Special Report: Helicopter Shopping and the Interfacility Transfer of Patients
SPECIAL REPORT
Helicopter Shopping and the Interfacility Transfer of Patients
By Mark J. Greenwood, DO, JD, Flight Physician, Aero Med Spectrum Health;Grand Rapids, MI
A rural hospital contacts an air medical service (AMS) provider to transfer by helicopter a patient with blunt trauma. The distance between the sending and receiving facility is 75 miles. The "Life Flight" helicopter crew receives the request at 00:00, and departs their base at 00:20. They abort the flight at 00:40 hours, 10 miles from the sending facility, because the cloud ceiling drops to 700 feet, 300 feet below the Federal Aviation Administration (FAA) minimum for night flight by helicopters. The sending facility then calls another AMS provider and requests that the patient be transported to the same receiving facility. They do not report the circumstances of the first provider's failed transport attempt. The second provider agrees to the flight because all of the weather reports-and those reviewed by a pilot at the company's national dispatch center-indicate that the cloud ceiling was at least 1,000 feet. The helicopter is able to reach the sending facility. They depart the sending facility with the patient at 02:00. At 02:05, prohibitive weather, of the same kind and in the same geographic area as encountered by the first provider, forces them to return to the sending hospital. The transfer is performed by ground ambulance, and the patient arrives at the receiving facility at 03:30.
Defining the Term
Requests to transport a patient by helicopter are made directly from the scene of illness or injury by emergency medical service (EMS) providers, or by health care providers who want to transfer a patient between health care facilities. When an AMS is called but is unable to transport the patient-a frequent occurrence because of weather conditions that prohibit flight-persons making the request may "shop" for services by calling other AMS providers. If the person making the request does not share the information that another provider was called but the provider either chose not to attempt the flight or to abort the flight while enroute, then this information is excluded from the aviation risk assessment performed by the pilots of the subsequently called AMS providers. In its most egregious form, the information may be "consciously omitted [by those making the] request with the hope that another aircraft might try nonetheless."1
Thus, "helicopter shopping" refers to the practice of calling, in sequence, different AMS providers to transport a patient, and continuing doing so until an AMS provider accepts the flight. The term, as used currently, implies that the person making the request is not forthcoming to subsequently called AMS providers about another provider's determination that hazardous weather conditions are present, and that these conditions caused them either to refuse to accept the flight request, or to abort the flight while enroute.
Helicopter shopping, because it has been found to be a contributing factor in a number of recent fatal EMS helicopter crashes,2 has become the subject of recent scrutiny by many organizations including the FAA,2 the National Transportation Safety Board,3 the National Association of EMS Physicians,4 the National Association of State EMS Officials,4 the American College of Emergency Physicians,5 and various air medical safety organizations.1,6 Because of its association with fatal crashes, the term has developed only negative connotations, which may have unintended consequences in the management of patients who benefit from being transferred by helicopter. The purpose of this article is to accurately define the term "helicopter shopping" and clarify how and when the practice may be appropriate. Sending facilities, if reluctant to call more than one AMS provider, will forfeit unnecessarily the opportunity to use a helicopter as a transport resource, and in doing so risk failing to comply with the laws that govern interfacility transfer (IFT).
Interfacility Transfer: Ground Ambulance or Helicopter?
In nearly every IFT, transport by ground ambulance is an option, and deciding to transport a patient by helicopter instead implies that the sending facility assessed the risk-benefit criteria for each different mode of transport. Medical decision making about IFT is difficult even under the best of circumstances. But decision-making is further complicated when helicopter transport is indicated, but weather conditions are "marginal." There may be specific geographical areas of prohibitive weather, either localized and isolated, or widespread, and aviation-related factors are, like a patient's medical condition, exceedingly dynamic. In particular, weather conditions-and reporting of weather conditions, which themselves may be inaccurate, (or in some geographical areas, absent) may change, and the changes may be unforeseeable.
Careful consideration of the benefit and risk of AMS transport versus ground ambulance transport is essential for sending facilities not only to provide appropriate patient care, but to comply with regulations that govern transfers. In particular, rules under EMTALA must be kept in mind by the sending facility:
for appropriately determining (and certifying) that the medical benefits expected from the transfer outweigh the risks;
for assuring that no material deterioration of the patient's condition is likely to occur during transfer;
for providing ongoing care within its capability until transfer to minimize transfer risks, and
for assuring that the transfer be made with qualified personnel and appropriate medical equipment.
