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.     

Medical helicopters in wilderness search and rescue operations

Medical helicopters may be asked to assist in wilderness search and rescue (SAR) operations to quickly reach patients in remote areas and provide medical care and transport of sick or injured persons. The number 1 priority for any medical helicopter involved in an SAR operation is safety, which is considered at each decision point. The involvement of a medical helicopter service begins with a request from a local agency for support. Obtaining key information about the SAR operation from the local agency is essential for deciding whether to accept the mission and for making appropriate preparations for the mission. While en route to the SAR location, the medical crew can review the information regarding location and patient status. Once on location, the crew can survey the scene from the air before landing at the command post to brief with SAR personnel regarding the mission. An initial survey of the scene from the air is important for identifying landing zones and evaluating the terrain where the rescue will occur. A face-to-face briefing with SAR personnel is preferable to learn specifically what type of mission is requested. The medical helicopter crew is empowered to decline the mission for safety reasons at any step. The actual rescue may be done by inserting the helicopter at the scene in nontechnical terrain or by having SAR personnel extricate the patient and deliver him or her to the medical helicopter crew at the nearest safe landing zone. Medical care and transport of the patient as indicated by injuries or illness then occurs. Finally, a postmission debriefing is essential for identifying problems that occurred during the mission and implementing corrections for improvement.     

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.     

Influence of the helicopter environment on patient care capabilities: flight crew perceptions

INTRODUCTION: Flight crew perceptions of the effect of the rotary-wing environment on patient-care capabilities have not been subject to statistical analysis. We hypothesized that flight crew members perceived significant difficulties in performing patient-care tasks during air medical transport. METHODS: A survey was distributed to a convenience sample of flight crew members from 20 flight programs. Respondents were asked to compare the difficulty of performing patient-care tasks in rotary-wing and standard (emergency department or intensive care unit) settings. Demographic data collected on respondents included years of flight experience, flights per month, crew duty position and primary aircraft in which the respondent worked. Statistical analysis was performed as appropriate using Student's t-test, type III sum of squares, and analysis of variance. Alpha was defined as p < 0.05. RESULTS: Fifty-five percent of programs (90 individuals) responded. All tasks were significantly rated more difficult in the rotary-wing environment. Ratings were not significantly correlated with flight experience, duty position, flights per month or aircraft used. CONCLUSIONS: We conclude that the performance of patient-care tasks are perceived by air medical flight crew to be significantly more difficult during rotary-wing air medical transport than in hospital settings.     

Trauma and nontrauma cardiopulmonary arrest: a national survey

INTRODUCTION: This survey attempts to identify the current standard of care for the air medical transport of the patient in cardiopulmonary arrest. METHOD: An Association of Air Medical Services/National Flight Nurses Association-approved survey by a single mailing with an anonymous response. SETTING: All rotor-craft programs with current memberships in AAMS. RESULTS: Fifty-three of the 178 questionnaires mailed were returned. Program demographics, crew composition and transport volumes were typical of other reported national experiences. The majority of programs (84%) had standing operational protocols for trauma and non-trauma cardiopulmonary arrests. The indications for not initiating or discontinuing CPR, the transport of the patient in cardiopulmonary arrest, triage and financial considerations varied widely between air medical programs. CONCLUSIONS: This study provides some insight on the current air medical management of the patient in cardiopulmonary arrest. National practice guidelines should be developed and tested prospectively in future studies.     

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.     

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.     

The effect of an in-flight, emergency training program on crew confidence

INTRODUCTION: Despite some progress, the air medical transport profession continues to experience widely publicized accidents that result in injuries and death to crew members and patients. An air medical crew member's experience, training and confidence may affect his or her ability to deal effectively with an in-flight emergency, and may also affect his or her behavior before and after the emergency. SETTING: A hospital-based, rural rotor- and fixed-wing program flying approximately 890 flights per year. Seventy-seven percent of these flights are interfacility. METHODS: A pretraining survey evaluated the experiences of air medical crew members and pilots. A 20-question assessment tool based on a 5-point Likert scale evaluated how confident the individuals were in their ability to react to in-flight emergencies. An extensive in-flight emergency training program was then conducted. Personnel were asked to complete the same questionnaire one month and six months after the training. RESULTS: On the pretraining questionnaire, flight crew members with neither prior training nor actual experience in in-flight emergencies showed the lowest level of confidence. Those with prior training, actual in-flight emergency experience or both, responded with higher levels of confidence. The mean confidence scores of the study participants increased from 82 pretraining to 89 at one month post-training and remained at the increased level six months after training. CONCLUSIONS: A training program focusing on in-flight, aircraft-related emergencies can increase the crew's confidence during such situations. This increase in confidence is most noticeable in those without previous training or experience and is maintained for at least six months. Several other benefits occur from the training program.     

