in Salt Lake City, Utah, to discuss and formulate recommendations to address the top issues that threaten the future of air medical transport services. This congress was open to anyone engaged in the field of air medical transport. This historic meeting resulted in a plan to enhance transport safety, foster appropriate utilization, improve in-flight medical care, maximize cost and reimbursement effectiveness, and develop strategies to reduce the adverse effects of new regulatory and compliance mandates. OBJECTIVES: This article describes the significance of the Air Medical Leadership Congress and the 10-Point Plan method used to develop it.     

Use of local climatic data to determine if weather precludes the operation of an air medical system

INTRODUCTION: Weather is one of many factors that affect safety in an air medical program. Syracuse, New York, has notoriously bad weather, and some have questioned whether an air medical service is practical given central New York's climate. This study was undertaken to determine the extent to which the area's climate could be expected to limit the availability of an air medical service. METHODS: CAMTS weather minimums for rotor-wing programs were compared with 1996-1997 hourly weather observations from the Northeastern Regional Climate Center (NRCC) and sunrise/sunset data from the United States Naval Observatory to determine how frequently weather conditions could be expected to preclude an air medical response in the greater Syracuse area. RESULTS: Exactly 17,544 hourly observations were made. CAMTS weather minimums would have precluded local flights for 606 (3.5%) of these hours and cross-country flights for 1111 (6.3%) hours. Cross-country flights were more likely to be precluded than local flights (P = .001), and both local and cross-country flights were more likely to be precluded at nighttime than in the daytime (P = .001). All flights were more likely to be precluded during winter months than during summer months (P = .000). CONCLUSION: The weather in central New York generally does not preclude the operation of an air medical services system.     

Monitoring the appropriateness of air medical transports

INTRODUCTION: With pending changes in the health-care system, there are increasing pressures for each aspect of health care to justify its use. Several organizations, including the Association of Air Medical Services (AAMS), have published position papers listing appropriate indications for air medical services. Additionally, the Commission on Accreditation of Air Medical Services (CAAMS) specifies that air medical services monitor their flights for appropriateness. The purpose of this study was to determine how often the air medical transports by this program met at least one of the AAMS criteria. METHOD: The AAMS position paper was paraphrased into an equivalent checklist and a category, "None of the above criteria met," was added. Immediately after each transport, a flight nurse indicated on the checklist which criteria the patient met supported by documentation in the flight care record. RESULTS: During a one-year period (March 1, 1992 through February 28, 1993), 558 patients were transported. Of these, 547 (98%) met at least one of the AAMS appropriate-use criteria. CONCLUSION: The AAMS "Appropriate Use of Air Medical Services" position paper provides a foundation to monitor the utilization of an air medical transport program, which can be used to meet both government payer requirements for justification and the CAAMS requirement for utilization review.     

A national survey of air medical infectious disease control practices

INTRODUCTION: Caring for an infectious patient in the air medical environment presents a special challenge to all air crew members (ACMs) involved. The purpose of this study was to survey the infectious disease control practices of air medical programs (AMPs) that are members of the Association of Air Medical Services. METHODS: A structured telephone survey was designed to gather data. Using one interviewer (an undergraduate student) with no knowledge of the study's goal minimized experimental bias. AMPs from 151 geographically selected areas were called between June and August 1996. Only the programs' chief flight nurses (CFNs) were targeted as respondents. RESULTS: The response rate was 91% (138 of 151). Although no program refused to participate, 13 CFNs were unavailable to be interviewed. Mission profile was 32% scene and 68% interhospital with an annual average of 950 patient transports per program. Transport type was 61% rotor-wing aircraft, 17% fixed-wing, and 22% both. Flight physicals for ACMs were required by 57% of the AMPs. Pre-employment screenings for rubella, tuberculosis (TB), and varicella were noted. Interestingly, 17% of the AMPs reported pre-employment HIV testing. Immunization was mandated by 57% of AMPs, including hepatitis B virus, measles, rubella, and tetanus. Nine percent of the respondents refused to accept a transport with specific contagious conditions, primarily TB. A formal decontamination policy was in effect at 88% of the AMPs, and OSHA-approved filter masks were available at 70%. Pathogen exposure reporting was required by 97%. CONCLUSION: A current, comprehensive infection control program, continuing education, and 100% compliance with standard precautions will help reduce the possibility of accidental exposures. These strategies to reduce transmission also can be extended during training sessions to the prehospital and hospital personnel with whom the air medical program serves.     

The use of chemical restraint in helicopter transport

Introduction: Helicopter transport of the combative patient is a major safety hazard facing air medical teams. Although physical restraints alone are helpful, the addition of chemical restraint (CR) often is necessary to control these patients while in flight.

