Patient Safety Tip of the Week
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
In the past year we have done several columns on the “epidemic” of EMS helicopter crashes (see our July 8, 2008 Patient Safety Tips of the Week “Medical Helicopter Crashes” and February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture”, and our October 2008 What’s New in the Patient Safety World column “More Medical Helicopter Crashes”). In all in 2008 there were either 7 EMS helicopter crashes, in which 28 people died or 13 helicopter crashes with 29 deaths, depending on your source of information and exact timeframe. Our previous columns looked at multiple aspects of the crashes but have centered on the issue of appropriateness of medical helicopter runs.
Last week the Washington Post ran a series on the safety issues involved in medical helicopter crashes and did its own investigation into the 2008 crash in Maryland that took the lives of a patient, 2 EMT’s and a pilot and left a second patient seriously injured. The lead article (Gaul 2009) focuses on many of the financial issues involved. The second article (Flaherty and Johnson 2009) does a root cause analysis of the Maryland crash and the subsequent search for the downed helicopter.
They point out that this $2.5 billion industry is now dominated by private, for-profit companies and continues to grow rapidly, especially fueled by generous reimbursement from government and private health insurers (air transport costs roughly ten times what ground ambulance services cost in any region). Growth of medical helicopter services especially increased after Medicare, the nation’s largest payor of healthcare services, changed its methodology of payment in the 1990’s and then added a 50% premium for rural flights in 2002.
The article further describes the administrators of some medical helicopter companies pressuring pilots to accept all flight (even in questionable weather conditions) and “fishing for the golden trout” (meaning finding all the air transports possible). And it describes how some of the companies cozy up to those most likely to refer patients for their services (the emergency medical community and the hospitals). But they also point out the financial attractiveness of helicopter transports to the receiving hospitals.
A primary root cause of the problem is money. Simply put, the medical helicopter industry today is a very profitable one. Competition for patients is heavy. One of the articles in the Washington Post series tells of an instance where two medical helicopters went to pick up and transport a trauma patient (Flaherty 2009b) from a small rural hospital to a large urban trauma center. One helicopter had been called in via the traditional EMS system. The other had been summoned via a direct phone call to the helicopter pilot by a nurse who was employed by the helicopter company but who happened to be working at the hospital that day.
Competition even entered indirectly into the Maryland crash, where direct financial reward does not come from each transport (the Maryland system is publicly funded and run by the Maryland State Police). In that crash, the pilot was initially reluctant to fly into a heavily fogged-in area but heard that one of the commercial medical helicopters in nearby Washington, D.C. had flown into a nearby area. He basically said “If they can do it, I can do it.” and decided to fly that fateful night.
Another root cause is “helicopter shopping” where EMS responders or hospitals call multiple helicopter services even after one has refused to fly because of bad weather.
Yet another root cause is an unintended consequence of a law passed many years ago to encourage competition among major airlines. The Airline Deregulation Act of 1978 prohibits the states from interfering with airline prices or routes or service. That, of course, was intended to apply to passenger (and perhaps freight) air travel and not really intended to cover medical helicopter services. Nevertheless, the wording of that Act has been used in the court system to fight any attempts by state or regional emergency planning organizations to oversee comprehensive management of the medical helicopter programs. So it is only the FAA that has had regulatory oversight of the medical helicopter industry. Just as in the case of the general airline industry, the FAA has been roundly criticized for many years for its cozy relationship with industry and its tendency to hope issues are corrected voluntarily rather than by mandate. Innumerable recommendations for safety improvement made by the NTSB (National Transportation Safety Board) have never been mandated by the FAA nor implemented by the general airline industry or the medical helicopter industry. The FAA often responds that the industry felt that the recommended changes were too expensive. A few years ago the NTSB had made recommendations about adding terrain warning alarms, night vision goggles, flight risk assessments, and others but the FAA neither mandated these nor monitored how many companies voluntarily adopted them. The FAA, following last year’s rash of medical helicopter crashes, has begun the process of developing the new safety rules (eg. terrain warning systems, formal flight risk assessments, and others) but we haven’t yet seen those actually implemented.
The root cause that we have been so concerned about is the use of medical helicopters for transport of patients who are more appropriately transported via ground ambulance. There are many anecdotal reports of patients with relatively minor injuries being transported by helicopter, only to be discharged from the hospital emergency room without requiring admission. Most significantly, there is no database nationally or at the state or regional level that addresses the appropriateness of the helicopter transport.
