ITIJ Air Ambulance Review March 2019

AIR AMBULANCE

March 2019 Issue

International Travel & Health Insurance Journal

REVIEW

Apples and oranges - P04

Pricing in the global air ambulance industry – what’s fair?

Brains, planes and automobiles - P14 Traumatic brain injury transports

The Air Ambulance Consumer

Stronger together - P28

Shielding patients from huge bills

what do these mean in practice?

Protection Act - P26

Provider partnerships –

Accreditation news - P22

The latest from EURAMI, CAMTS and NAAMTA + More Inside

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AIR AMBULANCE REVIEW

CONTENTS Apples and oranges - 4 Pricing in the global air ambulance industry – what’s fair?

Interview: Mark Jones, CEO and Founder of Air Ambulance Worldwide - 24 The Air Ambulance Consumer Protection Act introduced in the US - 26 The Act aims to shield patients from huge air ambulance bills not covered by insurance policies

SAFETY: The #1 priority - 10 ER24 explains what it takes to guarantee patient safety in aeromedical transfers, and asks if there remains more to be done

Stronger together - 28 Provider partnerships – what do these mean in practice?

A complex mission - 12 Air Alliance completed an AV ECMO transfer in Europe Brains, planes and automobiles - 14 Traumatic brain injury transports In the time of duty - 38 AirCARE1 shares details of a timesensitive transfer With military precision - 40 AirLec Ambulance evacuated a patient from a warzone Accreditation news - 22 Rounding up the latest news and views from the organisations that accredit international air ambulance services

The information contained in this publication has been published in good faith and every effort has been made to ensure its accuracy. Neither the publisher nor Voyageur Publishing & Events Ltd can accept any responsibility for any error or misinterpretation. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or firm mentioned is hereby excluded. The views expressed do not necessarily reflect

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those of the publisher.

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The first ITIJ Air Ambulance Review to be published this year, considers whether pricing is fair in the international fixedwing air ambulance business – typically, we found that it really depends on who you are talking to with regards to opinions on this! Payers might wish for lower medical evacuation costs, but when a person’s life is at stake, the quality of the provider flying such missions is what matters most, and in the air ambulance sector, as in life, you get what you pay for.

ITIJ has often written about the dangerous practice that some tourists – mostly in Europe – partake in: balconing. This is resulting in horrific head injuries, and air ambulance companies are being asked to transport patients with traumatic brain injuries around the world. Such flights need careful consideration and preparation – Dr Simon Forrington of Capital Air Ambulance explains best practice in this area on p14.

Elsewhere, industry experts have contributed case studies and opinion pieces to inform and educate readers on all matters medevac.

Enjoy!

Mission accomplished - 42 AMREF reports on an evacuation from Yemen to Jordan

Editor-in-Chief: Ian Cameron Editor: Mandy Langfield Copy Editors: Sarah Watson, Stefan Mohamed, Lauren Haigh & Robyn Bainbridge Contributor: James Paul Wallis Designers: Robbie Gray, Tommy Baker, Will McClelland Advertising sales: James Miller, Kathryn Zerboni, Marlon Stanley

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EDITORIAL COMMENT

Mandy Langfield Editor

Printed by Pensord Press Copyright © Voyageur Publishing 2019.

Materials in this publication may not be reproduced in any form without permission INTERNATIONAL TRAVEL & HEALTH INSURANCE JOURNAL ISSN 2055-1215

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FEATURE

APPLES AND ORANGES Pricing in the air ambulance industry Does a variation in pricing in the international fixedwing air ambulance industry reflect differing quality of providers, or are some providers simply making more profit than others? James Paul Wallis reports

I

t’s no secret that international air ambulance flights are not cheap. While the healthy size of the sums that insurers and assistance companies regularly pay providers may be common knowledge in the industry, the mainstream media all too often features scare stories of uninsured travellers languishing in foreign hospitals while they try to crowdfund the cost of a flight home on a medical aircraft.

The prices are high, but are they fair? It’s a topic that is regularly discussed within the industry, not least at the various International Travel & Health Insurance Conferences (ITICs) that take place around the world.

Last November at ITIC Global in Geneva, for example, Dr Bettina Vadera, Chief Executive and Medical Director of AMREF Flying Doctors, Kenya, shared a stage with industry 4|

veterans Andy Lee and Julie Remmington to discuss the balance between quality and cost.

Both Lee and Vadera highlighted that quality and cost are linked, and that not all providers offer the same level of service.

Such discussions can raise comments that touch on seemingly contradictory viewpoints that (with slight exaggeration) on the one hand, these missions are cash cows that are potentially lucrative enough to lure in the cowboys who cut corners and reap huge rewards; while on the other hand, it is a pricesensitive market where even large operators with multi-aircraft fleets must work hard to maximise plane usage in order to make ends meet. To shed some light on the issue, ITIJ spoke to international fixed-wing air ambulance providers around the world for their take.

AIR AMBULANCE REVIEW

FEATURE

Highly competitive For Hemma Niederegger, Project Manager, Sales and Marketing at Tyrol Air Ambulance of Austria, the air ambulance industry is not an easy dollar – rather, providers need to keep a lid on costs: “The air ambulance industry is a very competitive industry, especially in Europe, and therefore there is a certain price pressure on the providers.” While this might seem to favour unscrupulous, cut-price providers, Graham Williamson CEO at LIFESUPPORT Air Medical Services, reflects that ‘racing to the bottom’ is not sustainable: “The providers we see come and go typically enter the business to compete on price. They lack quality and they lack accreditation. The result is their quick entry into, and often rapid exit from the market.” However, Niederegger suggested that companies that make the effort to offer a high-quality service might not find it easy to raise their prices to match: “Further price pressure arises because not every air ambulance company adheres to the same medical standards. This is due to the fact that even within the European Union, there is no

A provider with lower standards may hire pilots who are less experienced and charge a lower salary uniform legal basis regarding the quality criteria for medical patient transports. This results in different levels of investment, which also influences the pricing of providers.”

Asked whether established providers have similar fees for similar missions, Eva Kluge of Air Alliance, which has bases in Germany, Austria and the UK, told ITIJ: “In principle, yes, at least for the same types of aircraft.

Pricing depends also largely on where the aircraft is located (time to patient) and how

Price pressure arises because not every air ambulance company adheres to the same medical standards long the mission will be. If a routing is 30-60 minutes shorter, it can make quite a difference in the quote. Variable costs (fuel, permits, etc) are more or less the [same] for everybody.”

The only real way to lower costs, said Kluge, is to reduce funding on niceties such as staff and training – not necessarily areas where an insurer might want their air ambulance partner to skimp on investment: “You cannot save that much on the aircraft. However, a provider with lower standards may hire pilots who are less experienced and charge a lower salary. They may also try to save on medical equipment (using older or expired models) [or] on team training, and they may use cheaper medical staff with lesser qualification: doctors or nurses/paramedics who are not clinically current are an example.”

Paul Tiba, Managing Director of France’s Airlec Air Espace, also stated that staff investment makes up a significant contribution to providers’ costs: “As far as we are concerned, in France, the main challenge is the employees’ cost. I strongly believe that it will be a more and more tight job market for both [talented]/specialised medical doctors and experienced pilots. We decided not to compromise our highest standards of quality and to follow the market.”

The advantage of eschewing such ideals and instead minimising investment is that a provider can afford to undercut its competitors to attract business or charge the going rate and enjoy a higher profit margin. However, in the long run, there is a clear and present downside to the dimestore strategy, said Kluge: “All this is putting the patient’s safety at risk and will cause – sooner or later – a loss of reputation for the provider.”

On another note, Tiba suggested that it’s not only a difference in quality that may result in a difference in pricing. There could be other factors that mean that providers are not competing on level terms, he suggested: “Different social regulations also bring [a] lot of unfair competition. For instance, it is totally forbidden to hire freelance pilots for commercial operations in France, while other countries

>>

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AIR AMBULANCE REVIEW

appreciate it.” Perhaps more surprising is the suggestion that some providers are able to endure despite, in fact, not being able to make ends meet, instead using just their income from flights. Tiba revealed: “I do not think everyone has fair prices, but I understood some are making more loss (not profit!) than others. I would even suggest that some have been dumping for several years. Some others are receiving massive subventions and donations and it is somewhat unfair and creates distortion in competition.”

There are many ways to respond to demands of competition. One would be to strive to offer a better service for a lower price; another is to lean on transparency in the offering and the pricing structure. One example of a provider with a clear-cut structure to calculate prices is US-based AMR Air Ambulance. Jay Paladino, General Manager, explained: “With regards to pricing, we generally use a fixed rate per mile and a ‘base’ rate (commonly referred to as a launch fee). We do this because with US insurance, this is how plans are setup to pay. The mileage rate is based upon loaded miles.”

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FEATURE

Due diligence Returning to the question of quality, there’s an onus on purchasers to do their homework and not simply buy the proverbial ‘pig in a poke’.

Kluge commented: “Any assistance company should adhere to a strict aeromedical vetting process in order to avoid black sheep and to compare apples with apples.” Speaking to ITIJ in the capacity of an independent consultant,

Andy Lee recognised that buyers rightfully look for a best deal, but added that all too often, operators lose flights because payers don’t take the necessary due diligence steps to understand the benefits available from the more expensive quote, such as a higher level of insurance indemnity for aircraft and medical malpractice. ‘The provider with the higher quote may have spent more on flight crew and medical team validation training’, >>

AIR AMBULANCE REVIEW

he added, and may be offering an aircraft that is more appropriate for the mission. The tension between cost and quality is not new, and Niederegger doesn’t see it improving: “We have noticed a trend emerging where more importance is being placed by the customer on the price and quick handling of the mission than the patient’s wellbeing and the medical checks necessary to ensure a risk-free transport.”

