Let’s start by looking at what is meant by the term ‘intensive care’. The UK’s Intensive Care Society (ICS) defines it as looking after ‘patients whose conditions are life-threatening and need constant, close monitoring and support from equipment and medication to keep normal body functions going’ and defines such units as having ‘higher levels of staffing, specialist monitoring and treatment equipment … and the staff are highly trained in caring for the most severely ill of patients’. So, can air ambulances provide this level of care? Certainly some specialist operators that have invested time and money into building up their medical and staffing capabilities can offer intensive care in the air, but to what extent does this replicate a hospital ICU, and is that really the right question to be asking?
Certainly, not all air ambulances can handle patients requiring intensive care, even though many claim to. And validating which ones are ICU-proficient is difficult because of the lack of national, international or global standards that might determine eligibility of standards and validate the training of air ambulance ICU crews. Thus, there are some who believe that there are operators in the global air ambulance industry who are not living up to the challenge of transporting critically ill patients as well, as safely, or as appropriately as they might. In particular, they believe that the industry is not providing the kind of internationally or globally accepted training standards that are expected of air ambulance crews who take on the task of transporting critically ill, intensive care patients. So, how do you determine an appropriate air ambulance provider for your ICU patient?
Dr Gert Muurling, chief executive officer and medical director of Globalmed International, is one of many in the worldwide air ambulance industry who believes that the transport of intensive care patients by air should be as good as it is on the ground in a high-quality hospital ICU, but he questions the training requirements of those who must provide intensive care in the air. He contends: “The often heard or read minima for physicians being qualified to do transfers of critical care patients [by air] are ridiculous to my mind. Three or six months of intensive care experience is by far not sufficient to cope with the [problems that might arise], especially during long-range flights.”
He adds that the same is true for the qualifications of flight nurses: “Intensive care transports are not scoop-and-run missions, but can involve a lot of work on the nursing side – preventing decubital ulcers, caring for the soft tissues, and at the same time carrying out a lot of routine work, such as measuring various catecholamines and monitoring different modes of mechanical ventilation –[this kind of] experience is often not seen with paramedics.” He emphasised that the patients and the insurance company have a valued interest in having a specialist on the flight, even if they know that in 90 per cent of cases, nothing spectacular is going to happen.
Three or six months of intensive care experience is by far not sufficient to cope with [the problems that might arise], especially during long range flights
We often hear of patients who would ordinarily be tended to in a tertiary care ICU being transferred for purely medical reasons, with much of the attention, expertise and technology they might find in land-based hospitals. But even the staunchest advocate of air ambulance ICUs would not claim they are the equal of hospital-based ICUs with their access not only to technology, but all the specialised medical expertise that a hospital can muster. Nonetheless, air ambulances that can handle critical care patients have proven a valuable segment of the healthcare continuum in this increasingly mobile society.
But given the lack of documented standards, internationally or globally, how do assistance companies choose an ICU-competent air ambulance to deal with their most medically sensitive patients? Certainly, there are many patients who don’t need the ICU level of care, who are just being shipped home for economic reasons – $19,000 for a repatriation versus $35,000 for a cardiac catheterisation and all the trimmings in a foreign hospital often makes the choice for the assistance company an easy one. But when the need arises and it comes to choosing an ICU-proficient air ambulance, what should assistance companies expect regarding the ICU capabilities on an air ambulance?
Stuart Cox, senior flight nurse at CEGA Air Ambulance in the UK, believes patients have the right to expect the same level of intensive care proficiency in the air as in the ICU of a land-based hospital. “This is completely the standard we should expect. This includes monitoring, blood gas analysis, skills and competency.” He adds: “There have been many advances in portable medical technology making this possible. In addition, medical staff should be assessed by an air ambulance provider with an interview and skills assessment such as simulation training.” But such a high standard of uniformity is not always the case, says Cox. He agrees that for air ambulance crew members, there is not a standard of care or accreditation that validates their ability to provide ICU services beyond the CAMTS or EURAMI standards, thus there are a lot of air ambulance firms promoting themselves as ICU-capable, though they may not be.
