Air medical referring customer satisfaction: a valuable insight

INTRODUCTION: To remain competitive and survive, air medical programs must have a mechanism for obtaining customer feedback, especially when alternate transport options are available. The goal of this survey was to examine the air medical service's performance as perceived by customers requesting the transport. METHODS: Surveys were mailed to 400 referring customers who had contact with the flight crew during the transition of patient care. The survey consisted of 16 statements evaluating the service by using a 4-point Likert scale, three demographic questions, one statement evaluating overall satisfaction, and two open-ended questions for comments or suggestions. RESULTS: Two hundred forty-four surveys were returned for a 61% responses rate. Results indicated referring customers are satisfied with the service provided Written comments and suggestions were divided into two categories, positive comments and suggestions for improvement. Three common themes were identified within the suggestions for improvement: crew rapport, communications, and operations. Suggested improvements were evaluated, and selected strategies were incorporated into program operation. CONCLUSION: Customer feedback furnishes valuable insight into their needs and perception of a service. Comments and suggestions for improvement can promote critical inquiry into service operation and provide a catalyst for improvement.     

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.     

The use of consumer-satisfaction surveys by an air medical program

Surveys were distributed to referring and receiving hospitals or to EMS agencies that used the air medical service. The respondents were asked to evaluate the dispatcher's, pilot's and flight crew's professionalism and courteousness on a Likert scale and through written comments. Phase 1 of the survey distribution was discontinued after problems were encountered due to the distribution process. Phase 2 consisted of the air medical program mailing surveys directly to the referring and receiving facilities or to the EMS agencies. In terms of courteousness and professionalism, 90% of the respondents' answers fell within the strongly agree to neutral range. Questions regarding pilots and dispatchers were often left unanswered. Two areas were identified as needing further work on the part of the medical flight crew: follow-up with referring hospitals on patient outcome and identification of flight physicians vs. flight nurses.     

A review of drug use during air medical transport to optimize an air ambulance formulary

INTRODUCTION: The advent of air medical transport has pushed the delivery of critical care medicine into the prehospital arena. As a result, a wide variety of pharmacologic agents must be available in the air medical setting. PURPOSE: The purpose of this study was to conduct a retrospective review of drugs used during air medical transport to allow a streamlining of the air ambulance formulary. METHODS: All flights completed since the inception of the study's helicopter air ambulance program in 1985 through September 1991 were analyzed to determine which medications were used in flight. Drugs were counted if they were administered while in flight for either a scene or interhospital transport. RESULTS: Review of 2,694 flights showed that 45 individual drugs had been routinely carried during the study period. Many of these agents were administered fewer than five times during the six years, and 10 drugs were not used at all. CONCLUSION: As a result of this investigation, the formulary for our air medical transport service was modified. The authors recommend similar critical audits of drugs carried in flight be performed by other air ambulance services.     

U.S. Army MEDEVAC in the new millennium: a medical perspective

The U.S. Army Aeromedical Evacuation community (MEDEVAC) possesses a long-standing tradition of excellence in the care and transportation of combat casualties. Recent developments in civilian air medical transport and quantitative review of MEDEVAC operations have identified potential areas for improvement, concentrating on enhanced flight medic standards, training, sustainment and medical oversight of the air ambulance system. These proposed changes are discussed in detail, from the perspective of current emergency medicine and aviation medicine standards of practice. If instituted, these changes would facilitate the emergence of a true air medical transport capability comparable with the civilian community standard.     

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.     

Physician roles in aeromedical evacuation: current practices in USAF operations

Physicians play an increasingly important role in the critical medical process of aeromedical evacuation (AE). Incomplete or inappropriate preparation for AE can result in increased patient discomfort, and in the worst cases, potentially serious or insurmountable in-flight medical problems. During military operations and in response to natural disasters, physicians are responsible for four processes necessary for a successful AE mission. These include: 1) AE screening, including determination of appropriate classification, precedence, and special medical requirements; 2) validation; 3) medical preparation; and 4) clearance. Physicians responsible for preparing patients for AE need to understand both the patient evacuation system and the unique medical aspects associated with AE. The U.S. military patient evacuation system is comprised of three principal transportation phases: casualty evacuation; inter-theater AE; and intra-theater AE. Important elements of the USAF AE system are patient movement requirements centers, the validating flight surgeon, aeromedical staging facilities, AE liaison teams, aeromedical crews, and critical care air transport (CCAT) teams. Important medical aspects unique to AE include the effects of flight physiology on medical conditions, oxygen limitations, and distinctive medication and supplies requirements.     

The 2003 Air Medical Leadership Congress: findings and recommendations

To address important concerns facing the air medical community, 149 air medical transport leaders, providers, consultants, and experts met September 4-6, 2003, in Salt Lake City, Utah, for a 3-day summit-the Air Medical Leadership Congress: Setting the Health Care Agenda for the Air Medical Community. Using data from a Web-based survey, top air medical transport issues were identified in four core areas: safety, medical care, cost/benefit, and regulatory/compliance. This report reviews the findings of previous congresses and summarizes the discussions, findings, recommendations, and proposed industry actions to address these issues as set forth by the 2003 congress participants.     

