A ground ambulance providing a level of medical care higher than ALS, staffed with specially trained nurses and paramedics.
The most basic level of medical care provided in an ambulance, usually by First Responders and EMT’s.
A more advanced level of medical care provided in an ambulance, usually by paramedics.
Maintaining the resources necessary to respond with an air ambulance to an emergency is a complex and costly undertaking, much like that of fire departments and hospital emergency departments. The high fixed costs of maintaining a response infrastructure are necessary in order to be ready to serve.
This is especially problematic in maintaining rural emergency care services. Recent studies from the Capitol Area Health Roundtable and the Government Accountability Office (GAO) have highlighted that current reimbursement does not adequately support the cost of maintaining services.
Helicopters and fixed wing aircraft cost millions of dollars to purchase or lease, operate, house and maintain. Highly trained crews available on a 24-hour/7 days per week basis, and the infrastructure which governs, trains, funds, supports, and links them and their service to the EMS system, are also expensive.
As few systems are publicly funded, maintaining the availability of this essential resource inevitably translates into a single patient mission charge that seems expensive in comparison with a lower-priced ground ambulance for the same mission. It has proven a mistake, however, to make such an isolated comparison and to equate the lower charge with cost-effectiveness and the higher charge with costprohibitiveness. In the managed care push of the mid-1990’s, air ambulance service was interpreted by some in this way, as an expensive system contributing to the high cost of health care. They postulated that the industry would shrink and require redesign. That did not happen and, as the value of air ambulance service is increasingly demonstrated, reimbursement for air medical services has actually improved and services have expanded in response to other changes in the healthcare system.
At least one carefully constructed economic model comparing helicopter versus ground EMS has been crafted. It demonstrates that on a system level (that is, funding a system of air ambulances versus a system of ground ambulances covering the same large geographic area and volume of calls), the cost per patient transported would be $4,475 for the ground system and $2,811 for the air system (1991 dollars). A cost-effectiveness study of helicopter EMS for trauma patients by Gearhart and colleagues concluded that such service is, indeed, cost-effective. In looking at the cost per year of life saved by 500 emergency medical interventions, another researcher found the average to be $19,000 (e.g. clot-busting medication treatment for heart attack is $32,678; kidney dialysis is $40,000). That study estimated paramedic ground EMS to cost $8,886 per year of life saved while the Gearhart paper establishes a comparable figure for medical helicopter use of $2,454.
As increasingly difficult decisions about apportioning health care dollars in our aging society are faced, air ambulance service should not only be considered cost-effective in its current roles, but may increasingly serve medically isolated populations in new ways.
Children are very resilient patients who often do not show signs of a severe illness or injury until they are close to death and then suddenly deteriorate. When this occurs, they require access to neonatal and pediatric intensive care units, which are becoming increasingly limited. Therefore, the care of these neonates, premature infants, and young children is another primary use of Air Ambulance and Medical Flights, with the speed and higher level of care provided en route by an air medical team.
When a pregnant woman experiences complications, they can be life-threatening for both mother and child, and often require the specialized care found in larger hospitals. Timely Air Ambulance transfer to such facilities while the patient(s) receives care from obstetrical/ neonatal specialists has been shown to be safe, cost-effective and beneficial. Transfer via critical care ground ambulance is also successfully employed in these kinds of cases. However, when time is critical and a specialty team from the receiving hospital is sent to bring the patient(s) to the specialty center, air ambulance transport minimizes the out of hospital time for both the patient and the specialty care givers in a way that cannot be accomplished via ground.
In 1926, the United States Army Air Corps used a converted airplane to transport patients from Nicaragua to an Army hospital in Panama, 150 miles away. The routine interhospital military use of airplanes1 dates to World War II, as does the first air evacuation of U.S. soldiers from the site of injury, which occurred in what was then Burma.
The routine medical evacuation mission of helicopters, however, evolved unintentionally during the Korean conflict in the 1950’s. Because roadways in the fighting front of Korea were often rough and indirect, they could not be relied upon for the rapid and gentle evacuation of troops to the field surgical units. Instead, helicopters on other missions would be rerouted to pick up the critically wounded and fly them quickly and smoothly, often in time to benefit from life- or limb-saving surgical care.