Indeed, Andy Lee believes that until there is ‘a level playing field with an agreed standard across the industry’, the pricing variation will continue. It has to be said that creating a truly level playing field would require some fairly big steps. Lee suggested that the key would be to have a single, industry-regulated standard that applied across the board. To achieve that, he said, ‘you would need payers to become more aware of what they are paying for and whether it is the best option to mitigate risk to the patient during transfer; the accrediting bodies to agree on a minimum standard; and payers to come together and agree to only use accredited operators’. He added: “This, in my opinion, means insurers/assistance companies would make a judgement on the service to be used on availability, positioning and price, knowing that the operators are

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FEATURE

all similarly compliant with an agreed standard.”

Such moves may be some way off and working against such co-operation are the pressures of competition – and also, perhaps, a desire for freedom of choice among both the payers and the providers, not all of whom want to sign up

any assistance company should adhere to a strict aeromedical vetting process to an accreditor, even if they have the quality to make the grade. In the meantime, forums such as ITIC ‘offer a way to take steps in the right direction’, said Lee, who referred to the Air Ambulance and Medical Assistance Forum that took place in Geneva at ITIC Global and saw insurers and assistance companies present mission case reports together with air ambulance operators. Lee explained: “This was

the first time this has happened and should continue [at ITIC Global] in Malta this year, as dialogue creates understanding and helps form trust in a relationship.”

Considering all this talk of competition and cowboys, does all this mean that prices from reputable providers are already at rock bottom with little or no wiggle room for offering reduced rates to reward valued clients or to entice new customers? Niederegger confirmed that the scope for discounts is ‘very limited’.

However, there are some circumstances where prices can be lowered, she noted: “An example would be so-called ‘empty legs’, where a provider’s aircraft is positioned at a location after finishing a mission, and another patient happens to be awaiting transport either at the same location or en route to base.” So, there may be the occasional opportunity for an insurer to save a bit of money on an air ambulance flight, but in reality it seems that in the air medical world, as with everything else really – you get what you pay for. ■

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INDUSTRY VOICE

SAFETY: THE #1 PRIORITY Dr Robyn Holgate, Chief Medical Officer of ER24, explains what it takes to guarantee patient safety in aeromedical transfers, and asks if there is more still to be done

P

atient safety forms the basis of any clinical quality performance review nowadays.

Since the 1999 report by the Institute of Medicine (USA), titled To Err Is Human, which estimated that as many as 98,000 patients die annually from preventable medical errors, many hospital-based healthcare providers are focusing on improving patient safety efforts. Growing financial pressures globally are forcing us to reexamine how we can better provide improved value in aviation medicine. These trends of more affordable service delivery are becoming the new norm. In light of these cost constraints and affordable healthcare solutions, are we doing enough to promote patient safety and clinical quality in the aeromedical environment?

A small error in judgement could change the health of a country, hence it is critical that we implement systems within our aeromedical environment to keep our borders, healthcare providers and patients safe.

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Check please The healthcare sector initially looked towards the aviation industry to assist and implement checklists for our patient safety initiatives.

No doubt checklists have been instrumental and invaluable in assisting us to achieve our patient safety goal of preventing human error in healthcare. Examples include Emergency Medical Care and Resuscitation checklists and the recent surgical safety checklist by the World Health Organisation. In our own aeromedical environment, we have implemented checklists to manage equipment, pre-flight, in-flight and postflight checks and these checks have decreased the incidence of near misses. I recall a flight many years ago where I forgot the monitor; forgivable at 2 a.m.? Fortunately, the flight was without incident. Checklists, discipline and teamwork that we have adapted have formed a critical part of all our patient safety initiatives at ER24 Global Assist. In order to ensure patients

received the safest, most reliable care, we needed to move beyond a mechanical type environment with checklists to an integrated Quality Improvement programme which embraced the opportunity to provide compassion, dignity, discussion and empathy for our client base.

Our programme thus includes a culture of safety, adverse event management, medication safety, teamwork and communication, trigger tools, and much more. For example: weekly safety meeting/team interactions, combined safety training and attending crew resource management sessions.

Checklists have been instrumental and invaluable in assisting us to achieve our patient safety goal Confidentiality We have a confidential reporting system for adverse events, and the emphasis during our reviews has shifted from a traditional model of blame to that of a just culture. Following adverse events where a trend is identified, we have taken to releasing patient safety alerts internally. The very nature of our emergency business lends itself to adverse events, the human factor ever-present. Examples of recent adverse events include dispatch delay and medication error. Although we record less than one per cent of call volume as adverse events, less than international trends, we take every reported incident seriously, with the ultimate goal being to conclude our investigation and implement improvements to avoid a recurrence of such events. One such example is a recent adverse event where an opioid analgesic was used in place of Adrenaline

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INDUSTRY VOICE

Where to next for patient safety initiatives?

(Epinephrine) in an infusion; fortunately without any adverse effect for the patient. As a result thereof, all schedule analgesics are now kept in a separate pouch inside our drug bags, and resuscitation drugs are readily accessible.

A small change as a result of patient safety reporting systems being implemented.

We have developed trigger tools to further support our passion for patient safety. These are our red flag incidents as well as prospective triggers to evaluate the health within our environment and these are reported monthly.

Cost and clinical outcomes Clinical cost efficiency is critical to sustain our business. We must strive to provide the best possible care while managing costs in order to keep our exceptional clinical reputation, in a cost-sensitive environment. Clinical indicators such as response times (a two-hour activation time for international air ambulance cases subject to clearances and other logistical challenges), intubation (> 80 per cent first pass intubation success) and intravenous insertion success (99 per cent inserted in less than three attempts) are proudly equivocal to the best in the world. We have researched

Emphasis during our reviews has shifted from a traditional model of blame to that of a just culture and acknowledge that mechanical ventilation is the gold standard for all our intubated and ventilated patients, hence we have invested in the best equipment to empower our team to do their best clinically. Examples include the Hamilton T1® ventilator, Draeger®Oxylog 3000 plus and Zoll/Phillips ECG monitors with invasive pressure transducing and 12-lead ECG capability for cardiac/haemodynamic monitoring, and point of care arterial blood gas monitoring. Our neonatal successes should be celebrated: the smallest baby transported by our speciality neonatal team weighed just 500g and we were able to initiate high flow ventilation.

We re-intubated six per cent of our babies due to blocked or inappropriately sized tubes, and subsequently began weaning high percentages of oxygen (which is toxic in premature neonates) in the majority of our babies.

Our goal is always to achieve and then to maintain or exceed our standards. We have international accreditation via NAAMTA, an achievement we are proud of, that will take significant effort to maintain. We have installed state-of-the-art software in our Contact Centre to ensure a faster, more accurate dispatch to any emergency with additional clinical resources to ensure our staff understand patients’ emergencies. The foundation for reviewing quality clinical performance has been achieved at ER24 Global Assist; our next step is to automate our reports, research and present our findings internationally. ■ Dr Robyn Holgate is the Chief Medical Officer of ER24. She star ted her medical career as an ICU and trauma nurse, and later completed her Bachelor of Medicine and Surgery (MBBCh) at the University of Witwatersrand in Johannesburg, South Africa.

She’s also obtained her MSc in Medicine (in Emergency Medicine). After gaining clinical and emergency medicine experience within the state sector, she moved to ER24 in 2009.

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AIR AMBULANCE REVIEW

CASE STUDY

A COMPLEX MISSION

Air Alliance Medflight reports on the repatriation of a patient on VA-ECMO for cardiac failure The patient Air Alliance Medflight received a request to repatriate a 36-year-old male from Las Palmas, Gran Canaria, to the Royal Brompton Hospital in West London, UK. This previously healthy patient was on holiday with his wife and young family in Fuerteventura when he began to experience vague intermittent chest discomfort over a period of three days, accompanied by a gradual onset of breathlessness on exertion. He then presented acutely to a local clinic where he was found to be hypoxic (SpO2 80 per cent on air) and in cardiac failure (P 120 bpm, BP 100/60, with signs of pulmonary oedema). The ECG was abnormal with lateral ST changes, and the cardiac echo demonstrated global hypokinesia. Both Troponin (3000 mcg/l) and BNP (10,000 pg/ml) were markedly raised. The presumed diagnosis was of an acute myocarditis, probably viral in origin.

He was swiftly transferred via helicopter to the Dr Negrin University Hospital Las Palmas, where he was initially managed with appropriate anti-heart failure medication and oxygen. Coronary angiography was normal.

Worsening heart failure over the next three to four days necessitated transfer to an intensive care environment and commencement of nasal CPAP. His cardiac failure continued to worsen. He required the placement of an IntraAortic Balloon Pump (IABP) to help offload his left ventricle and optimise his coronary perfusion. However, the clinical situation deteriorated further, and the local surgical and medical teams were required to initiate full mechanical cardiac support by commencing Veno-Arterial Extra Corporal Membrane Oxygenation (VA ECMO).