Methods: A survey was conducted to determine the current practices of using nonparalyzing CR in air medical transport programs nationwide. The survey consisted of 24 questions on the use of CR during transport. Each U.S. program belonging to the Association of Air Medical Services was contacted by telephone, and a flight nurse or paramedic provided answers based on personal experience and statistics compiled by his or her individual program.

Results: Of the 100 programs responding, benzodiazepines were used most commonly to control agitation with 51% using midazolam. Patients with a head injury required CR more frequently than any other condition (73%). Crews flying larger aircraft reported less need for CR. A physician order was required by only 30% of the programs, but delays infrequently endangered the patient (2%). Only 7% of the responding programs had a patient whose condition deteriorated because of CR.

Conclusion: CR is necessary in air medical transport. Most programs use short-acting benzodiazepines. Crews in smaller aircraft use CR more frequently, and head injury is the most common condition requiring such restraint.     

A rural ambulance helicopter system in northern Sweden

INTRODUCTION: In Sweden, several ambulance helicopter programs have been used during the past 3 decades. This article describes one of these programs. SETTING: The catchment area of the helicopter system under study was a typical rural setting with a population density of less than 5 people per square kilometer. METHODS: We describe in detail, with special reference to medical aspects, the activities of an helicopter ambulance program in 1997. RESULTS: A total of 288 missions, including 328 patients (204 men), were analyzed. Trauma cases (29%) and patients with cardiovascular (24%) and neurologic problems (13%) dominated the missions. One-sixth of the cases occurred at night. The median response time was 12 minutes, and the median on-scene time was 28 minutes. The medical interventions performed included intubations; central venous catheter, arterial needle, and duodenal tube insertions; and medication administered intravenously, orally, and intrabronchially. CONCLUSION: We detected a higher rate of trauma cases than in previously published investigations, probably related to the outdoor activities of the area. We believe that the rapid institution of thrombolytic treatment in suspected acute myocardial infarction and a more rapid and flexible transport of trauma cases in a rural area are important. We estimate that, in most cases, the helicopter service could provide a quicker transport than a ground ambulance; however, for short distance transports, ground ambulance is faster than helicopter ambulance.     

Effect of transport team interventions on stabilization time in neonatal and pediatric interfacility transports

INTRODUCTION: During interfacility transport, the length of time taken by the transport team to prepare the patient for transport is often perceived as a problem by referring hospital staff. The purpose of this study was to examine the effects on time at the referring hospital of the number and complexity of interventions performed by the transport team to stabilize the patient prior to transfer. SETTING: Interfacility transfers by the provincial infant transport team (ITT) to British Columbia's Children's Hospital. METHODS: This was a prospective study of emergency neonatal and pediatric interfacility transfers. After each transport, the team completed a questionnaire about interventions performed and stabilization time. Transports were classified by the complexity of interventions performed: none, low (intravenous line, blood gas, nasogastric tube, Foley catheter, oxygen administration), or high (intubation, central venous access, arterial lines, chest tube insertion). RESULTS: Thirty of 55 transports required no intervention (mean stabilization time=52+/-25 min). Sixteen transports required low level intervention (mean=60+/-22 min). Nine transports required high level intervention (mean=140+/-52 min). The stabilization times for "no" and "low" levels of intervention were not significantly different (P=.3), but the time for "high" level intervention was significantly higher (P<.01). CONCLUSIONS: The need for the transport team paramedics to perform high level interventions significantly increased the time at the referring hospital. In contrast, the time taken for them to perform or reperform low level interventions, whether one procedure or two, was not a significant source of delay.     

EMS provider level does not impact use of air medical transport

INTRODUCTION: The local emergency medical services (EMS) provider level within a nearby EMS system changed from EMT-I to paramedic. This increase in level of care was expected to decrease utilization of air medical transport and increase acuity of patients flown. SETTING: Semirural, mountainous area with an annual volume of 2800 transports. METHODS: Retrospective review of the EMS database performed for the 24-month period before and after the change in local provider level. The number and acuity of patients flown was recorded. Data analysis was performed using chi-square with significance at P <.05. RESULTS: A total of 53 flights with an EMS call volume of 2544 were flown in the 24-month period before the change in EMS provider level, and 54 flights with a call volume of 2842 in the following 24-month period (P >.05). The number of patients with abnormal vital signs or injury severity markers was not different between the 2 periods (P >.05). CONCLUSION: The change in EMS provider level from EMT-I to paramedic in this semirural area had no impact on the number of air medical transports. The acuity of patients flown after the change in EMS provider level remained similar based on common hemodynamic and injury severity markers.