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The history of air ambulance transport has been impressive; from the relatively unsophisticated balloon transports of injured soldiers during the Crimean War in the 19th century, through the early years of aviation, the Korean and Vietnam conflicts to the present when air medical transport is virtually everywhere in the world. Rotor-wing services have proven their place in reducing morbidity and mortality for patients from rural and remote environments. Fixed-wing services provide speed and long distance capability.
There are hundreds of aeromedical programs and thousands of aircraft involved in EMS transport. Airborne care can range from simply accompanying a patient on an intra-hospital transfer on either a fixed- or rotary-winged aircraft to the full surgical facilities on board one of the Canadian Ministry of Transport's Canadair CL-600 Challengers. This very wide range of geographic and care requirements makes the user doubly dependent upon industry standards to aid in the educated selection of an EMS service.
After a long period of inconsistent methods and motivations, there are now groups and trends directing the industry towards regulatory standardization. To appreciate these trends, their driving forces, and the way that they can help in the selection and use of aeromedical services, we offer a brief review of the current situation.
The undisputed goal of all regulatory efforts addressing the aeromedical industry is to institute a system of control that treats the service providers equitably and insures the safety and welfare of patients. Even with this fundamental consensus of purpose, the issue of regulation in air medical transport has always been hotly debated. Perhaps it is this passionate appreciation of fundamental goals which so complicate the debate on how to acheive them.
The lack of effective regulations and implementation has caused confusion for the people who hire air medical transport services, and anguish and animosity among providers. Unfortunately, due to the relatively short period that modern air medical transport has been in existence, about 20 years, regulation has failed to keep pace. Providers show a desire for change but disagree significantly on the focus of the process and important factors to be included. New programs have recently come into existence which will hopefully begin a period of greater industry cohesion and better patient care.
New Programs
The proposition currently in process is the air ambulance endorsement on the Operations Specifications (Ops Specs) of Part 135 certificate holders, and the Uniform Fixed-wing Air Ambulance Regulation (UFAAR) Project. Although both of these projects come from different perspectives, their goals are consistent and entirely compatible. Finally, there seems to be substantive progress in this area.
The Ops Specs requirement has been mandatory since the middle of 1993. The process development involved considerable input from those involved in air medical transport and took nearly two years of research and development to reach the final product. This initiative is focused on the aviation aspects of air medical transport and includes factors affecting the integration of aviation concerns with medical functions.
Any Part 135 certificate holder who provides aircraft services or engages directly in providing air medical transport must have an endorsement in their Operations Specifications (Item A-24) which authorizes them to conduct air ambulance operations. Unlike a failed attempt at such regulation in the late 1970's, much research was done prior to implementation and the timing was right for setting compliance deadlines for these new requirements. One of the initial goals of the program was to quantify the number of certificate holders and aircraft involved in air medical transport. Since the program is still new it may be some time before there is an accurate tally of providers and aircraft available.
The Ops Specs requirement is based largely on the integration of aviation and medical functions. The certificate holder is evaluated on several aspects of their program such as training and orientation programs for medical and aviation personnel, medical equipment installation and aircraft configuration, medical equipment inspection and maintenance as well as policies and procedures specific to medical transport. Thus far the program has been received by Part 135 operators with optimism.
The complementary project affecting the medical and patient care issues is the Uniform Fixed-wing Air Ambulance Regulation (UFAAR) project. As the name implies, the UFAAR is focused on the fixed-wing segment which is widely considered the segment requiring the most attention. The UFAAR originated in the lack of uniformity of state level regulations.
Problems at the state level revolved around the lack of consistency from one state to another as well as the issue of preemption of state powers by federal mandates. It also noted the lack of coordination between the FAA and state health regulators which failed to address the integration of aviation and medical aspects. The UFAAR was a result of three years of research and development and has also been endorsed by national aviation and air medical organizations alike. The UFAAR has been unanimously adopted by the National Association of State EMS Directors as the model document to be used in drafting state regulations.
