When transferring patients between healthcare facilities, it is essential that there are:

1. Effective communication between transferring and receiving teams
2. Appropriate documentation regarding the patient’s condition and treatment plan
3. Informed consent and adequate assessment of the patient’s stability before transfer
4. Highly qualified personnel for the transport.

These four elements are vital to avoid complications or harm to the patient, which could in turn result in legal action against the healthcare providers involved.

Identifying risks

In medevac missions, air ambulance teams are taking the patient out of the comfort zone of the hospital into ground and air ambulances. 

“In these circumstances, the observations and treatment of the patient’s condition become more challenging, especially when the patient’s condition is evolving,” said Dr Winston Jong, Group CEO and Group Medical Director of EMA Global.

The medical escort team is limited by the equipment and medication they carry on board, said Dr Jong. This could be an issue if the patient’s condition changes and requires certain medications that were not packed before departure, he added.

Success lies in a deep understanding of aviation law, proactive planning, and close collaboration with aviation authorities and operational partners

Tom Hienckes, Business Development Manager at European Air Ambulance (EAA), highlighted that when his medical crews conduct in-person assessments before the start of a mission, often the expected medical status does not match the patient’s actual condition.

Furthermore, once the medical team crosses an international border, they no longer hold any medical legal rights to practise. This can lead to a lack of clarity surrounding issues such as whether the medical escort team is allowed to move the patient out of a hospital while they are in a foreign land and whether they have permission to alter the patient’s condition.

“The way to navigate this is to have an open conversation with the team that last treated the patient,” Dr Jong suggested.

Further to this, he added: “Flight schedules need to be adhered to, and flight crew duty hours are well defined and not to be exceeded. Occasionally, the aircraft malfunction/technical issues with the aircraft lead to the grounding of the aircraft and urgent plans need to be made to offload the patient.”

“Logistical risks encompass operational delays due to weather conditions, airport restrictions, overflight or landing permit issues, and, at times, the unavailability of ground ambulances,” noted Hienckes. “Additionally, regulatory challenges, such as compliance with aviation laws, managing the import/export of medical equipment, and obtaining necessary crew visas, can further complicate operations.” 

In countries where EAA does not operate regularly, delays coming from regulatory requirements are sometimes unavoidable, said Hienckes. EAA’s medical teams conduct thorough pre-transport assessments to identify potential risks and determine care requirements. 

He emphasised the importance of real-time communication tools, robust contingency plans, and strict adherence to international standards.

Dr David Farnie, Medical Director of Global Healthcare Management at GeoBlue, pointed out that long-haul missions often require additional stops and more time outside the hospital. “To reduce risks, it’s crucial to have experienced personnel who can manage the logistics of medical transport, along with expert clinical staff,” he said. 

“These teams should be familiar with local healthcare practices, airport regulations, and the impact of air travel on patients. Medical staff must also understand how flying and the transport itself can impact the patient’s medical situation and apply this knowledge to mitigate the potential for risk during the transport, recognising that patients must be cleared for evacuation with a ‘fit-to-fly’ order from the treating physician.”

Dr Ozan Raimondo Perri, Medical Doctor at Marm Assistance, stated that a detailed pre-transfer assessment forms the foundation, ensuring the appropriate medical resources, equipment, and expertise are in place. “Equally important is a commitment to efficiency – ensuring solutions are not just medically sound but also cost-effective … By combining clinical precision with operational flexibility, it’s possible to address patient needs while maintaining the highest standards of care and resource optimisation,” he said.

Maintaining high-quality care

To ensure continuity of care remains at a high level during long-distance flights and wing-to-wing transfers, Dr Jong 

said that the medevac team needs to fully understand the condition of the patient before the mission, most importantly before they leave the hospital. 

Dr Perri added: “Every transfer begins with a comprehensive assessment of the patient’s condition, enabling the careful selection of medical equipment, supplies, and highly trained personnel tailored to the situation. 

“The team needs to stabilise the patient on the ground before they are airborne. They need meticulous planning and execution. Although fine adjustments can be made on 

the equipment while in the air, all major changes in the  equipment settings must be made while in the hospital in case such manoeuvres are not well tolerated.” 

Hienckes agreed that maintaining high standards begins with a thorough pre-flight assessment of the patient’s condition to identify specific needs and potential risks. 

“As per aviation authority regulations, our flight crews are subject to strict working hour limitations. At EAA, we extend these same rules to our medical crews. On long-range air ambulance flights, particularly those involving intensive care patients, we exchange the entire crew during stopovers.” 

This ensures that both flight and medical teams are rested and fully prepared to provide optimal care for the patients. 

Dr Farnie added that sometimes air ambulance providers work with external partners for wing-to-wing transfers. 

“In these cases, we expect the provider to have established, reliable partnerships, ensuring that the external partner meets the same high standards. We expect timely updates from the provider on milestones like permits, aircraft positioning, and timelines, including tech stops. Once the mission begins, real-time updates on patient pick-up, tech stops, and arrivals are critical.”

He stressed that clinical updates are equally important, with a final medical report required upon completion. “The provider’s medical director or their designee should review 

the case and ensure the right team and equipment are on board. If necessary, the provider’s medical director should communicate directly with the treating physician to confirm the patient’s status and transport plan.”

Dr Farnie continued: “Finally, providers often communicate with non-medical stakeholders like patients, family members, or even the patient’s employer. It’s essential to share important medical or operational information with care, balancing transparency with compassion. When non-family members are involved, providers must also be mindful of what information is appropriate to disclose.”