The senior medical team at Air Alliance were in direct contact with the medical director of the patient’s assistance company. The option for urgent repatriation to a major UK ECMO centre, where full back-up facilities including the capability for cardiac transplantation could be provided, was discussed. The University Hospital in Las Palmas had performed an excellent job stabilising the patient thus far, but to give this patient the best chance of a successful outcome, transfer to a specialist cardiac centre would be required. Air Alliance confirmed that they had access to the required expertise and airframe to undertake this mission.

oxygenator and returned via another central catheter back into the venous circulation. In VA ECMO, blood is taken from the venous side of the circulation and then through an oxygenator, as before, but returned under pressure to the arterial side of the circulation in order to generate adequate systemic blood pressure and flow to replace the function of the failing heart. VA ECMO may be instituted for a variety of reasons, either to allow time for the heart to recover, for example in viral myocarditis, or alternatively as a bridge to implantation of a Ventricular Assist Device (VAD), or Cardiac Transplant.

What is ECMO?

The team

ECMO can be used for two main groups of patients: those with acute respiratory failure (Veno Venous ECMO) and those with some forms of cardiac failure (VA ECMO). In acute respiratory failure, blood is taken from one of the central veins, run through a membrane

Given the complexity of this transfer, we had a larger-than-usual retrieval team totalling nine people, including a senior Air Alliance flight nurse (to provide aircraft familiarisation and logistical support), two pilots, a consultant cardiothoracic surgeon, consultant intensivist, senior perfusionist, and two ECMO ICU nurses.

The aircraft For this transfer we used a Challenger 604 aircraft (CL604).

The challenges Clearly this is a highly unusual mission. As there was only a small window of opportunity for safe transfer given the clinical condition of the patient, we needed to organise this complex response in a very limited time. An additional challenge was that the majority of the specialist team were relatively new to the logistics of fixed wing international air retrieval. Using our ECMO checklist, our on-duty clinical co-ordinator discussed requirements with the ECMO retrieval specialists. It was confirmed that all kit and equipment was compatible and able to be safely secured whilst on board.

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case study

The required electrical and gas adapters, extra suction machine and substantial oxygen supplies were loaded onto the Challenger in our Cologne base and the aircraft positioned to London to collect the ECMO team. The team gathered in London the following morning, engaged in a pre-flight brief with the flight crew, and commenced loading the aircraft (a complex process given the extremely large amount of specialist equipment needed).

Pilot duty hours would be optimised by employing a ‘spilt duty’ roster in order to give the medical team a comfortable time margin to stabilise and prepare the patient for transfer. Timings, weather factors and routing were discussed. Roles were allocated and we discussed in detail where each of the team members would sit on the return flight so as to be best placed to deal with failure of the ECMO circuit. The four-hour positioning leg was used to develop a whole team ethic so the Air Alliance nurse and the retrieval team could work seamlessly together.

We then went through a ‘dry run’ with all equipment mounted on the patient stretcher, including all of the electrical, oxygen and air supplies. This was particularly important for the loading and unloading process which we knew would inevitably happen at night.

On arrival at the treating hospital, the team took a detailed handover of the patient and began the lengthy process of establishing the patient on our equipment and packaging him for retrieval.

Our nurse spent a great deal of this time caring for the patient’s spouse, who was understandably extremely worried and distressed. Once all of our equipment was in place and we were certain that the patient was fully stabilised, we began the process of returning to the airport. A decision was made as to who should travel with the patient for the land transfer in the bariatric ambulance, and we also needed an additional ambulance to carry the remainder of the staff and the support equipment. Our provider in Spain, EvoloMedica, led by Dr Carlos Alonso, provided exceptional support by delivering suitable ground ambulances and logistical support in Gran Canaria – including organising a police escort from hospital to airport.

Loading a patient with this level of lifesupporting equipment onto a CL604 is extremely challenging. We needed to raise the patient to the doorway, in a horizontal position, in a manner where all monitoring equipment remained visible to the crew and the many tubes and wires remained secure. This was

D L AN NG FF N, E O O P T LU DRO ENT PATI

GRAN CA NARIA , SP AIN PATIENT PI CK UP

achieved by careful placement of equipment, crew positioning, and use of the Challenger’s electrically operated loading system. The flight departed Las Palmas airport at 9 p.m., arriving back into London Luton at 1 a.m. In-flight care was busy but uneventful, due in no small part to the extensive preparation and planning by the crew.

Thankfully, the patient had a stable transfer with no in-flight issues, arriving in the similar critical condition in which he was collected in Las Palmas. The patient was off-loaded onto a specially designed and equipped ECMO retrieval ambulance used by The Royal Brompton team, with a support vehicle, and continued onwards to the London hospital.

This was an extremely successful transfer despite all of the potential pitfalls that were lying in wait. The mission was made possible by using all available time engaged in careful planning, and the very high skill set of all involved: the ECMO retrieval team, the UK office medical director with clinical co-ordinators in Birmingham and Cologne, Air Alliance nursing staff, plus the specialist equipment and expertise from the company. ■

Maeve O’Driscoll Air Alliance Flight Nurse and Clinical Lead for Critical Care, BMI Hampshire Clinic.

Maeve completed her Nurse training in Dublin. She has had a successful career working in ITU over the past 30 years. She is currently working as Clinical Lead for Critical Care. Maeve has gained extensive experience in fixed wing international air ambulance repatriation and retrieval - previously working with AirMed, Oxford and currently with Air Alliance,

David Quayle Air Alliance Clinical Services Manager.

David did his nurse training in the Isle of Man qualifying in 1989. He has always worked in acute care, including in Cardiothoracic Intensive Care as a Senior Charge Nurse and, since 2009, in international fixed-wing air ambulance Repatriation and Retrieval. He is former Chair of the RCN’s influential Critical care and Flight Nursing Forum, an associate lecturer at Birmingham City University and is a CAMTS Global site surveyor.

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BRAINS, PLANES AND AUTOMOBILES

Dr Simon Forrington discusses best practices in the aeromedical retrieval and transfer of head-injury patients

Introduction An acquired brain injury (ABI) refers to damage sustained by the brain after the time of birth and is therefore not caused by a congenital abnormality. Examples of ABI include the various types of stroke, infections such as meningococcal meningitis and any injury to the brain from physical trauma. This article discusses some of the issues involved in the aeromedical 14 |

retrieval of this patient group. Secondary/tertiary retrieval missions, during which a patient is transferred from a hospital facility to another healthcare facility, such as a hospital in another country, is the main focus for discussion.

Acquired brain injury is increasing in frequency and represents a significant burden for healthcare providers, including within the aeromedical transfer and retrieval sector. The latest figures

from Headway (the Brain Injury Association charity based in the UK) show that in 2016-17, there were 348,453 admissions to UK hospitals with ABI. That represents 531 admissions per 100,000 population, and a National Health Service (NHS) admission occurring approximately every 90 seconds. Admissions with ABI have increased in the UK by 10 per cent in the last 10 years.1 >>

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FEATURE

Sufferers from ABI may be left with devastating and life-changing loss of brain function, including disorders of thinking, feeling, talking and walking. Survivors of ABI, their families and carers often require significant degrees of help and support in the aftermath of injury. When ABI occurs away from home, for example when on holiday or when working overseas, patients and their carers have an even greater level of difficulty and distress. Aeromedical transfer providers have an important role in delivering patients and relatives to the comfort of familiar surroundings and a healthcare system more able to service complex long-term medical and rehabilitation requirements. Crucially, the patient transfer, although in itself unlikely to improve the outcome for the patient, should not cause further harm. It should certainly be as painless and stress-free as possible during an undoubtedly difficult time.

Primary and secondary brain injury The clinical pathology of ABI is commonly referred to as ‘primary’ and ‘secondary’ brain injury. Primary brain injury refers to the damage caused to the brain at the time of the event. This would include, for example, direct trauma to the brain resulting from a serious road traffic collision. By definition, the damage caused in primary brain injury has happened before there was an opportunity to perform medical interventions. Little can be done later to mitigate this.

Secondary brain injury is that which occurs in the hours, days and weeks after the primary

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Aeromedical transfer providers should aim to prevent secondary brain injury during patient transportation injury has occurred. Examples would include complications from impaired blood flow to healthy areas of the brain due to swelling and raised intracranial pressure. Medical interventions following ABI are generally aimed at preventing or reducing secondary

brain injury. Aeromedical transfer providers should aim to prevent secondary brain injury during patient transportation and continue therapies and management strategies already in place with this aim.

Preventing and reducing secondary brain injury - Traumatic Brain Injury The Brain Trauma Foundation (BTF) Guidelines for management of severe traumatic brain injury (TBI) are now in their fourth edition2. In this patient group, good quality evidence for interventions that improve outcomes with good functional recovery remains lacking. General principles involve managing raised intracranial pressure (the pressure within the cranial vault), targeting cerebral perfusion pressures (the pressure driving blood flow to the brain) and avoiding even short periods of hypoxia and hypotension.

- Cerebral perfusion and blood pressure targets Cerebral perfusion pressure (CPP) can be calculated when the intracranial pressure (measured from a direct indwelling pressure monitor or ‘bolt’) is subtracted from the mean arterial blood pressure. The BTF advocate targeting a CPP of 60-70mmHg following TBI (level IIb evidence). Blood pressure should be targeted as maintaining a systolic blood pressure > 100mmHg in patients 50 to 69 years old and > 110mmHg in patients 15 >>

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to 49 or over 70 years old (level III evidence).