Cox told ITIJ that CEGA uses the ICS standards for its definition of intensive care. The ICS has three levels of critical care that follow the Department of Health’s Comprehensive Critical Care document. Levels one and two relate to high-dependency patients and level three are intensive care patients, classified as ‘requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems’.
Matthew Flannery, chief flight nurse for US-based Air Ambulance Specialists, agreed that extremely high levels of medical care can be achieved in the air: “Medical equipment, communication devices and experienced, well-trained staff mean that crews can provide incredibly advanced medical care during transport for the vast majority of patients whom we transport. (Patients requiring) invasive monitoring, LVADs (left ventricular assist devices), multiple care drips and ventilated patients requiring specialty care such as NICU (neonatal intensive care units), IABP (intra-aortic balloon pumps), ECMO (extracorporeal membrane oxygenation) and bariatric services, can all be transported effectively and safely with strategic planning and the co-operation of the sending facilities.” In effect, said Flannery: “Only a minority of patients have conditions … or are so unstable that they cannot be transported safely by a well-trained team. An experienced, well-trained team can transport critically ill patients and care for them as one would expect of a high-level ICU.”
Flannery also noted, though, that it isn’t easy to standardise such services: “As with medicine in general, there are significant differences between aeromedical services and the level of treatment they provide. Aeromedical services carry vastly different equipment, medication, team configurations, training requirements and work under widely varying state and government regulations. While there are several different accrediting bodies attempting to increase consistency and patient safety, they are not a requirement for air ambulance operations nor are there consistent nationally or internationally required standards for such services.”
Dr Laurent Taymans, president of the accreditation body EURAMI, agrees that a patient should expect the same level of intensive care proficiency in the air as in a hospital-based ICU. But he notes there are challenges in delivering that level of proficiency and service. “The air ambulance is equally, if not more, challenging when it comes to patient care,” he says. “The stresses of flight have an impact on patients. Not only should there be the best medical material onboard, but also the best medical crew to avoid adverse outcomes.” He added: “All good air ambulance companies will evaluate not only the pathology of the patient they are transporting, but also the opportunity of that transport. It is clear that the objective is to transport a patient to a better or equal level of standard of care safely and in a timely manner. And sometimes, transporting a critically ill patient is the only choice as the … standard of care on site is extremely bad.” He adds: “On the other hand, it is sometimes best to advise that transporting the patient has no medical benefit for the patient and carries a risk.”
CEGA’s Cox concurs: “Just as a good surgeon needs to know when not to operate, part of the art of being a first class air ambulance provider is knowing when and where not to transfer patients. What is crucial is that this decision must not be taken on commercial grounds, but on what is clinically best for the patient and their safety.”
Can aerial care ever match a ground ICU?
Eileen Frazer, executive director of CAMTS (Commission on Accreditation of Medical Transport Systems) also believes that patients and their families, and by extension their insurers, do not feel too much is being asked of aeromedicine or the people practicing it. She tells ITIJ: “We need to be able to get patients to the trauma centres and critical care hospitals that are equipped and staffed to handle the patient’s needs, and in doing so we must be prepared to deal with the critically ill or injured [patients], even though air crews cannot have the personnel and resources of a hospital at hand.”
Dr Thomas Buchsein, medical director of Germany’s FAI (Flight Ambulance International), challenges claims that air ambulances are up to the standard of top-grade hospital ICUs, and feels that the brochures of some air ambulance providers are tailored for insurers and assistance companies who can potentially be ‘misled as to what is possible in the air and what is not’. He says that ever since he started flying as a doctor on air ambulances in the 1980s, air ambulance companies have been promoting ‘flying intensive care units’, which he says in many cases is ‘blatant nonsense’ and in such circumstances ‘air ambulance operators and their flight nurses and flight doctors … are time and again confronted with disappointment and frustration … when the ‘flying ICU’ can’t meet the requirements and patients are left behind’.
It seems that despite the promises made in brochures and on websites around the world, there is no realistic expectation – at least, among the medical community – that the airborne ICUs can achieve parity of service with hospital ICUs. But then perhaps that isn’t the point. Perhaps it’s simply that they have different functions and may fit into a continuum of healthcare services for patients in a variety of situations. It is clear they fit into this continuum of care just by looking at the numbers of hospitals around the world that have built aeromedical services into their systems.