Further, appropriate IFT requires that the risk versus benefit for helicopter transport be re-assessed, as information is obtained during the course of patient care and while mobilizing transfer resources.
Context of Interfacility Transfer by Helicopter
Two recent changes-one economic and the other medical-have led to the practice of "helicopter shopping." A change in reimbursement structure "dramatically changed ... [and] was followed by extraordinary growth in the number of AMS providers throughout the country. As a result, the number of medical helicopters then more than doubled, from under 400 in 2000 to over 830 today. Further, the predominant model has changed to private, for-profit operators of independently based helicopters instead of non-profit hospital-based or governmental helicopters."7
Historically, AMS providers were facility-based, such that only the largest of hospital systems owned or operated helicopter services. And the service was provided to well-defined and exclusive geographical areas. For sending facilities in the AMS provider's service area, if the provider was unable to accept the flight or aborted the flight request, transport by another AMS provider was not an option; the patient would be transported by the local ground ambulance, critical care team by ground ambulance, or simply not transferred at all. Helicopter transport, if it happened at all, would occur later, but only as indicated according to the patient's condition, and as weather conditions improved.
Where there were once well defined, exclusive service areas, many geographic locations now are served by multiple programs. In areas served by multiple AMS programs, it is natural, and so expected, that an EMS provider on scene, or a person from a sending hospital facility, will in succession request transport by helicopter from AMS providers who have bases nearby.
The second change leading to the practice of helicopter shopping, though less significant a factor than the first, is the increase in need, for medical reasons, by sending facilities to transfer patients by helicopter. Adding to the traditional indications for IFT by helicopter-trauma, critical care and other specialty services-are conditions that are time-sensitive, where definitive treatment is either best provided, or only available, at regional centers. Treatments for "time-sensitive" conditions include intracoronary interventions for ST segment elevation MI, and interventional procedures for stroke and subarachnoid hemorrhage.
"Helicopter Shopping" by Sending Facilities
Though the increase in number of AMS providers means greater opportunity for sending facilities to transfer patients by helicopter, the increase in AMS providers has led to unhealthy competition among neighboring AMS providers. With growth in AMS providers reaching the limits of what the market will allow, has come economic pressure to perform transports. And the stakes are significant. If the number of flights needed to continue to operate new programs or bases, or to continue operations of established programs or bases, then failure to be profitable may result in loss of employment for crewmembers. Together with increased competition, are contractual arrangements and affiliations-between sending facilities, receiving facilities, and AMS providers-that may further complicate risk-benefit assessment and complicate, if not negatively impact, medical decision making. Finally, in contrast to scene flight requests by EMS providers, IFT are usually not monitored by any type of regional EMS, so hospitals are in a position to earn their reputations as being "the most aggressive of all 'helicopter shoppers.'"
Safety in IFT by Helicopter: Whose Responsibility?
If one helicopter is unable to respond to a request for transport, or aborts a flight while enroute, another helicopter may be able to complete the flight without subjecting the patient to undue aviation-related risk. This is because certain AMS providers may not be able to accept or complete a flight due to local weather conditions, but subsequently called providers may be able to complete the flight without encountering those weather conditions, simply because of a different geographic location. So, to not call another AMS provider simply because one provider was unable to complete the flight would be to miss the opportunity to take advantage of the benefits of helicopter transport. The goal then is to develop procedures, not to eliminate the practice of "helicopter shopping" per se, but to ensure that it is done in accordance with standards that mitigate risks related both to aviation and medicine.