Simple measures such as ensuring the tube ties (on intubated patients) are not so tight that they occlude venous drainage and sitting the patient at 30 to 45 degrees to aid venous drainage and minimise fluid shifts during take-off and landing, are well-known and commonly practised.

- Other therapies Other therapies such as osmotherapy and decompressive craniectomy are used, but evidence of long-term improvement in outcomes remains lacking. Active cooling is no longer advocated and, instead, the maintenance of normothermia and avoidance of hyperthermia are important principles used in many neurosurgical intensive care units.

Phenytoin or Keppra (Levetiracetam)3 may be used following brain injury as prophylaxis against seizures; however, post-traumatic seizures have not always been associated with worse outcomes2.

- Stroke In the UK, recent emphasis has been placed on the rapid diagnosis of stroke in the pre-

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hospital environment and expedited transfer of the patient to a tertiary specialist stroke centre. Ambulance services often use prehospital triage tools such as FAST (face-armspeech-test). Tertiary units are able to provide specialist advanced interventions such as stroke thrombolysis. The London hyper-acute stroke model has improved patient outcome by offering such specialist services while saving the NHS money4, 5.

Good quality evidence for interventions that improve outcomes with good functional recovery remains lacking Practicalities of transporting the brain-injured patient - The decision to undertake the transfer There are times (such as in the acute phase of the illness or immediately following a deterioration in condition) when ABI patients may be less suitable for transfer and the risks

of undertaking such a mission may outweigh the benefits. Any transportation of a patient in the early stages following serious injury, either within the confines of a hospital or outside, can be difficult and dangerous for the patient.

During an aeromedical transfer particularly, there are the issues associated with cabin pressure, relative hypoxia and the physical forces placed on the body, particular under heavy acceleration and deceleration during take-off and landing.

- Air ambulance or commercial airliner The decision relating to the platform on which to transfer a patient depends on the complexity and acuity of the injury.

This is also sometimes influenced by financial constraints, particularly when the retrieval mission is to be privately funded by individuals, as opposed to through an insurance policy. In these circumstances, if a commercial airliner is to be used, it is generally wiser to wait for relative patient stability, removal of tubes and lines and when the risks of any patient deterioration during flight is felt to be low. In more complex injuries requiring a higher level of care and where the risks of patient deterioration during flight are felt to be higher, it is generally accepted that an air ambulance would be the transfer modality of choice. >>

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- Acute phases of illness In the days immediately following ABI, patients are often unstable. TBI patients may well have other traumatic injuries, which require complex intensive care prior to transfer.

Intracranial pressure is often labile and significant fluctuations can occur on minimal patient movement. In these situations, it is often prudent to wait until the clinical picture is more stable and more favourable.

However, there may be a perceived need to quickly move such a patient to a higher level of care; for example, from a remote area or location with only basic medical facilities and less able to manage the case. Clearly, a thorough risk assessment needs to be made and individualised to each case, taking these factors and others into account.

If intracranial pressure monitoring is still in-situ, in the form of a bolt or an extraventricular drain, this may indicate that the patient remains somewhat unstable in terms of their head injury. Caution should be taken when considering transfer of these patients.

Intracranial pressure monitors are often removed when a period of stability has been achieved and when the likelihood of further deterioration (such as a re-bleed from an aneurysm) is lower.

Moving patients with intracranial pressure monitors can therefore be more hazardous, both in terms of a labile intra-cranial pressure and in managing the devices themselves in the flight environment. Retrieval providers may wish to wait for removal of these devices and the patient stability that this infers. However, this needs to be balanced against the clinical urgency of the transfer.

- Post-neurosurgery If the patient has required some form of brain surgery, the clinical picture is likely to take some time to stabilise post-operatively.

Following some types of surgeries, air may be present within the cranial vault. This in itself rarely causes a problem, but if there is no

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route of egress for this air, problems can be encountered during transfer. At normal cabin pressures of 5,000 to 8,000ft, humidified air may expand by up to 30 per cent and this expansion could cause dangerous rises in intracranial pressure. A period of days, or sometimes even weeks, may need to elapse to facilitate safe repatriation. Direct consultation between the aeromedical retrieval team and the treating neurosurgical team is good practice.

In cases where transfer is needed expeditiously, careful consideration of using a lower cabin altitude throughout the flight needs to be made. Any decision to fly at lower altitudes and, hence, at a sea-level cabin pressure, needs to be balanced against the additional time taken for such a transfer, which may also negatively impact the patient.

- Agitation and delirium Following ABI, it is common for patients to experience disorders of cognition. The ‘irritable brain’ may lead to patients becoming agitated, difficult to manage and potentially a danger to themselves and/or the transferring team.

Dr Simon Forrington is Chief Medical Director of Capital Air Ambulance (CAA). A HEMS consultant with North West Air Ambulance Service and leading figure in the UK aeromedical sector, Dr Forrington is an experienced senior flight physician. He previously served as a senior flight physician for both CAA and AMREF and was co-designer of the standardsetting NAPSTaR course (Neonatal, Adult and Paediatric Safe Transfer and Retrieval).

Clearly, this is particularly important in the confines of an aeromedical retrieval mission, with the safety of the aircraft, patient and crew at the forefront of considerations.

Agitation and delirium can sometimes settle with the course of time and again it may be prudent to wait if there is potential for resolution of these symptoms. However, should transfer be indicated, effective plans for managing agitation, including controlled and targeted pharmacological sedation should be agreed during the planning phase. ■ References 1. Headway. The Brain Injury Association. www.headway.org.uk. Website accessed November 2018 2. Carney N, Totten A, et al. Guidelines for the Management of Severe Traumatic Brain Injury.

4Th Edition. September 2016. Brain Trauma Foundation 3. Chaari A, Mohamed AS. Levetirecetam versus phenytoin for seizure prophylaxis in brain injured patients: a systematic review and meta analysis. In J Clin Pharm. 2017 Oct; 39(5): 998-1003 4. Jauch EC, Saver JL. et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke. AHA/ASA Guideline. 2013 5. Bouverie J. Major changes in stroke care can save lives. Blog. www.england.nhs.uk 19 July 2017 6. Whitely S. MacCartney I. et al. Guidelines for the transport of the critically ill adult (3rd Edition 2011). Intensive Care Society 7. National Institute for Health and Care Excellence. NG39. Major trauma: initial assessment and management. February 2016

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ACCREDITATION UPDATE ITIJ contacted CAMTS, EURAMI and NAAMTA to find out what the various accreditation organisations have been up to over the past 12 months, and what they hope to achieve in 2019 NAAMTA global Last year was productive for NAAMTA Medical Transport and Medical Escort Accreditation.

Providers are seeking us out to attain the benefits of a service-oriented accreditation programme. Our numbers continue to increase, with 26 accredited programmes throughout the world. We have 17 audits scheduled for 2019 and several newcomers pursuing accreditation. NAAMTA accredited members span a variety of services ranging from community-based organisations, hospital programmes, interstate, international, and military service providers. We are committed to continuing the assets of our services and look forward to several positive changes in 2019.

First, our company branding, our name, has been changed to NAAMTA Global. With global inquiries into our accreditation and the increased growth of our international customers, we felt it important to say it in our name.

As a learning management system, our course content is expanding to further help our customers for training and demonstrate competency We are excited to welcome Andy Lee as our newest employee. He has been hired to head our international business development and base operations in Malta.

In line with our ISO 9001:2015 accreditation, we strive to improve the quality of our services. For example, during 2019 we will be releasing and publishing an update to the NAAMTA Standards.

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CAMTS/CAMTS Global Last year was a busy time of expansion and consolidation. For example, CAMTS accredited 58 medical transport services. Those 58 programmes included 271 bases. For initial accreditation site visits to new applicants, this means a site surveyor will visit every base.

Accredited programmes are listed on the camts. org and camtsglobal.org websites.

In addition to complex site surveys, we

All the new site surveyors have at least 10 years’ air and ground transport experience

Being known as a customer-centric accreditation, we are committed to offering tools that help our members attain and maintain compliance. Our member page, known as the NAAMTA Intranet, has been our platform offering the support that accredited programmes need. Specifically, our online compliance tools, business forms, workflows and routing approvals are used to assist customers in their own processes as well as in demonstrating continuous commitment to NAAMTA Accreditation Standards.

Since our beginnings, we’ve provided tutorials to assist customers with the process of accreditation.

Our library will expand to help alliance members use NAAMTA tools. We are releasing a new series to the ‘NAAMTACAST’, a new and developing podcast, and a NAAMTA vlog available soon on the NAAMTA website. The NAAMTA Learning Centre has also received a shot in the arm. As a learning management system, our course content is expanding to further help our customers for training and demonstrate competency.

Finally, NAAMTA is putting the NAAMTA Symposium back on our calendar. Historically, the symposium has been a place where alliance members meet and learn about industry trends, organisational improvements, multi-disciplinary approaches, and creating positive influences within their organisation and across the globe.

completed the standards and process for Special Operations – Medical Retrieval, which were accepted by both the CAMTS and CAMTS Global Board of Directors and is available worldwide. Special Operations – Medical Retrieval includes criteria for services that provide tactical rescue or SWAT: callouts and citizen recovery from potentially unstable environments. There are already two applications for this specific accreditation.

The 11th Edition CAMTS Accreditation Standards were published in October 2018.

The Standards Committee (organised per American National Standards Institute (ANSI) policies) spent 18 months meeting and discussing comments from the public and peers who visit our website to comment on the drafts of standards.