The Army, seeing this advantage over ground transportation, rapidly began testing dedicated medical helicopters. During the course of the war, over 22,000 troops were evacuated by helicopter. It is felt that rapid, smooth field evacuation and the specialized skills offered by surgeons seeing hundreds of patients earlier at the field hospitals contributed to a reduced mortality rate for wounded, hospitalized soldiers, compared with previous wars.
The Viet Nam conflict brought further sophistication to the same general concept: fast and smooth air evacuation of the critically injured to field surgery for stabilization. The aircraft changed, as did medical capabilities. Field emergency care and rapid evacuation for over 800,000 troops reduced the war-long mortality even further.
A theme from WWI through Viet Nam began to repeat: stabilize the critically wounded soldier in the field, provide advanced care enroute, and get the patient to a trauma-qualified surgeon in less than an hour, and the extent and impact of injury, including the likelihood of death, can be reduced.
In 1966, the landmark National Academy of Science white paper Accidental Death and Disability: The Neglected Disease of Modern Society underscored the profound impact of death and disability caused by injury, particularly car crashes. It also detailed a lack of coordinated response to injury, including the observation that “Helicopter ambulances have not been adapted to civilian peacetime needs.”
The National Academy of Science white paper contributed substantially to the development of the modern EMS system and its trauma care subsystem. Its impact was compounded by the influence of returning military units, and military medical helicopter pilots discharged to law enforcement and other public safety flying roles. These led to the dual-purpose adaptation of military and public safety helicopters to the evacuation of injured civilians, such as the Military Assistance to Safety & Traffic (MAST) program, established in 1970, and the Maryland State Police aviation program which in March, 1970, became “the first civilian agency to transport a critically injured trauma patient by helicopter.”
The first civilian hospital-based medical helicopter service was established in 1972 at St. Anthony’s Hospital in Denver, Colorado. By 1980, some 32 helicopter emergency medical services (HEMS) programs with 39 helicopters were flying more than 17,000 patients a year. By 1990, this grew to 174 services with 231 helicopters flying nearly 160,000 patients. Ten years later, 231 helicopter services with 400 aircraft were flying over 203,000 patients each year.10 By 2005, 272 services operating 753 rotor-wing (helicopter) and 150 dedicated fixed wing aircraft were in operation. There are now approximately a half-million helicopter and fixed wing transports each year.
Historically, the typical helicopter EMS service has been operated by or affiliated with a hospital with one or two aircraft. In the past decade, many of these services have become independent, community-based resources with hospital affiliations. The rapid growth of AMS, particularly in the late 1980’s and again in the last 5 years, can be attributed to changes in the overall health care system. The need to quickly bring critically injured patients to surgical care brought AMS (mainly medical helicopters) into existence. In more recent years, the closure of rural hospitals because of reimbursement and other financial pressures, or their conversion to Critical Access Hospitals (CAH’s) with reduced services and fewer specialist physicians, has created large geographical gaps in the availability of specialized surgical resources. Unfortunately, these rural areas are also the location of the most serious car crashes and are where 60% of fatal crashes in the U.S. occur, a rate nearly double that of similar accidents in suburban or urban areas.
The use of aircraft with skilled medical crews helps to close these gaps and improves access to specialist care. As more time-dependent medical treatments (e.g. “clot-busting” drugs, angioplasty, or surgery for heart attacks or strokes) have been shown to improve patient outcomes, the absence of specialty care and physicians in these same areas continues to contribute to the increased use of aircraft to get patients rapidly to these life saving treatments at specialty hospitals.
Research in the early 1970’s reinforced the notion held by wartime physicians that, for the critically injured patient, surgical intervention in the first hour after injury was crucial. The notion of this “Golden Hour” has survived, with minor variation, to the present day. With this influence, the Accidental Death and Disability…white paper, and the fresh experience of military medical helicopter success in this arena, it is understandable that civilian HEMS adopted trauma as its predominant mission in its early years.
It is estimated that there are around 400,000 helicopter EMS missions flown each year. There are an additional 100,000 – 150,000 fixed wing medical flights each year. In 2002, there were roughly 400 dedicated EMS helicopters. At the close of 2008, there are a little more than 800 flying EMS missions. Valid reasons exist for the growth in air medicine that are specifically linked to the changes in the overall healthcare system. The top three include:
1. An aging demographic.
According to the US Department of Health and Human Services, “It was estimated that in 2000 there were 605 million persons worldwide aged 60 years or older. This number is projected to increase to almost 2 billion by 2050.” This trend is particularly noticeable in the US, with a rapidly increasing aging population, especially in rural areas. The medical needs of this population demographic are reflected in the growing rates of trauma, as well as the increased occurrence of time-dependent diseases such as heart attack, stroke, and non-trauma surgical emergencies such as gastro-intestinal bleeds.