Air ambulance regulations: a model

Prior attempts at establishing minimal federal air ambulance regulations and standards have been unsuccessful. However, reports of poor patient medical care during transport by some air ambulance services is now forcing many states to initiate air ambulance regulations. In 1984, the State of Utah Emergency Medical Services convened a special subcommittee to develop aeromedical regulations for the State of Utah. Using a three-level approach based upon the patient's requirements for basic, advanced, or specialized medical care and the urgency of transport, the subcommittee was able to derive medical categories necessary for the selection and utilization of air ambulance services. Minimum air ambulance regulations were then established for aircraft configuration, flight crew requirements, minimal equipment and medications, and the responsibilities of the medical director or designee for each of the three levels of medical care. We conclude that the application of a levels approach based upon the patient's medical requirements may be useful in assisting other states attempting to establish flexible but specific regulations directed at the safe transport of patients by aeromedical evacuation.     

Scientific problems of medical support of the Air Forces staff

The authors consider three leading directions of aeromedical investigations oriented at: creation of scientific fundamentals to provide a human factor in development of new air to complexes for protection of aviation specialists from flight effects and for their labour means humanisation, improvement of psychophysiological selection, development of methods and technical means to form professionally important qualities and psychophysiological training of air force staff, health condition medical control, methods and means of condition correction, serviceability restoration and combat-capability increase. The most urgent scientific problems are characterized within the given trends. The examples of practical effectiveness of the investigations carried out are described.     

Reduced emergency department stabilization time before cranial computed tomography in patients undergoing air medical transport

INTRODUCTION: Advanced patient stabilization skills provided by air medical providers were hypothesized to result in streamlined emergency department (ED) stabilization of patients with head injuries requiring urgent cranial computed tomography (CCT). The goal of this study was to compare initial ED stabilization times between air- and ground-transported patients requiring urgent CCT and emergency neurosurgical hematoma evacuation. SETTING: Academic Level trauma center (annual ED census 60,000) receiving patients from ground EMS and a nurse/paramedic air medical transport team. METHODS: This retrospective study identified, from a database of 15 months of ED visits, consecutive group of adults who had CCT performed within 60 minutes of ED arrival and underwent emergent craniotomy for intracranial hematoma. Demographics, hemodynamic status, patient acuity, and time intervals between ED and CCT suite arrivals were compared between air and ground patients using chi-square, Fisher's exact, and t-tests (p = 0.05). RESULTS: Eleven air- and 39 ground-transported patients were eligible. All patient acuity data were similar between groups. Air patients were more likely to be intubated (100% versus 71.8%, p = .04) and had shorter mean ED stabilization times (29 versus 40 minutes, p = .02) than the ground. CONCLUSION: This study suggests that advanced patient stabilization offered by air medical transport may result in reduced ED stabilization time for patients requiring urgent craniotomy.     

Anxiety in adult fixed-wing air transport patients

INTRODUCTION: Critically ill patients may experience anxiety because of the method of transport, possibly having an impact on both patients and their health care providers. The purpose of this research was to study the presence and degree of anxiety in fixed-wing air transport patients. METHODS: Subjects were 41 patients 25 to 79 years of age. Self-ratings of anxiety were obtained and vital signs were recorded at five predesignated points before, during, and after the flight. Additional questions addressed current and previous experiences and perceptions of flying. RESULTS: Anxiety ratings were generally low, averaging approximately 1.9 on a 1 ("worry-free") to 10 ("completely terrified") scale. Anxiety was greatest in anticipation of the flight. Fourteen percent of patients had never flown before; patients with little or no flight experience had significantly higher anxiety ratings. However, in all cases anxiety declined steadily as the flight progressed. Most patients (82%) reported greater worry about their medical condition than about the flight. CONCLUSION: Anxiety is generally low among adult fixed-wing air transport patients and decreases further over time. This decrease was true even for patients who initially reported high levels of anxiety before the flight. The data suggest that previous flight experience can be used to predict anxiety during air medical transport.     

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.     

The use of aviation transport in providing medical care to the victims in an earthquake focus]

2584 wounded were evacuated by helicopters during Armenian earthquake, December, 1988--that was 20% of all hospital cases. But, practically, the possibilities of aviation in Spitak and Leninakan regions were far more extensive. The more effective employment of air transportation for evacuation could be attained by the following measures: organization of a sole command and action coordination between medical service, air command and rescue teams, preliminary rescue planning, efficient organization of triage and evacuation of wounded, special training of medical staff in air evacuation. The extreme conditions of flights in emergency situation of catastrophe or calamity need high working capacity and firm professional skill of flight crews.     