In July 2018, the CAMTS and CAMTS EU Board members met in Munich at the ADAC Roylen Griffin is the Founder and Executive Director of NAAMTA. Prior to forming NAAMTA, Griff worked for a major medical transpor t service based in the western US. In just three shor t years, NAAMTA has formalised its accreditation offering, established a growing customer base, and become a viable leader in the medical transpor t accreditation industry.

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headquarters where CAMTS EU was rebranded as CAMTS Global. In July 2019, there will be a CAMTSCAMTS Global Board meeting in Seattle.

Guests from professional agencies in Asia and Europe will be invited to attend as we expand the number of organisations represented on the CAMTS Global Board of Directors.

In March 2019, a site surveyor class will add 16 new surveyors to the current pool of 60 active site surveyors. Two of the new surveyors are medical transport clinicians from Europe, several are pilots and several more have neonatal/paediatric transport backgrounds. All the new site surveyors have at least 10 years’ air and ground transport experience. They will be assigned with senior site surveyors to meet the needs of the increasing number of neonatal and paediatric transport teams and the potential for more international site visits.

CAMTS Site Surveyors conducting a site visit in Bangkok.

Eileen Frazer, RN, CMTE has been the Executive Director of the Commission on Accreditation of Medical Transport Systems (CAMTS) since its inception in 1990. Eileen is a former Chief Flight Nurse who served as the Safety Committee Chair for AAMS and did the feasibility study in 1988 that led to the development of CAMTS. Eileen set up CAMTS as a non-profit corporation and wrote many of the policies and standards that guide the accreditation process. She received the Jim Charlson Award for aviation/safety in 1991, the Marriott-

EURAMI The European Aero Medical Institute (EURAMI) has welcomed 2019 with a new Managing Director as well as a newly elected Board to support the growth and development of the organisation. Dedicated to promoting excellence and quality in aeromedical transportation, EURAMI is currently reviewing its Version 5.0 standards to incorporate recent developments and changes within the industry. As introduced

by Dr Terry Martin, Chief Auditor, EURAMI’s current priority is to adjust its scoring methodology to ensure a high level of consistency as well as to recognise that there are critical ‘must haves’ for safety and medical quality, all of which must be met to be credentialed, while other items may be fulfilled for an overall score.

Another focus in 2019 will be the addition of auditors for Air Ambulance, Rotary Wing and Commercial Airline Escort sector audits to ensure even better availability and geographical coverage. Thus, EURAMI is entertaining its first auditor training with more than 10 confirmed participants from all

There are critical ‘must haves’ for safety and medical quality, all of which must be met to be credentialed over the globe in spring 2019. The training – the first of its kind within the organisation – will be attended by both current and new auditors to ensure a mutual standard at all audits across the organisation.

EURAMI President Dr Cai Glushak has announced his plan to expand the association’s communication channels with members as well as external stakeholders to ensure it

A priority for EURAMI going forward is to ensure … objectivity and integrity in the accreditation process actively seeks input and feedback on standards and monitoring, as well as other means in which accreditation can bring credibility to the aeromedical industry. As stated in his first message to members, a priority for EURAMI going forward is to ensure, to the greatest possible extent, objectivity and integrity in the accreditation process and this implies moving toward heightened transparency and consensus.

It will indeed be a busy year for EURAMI auditors, with more than 15 re-accreditations of current providers as well as several primary accreditations already confirmed. EURAMI will continue its growth and expansion globally across its accreditation categories.

Claudia Schmiedhuber (Managing Director)

will be present at the ITIC conferences, meeting with members and interested providers and will update EURAMI members with regular communication on the association’s progress.

With many exciting projects in the pipeline, the EURAMI Office and Board is looking forward to an exciting and productive 2019!

Claudia Schmiedhuber is Founder & CEO at Alpine Health Consulting e.U and Managing Director at the European Aero Medical Institute (EURAMI). EURAMI offers quality accreditation for air ambulance, rotary wing and commercial medical escort providers on a global scale. The association is focused on promoting excellence in aeromedical practices and standards.

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PROFILE

COMMUNICATION, CONSOLIDATION AND CARE Mark Jones, Owner of Air Ambulance Worldwide, spoke to ITIJ about his time in the industry You’ve been in the international air ambulance business since 2004; what are the main changes you’ve witnessed during this time?

I have witnessed many – but the main changes that I have seen are the improvements in communications. These have come in the form of cellular, satellite and internet quality and availability. This allows the clients, providers and medical teams on flights to be more effective and efficient. The quality of medical care and overall process is enhanced by these improvements.

Also, there have been improvements in aeromedicine and medical equipment. Another change is the recent consolidation of companies over the past three to five years.

Our standard protocol is to go to the treating facility to perform a bedside assessment of the patient Communication is a top priority in the travel and health insurance sector; how does AAW ensure that clear and sufficient medical advice is obtained from a treating hospital before you pick up a patient?

The first step in attempting to confirm a patient’s medical condition is to ensure that we have obtained the best possible pre-flight medical 24 |

report. The quality of the report can vary based on factors such as location, language and in some cases the availability of the medical staff providing the report. Some countries or hospitals will only give doctor-to doctor reports, and we try to plan for this eventuality so as not to delay the flight.

We have had cases where we required a translation service, but typically our staff handle the day-today cases. We obtain all current medical records from the sending facility, including CT scans, H&P and so on before we depart. Our standard protocol is to go to the treating facility to perform a bedside assessment of the patient. This confirms the information that we were provided and ensures that the patient’s medical condition has not evolved since the pre-flight assessment was obtained. Once it is confirmed the patient is fit to fly, we will then depart.

Your recent purchase of Aero National has increased your ability to serve US-based patients; is this acquisition the beginning of a global expansion plan?

The purchase of Aero National, although early in the integration, has proven to be a solid strategic move. Their location adds to our geographic footprint and increases the value proposition to our clients by providing a high-quality provider in an area where there is little service. When it comes to expansion, we are looking at strategic rather than global expansion. The location of Aero National lends itself to further expansion and to providing a comprehensive solution for our hospital, assistance and individual clients.

The value of accreditation is an ongoing debate in the air ambulance sector; what made you decide to obtain EURAMI accreditation, and why did you choose this organisation rather than another one? Do you find that insurers were more willing to work with an accredited air ambulance company?

EURAMI was the only worldwide accreditation organisation in 2009.

I hold true to my belief that accreditation does add value to a company, the industry and the clients that we serve. We first applied for accreditation in 2009 because I could see the value that accreditation brought to a company.

Not necessarily that it would help us obtain additional clients, although it did, but that by going through the ‘process of accreditation’ and having the organisation work with us, it would improve our company as a whole.

We chose EURAMI for a few reasons; one was that we were dedicated to serving the worldwide demand for quality providers and EURAMI was the only worldwide accreditation organisation in 2009. The other credentialing organisations were domestic US only, although that has changed to a degree now. Also, I was familiar with the other organisations and we believed that we would get the greatest hands-on support from EURAMI. They were helpful in answering questions that are a normal part of our striving for continuous improvement. In regard to insurers working with accredited providers, that is why I had made the decision in 2009 to become EURAMI accredited, I could see that the industry was moving in that direction and so we committed the resources to obtaining accreditation.

I could see that the industry was moving in that direction and so we committed the resources to obtaining accreditation

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PROFILE

You have Special Care accreditation from EURAMI – how much more difficult was this level of accreditation to achieve than an ordinary accreditation?

We are always working to improve our service and continually raise the bar of excellence for our teams. We were honoured to reach the level of recognition that we did during our last audit which was Long Range / Intercontinental Fixed Wing - Advanced Adult Critical Care.

We were able to reach the advanced level due to the type of cases and the level of care that we can provide. If a company cannot provide a certain level of care, it will merely take time and dedication of resources to obtain the next level of care if they so desire. Everyone may not have the need to reach other levels, yet they can be a good provider.

At the recent ITIC Global in Geneva, cases were discussed where air ambulances had taken off to collect a patient before landing permits were obtained, or where a guarantee of payment/coverage had yet to be issued.

Have you experience in such missions, and how do you manage these risks?

In the scenario that you ask about (leaving

The ability to stay ahead of the curve regarding technology and regulatory requirements of 2020 aviation standards will present challenges for some of the smaller providers without a landing permit) there are multiple risk factors that must be considered. Key considerations are the patients’ medical condition, current level of care and the experience we have with the country in question. Sometimes the risk is low because of the frequency and familiarity that you have with them. Others, such as Cuba, preclude departure without an issued permit. Like much of what we do, the decision is often based on the relationship we share with the client.

Mutual trust goes a long way when weighing these factors.

What do you enjoy most about your role?

Every day, I look forward to walking into our corporate office and seeing each and every one of our employees. I know that over the next 24 hours we will help our clients, patients and their family members through a difficult time in their life. No one wakes up and says, ‘I think today I will need an air ambulance’, but when they do, we will be there to help them. That makes me feel good.

What do you view as the biggest challenge facing the air ambulance industry in the current economic climate?