2. Closure of emergency departments and hospitals, as well as local, community-based ambulance services.
According to the American Hospital Association, emergency departments in community hospitals have declined from just over 5000 in 1992 to approximately 4600 in 2002, a trend that is expected to continue. As a result, air medicine is becoming the health care safety net and access point for many rural individuals and communities.
3. Changes in the delivery and availability of rural healthcare.
Rural hospitals have been undergoing a rapid change in mission and structure during the last 50 years. In an effort to help maintain a sufficient number of hospitals, the Centers for Medicare & Medicaid Services has developed the Critical Access Hospital program which pays full cost for Medicare beneficiaries. This has come in exchange for structural changes in the hospital, which include reducing beds to 25 or fewer and shortening average length of stay to less than 96 hours. The expected result is to keep hospitals open, which is a tremendous benefit to rural communities. However, it also leads to a concurrent need to transfer complex patients to distant trauma and tertiary care centers, requiring a rapid and even more sophisticated medical transport system.
Higher Level of Care
Helicopter emergency medical services (HEMS) are integral to the US healthcare system for several reasons:
The crews aboard air ambulances provide more than the advanced-life-support-level medical skills and equipment found on ground ambulances. In addition, they bring the additional skills, equipment and supplies of a tertiary hospital, including more advanced drugs, and more sophisticated critical care medical skills whenever they respond to a community hospital, to the scene of an injury or accident, or to a pre-planned rendezvous point with a ground ambulance (a common practice for fixed wing, or airplane, air ambulances). This higher level of care is especially important in rural areas, which may have few advanced-life-support ground ambulances to call upon. The current configuration for the medical crew on board advanced-medical-support units is most typically a specially trained critical care nurse and paramedic. Other specialist caregivers or physicians may be added to the team as needed. This configuration effectively initiates tertiary hospital care directly at the patient’s bedside, whether at the
scene of an emergency or at a community hospital. Almost exclusively, the AMS team handles the most critically ill and injured patients. The benefits of air transport have been demonstrated to outweigh any stressors that flying might add, even for the sickest trauma and, notably, heart attack patients.
Speed, Access and Better Patient Outcomes
Helicopter air ambulances are used to transport patients from the emergency scene to a hospital, and for shorter flights between smaller hospitals and trauma centers or specialty hospitals (burn or cardiac centers, for instance). Fixed wing air ambulances (airplanes) are used for transporting patients on longer inter-hospital flights.
Air medical transport is beneficial not only because it provides a higher level of medical care to the patient en-route, but also because it provides speedier response and travel times. When treating the critically ill or injured, it is always important to minimize the time spent delivering a patient to a physician’s direct care. Helicopters fly point-to-point, minimizing the distance traveled and avoiding the traffic delays experienced by ground ambulances.
Patients isolated from ground EMS or trauma centers by distance, lack of ambulancepassable roads or by terrain features such as mountains, canyons, forests, and bodies of water, benefit greatly from air medical service. Helicopter EMS is also a timesaving way to avoid urban and suburban traffic congestion.
Patient Conditions and Transport Selection
Following are the top three patient conditions most often associated with Helicopter Emergency Medical Services (HEMS):
• Cardiac Care/Myocardial Infarction: Several studies suggest that the scarcity of cardiac intervention centers have resulted in a greater need for HEMS in quickly transporting cardiac and cardiac-arrest patients, particularly outside of urban areas.
• Cerebrovascular Accidents/Strokes: As with heart attacks, only a short window of time exists in which anti-thrombotic treatment can result in patients suffering little to no long-term damage and disability. That treatment window is optimally within 90 minutes but generally no more than three hours. Therefore, patients transported to specialty centers for the treatment of strokes can benefit from a well-coordinated ground and air system to accomplish early transfer.
