POSTED: December 23rd, 2019
POSTED IN: EPIC - The Official Newsletter of MOCEP, November/December 2019,
Written by Charles Sheppard, MD, FACEP and Sabina Braithwaite, MD, FACEP
The recent publication of the NTSB report on a fatal air ambulance crash in Ohio in January 2019 makes me want to raise awareness of EMTALA obligations in interfacility transfers. According to EMTALA, the sending physician is responsible for the qualifications and abilities of the mode of transport for her/his patients. If you have not read the preliminary NTSB report about this crash, I urge you to do so; the report is available here. It is concerning and eye opening to the dangers not only the crew for this service, but also any patients on board were repeatedly placed in.
I also urge you to read the CAMTS’ response to this crash. As this incident illustrates, while calling a second helicopter service when the first has declined for weather may be appropriate in rare circumstances (IFR service, weather lines, etc.), it also comes with great risk and that should be conveyed to the second service. This “helicopter shopping” has been identified as a high risk practice that risks safety of all involved.
There is often a misconception that using a helicopter saves time. In some cases this is true. But it contributes to improved patient outcome in only a subset of these cases. Many physicians are unaware that time for helicopter transport includes numerous elements: activation time (5-8+ minutes to check weather and launch), flight time to scene/facility, transit and load time between helipad and patient and patient handoff, helicopter crew patient assessment and stabilization measures for transport, flight time to receiving facility, and transit from helipad to definitive care location. From a patient-centered perspective, the flight time is only one fraction of the time involved. The Helicopter may, however significantly shorten the “out of hospital time” which may be important for a subset of patients as well.
The second idea to address is the “closest aircraft” concept. This probably made some sense when Missouri had six aircraft, but now that there is one on every corner it makes less sense. The second (and often 3rd) closest aircraft are often less than 10-20 minutes different in arrival time to scene or hospital and may in fact arrive at the destination sooner depending on distance, scene time, and aircraft type (air speed). Because of these nuances, it is the sending person’s responsibility to either be personally aware of capabilities, charges, and safety culture of the surrounding aircraft, or to inform themselves prior to making a decision. Many patients could (and would be happy to) wait an additional 10-20 min to save $30,000 and have a safer better trained crew. However, there is currently no consistent, transparent, or proactive mechanism for patients to be involved in choosing mode of transport, transport provider, or expense for either ground or air transport in critical situations. Many conditions don’t require a flight in the first place. There are very few diagnoses/patients for whom the potential time savings to definitive care would make a clinical difference in outcome. The joint ACEP / NAEMSP / AMPA / AAEM position statement provides helpful guidance on the various facets of appropriate utilization of HEMS above and emphasizes the importance of assessing what the specific expected benefit to the patient is for using HEMS, be it time savings to definitive care or critical care capability.
There is still a lot of debate about what caused this crash and if it could have been prevented. Former employees of the company have raised several concerns during the investigation that the company CEO has publicly denied. The investigation into the helicopter crash is still ongoing and a final report has not yet been released. Either way, it is imperative for the sending provider to weigh the potential risk to the flight crew and patient when they fly a patient, just as they weigh the risks and benefits of ground transport or a prolonged ground transport if there are only 1 or 2 ambulances in that county. While we always want to include physician discretion in making this type of decision, the inclusion of updated HEMS utilization guidelines or incorporating the NHTSA funded evidenced-based guideline and/or NAEMSP position statement (linked above) may be useful when making such a critical decision. While it would be great if the flight companies were involved in these decisions (outside of weather safety conditions), ultimately the sending physician remains responsible for the decision, although the patient is the one who bears the financial and medical consequences of that choice.
As many of us never received education regarding appropriate flight utilization during residency, having access to these resources in an easily available and accessible format when making these critical decisions would be useful but seems unlikely in the current competitive market.
While we more critically assess not only the appropriate mode of transport (ground, air, private vehicle!) for our patients, consider the cost, safety and patient outcome impacts of this choice, the choice of receiving facility (particularly when it is not the “closest”) must be part of the decision as well. It is critical that our documentation explain and support the choices that are made, as well as any shared decision-making with patient/family in this regard. Many times, it isn’t the decision to transport (or not) to the closest hospital that turns out to be the problem for billing, insurance coverage and fee collection, but the fact that the rationale was not fully documented.
Both federal and state legislators are looking closely at the expense of helicopter EMS. MOCEP is working with WPS (regional Medicare) to develop strategies to raise physician awareness on the nuances of documenting medical necessity for transfer, how to choose the appropriate transport option, and how to document why the specific receiving hospital was chosen (and why a geographically closer facility was not appropriate to meet the patient’s needs). For physicians who would like more information on this complex and difficult subject, your regional EMS committee and medical director who has expertise in emergency medical services can be a great resource.