I am sure that there are many challenges that will come to light over the next few years, but the aircraft upgrades are certainly looming large on the horizon for some. The ability to stay ahead of the curve regarding technology and regulatory requirements of 2020 aviation standards will present challenges for some of the smaller providers. Upgrades are both expensive and time consuming to install, and the process has the added disadvantage of grounding part of your fleet for the duration of the upgrade process. Like so much of our existence – planning becomes key. ■

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AIR AMBULANCE CONSUMER PROTECTION ACT INTRODUCED IN THE US

With balance billing for air ambulance services hitting the headlines time and time again, the US Senate has taken action in an attempt to limit the risk of people who need emergency air medical transportation being billed tens of thousands of dollars for costs not covered by their insurer

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What?

Introduced to the US Senate in October last year, the Air Ambulance Consumer Protection Act requires the Department of Transportation (DOT) to establish an advisory committee to make recommendations for a rulemaking to: • Require air ambulance operators to clearly disclose charges for air transportation services separately from charges for non-air transportation services within any invoice or bill.

• Provide other consumer protections for customers of air ambulance operators.

The bill makes provisions relating to air transportation consumer complaints applicable to air ambulance transportation. It also allows an air ambulance customer to file a complaint requiring DOT to investigate whether air carriers or ticket agents have engaged in unfair or deceptive practices or unfair methods of competition.

An air ambulance operator shall include the hotline telephone number established for consumer complaints on any invoice, bill, or other communication provided to a passenger or customer of the operator.

Why? Complaints and enquiries from insurance consumers who are receiving huge bills in relation to air ambulance transportation costs that weren’t covered by their insurance plan are rising across the US. As an example, the Missouri Department of Insurance, Financial Institutions and Professional Registration (DIFP) reported a complaint from an individual who had suffered from encephalitis, who was transferred across state lines in a fixed-wing air ambulance. The claim on the person’s insurance was denied as not medically necessary, under the rationale that the originating facility had the appropriate level of expertise to treat the condition. The patient received a bill in excess of US$100,000.

In July 2018, the DIFP convened a roundtable that brought together regulators and representatives of health insurers. One of the areas of concern that was discussed at this meeting was the growing problem of air ambulances and balance billing. In order to better understand the problem, the DIFP initiated a data call for all large insurers in the state. Estimates derived from this data suggest that of the $25.7 million billed for air ambulance services in 2017, Missourians could have been balance billed a maximum of $12.4 million, which equates to $20,000 per person.

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Unintended consequences?

The US Association of Air Medical Services (AAMS) has voiced its concern about potential unintended consequences that could result from the implementation of the Act. The organisation said: “While it is the position of AAMS that all our members advocate on behalf of their patients and work toward solutions that keep patients out of the middle in negotiations with insurers, this legislation doesn’t do that – it only provides insurers with smaller portions of patient’s bills to cover while erecting ‘borders in the sky’, making it difficult or impossible to transport patients across state lines. We can do better – we can require transparency, fix Medicare, and solve for greater healthcare access.”

Instead, the AAMS suggests that legislation entitled Ensuring Access to Air Ambulance Services Act of 2017 (S.2121) be supported.

“This legislation,” said AAMS, “would establish mandatory cost and quality reporting requirements on air medical operators, and update the Medicare fee schedule for air medical services. The bill was designed and drafted to provide a long-term solution to the shortfall in Medicare reimbursements which is already leading to base closures and the curtailment of air medical operations across the country.

Air Evac Lifeteam President Seth Myers spoke to ITIJ about the Act: “I am excited by the opportunity that the Committee has to provide recommendations that ensure sustainability for air medical services and accessibility for those patients who depend on it. The industry is working to ensure that no patient should receive a balance bill and that insurers and government healthcare programmes should pay reasonable fees based on the cost of providing the service. This would eliminate the need for balance billing and remove the patient from the negotiation. One wonders as to the purpose of insurance programmes, be they government programmes or commercial insurance products, if they do not cover the costs of the medical – especially emergency medical – services incurred by their beneficiaries.

In the US, state authorities have very limited regulatory authority over air ambulances. Such services are governed by the Federal Aviation Deregulation Act of 1978, which carved out broad federal pre-emptions to state regulation of aviation. The Act specifies that states may not regulate in any way the ‘price, route or service of an air carrier’.

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A

nnouncements of partnerships between international air ambulance providers make for good public relations (PR). But it’s not always clear from the statements released by organisations how these partnerships translate to making a practical difference in the way the organisations can work together. Is there a difference in how a provider would organise a wing-to-wing mission with a previously partnered company compared to any other? To find out, ITIJ spoke to a selection of providers about their partnerships to find out what’s behind the headlines 28 |

Wing-to-wing The main focus for partnership agreements tends to be wing-to-wing missions: where one provider picks up the patient and flies to a mid-point rendezvous with a second provider that completes the journey. There are various reasons why a provider might opt for a wingto-wing rather than working alone, such as a faster response time – the patient can be picked up quickly by a local company and the journey started while the remote provider is en route to the hand-over point. Reducing the travel time not only makes for a faster pick-up, but on longrange missions can help deal with crew rest time restrictions. David Fox, President of Fox Flight

Air Ambulance (Fox Flight), commented: “The bottom line is wing-to-wing transfers speed up the repatriation process for the patient. Because of the long distances that are involved in these kinds of missions, using a wing-to-wing partner eliminates the need to reposition or rest air crews to cover duty times, which can take days off the wait for the patient. Also, some carriers have better relationships in certain countries that make the logistics of long-distance transfers easier. So you get the patient home sooner and the costs are similar.”

As well as response time, there may be a benefit to have each provider cover the part of the mission that’s in a region they’re familiar with.

Pictures from Fox Flight, showing Fox Flight and Awesome Air meeting on the tarmac in Tenerife to exchange a patient.

BREAKING NEWS:

Air ambulance provider X announces formation of partnership agreement with air ambulance provider Y. It’s a regular headline and a feel-good story, but what is the substance behind such announcements? James Paul Wallis reports on how these deals can benefit patients and payers alike

Anne Rodenburg is Commercial Director at US and Mexico-based AirLink Ambulance, which is among a number of partners that work for Luxembourg-based European Air Ambulance’s international Air Alliance. She commented: “One of the major benefits of partnerships is making use of specific local knowledge and expertise. It makes sense to maximise partners´ experience.”

Indeed, David Ewing, Executive Vice-President of Global Markets for Skyservice Air Ambulance International, noted that its partners ‘were sought out based on their expertise, reputation and medical treatment capabilities’: “While the concept of wing-to-wing transport is a good

one, you can’t just do a wing-to-wing with any provider. The levels of care provided by air ambulance companies is not all the same, there are services who excel in patient care and transport, those were the ones we sought out and who sought out us to enter a formal partnership agreement.”

Frank Condron, PR Officer for Fox Flight, added: “Companies like Fox Flight and Awesome Air, for example, are both capable of transferring a patient from South Africa to the US on their own. But the resources that would have to be committed to complete such a mission in terms of air crew, given the time required and duty-time constraints, would put limits on other

missions that could be taken on, likely for days.”

Any air ambulance mission requires planning and co-ordination, but a wing-to-wing mission ups the ante as the hand-over must be carefully organised. Fox Flight of Canada and Awesome Air Evac of South Africa signed an affiliate agreement in February 2018, but first worked together in August 2017 on what was Awesome Air Evac’s first wing-to-wing patient transfer.

The 22-hour mission involved flying a ventilated patient from Johannesburg, South Africa to Kansas City, US with a hand-over in Tenerife, Spain. Speaking at the time, Aaron Payne, Director of Communications for Fox Flight, described the mission as ‘especially complicated’ | 29

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and said: “We had to work closely with Awesome Air Evac to make sure the hand-over in Tenerife was smooth – and both dispatch teams had to arrange landing, customs and refuelling at airports in various jurisdictions at various times around the clock to keep the transfer moving.

Due to the patient’s condition, we couldn’t afford to have any delays along the way.”

Due to the complexity of these missions, the conscientious provider will want to make sure that the wing-to-wing partner is a reputable firm that’s likely to perform their part of the mission to a good standard.

Homework David Fox, President of Fox Flight, told ITIJ that deals such as the one with Awesome Air Evac are ‘formal agreements that spell out in clear terms the standard of care and professionalism each partner will maintain and what services each partner will provide for each wing-to-wing mission’. The agreements also ‘provide guarantees related to insurance 30 |

FEATURE

There has to be a due diligence process and regulatory requirements’, he said. A key point though, is that before signing such an agreement, it’s important to do your homework.

In a recent example, last November AMREF Flying Doctors of Kenya and UK-based Capital Air Ambulance announced their formation of a ‘wing-to-wing air ambulance alliance’ offering flights between Africa to Europe. In the companies’ statement, they highlighted that ‘medical protocols, equipment and staff have been aligned to operate at the same level to ensure patient care is consistent across the entire repatriation’. What may not have been obvious to the casual reader was the amount of work that went on behind the scenes in the lead-up to the announcement.

Speaking to providers, it becomes clear that there has to be a due diligence process to make sure that the potential partner is a brand that it’s safe to connect with.

This reveals that the key element to a partnership is the level of trust between the providers. For example, David Fox said of the 2018 agreement: “Having worked with Awesome Air in the past, we know them to be a quality air ambulance operator capable of meeting the standards of care and flight operations our clients have come to expect.”

On this point, Anne Rodenburg commented:

The agreements also ‘provide guarantees related to insurance and regulatory requirements’ “Before formalising the relationship, there is a careful selection of partners and a process of getting to know each other well.

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secure management of patient data, for example.

Having important topics pre-arranged and agreed on in a written document contributes to a swift and cost-effective intervention when working together.”