We previously noted a 2006 study done by Dr. Bryan Bledsoe and his colleagues that was a meta-analysis of helicopter transport of trauma patients. Using several widely-used injury severity or trauma scores, they showed that almost 2/3 trauma patients brought by helicopter to a trauma center had minor or non-life-threatening injuries and that 25% were discharged from the hospital within 24 hours. Some helicopter services apparently have rates as high as 20% of transported patients being discharged from emergency rooms shortly after arrival (Greene 2009). Even in Maryland, where the trauma system is a model and the medical helicopter system a public one, the post-crash hearings revealed that almost half of patients transported by helicopter to trauma centers were released within 24 hours (Dechter 2008).
Time of transport is also important. Often, responders in the field do not appreciate the relative transport times involved in air vs. ground transport. In our February 3, 2009 Patient Safety Tip of the Week “NTSB Medical Helicopter Crash Reports: Missing the Big Picture” we noted we had that very day chanced upon a medical helicopter evacuation scene that is exactly 29 minutes from the Trauma Center. Quite frankly, there is no way that the whole process of helicopter transport could have gotten that patient to the Trauma Center faster than ground transport would have.
Much of the argument centers on the need for explicit criteria to help decisions about helicopter transport. There have long been guidelines for what patients should be transported to level I trauma centers. These are the guidelines developed by the American College of Surgeons that are based upon both physiologic condition of the patient, physical signs of injury, and other predictors of injury such as mechanism of injury and some other factors related to the crash site. However, those guidelines do not address who should be transported by helicopter and who should be transported by ground ambulance. In the Maryland crash, it apparently was the factors not directly related to the patients but rather mechanisms of injury (intrusion of the rear end of the car more than one foot) that led to the decision to use air transport. The Maryland Medical Protocols for Emergency Medical Services Providers was subsequently revised with regard to helicopter transport for “C” and “D” trauma patients. Those categories are the categories related to mechanism of injury or other factors related to the crash (eg. ejection from the vehicle, high speed of crash, death of another occupant, etc.) and those related to patient characteristics such as age, history of dialysis or anticoagulation, etc. For those two categories, the trauma decision tree calls for those patients to be transported by ground if they are within a 30-minute drive to the nearest trauma center and requires consultation with the receiving trauma center for decisions about helicopter transport. Since those revisions were made, the number of medical helicopter transports has dropped by about half (Flaherty and Johnson 2009).
Multiple factors undoubtedly contribute to the high use of medical helicopter transport. Concern for the patient or the trauma victim obviously is the number one factor. We spent years developing good trauma systems that help get appropriate patients to the level I trauma centers within the “golden hour”. And the ACS criteria have proven very useful in triaging those patients to the appropriate site. But other considerations may also be driving the use of medical helicopters. Concerns about possible EMTALA violations (the federal “dumping” statute that also calls for hospitals to assess and ensure stability and safe transport of patients) and malpractice liability also enter into the decision-making process. The time pressures and complex nature of the trauma scene also affect the decision-making process. And there are varying degrees of medical and field experience in the first responders. Even “drama” comes into play (one of the passengers on the Maryland crash actually went along to see what a medical transport is like). And, unfortunately, financial considerations and the sometimes cozy relationships between the helicopter companies and the EMT or hospital personnel may also play a role.
Are there good systems? Yes. Despite the 2008 accident, the Maryland system remains a model system and has shown resiliency and a leadership role. The public system in Maine, also profiled in the Washington Post series, is also well run and coordinated well with the state’s ground ambulance and EMS system.
It is time for the federal government to either step up and undertake appropriate safety oversight of the medical helicopter industry or, better yet, change the law to allow state or regional emergency medical systems to do the oversight. Just as in all areas of healthcare, we need to be able to monitor outcomes and to do that you need good data collection. Inclusion of criteria for air transport into trauma guidelines would be a major step. We would hope that the ACS would use the Maryland experience and add such criteria to their guidelines so that the same approach applies regardless of what state a trauma victim might be in.