To mitigate aviation-related risk requires that all persons involved in IFT decision making act in accordance with standards that reinforce a culture of safety. Criticism in cases of IFT by helicopter that resulted in crashes-many resulting in multiple fatalities-has focused on poor communication between sending facilities and AMS providers. Consequently, steps have been taken to mitigate aviation risk by encouraging communication between those who request helicopter transport and the AMS provider. For example, even the FAA has acknowledged the role that non-aviation persons play in aviation risk management. In a letter addressed to each state's department of EMS, the FAA made recommendations that are no less relevant, and perhaps even more so, to sending facilities. They directed that procedures be developed to:
"ensure that, after an EMS operator has refused a flight assignment, subsequently called operators are made aware of the circumstances surrounding the first (or subsequent) operator's refusal(s). This will ensure that the best decisions are made at the operator level, and that only flight assignments that can be conducted safely will be accepted. Rather than have the dispatcher attempt to determine if the reason(s) for refusal are material to subsequently called operators, EMS dispatchers should pass along the reason(s) for refusal to all subsequent requests to operators for the affected flight request."2
And if the "circumstances surrounding" a prior request involves a flight that was aborted because of weather conditions encountered while en-route-that is, conditions not identified either by forecasting or in reports of current weather conditions-then this information would be particularly important to share, as it would be highly relevant for aviation-related decision making by the AMS provider. The Commission on Accreditation of Medical Transport Systems has produced a DVD, "Hazards of Helicopter Shopping," that describes an actual event that resulted in a fatal accident, and what types of communications are necessary to avoid such results. It is available from the CAMTS website: www.camts.org.
To mitigate medical-related risk in IFT requires careful risk-benefit analysis as required under EMTALA and which encompasses considering factors such as mode of transport, choice of destination, and the extent that stabilization should occur before transfer.
Conclusion
Although the request for transport of a patient by subsequent AMS providers, following a refused or aborted flight by the first AMS provider, is rightly considered "an inherently hazardous event," "helicopter shopping" need not have negative connotations. This is provided that procedures are in place that address the dynamic and intertwined risks related to aviation and medicine. And though AMS providers must decide if conditions allow for safe flight, and must rely on sending facilities to share information responsibly, it is the sending facility that ultimately must decide whether the risk of foreseeable or unforeseeable delays associated within calling one or more AMS providers outweigh the benefit of other transfer options.
References
1. RP5-To Discourage Helicopter/Fixed Wing Shopping by EMS or Medical Providers and provide a Method of Information Sharing; Air Medical Safety Advisory Council www.amsac.org/recommendedpractices_draftRPS_Final.asp. (Accessed June 6, 2009.)
2. Ballough JJ. FAA Letter to State EMS Directors (From the model letter to be used by state EMS officials for distribution to local EMS provider agencies). www.ntsb.gov/Dockets/Aviation/DCA09SH001/410507.pdf. Accessed June 6, 2009.
3. Issues on Emergency Medical Services (EMS) Helicopter Operation Safety: Public Hearing. National Transportation Safety Board Office of Aviation Safety, Washington, D.C.; February 3-6, 2009. http://www.ntsb.gov/events/Hearing-HEMS/default.htm. Accessed June 7, 2009.
4. Air Medical Services: Future Development as an Integrated Component of the Emergency Medical services (EMS) System: A Guidance Document by the Air Medical Task Force of the National Association of State EMS Officials, National Association of EMS Physicians, Association of Air Medical Services. Prehosp Emerg Care 2007;11:353-368.
5. Statement from the American College of Emergency Physicians on Air Medical Safety. www.ntsb.gov/Dockets/Aviation/DCA09SH001/410414.pdf. Accessed June 6, 2009.
6. Position Paper on Helicopter Shopping; Principle Author: Cliff Larrabee. International Association of Flight Paramedics. www.flightparamedic.org/docs/HelicopterShopping.pdf. Accessed June 6, 2009.
7. Summary Position Statement of The National Association of State Emergency Medical Services Officials (NASEMSO) on the Need for Shared State and Federal Regulation of Air Medical Services. www.ntsb.gov/Dockets/Aviation/DCA09SH001/409995.pdf. Accessed June 7, 2009.
A rural hospital contacts an air medical service (AMS) provider to transfer by helicopter a patient with blunt trauma. The distance between the sending and receiving facility is 75 miles. The "Life Flight" helicopter crew receives the request at 00:00, and departs their base at 00:20. They abort the flight at 00:40 hours, 10 miles from the sending facility, because the cloud ceiling drops to 700 feet, 300 feet below the Federal Aviation Administration (FAA) minimum for night flight by helicopters. The sending facility then calls another AMS provider and requests that the patient be transported to the same receiving facility.Subscribe Now for Access
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