With such a trusted partner, a provider can confidently publicise that they can handle long-range missions that include wing-towing transfers – knowing that the partnered organisation has the capabilities to perform their section of the mission. Of the August 2017 mission, Shane Marais, General Manager of Awesome Air Evac, commented: “In order to complete a complex mission like this, you have to have complete confidence in your wing-towing partner.”

David Fox explained it this way: “When we carry out a wing-to-wing mission we have certain expectations when it comes to medical care and logistics. With an agreement in place, both wingto-wing partners know what the expectations are and there is a comfort level in knowing how the trip is going to be handled from each end.”

Beyond accreditation The process is easier if the organisations involved are already aligned to a certain degree – with similar documentation, procedures and equipment. For example, the process for Capital Air Ambulance and AMREF Flying Doctors to partner was made easier by the fact that they were both already accredited by the European AeroMedical Institute (EURAMI).

Explaining why Fox Flight Air Ambulance favours partners that hold EURAMI accreditation, David Fox said: “Because we are EURAMI-certified, we feel that companies with the same third-party verification are going to have the same level of

care and professionalism that we expect. We could partner with a company with another air ambulance certification, but EURAMI seems to be more focused on international transfers.”

ER24 Global Assist of South Africa is partnered with air ambulance providers including Luxembourg’s European Air Ambulance and Skyservice Air Ambulance of Canada. Alastair Lithgow, ER24 Global Assist Fixed-wing Coordinator, said: “The benefit of having these

agreements instead of working on an ad-hoc basis is that we can confidently expand each other’s footprints in various regions around the world. Besides this, when these agreements are reached, we can guarantee quality of patient care and standards of safety. This means we can each offer our clients the highest standards of care and customer satisfaction in all areas that we jointly service while being confident in the financial arrangements that the agreements cover.” >>

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AIR AMBULANCE REVIEW

FEATURE

Speed and convenience Asked whether there is a downside – where having an agreement with one provider makes it harder to work with other, non-partnered

When these agreements are reached, we can guarantee quality of patient care and standards of safety providers – David Fox responded: “We haven’t experienced that at all. Wing-to-wing transfers represent an important piece of our business – we do between 30 and 40 a year – and we’ve found it to be a very beneficial for all the companies involved.”

Remarking on Skyservice Air Ambulance International’s partnerships, which have been very successful for all parties and have been in effect for many years now, Ewing said: “We continue to seek out partnerships in distant parts of the world where we have no existing partners in order to enhance our portfolio and expand our offering to our existing – as well as potential new – clients.”

However, while a company may work with non-partners when appropriate, having already done the homework speeds things up when arranging a wing-to-wing with a trusted partner, which ultimately means the patient can get in the air sooner.

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Frank Condron said: “[The partners] can move immediately to talking about the mission at hand instead of taking time to verify qualifications over and over again. So there is clearly a benefit attached to working with a partner you know and trust, and the client benefits from the reduction in turnaround time required for dispatching aircraft and getting the patient home.”

Another aspect is the convenience for the customer of dealing with providers that will take care of co-ordination between themselves, giving the client just one point of contact to deal with.

Under Capital Air Ambulance and AMREF Flying Doctors’ wing-to-wing agreement, for example, customers need only deal with one operations centre. Judy Groves, Marketing Director at

Capital Air Ambulance parent company Rigby Group Plc, said: “For insurers and assistance companies, arranging a global medical assistance flight is now more convenient, straightforward and reliable – with only one operations centre and set of logistics to deal with.” Further benefits

Further benefits Even setting aside wing-to-wing missions, partnerships can also bring potential benefits in terms of marketing and brand awareness.

For example, under the agreement between Fox Flight Air Ambulance and Awesome Air, each will recommend the other to clients in need of aeromedical repatriation services in their respective markets.

Furthermore, some partnerships are aimed at extending

>>

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AIR AMBULANCE REVIEW

capabilities rather than dealing with geographical range. Hemma Niederegger, Project Manager, Sales and Marketing at Austria-based Tyrol Air Ambulance (TAA), commented: “TAA has a close partnership with Pediatric Air Ambulance, a specialised provider of intensive care transports for children and babies. The partnership is profitable for both sides: TAA has access to specialist doctors as well as the necessary medical equipment, while Pediatric Air Ambulance has benefits from swift access

FEATURE

to Tyrol Air Ambulance aircraft for their missions.” Here, the pre-partnership work included testing relating to power supply and functionality on board, safe and professional stowage of medical equipment and evacuation training for the medical crews.

Judy Groves emphasised that the main benefit of partnering is how closely the companies can work together: “Given that EURAMI-accredited organisations are aligned to EURAMI requirements on protocols, equipment and staff practices, it distils down

to working as one team rather than two teams collaborating. The end result is that, from a customer perspective, there is one point of engagement and control from beginning to end.

A truly ‘bed to bed’ service with consistent high standards of medical care, optimised logistics, minimised waiting times, and consequently a more cost-effective service proposition.”

As a final note, in case you’re wondering

Partnerships can also bring potential benefits in terms of marketing and brand awareness whether these partnership deals are a fire-andforget solution, it seems these are relationships that must be maintained. David Fox told ITIJ that each of the agreements that Fox Flight has (it’s partnered with not only Awesome Air Evac, but also Germany’s FAI rent-a-jet, Tyrol Air Ambulance of Austria and US-based Air Ambulance Worldwide) is reviewed on an annual basis. Frank Condron specified that as part of an agreement, each party is expected to keep all relevant documentation and certifications current and up-to-date, subject to audit by the other party at any time.

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AIR AMBULANCE REVIEW

CASE STUDY

IN THE TIME OF DUTY

Denise Waye of AirCARE1 reports on a logistically challenging flight that required complex co-ordination of flight crew to ensure adherence to duty times

A

nyone working in the air ambulance transport industry understands that even a simple mission can turn into one fraught with obstacles and challenging hurdles that need to be overcome. Knowing challenging flights are part of the business, we at AirCARE1 believe proactive planning that includes a variety of options, along with collaborative efforts from all members of the team, are key to having successful mission outcomes. Recently, AirCARE1 had a logistically challenging flight that required all of the above to ensure mission success.

S E, U TAT NS FF O O G P RO ORE NT D PATIE

The mission Our team was asked to perform a flight from Mexico City, Mexico to a city in the state of Oregon in the US. The patient was a 56-yearold male, an outdoor adventurist who had gone to Mexico City to paraglide, and had sustained multiple injuries from an accident while undertaking his favourite activity. While paragliding, he missed his planned landing zone and consequently set his eyes on a nearby landing zone that was complicated by power lines on one side and a fence on the other side.

He felt his experience would

allow him to land safely, but in order to make this landing zone, he needed to execute a series of aggressive turns. Unfortunately, one of these steep turns caused his parachute to collapse and he plummeted 40 feet to the ground.

The patient The patient sustained multiple injuries, including fractures of the pelvis, wrist, multiple ribs as well as multiple compression fractures of T-1 through L-5 thoracic-lumber vertebrae. He was treated at a local trauma centre in Mexico City and needed medical evacuation back to the US for further treatment.

Flights to many parts of Mexico, as well as other international locations, present a variety of challenges. Handlers are obtained at locations south of the US border in order to facilitate a smoother mission. Since general aviation aircraft are not allowed to land in Mexico City, the city of choice for this destination is Toluca, Mexico. Toluca is southwest of Mexico City and travel by ground ambulance is approximately a one-hour drive through mountain roads.

On this particular mission, our aircraft landed at Toluca airport and taxied over to customs, where we were met by the customs agent as well as our assigned handler. Once the flight and medical crew disembarked the aircraft, they were required to unload all medical

Changing out ight crews proactively prevented possible duty time issues

MEXICO CI TY, MEXIC O PATIENT PIC K UP

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equipment and bags, which were then run through the customs officers’ X-ray machines.

Once the bags were reloaded onto to the aircraft and all customs requirements were met, the aircraft was towed over to the FBO (fixed base operator), where the crew was to meet the ground ambulance.

A delay with the ground ambulance ensued when the FBO demanded a ramp fee to be paid prior to allowing the ambulance access to the aircraft on the tarmac. After negotiations with the FBO that took over an hour, the issue was resolved, and the medical crew was able to commence their journey into Mexico City for a patient bedside pickup.

AIR AMBULANCE REVIEW

case study

The medical crew made bedside contact with the patient, who was generally in stable condition. The patient was dehydrated (which is quite a common problem when picking up patients in Mexico) and was breathing shallowly due to his rib fractures. The medical crew started him on fluids as well as supplemental oxygen to help with his oxygenation.

Although injuries of this nature are usually quite painful, the patient refused pain medication. The crew did provide the patient with noise cancelling headsets with music as well as aromatherapy with essential oils to help provide a calm and relaxing atmosphere during the flight.

The FBO demanded a ramp fee to be paid prior to allowing the ambulance access to the aircraft on the tarmac The round trip to Mexico City and back took longer than anticipated due to traffic along the way. When the crew arrived back at the airport, another hour ensued with customs checking all of the patient’s baggage, including his parachute that he wanted to bring back with him!

The initial itinerary had one set of pilots fly the entire mission to the destination and then remain overnight due to duty time. However, with the unexpected ground delays in Toluca,

the weather in Oregon was forecast to be marginal at the time of expected arrival. This necessitated filing an alternate airport due to the bad weather.