And if you are a small rural hospital and just use the medical helicopters for transferring patients with acute MI or acute stroke for definitive procedures, make sure you also know the outcome data. If you wait for the helicopter but never get anyone to the tertiary care hospital within the therapeutic window for primary angioplasty, you better rethink your strategy. Again, the lack of good outcome data related to transports is detrimental.
Our advice from prior columns: Even if your organization does not own its own medical helicopter, there are things you can do to help ensure the safety of your staff and patients. First and foremost, make sure the benefit of the helicopter trip is likely to outweigh the risks. Second, make sure the company that runs the helicopter has a culture of safety. If it uses standardized dispatch protocols, has night vision imaging equipment and terrain awareness and warning systems, does flight risk assessments, is meticulous in maintenance, has (and enforces use of) helmets and shoulder harnesses, and has good training programs for its pilots and any of your staff that may fly – that’s the sort of partner you are looking for. You should be participating in simulation exercises and other crew resource management drills with them. Also, the medical helicopter transport is another great process to consider for one of your FMEA (Failure Mode and Effects Analysis) activities. Get good data from the helicopter company about transport times and any issues that arose. Make sure you get the data you need from the receiving hospital on key measures like time to angioplasty. And beware of the old adage that new safety technology may simply push the envelope – there is a tendency to take more risks when the system is perceived to be safer. So a healthy dose of skepticism and vigilance is always a good thing.
Update: See also our November 2010 What’s New in the Patient Safety World column “FAA Safety Guidelines for Medical Helicopters Short-Sighted”
References:
Lowy J (Associated Press). Safety board probes EMS helicopter crashes. Houston Chronicle. Jan. 15, 2009
http://www.chron.com/disp/story.mpl/side/6212321.html
Emmons N. NTSB to Issue Helicopter EMS Safety
Recommendations.
February 9, 2009
http://include.nurse.com/article/20090209/NATIONAL01/102230015/-1/frontpage
Gaul GM, Flaherty MP. The Deadly Cost of Swooping In to Save a Life. Washington Post 2009; August 21, 2009
http://www.washingtonpost.com/wp-dyn/content/article/2009/08/20/AR2009082004500.html
Part One
The Deadly Cost of Swooping In to Save a Life
Medical helicopters are a $250 billion industry and growing fast. A closer look at what's really at stake.
By: Gilbert M. Gaul
and Mary Pat Flaherty
http://www.washingtonpost.com/wp-srv/special/nation/medical-helicopters/?sid=ST2009082100030
Flaherty MP, Johnson J. FATAL FLIGHTS Where's Trooper 2? Vanishing in Midair.
Washington Post 2009; August 23, 2009
http://www.washingtonpost.com/wp-dyn/content/article/2009/08/22/AR2009082202372.html?sub=AR
Flaherty MP. Audio Sidebar: Two Helicopters, One Patient,
Mixed Signals.
Washington Post 2009; August 21, 2009
FAA Introduces New Medical Helicopter Rules
NewsInferno.com. Date Published: Monday, April 27th, 2009
http://www.newsinferno.com/archives/5800
Bledsoe BE. Wesley
AK. Eckstein M. Dunn TM. O'Keefe MF. Helicopter scene
transport of trauma patients with nonlife-threatening injuries: a
meta-analysis. Journal of Trauma-Injury
Infection & Critical Care 2006; 60(6):1257-65 http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-200606000-00015.htm;jsessionid=LzvDYgJNbkdJpBhDDCFtr3VBPJJ6WwQ1bvdXstQHvMNQ7Lk0Mygl!447927974!181195628!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search
Greene J. Rising Helicopter Crash Deaths Spur Debate Over Proper Use of Air Transport.
Annals of Emergency Medicine 2009; 53: A15-A17 (March 2009)
http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS0196064409000316.pdf
Dechter G, Jones B. Md. medevac crash raises question about trauma procedures.
The Baltimore Sun. October 1, 2008
http://www.volunteerfd.org/sogs/articles/430962
Maryland Institute for Emergency Medical Services Systems. The Maryland Medical Protocols for Emergency Medical Services Providers.
Effective July 1, 2009
http://www.miemss.org/home/LinkClick.aspx?fileticket=WKeNmP%2bDJ9w%3d&tabid=106&mid=534
Flaherty MP. Protecting the Lives of Those Who Save Others. LifeFlight of Maine Favors Practicality, Safety Over Growth. Washington Post. August 22, 2009
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