Improved flight following through continuous quality improvement

Introduction: Flight following is a key component of an air medical transport service's safety program. National standards require conscientious adherence to flight following. EastCare monitored its compliance with internal flight-following requirements for three years. Setting: EastCare is a single-helicopter, hospital-based air medical transport service located in a rural region of the southeastern United States. It has a full-time staff of flight nurses, pilots and communications specialists. Methods: A continuous quality improvement (CQI) process was initiated to delineate specific areas requiring improvement. These areas were discussed at the air medical service's monthly CQI meetings. Results: In 1989, the communications specialists achieved flight following intervals of < or = 15 minutes in 98% of attempts. In 1990 and 1991, the frequency of flight-following intervals of < or = 15 minutes were 98.8% and 99.6%, respectively. The CQI process pointed out educational requirements, technological problems and other areas for improvement. Conclusion: The use of a structured CQI process for this service directly contributed to consistently strong compliance in the frequency of flight following.     

A validated pediatric transport survey: how is your team performing?

INTRODUCTION: Understanding referring practitioners' satisfaction with pediatric transport services is useful for quality improvement. Formal survey methodology was applied to develop a pediatric transport satisfaction survey. SETTING: Large metropolitan area in the Southwestern United States. METHODS: A four-stage process was used to create a 20-item pediatric transport satisfaction survey. The final survey was analyzed for test-retest and internal consistency reliability, and surveys were mailed to a large practitioner base. RESULTS: The survey encompassed three domains: patient care, accessing the transport system, and communication. Test-retest and internal consistency reliability were good (final Cronbach alpha coefficient of 0.88.) Of the 229 providers responding, 69% were local (<60 miles), and 31% were served by our long distance transport team (>60 miles). Respondents reported that physicians selected the transport team in 82% of cases, whereas 9% reported that the charge nurse decided. Transport team selection was based on: (1) ease of initiation, (2) fastest arrival, (3) presence of a physician on the team, (4) stabilization time at the referring facility, and (5) team providing best follow-up. Satisfaction with our transport service was high, with a median survey score of 83 (interquartile [IQ] range, 74-92). Physicians and nurses reported equal satisfaction. CONCLUSION: Survey design methodology was successfully applied to assess satisfaction with pediatric transport. This transport survey offers a reliable measurement of providers' satisfaction with transport services.     

Fetal evaluation for transport by ultrasound performed by air medical teams: A case series

The air medical team has limited options when evaluating the obstetrical patient and assessing fetal health during air transport to a high-risk obstetrical unit. Traditionally, physical examination and a Doppler stethoscope have been used to determine fetal heart rates and movement. However, with the advent of portable ultrasound technology, new information about the mother and child are available to the air medical crew. The Fetal Evaluation for Transport with Ultrasound (FETUS) is a screening examination that consists of an evaluation of the fetal heart rate, position, and movement and general condition of the placenta. The examination can be repeated in flight with no acoustic distortion from rotor noise. The additional information can be advantageous when transport decisions need to be made or when conditions do not allow Doppler stethoscope use.     

Radiology scheduling: preferences of users of radiologic services and impact on referral base and extension

RATIONALE AND OBJECTIVES: To study end-user attitudes and preferences with respect to radiology scheduling systems and to assess implications for retention and extension of the referral base. A study of the institution's historical data indicated reduced satisfaction with the process of patient scheduling in recent years. METHODS: Sixty physicians who referred patients to a single, large academic radiology department received the survey. The survey was designed to identify (A) the preferred vehicle for patient scheduling (on-line versus telephone scheduling) and (B) whether ease of scheduling was a factor in physicians referring patients to other providers. Referring physicians were asked to forward the survey to any appropriate office staff member in case the latter scheduled appointments for patients. Users were asked to provide comments and suggestions for improvement. The statistical method used was the analysis of proportions. RESULTS: Thirty-three responses were received, corresponding to a return rate of 55%. Twenty-six of the 33 respondents (78.8%, P < .01) stated they were willing to try an online scheduling system; 16 of which tried the system. Twelve of the 16 (75%, P < .05) preferred the on-line application to the telephone system, stating logistical simplification as the primary reason for preference. Three (18.75%) did not consider online scheduling to be more convenient than traditional telephone scheduling. One respondent did not indicate any preference. Eleven of 33 users (33.33%, P < .001) stated that they would change radiology service providers if expectations of scheduling ease are not met. CONCLUSION: On-line scheduling applications are becoming the preferred scheduling vehicle. Augmenting their capabilities and availability can simplify the scheduling process, improve referring physician satisfaction, and provide a competitive advantage. Referrers are willing to change providers if scheduling expectations are not met.     