8.5 French peripheral intravenous access during air medical transport of the injured patient

Introduction: This study describes a simple approach to peripheral large-bore intravenous (IV) access for the injured patient.Method: Retrospective chart review of patients identified by concurrent transport registry who received peripheral 8.5 F IV access during air medical transport for injury. The transport program consists of four remote-based BK-117 helicopters staffed by a nurse/paramedic crew. A peripheral 8.5 F IV access was obtained by protocol using guidewire technique over an existing peripheral IV. Crew education consisted of a combination of didactic and hands-on experience updated periodically on an ongoing basis.Results: From July 1991 through March 1995, 23 injured patients transported to a single Level I trauma center received a peripheral 8.5 F introducer. The patients averaged 30.9 years of age and were primarily male (78.3%) with blunt injuries (87%). Initial trauma score averaged 9.8; injury severity score averaged 24.6. All patients had at least one additional IV line; 21 of 23 patients were endotracheally intubated. Ground times averaged 19 minutes, flight time averaged 22.1 minutes, and in-flight fluids averaged 2239 ml or 101 ml per minute of flight. Complications associated with prehospital IV access did not occur.Conclusion: Peripheral 8.5 F access through a guidewire technique of an existing IV provides a rapid, simple approach to large-bore IV access in the injured patient transported by air.     

The impact of health personnel at the cohesion of military units

It is shown that in military units sociometric status of troops largely determined by the frequency of diseases in the following classes of diseases: mental and behavioral disorders (grade 7), diseases of the eye (grade 7), diseases of the ear and mastoid process (grade 8) and diseases of the digestive system (grade 11). Therefore, prevention efforts on these types of diseases will help to create cohesive military units, but it rebuet presence in the military link of the medical service of specialists.     

Trauma ultrasound feasibility during helicopter transport

Objective: To evaluate the feasibility of performing a standard four-view focused abdominal sonography for trauma (FAST) examination during helicopter transport using a hand-carried ultrasound machine.

Methods: In this prospective observational study, actual and simulated trauma patients were evaluated using the SonoSite 180 ultrasound machine by two air transport programs serving Level 1 trauma centers. FAST examinations were performed in flight by emergency medicine faculty, residents, flight nurses, and ultrasound technologists, who rated the difficulty posed by various factors using Likert scales (0 = not difficult to 5 = impossible). BK 117, Bell 230, and BO 105 medical helicopters flew in all aviating modes. Pilots were queried regarding avionics variations throughout the flights.

Results: Ten flight sonographers performed 21 FAST examinations on 14 patients (five actual, nine simulated). The median Likert value for each parameter was 0 except for patient position, which was 1 (somewhat difficult). Interquartile ranges were 0-0 for vibration, bedding, IV catheters, monitor cables, and ventilator; 0–0.5 for backboard straps; and 0–1 for sunlight, patient position, spider straps, gurney straps, and clothing. Mean examination duration was 3.0 minutes (range 1.5 to 5.5 minutes, SD 1.3). Pilots reported no effects on avionics in any flight mode.

Conclusion: The FAST examination using the SonoSite 180 in flight was rated by 10 evaluators to be performed easily. Examinations were conducted quickly and did not interfere with helicopter avionics. This digital ultrasound machine is the first one small enough to be used in most medical helicopters.     

Is air transport faster? A comparison of air versus ground transport times for interfacility transfers in a regional referral system

INTRODUCTION: Helicopter transport is often considered in an effort to minimize time to critical interventions, such as cardiac catheterization or arterial thrombolysis in stroke patients. However, for interfacility transports, the extra time considerations for helicopter preparation, takeoff, and time to get to the transferring hospital may not offset the slower transport times for local ground ambulances. The purpose of this study was to compare transport times for helicopter with traditional ground ambulance for interfacility transfers within a regional referral system. METHODS: All patients transported from an outside hospital to the intensive care unit of the University of Wisconsin were eligible for this study. Equal numbers of patients transferred by ground and by helicopter from each facility were sequentially selected. The following intervals were compared: time from call to dispatch, time from dispatch to arrival at the referring hospital, time at the referring hospital, transport time to the receiving hospital, and total transport time. RESULTS: One hundred forty-five patients were included in this study, transferred from 20 hospitals within the UW referral system. Dispatch times and time at the referring hospital were location independent, and each was shorter for ground transport. Ground dispatch times were 5+/-6 minutes, whereas for helicopter transport dispatch times were 17+/-8 (P<.001). Times at the referral hospital were on average longer for helicopter transport (31+/-11 minutes for air ambulance, 25+/-13 for ground; P=.008). Other intervals were location dependent. Arrivals were much more variable for ground transport, reflecting the fact that private ambulance services may have to travel some distance to reach the referring hospital (helicopter 18+/-8 minutes, ground 19+/-18 minutes). As expected, transport time from the referring hospital was shorter for helicopter transport. From each of the hospitals, average helicopter transport was as fast as the best ground transport. CONCLUSION: Helicopter transport was faster than ground transport for interfacility transfer of patients from all hospitals studied in our referral system. Under optimal dispatch and transport conditions, the time difference from several hospitals was minimal. For stable patients for whom the only issue is time to critical procedure, it may be reasonable for those hospitals to try ground transport first if timely service is available to transport in that way. Even for those hospitals, helicopter transport should be considered for these patients if ground transport is not optimally available, as well as for patients in whom minimizing time outside of the hospital is a significant consideration, or when transport of such patients impacts emergency medical services availability to the community for a significant time.     

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.