• Critical Trauma: Scene responses (i.e. motor vehicle crashes, stabbings, shootings, etc.) constitute 33% of HEMS missions. Medical studies have revealed correlations between HEMS transports and improvements in traumarelated
mortality and morbidity. As a part of an organized trauma system, HEMS reduces the injury-to-operating-room time significantly. HEMS discourages time-costly intermediate stops at small non-trauma center facilities. Such stops have been shown to be detrimental to trauma patients.
• Other conditions that may warrant air medical transport include:
o High Risk Obstetrics/Neonatal Care: When a pregnant woman or fetus experiences complications, these can be life-threatening for both mother and child.
o Complex Pediatrics: Children are very resilient patients who often do not show signs of a severe illness or injury until they are close to death, at which point they suddenly deteriorate. When this occurs, they require
access to neonatal and pediatric intensive care units, which are becoming increasingly limited.
o Complex Surgical and Medical Conditions: Air medical service is indicated for a number of other time-critical patient conditions. Examples of these include aortic aneurysms, poisoning or overdose, organ transplantation (movement of patients and organs), and respiratory complications requiring ventilator support. In addition, HEMS is often required when emergency kidney-dialysis is needed or when carbon monoxide poisoning or diving-related incidents have occurred.
Focus on Safety
Safety is the highest priority for air medical crews. After all, these are the people at work aboard the aircraft. However, providing these lifesaving services is not without risk. AAMS works closely with the Federal Aviation Administration (FAA), the National Transportation Safety Board (NTSB), and Congress to manage that risk for the sake of the crews and patients.
In recent years, special focus has been placed on advances in safety management systems, aviation technologies, and crew training. Numerous aviation technologies have been refined and incorporated into many air medical programs’ operations. Among these technologies are night vision goggles (NVSs) and enhanced vision systems, radar
altimeters, GPS navigation, satellite tracking, and, more recently, helicopter terrain alert warning systems (HTAWS). Survivability gear, which includes such products as fire retardant flight suits, helmets, eye protection, and satellite phones, also has become the standard for most air medical programs across the country.
In addition, enhanced crew and safety management systems have become a part of the everyday operation of air medical systems. Often referred to as Air Medical Resource Management (AMRM), such systems greatly improve both safety and efficacy on air medical missions by enhancing the ability of aviation personnel, flight crew, ground based communication staff, and management to interact proactively on a mission-tomission basis.
Safety management systems further help companies track incidents, identify issues, and solve problems before they happen or become system-wide mistakes that lead to tragedy. Some of the most important advances have been made in risk-management models. These simple management tools help pilots, crews, and managers determine
what environmental conditions are acceptable and greatly enhance the management of risk across air medical systems both large and small. While numerous advances and improvements have been made in air medical services
safety, more remains to be done, particularly with regard to the nation’s existing aviation infrastructure.
Currently, low-altitude aviation vehicles – including helicopters that perform such off-airport operations as air-medical, law-enforcement, firesuppression, and search-and-rescue missions – do not have access to certain
components of the aviation infrastructure, which was built specifically for scheduled, commercial airlines.
CAMTS accreditation is voluntary. However, several states and some governmental agencies have accepted or required CAMTS Accreditation for licensing, contracts or reimbursements.
Accreditation begins with an application form. The form indicates the service’s intentions to complete the process. The service then receives a Program Information Form (PIF). The PIF consists of a demographic section, a list of bases and a self-evaluation of the service, based on the CAMTS Standards. Response to the PIF self-study also requires attachments that include policies, education materials, quality management and safety processes. The PIF and attachments are submitted electronically within a year of applying for accreditation.
Once the PIF is complete and returned to the CAMTS office, it is reviewed by the CAMTS staff for completeness and sent to two Board members who will review contents for completeness and for additional questions that they document for the site surveyors. Site surveyors are then appointed, based on their experience and background related to the type of service (air/ground; fixed/rotor; critical care, ALS/BLS ground, etc.) they will visit.
The site visit is then scheduled at a time agreeable to both the service and site surveyors and at least 1 month prior to a Board of Directors meeting in order to be placed on the agenda for an accreditation decision. Once onsite the surveyors will conduct a series of interviews of personnel, look at training records, quality improvement programs, safety policies, etc. Their comments and observations are documented for the two Board members who present the program anonymously to the full Board. The programs are always presented by a six digit number – proper names and specific locations are not known by the full Board. If a Board member has a conflict of interest – he or she is excused while the program is presented and the Board deliberates.