Airspace and the law

According to airspace regulation, in the event of a medical legal issue, judgement is based on the laws of the country the plane is flying over. Conflicts may arise between the country of an aircraft’s registration, which applies its national aviation laws on board, and the airspace it is flying through, where local laws may prevail.

“While these frameworks are generally designed to align, nuances in areas like medical liability, patient data privacy, and operational permissions can lead to conflicts,” reflected Dr Perri.

Dr Jong stated that medical legal issues are addressed in the country of the receiving hospital or where the insurer is located.

Hienckes noted that “discrepancies can occur in areas such as jurisdiction over criminal acts, medical liability, or compliance with safety standards. These conflicts are typically navigated through international treaties like the ICAO Chicago Convention, which establishes baseline rules for aviation.” 

Being a member of an internationally accredited organisation like EURAMI or CAMTS is of value, but it does not negate the need to plan the missions with the utmost care

He said that EAA refers to pre-flight agreements and legal counsel to address specific regional requirements. Diplomatic discussions and case-by-case resolutions may also play a role in resolving challenges.

Dr Farnie reiterated that navigating conflicts depends on international law and guidance from applicable aviation organisations. “Additionally, geopolitical concerns can also impact transportation options, requiring alternate means (e.g. ground transport) in situations of war and/or where airports may be closed for security reasons,” he said.

Dr Perri added: “Years of coordinating international and intercontinental air ambulance operations have shown us that these challenges are rarely insurmountable with the right approach. Success lies in a deep understanding of aviation law, proactive planning, and close collaboration with aviation authorities and operational partners,” he concluded.

Licensing and accreditation across regions

Licensing and accreditation requirements for flight medical crews differ significantly between countries and regions, often creating challenges for air ambulance firms operating internationally. 

“Variations in language proficiency resulting in communication issues, scope of practice, and credentialling standards can complicate operations,” reflected Hienckes. “These differences can increase administrative burdens for firms as they must ensure compliance with multiple jurisdictions. It may also limit flexibility in deploying our crews across borders, raising costs and potentially delaying air ambulance flights,” he said.

Licensing can vary by country; however, many vendors seek accreditation from one or more recognised organisations, including the European Aero-Medical Institute (EURAMI), the Commission on Accreditation of Medical Transport Systems (CAMTS) or the National Accreditation Alliance of Medical Transport Applications (NAAMTA). 

Dr Farnie noted that “the variability, at times, can affect the scope of practice for physicians, nurses, paramedics 

and respiratory therapists. Therefore, accreditation through a major accrediting body can ensure high quality and consistency, mitigating that variability.”

Liabilities of adverse outcomes are often difficult to mitigate as there are no established governing bodies to undertake the task of mitigations, noted Dr Jong. “While being a member of an internationally accredited organisation like EURAMI or CAMTS is of value, it does not negate the need to plan the missions with the utmost care, especially regarding possible complications and how to be prepared for them,” he stressed.

Dr Perri added: “Ensuring that medical personnel hold the appropriate certifications for the regions they will operate in is critical, as is maintaining robust partnerships with trusted providers who are well versed in local requirements.

“Beyond compliance, aligning with global best practices in medical training and patient care ensures that teams not only meet but often exceed the expectations of diverse regulatory frameworks.”

Comprehensive cover

Insurers play a valuable role in patient transfers. ITIJ asked the industry whether they could do more to provide comprehensive and structured coverage to mitigate various risks.

Dr Jong reflected that coverage in this area is often fragmented and lacks standardisation. “A more comprehensive and structured approach to insurance coverage should include clear and specified limits for medical expenses, repatriation costs, and related expenses.

“Standardised policies would make comparison and selection easier for patients and healthcare providers. 

Insurers could also develop a global network of accredited medical providers to ensure access to quality care worldwide,” he said.

Dr Farnie noted that insurers have internal processes to update their policies in line with regulatory changes and  industry developments, and that GeoBlue is always looking for ways to enhance processes and coverage options and collaborate with providers to mitigate risks.

Dr Perri added: “Fostering closer collaboration with medical and operational providers can help insurers anticipate potential challenges and design policies that not only address emergencies but also optimise resource allocation.” 

He highlighted the necessity for a global malpractice insurance framework tailored specifically for air ambulance medical teams. 

“Currently, such insurance policies are often limited to national jurisdictions due to regulatory constraints. However, these teams frequently operate across international borders, exposing them to varying legal environments and potential liability risks. 

“Establishing a globally recognised malpractice insurance model would not only provide consistent protection for medical personnel but also enhance trust and operational confidence among patients and stakeholders,” he concluded.

Conclusion

Key risk factors during patient transfers include miscommunication between teams, a scarcity of medical equipment, bad weather and aircraft technical issues. 

Industry experts emphasise that maintaining a high level of care despite unexpected challenges begins with having a clear and comprehensive understanding of the patient’s condition before embarking on the mission. 

When challenges arise on board, conflict between the laws of the country of an aircraft’s registration and those of the airspace it is flying through can lead to further complications. While airspace regulation frameworks are generally designed to work with each other, there can be 

legal grey areas regarding medical liability, patient data privacy, and operational permissions. In these instances, medical accreditation might help vendors to align with global best practices while guidance from applicable aviation organisations and case-by-case resolutions could also be used to resolve challenges. 

Finally, while insurers can play a valuable role during patient transfers, experts suggest that coverage doesn’t always work cohesively. Standardisation of policies and a global network of accredited medical providers could provide more consistent protection for medical teams and patients.