... medical staff should be assessed by an air ambulance provider with an interview and skills assessment such as simulation training
Says Dr Taymans: “The difference between a good and bad air ambulance programme is the capacity to evaluate the opportunity for transport as well as its safety. It is clear that the objective is to transport a patient to a better or equal level of standard of care safely and in a timely manner.”
But some do it better than others, and that appears to drive competing air ambulance companies to seek standards of approval that validate their competency from bodies such as EURAMI and CAMTS. EURAMI provides a separate standard of accreditation – ‘Special care’ – for those providers where: “In addition to substantial compliance, the service demonstrates proven capabilities in air transports of special high-risk patients (eg IABP, ARDS, neonates, NO ventilation, and so forth) providing continued high-level care.”
CAMTS, meanwhile, is working on a new draft of its definition of ‘levels of care’, including a proposal to abandon use of the term ‘critical care’. Levels of care would be divided into four sections, with level one being the highest and including ‘those programmes that care and transport the most acutely ill or injured patients’, but there will also be a ‘Speciality designation’, which would be given to those services that ‘provide specialty care for a specific type of patient only and do not provide general transport care (i.e. neonatal, paediatric, burn patients, IABP, and so forth)’. Medical devices required at this level would include ventrical assist devices, isolettes or foetal monitors, and there are specific requirements of staff regarding their experience and certifications – from flight nurses to medical directors. Frazer stresses that CAMTS standards address patient care and safety, and the intention is to assess not only the medical director, but also the protocols used in transporting patients, training of staff, utilisation review and quality management and also the aircraft/ambulance, pilots and maintenance along with the interface of communications and safety management systems.
However, accreditation from these bodies is largely not mandatory. Furthermore, achieving standards by regulation is elusive in the air ambulance industry. As one observer told ITIJ, air ambulance companies are unregulated in many countries. Even within Europe and the US, there is no compulsory registration of standards. Companies in England must register with the Care Quality Commission, which regulates air ambulances as well as hospitals, general practitioners, and so forth; but that requirement does not extend to Scotland, Ireland or Wales. And there are no such requirements in much of the rest of the world, including the US, where accreditation is largely voluntary and so air ambulance companies can quite legally operate without being members of such organisations or meeting their requirements.
Cox of Cega stresses that there is ‘an enormity of variation, both within countries and internationally in respect to standards’ regarding ICU provision. He asserts that everyone involved in the air ambulance industry should strive for the same standards, irrespective of their location: “It should be critical care without walls, globally.” He added: “Ground ICUs within a hospital are defined, but ICU ambulances are not defined.” In respect to the provision of airborne ICU’s, Cox asserts: “I feel that the quality of air ambulance providers is much more about a company’s safety and organisation culture and experience, rather than about guidelines and regulation. Gary Andrews, president of the newly formed International Air Ambulance Alliance (IAAA), an umbrella organisation designed to represent fixed-wing air ambulance carriers, says unequivocally that his organisation believes it is beneficial to unify medical proficiency in the air. And although the IAAA is in its early stages of development, it is working towards such goals. He said to ITIJ that what the members of his group are doing is creating regional teams to understand the various cultural, regulatory and payer expectations by continent so as to learn and adapt to the goal of working with organisations that can achieve global standards. “But we need to learn and understand the variances that exist. [This is] challenging, but rewarding. So we are learning and adapting with the goal of working with organisations that can achieve global standards,” concluded Andrews.
It was primarily battlefield imperatives that propelled the air ambulance into the ubiquitous vehicle that healthcare providers rely on today – from transporting organs for otherwise terminal patients, to carrying patients to facilities that can save their lives. They are now, though, a fact of life and healthcare systems in virtually all countries on all continents. They have earned their role and have adapted and can now offer to transfer even the most critically ill of patients. The challenge now, though, is to make such ICU services consistent, and to operate in a transparent manner that means the insurer and partner assistance firm can be safe in the knowledge that the ICU air ambulance it has contracted to do the mission really can live up to its service promise.