Certifying Processes
An initiatives now in favor among providers is peer certification. The most successful was developed by the Commission on Accreditation of Air Medical Services (CAAMS). CAAMS has been closely identified with the Association of Air Medical Services (AAMS). The CAAMS process includes criteria for both rotor and fixed-wing service providers.
The criteria of the program requires a written application as well as an onsite inspection of the providers operation. The CAAMS process is comprehensive and relatively costly. There are still other programs, similar in scope that we will be presenting in future issues.
These programs are still quite new with just a few providers certified by each process. Their collective goal is for these certifying processes to eventually be used as selection criteria by user agencies such as hospitals and health insurance carriers. As with regulation, certification processes such as CAAMS may take some time to be accepted. This may be especially true since peer based certification processes prescribe optimum performance objectives rather than the minimums typically found in regulation.
Making the Most Of It
Even with the confusion of regulatory issues, there are ways to make sound choices about the services that you use. If you plan to begin from scratch, there are a series of questions at the end of this section which will help you to qualify services, or you may use any of the prequalified services listed within this section with confidence.
First, define which of the three recognized levels of care is appropriate to the situation. Designated Basic Life Support, Advanced Life Support, and Critical Care: each have different requirements and protocols. Any operator offering medical charter at any of these three levels must confirm that they satisfy the necessary equipment and procedural requirements for your needs.
Basic Life Support
This type of patient care is mostly preventative in nature. It is a phase of care that would be appropriate for a patient needing minimal external life support, but still in need of monitoring and care. This does not mean that any aircraft used for Basic Life Support transport can fly without personnel and equipment on board in order to react to a medical emergency. The absolute minimums (and they vary from state to state) include FAA approved stretcher and oxygen systems; provisions for cardiopulmonary monitoring, external respiratory and circulatory support, IV maintenance, and at least a certified Emergency Medical Technician.
Advanced Life Support
Advanced Life Support (ALS) certification means that an operator can provide an aircraft with all basic life support functions and the means to perform cardiac defibrillation, control dysrhythmia (irregular heartbeat), insert IV lines and administer drugs, and establish and maintain respiratory airways. In addition, personnel must be capable of providing care for whatever brought about the need for the transport, i.e. trauma, burns, cardiac failure, or other condition that would necessitate a higher level of care.
Critical Care
According to the Association of Air Medical Services (AAMS), Critical Care is defined as "caring for the critically ill or injured patient through the use of available knowledge and skills in an aeromedical environment by a professional flight nurse with advanced assessment skills". This means that the patient must be under the care of one (or more) very highly and specifically trained flight nurses. These nurses are, in turn, supported by a virtually endless list of highly sophisticated medical equipment. Because of the cost of such operations, this type of transport is used in the most severe cases.
Projections
The first decade of the 21st century will be a period of dramatic change for air medical transport providers. Health care reform is imminent. What form of health care delivery system will emerge after the pending legislation is finalized is anything but clear. How the changes will affect air medical transport is even more in question and the final analysis will hopefully not be an epitaph.
Although no one can with certainty say what percentage of the estimated $800 billion dollars spent on health care is for air medical transport, popular speculation places the percentage at less than 1%. This uses inflated per transport charges and transport volume. Unfortunately, due to the high profile of EMS helicopters in TV and print media, there may be a perception that these costs are excessive and that alternative service should be explored. Little more can be known until the final package is passed and implementation begins. One observation can be made. Air transport will not be unchanged by the health care reform no matter what the final program includes.
There is a great irony about the current events affecting this industry. On one hand there is significant progress being made in the area of regulation. On the other hand continuing poor economic conditions as well as pending health care reform tends to cast a gloomy pall over what should be a bright time in the industry's history. We must surely be at the low point and the only way to go is up. The programs in motion now may serve to provide a strong base for the future.
contains info from www.aircharterguide.com - Copyright 1995-2003 Boston Aviation Services
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