To ensure success of the mission, management discussions led to a decision to change out the flight crew during our customs stop in the US. Changing out flight crews proactively prevented possible duty time issues with the current flight crew and provided maximum flexibility for any other unforeseen issues.

This necessitated changing our original customs stop to one near our base of operations in order to accommodate a crew change. This was no small feat as we were already coming in to customs ‘after hours’. After a discussion with the Port Director at US Customs and Border patrol, we were able to obtain approval for inbound customs that would accommodate a crew change.

After clearing customs, and with a fresh crew onboard, the aircraft departed on its last leg of the mission to Oregon. By the time the aircraft arrived at the destination, the pilots were unable to land due to freezing fog and had to divert to the alternate airport. While the crew landed safely at the alternate, the intended airport was located on the other side of a mountain range.

We had previously informed our client that a

diversion due to bad weather might be a possibility but were hopeful it would not happen. The weather had closed in at the destination city at the last minute, making landing an impossibility. Getting the patient to his destination was becoming a challenge.

Fortunately, we had some options available since we had a relatively fresh pilot crew.

We called the client and discussed several options to include: waiting for the weather to clear, placing the patient in the emergency room at a local hospital overnight and finishing the flight the next day, or transporting the patient via a three-hour ground ambulance transport.

When it became apparent the weather would not be clearing anytime soon, the client requested the patient be transported to his final destination via ground ambulance.

The patient concurred with the decision as well. A member of our medical crew team accompanied the patient to the destination hospital. What was supposed to be a threehour ground transport turned into over a four-hour journey due to inclement weather that hampered the ground ambulance transport. The patient finally arrived at his destination safe and sound with stable vital signs and in good spirits after his adventurous mishap in Mexico.

In the end, it’s all about taking care of the patient and making a difference in their lives as we navigate the journey for them to get home safely.

Denise Waye is a Registered Nurse with a Bachelor of Science and Nursing. She is President and Founder of AirCARE1 Air Ambulance & Commercial Medical Escort Services.

Waye has over 24 years of experience as a critical care nurse. She received her Bachelor of Science and Nursing from the University of New Mexico and has worked in a variety of critical care patient settings including ICU, CCU, ED, and as an air ambulance flight nurse.

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AIR AMBULANCE REVIEW

CASE STUDY

WITH MILITARY PRECISION

Taking a civilian air ambulance into a warzone requires careful co-ordination with different authorities. When Airlec Ambulance was called to collect a patient in the Middle East, time limitations and information added to the complexity of the case. Below, the company reports on the mission

A

few months ago, one of our clients, International SOS, requested an urgent evacuation of a 33-year-old lady from a military hospital in an active war zone in the Middle East, to a place where medical care is more closely aligned with international standards for intensive care.

Patient’s medical condition This young patient had no special past medical history and had over a few days developed a fever with a sore throat, odynophagia, abdominal pain, and jaundice that was not improving after six days of treatment azithromycine and

paracetamol. She was initially assessed locally and transferred to the ICU of a military hospital in good clinical condition. Her subsequent blood work up showed severe liver and kidney failure with fulminant hepatitis complicated by acute coagulopathy, thrombocytopenia and metabolic acidosis.

A CT scan of her abdomen further revealed mild anasarca from pleural effusion, pericardial effusion, ascitis with hepatomegaly, splenomegaly and lymphadenopathy. The final diagnosis was an acute Epstein Barr Virus infection with liver and kidney failure, which was complicated by acute coagulopathy,

*Please kindly note that for obvious confidentiality reasons, we are not allowed to disclose sensitive details in this presentation*

40 |

Dr Yann Rouaud is an emergency physician with specialisation in Emergency and Disaster Medicine.

After working many years in public hospitals’ A&E departments he joined Inter Mutuelles Assistance in 2007 as a Medical Director. In 2012 he was recruited at International SOS. In his role as AIRLEC Group Medical Director, his daily commitment is to ensure that quality of delivery will fully match patients’ and clients’ expectations as well as meet the true spirit of AIRLEC Group: always go above and beyond.

thrombocytopenia and metabolic acidosis, with a possibility for a hematophagocytic lymphohistiocytosis. The patient was at high risk of acute haemorrhage because of deep coagulation disorders, with a need for comprehensive ICU medical management and a potential liver graft.

AIR AMBULANCE REVIEW

case study

Considerations and complexities To make this flight possible, and beyond dealing with the critical medical condition, Airlec Ambulance faced many operational challenges: ▶︎ Because of the extremely high confidentiality in regards to the military airport details, it was nearly impossible for our pilots to obtain any precise airport approach plate. ▶︎ The team had only 120 minutes allowed on site by specific insurance policy extension. ▶︎ This area is strictly forbidden to French air operators, so Airlec Ambulance had to obtain a mandatory special waiver from the French Ministry of Foreign Affairs. ▶︎ Because of the location of the patient, Airlec Ambulance actively sought security information from various stakeholders in

order to evaluate the risks/benefits ratio of the mission. ▶︎ For safe overflight-approach-landing-take off conditions in war zone country/airport there was a complicated necessity to liaise with many different parties: • French authorities.

• Military airport authorities.

•︎ Civilian authorities in the country. ▶︎ Although Airlec Ambulance anticipated this option, no military plane was sent to escort our aircraft from the air to the airport.

In-flight The patient’s haemodynamics and ventilation remained stable throughout the flight, with only one acute episode of nasal bleeding which was stopped with intravenous tranexamic acid (the decision not to perform any anterior/

posterior packing was made by the medical team due to the severe coagulopathy). The patient was finally safely handed over to the receiving medical team.

Paul Tiba, Chief Executive of Airlec Ambulance, told ITIJ: “It was a big challenge to implement a single civilian air ambulance in a complex military war zone system. It necessitated huge efforts and commitments from our operations team and ground handling agent to ensure the safety of the patient, medical team and pilots by securing overflightapproach-landing-take off in an active war country/airport. This included timely analysis of the situation and medical/operational capabilities, timely delivery of Labile Blood Products thanks to our agreement with French Blood Institute, and timely transfusion of the patient upon arrival of the team.” | 41

AIR AMBULANCE REVIEW

CASE STUDY

MISSION ACCOMPLISHED

AMREF Flying Doctors had to make a careful and detailed assessment of the risks to aircraft and crew before accepting a mission involving an evacuation from war-torn Yemen

O

n 29 December last year, we were asked to evacuate a patient with severe fractures of the lower limbs from Sanaa in Yemen, to Amman, Jordan.

With requests from conflict areas, we have to make an initial feasibility assessment that take into account: • The context and background of the patient as well as his/her medical condition.

• The security situation on the ground and in the air,.

• The required clearances for the mission, specifically the landing permit in Sanaa and overflight clearances from the Saudi-led coalition with the necessary time slots for accessing Yemeni airspace.

• Operational timelines in the interest of safety and patient care.

• Insurance requirements.

We established quickly that the mission could be executed successfully with operational, safety and security considerations catered for. The client and patient had been certified by the United Nations (UN), which had confirmed the necessity of the evacuation. We then received an initial positive security report and a green light from the insurer to proceed, but at a higher premium. We then applied for the necessary clearances with support from the UN.

We received an initial positive security report and a green light from the insurer to proceed, but at a higher premium Logistics When routing to Yemen for such a mission, although the aircraft is operationally capable of flying directly to Sanaa, the security situation in the country meant that we had the aircraft in Djibouti ready for the approved time slots 42 |

to access Yemeni airspace, which is controlled by the Saudi-led coalition. For the clearance application, we have to submit the routing – via Djibouti – and the submission has to be made at least 48 hours before the planned departure time. The details of the crew and airframe must be included in the submission.

The operational flight plan was as follows: • Cognizant of the time slots for Yemen airspace access – typically three to four hours – the aircraft would take off from Nairobi in the early morning.

• In Djibouti, they would make an operational tech stop, but also get a security briefing before the captain could make a final decision to proceed with the mission.

• The aircraft would then proceed to Sanaa, pick up the patient with a maximum ground time of 30 to 40 minutes and fly directly to Amman, approximately three hours flying time west of Sanaa.

After submitting all the necessary details for the flight clearance application, we were then advised that we would we have to re-submit the operational timelines. We would not be allowed to fly directly to Amman on our return leg; we would have to go via Djibouti. This had to be discussed with the client, as it meant a substantial change to the routing of the second leg – close to a 50-per-cent increase in distance.

The client gave us the go-ahead.

Meanwhile, the client asked if the patient’s brother could accompany him on the flight. The Citation Bravo C550 used on this mission is capable of carrying one accompanying passenger and we were operationally OK to do so, but as the brother was a Yemeni national, he needed to have a visa for travelling to Amman. This was subsequently obtained.

With all the relevant details clarified and submitted, we were finally given the clearances and time slots to fly on 3 January. With constant communication with the UN and other security agencies, the flight took off early in the morning.

The mission went successfully, landing in Amman at approximately 5.20 p.m. local time.

AMMAN ,

JORDAN PATIENT DR OP OFF

EN YEM AA , K UP C SAN I P ENT PATI

Dr Bettina Vadera is Chief Executive and Medical Director of AMREF Flying Doctors. Specialised in Emergency Medicine and Tropical Medicine from Germany, Dr Vadera moved to Kenya to join AMREF Flying Doctors (AFD) as a Flight Physician. She became the Medical Director in 2007 and Chief Executive in 2011. Dr Vadera leads the AFD management team and is responsible for the successful operation and business development.

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