Does crew resource management training work?

INTRODUCTION: Effective crew resource management (CRM) may play a major role in decreasing the number of accidents and increasing overall safety of air medical programs. The purpose of the study was to compare the responses of crew members, in a variety of situations, who received CRM training and those who did not. The numerical results of the responses were used to evaluate the effectiveness of CRM in increasing crew awareness and promoting team concepts. METHOD: During a 12-month period, crew members of randomly selected air medical programs (fixed- and rotor-wing) were surveyed by questionnaire. Participants were asked if they had received CRM, effective communication, and team-building training. The next 15 questions pertained to crew interaction/communication in everyday and emergent situations and were scored on a Likert scale (1 = strongly agree and 5 = strongly disagree). A lower total score indicated a greater understanding of team awareness and effective communication. RESULTS: The mean score of crew members who received the three identified areas of training (initial CRM, team-building, effective communications) (37.96, SD +/- 7.67) was found to be significantly lower than the mean score of those who had received none of the training (44.13, SD +/- 5.0) and P < .05. CONCLUSION: Based on the results, CRM training increases crew awareness and promotes team concepts in both everyday and emergent situations.     

Contribution of air medical personnel to the airway management of injured patients

INTRODUCTION: Air medical services are being pressured to demonstrate their value. Airway management is the first priority of care when treating injured patients in the prehospital setting. Injured patients with decreased Glasgow Coma Scale (GCS) are candidates for advanced airway procedures and air medical transport. RESEARCH QUESTION: The purpose of this study was to determine the extent of air medical crews' contributions to the airway management of the injured patient in the prehospital setting. METHOD: A study of adult (age > 12 years) injured patients encountered in a field setting, whose GCS on the arrival of the air medical crew was < or = 8, was conducted for 21 months (Feb. 1, 1991-Oct. 31, 1992). RESULTS: During the study period, 174 patients who met the criteria were transported by the air medical crew. All but one received advanced airways including oral tracheal intubation, nasal tracheal intubation or cricothyrotomy. Of those, 68 (39%) of these procedures were completed by ground personnel (ground group), and 105 (61%) were completed by the air medical personnel (air group). The mean GCS for the ground group was 3.69 and for the air group was 4.69. The distributions were significantly different (Wilcoxon Rank Test p = 0.0002). Nineteen percent (13/68) of the patients whose airways were successfully managed by the ground personnel had a GCS of 5 to 8, as did 44% (46/105) of the air group's patients. The groups' patients were not significantly different in age or sex distribution. CONCLUSION: Properly trained air medical personnel positively contribute to the prehospital care of injured patients by establishing definitive airways in patients with higher GCSs.     

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 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.     

Integrating emergency medicine residents into a well-established helicopter program

INTRODUCTION: The institution of an emergency medicine residency in a university-affiliated Level 1 trauma center in July 1993 provided a challenge to develop a curriculum and on-line learning experience for emergency medicine residents in a well-established helicopter program. The purpose of this study was to survey flight crew members, emergency medicine at tending physicians, and emergency medicine residents on the anticipated roles and educational experience of integrating the emergency medicine residents from a new emergency medicine residency into the flight crew of a well-established helicopter program. METHODS: A survey consisting of multiple choice, Likert scale, and open-ended questions was distributed to flight crew members (RN, RT, pilots, communication specialists, EM attendings, and EM residents [n=72]). RESULTS: 92% of surveys were returned. These surveys identified specific issues of concern and those areas believed to be of academic importance for the emergency medicine residents. CONCLUSIONS: The results of this study allowed for the creation and implementation of a progressive flight experience for EM residents that incorporates increasing responsibility on the flight crew as experience is gained.     

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.