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AMPA
Guide for Interfacility Patient Transfer
The Office of Emergency Medical Services (EMS) at the National Highway Traffic Safety Administration (NHTSA) is pleased to announce the completion of a “Guide for Interfacility Patient Transfer.” The guide was developed by an Interfacility Transfer Work Group consisting of representatives of national EMS organizations and federal agencies directly involved in interfacility transfer (IFT). AMPA was represented in this project by Ken Robinson.
The transfer of patients from one medical facility to another has become a national issue for EMS. Patient transfers between facilities or between facilities and a specialty care resource have increased as a result of regionalization, specialization, and facility designation by payers. The emergence of specialty systems (e.g., cardiac centers, stroke centers), rather than proximity of facility, often determines the ultimate destination of patients. Transfer may be necessary if payers provide reimbursement only for specific facilities within its plan.
IFT is provided by a variety of levels and types of personnel and agencies. Meeting patient needs and maintaining continuity of care are only two of the many issues related to IFT.
NHTSA EMS convened an initial meeting in 2002 of representatives from the EMS community to discuss this issue. At that time, it was determined that consensus guidelines would be very useful to promote consistent high quality patient care while allowing variation to meet unique local needs. The Interfacility Transfer Work Group was designated and took on the task of completing the guide for IFT.
The guidelines contained in this document are based upon a combination of available objective evidence, a review of generally accepted practices, and the consensus of expert opinions in the field of IFT; in short, the best information available. At several points, the document was informally reviewed by the organizations represented by the IFT Work Group members. The final document is the result of this entire process.
The intended audience for this guide is the agency providing IFT at the local, regional, or state level, as well as those involved with planning for IFT or dealing with related issues. This audience may include a variety of decision makers, such as program administrators, agencies with EMS jurisdiction, physicians providing medical oversight for IFT, or hospitals dealing with related issues.
This guide can be used to provide general guidance, references and ideas for conducting a systematic assessment of the processes and personnel supporting IFT, and how they can be enhanced to provide optimal delivery of care. The overarching principle adopted by the work group was that all decisions should be motivated by the desire to match patient need with appropriate knowledge, skills, equipment, and an infrastructure to enable safe, effective, and efficient IFT.
To access the “Guide for Interfacility Patient Transfer,” visit the NHTSA Web site at www.nhtsa.dot.gov, then click on “Emergency Medical Services Program” in the “Quick Links” section. You should see the Guide listed as “NEW” near the top of the Web page.
The following is the next in a series highlighting AMPA members.
Mike Brunko, MD, is currently the president-elect of AMPA. He assumes the office of president at the 2006 AMTC.
Mike trained in emergency medicine at Denver General/St. Anthony's / St. Joseph / Porter Memorial Hospitals Emergency Medicine Residency and has practiced in Denver since graduating. He has worked at a number of hospitals, including Denver General Hospital, and he now works in the department of emergency medicine at St. Anthony Hospital.
Mike has worked in EMS for approximately 23 years. His experience began as a resident and in 1986 he became the paramedic quality assurance coordinator and then the assistant medical director-paramedic division at Denver General Hospital. In 1991 he began working at St Anthony Hospital, and a few years later he became the medical director for Flight for Life. He is presently the chairman of the Flight for Life Medical Advisory Group and is on the Foundation and Advisory Board for Flight for Life.
Mike is a founding member of AMPA and has maintained active membership since 1992. He has served three terms on the AMPA board of trustees and is nearing the end of his term as president-elect. For the past 5 years he has served on the board of directors of the Commission on Accreditation of Medical Transport Systems (CAMTS). This is a responsibility he takes very seriously, and he has put a great deal of time and effort into this role.
He has lectured at numerous conferences, locally and nationally, on topics related to emergency medicine, EMS, and helicopter EMS. In addition, he has published widely in EMS and emergency medicine journals and textbooks. He has also served as a contributing editor and section editor for the Journal of Emergency Medicine.
Mike is an educator for many local training programs. He has lectured at the University of Colorado Health Sciences Center Medical School, the St. Anthony Hospital Paramedic School (ACLS and ATLS), and has given numerous emergency medicine grand rounds at Denver General Hospital. In addition, he is a physician leader at his institution and is currently serving, or has served on, several hospital committees, including the Medical Executive Committee, the Nominations Committee, the Credentials Committee, and the Medical Leadership Group.
Mike is active in public safety and has served on the Stapleton International Airport Crisis Management Committee, as the tournament physician for The International Golf Tournament, as the physician coordinator for the 1990 NCAA Final Four Medical Coverage, and as the on-scene medical coordinator for the Continental Flight 1713 Crash in Denver. He has also served as the Denver Broncos' team physician and as Mile High Stadium Physician for Denver Bronco NFL games.
Through his participation in AMPA and CAMTS, Mike has made a significant contribution to the education and safety of the air medical transport industry. AMPA is grateful for his efforts and is proud to have him as a member.
ASTNA
Celebrating 25 years
In the United States in 1981, civilian hospital-based helicopter programs had been in existence for 9 years. That same year:
Also in 1981, after a year of developing bylaws, the National Flight Nurses Association was founded and Jean Mason was elected the first president. In 1997, the name of the organization was changed to the Air and Surface Transport Nurses Association to reflect the fact that flight and ground transport nurses shared a common role. Today, ASTNA has over 1,800 members from 12 different countries. The organization comprises hospital-based, public service, military, and private providers of both emergency and nonemergency patient air and ground transport. It is the nationally recognized professional organization for nurses practicing in the critical care transport industry.
The theme of this year's Air Medical Transport Conference, held in Phoenix, Arizona, is “Shaping Our Future.” Join us September 24-27 to celebrate the accomplishments of ASTNA thus far and to plan for the next 25 years and beyond. This is your chance to get involved and play a role in shaping the future of your professional association.
ASTNA member activities during AMTC include:
In addition, association updates are presented as the outgoing board members are recognized for their contributions and the incoming board of directors is introduced.
This is your chance to network with other members as we commemorate 25 years of ASTNA history and begin a year of celebration - you won't want to miss it!
IAFP
IAFP presents first annual leadership seminar at AMTC
As you make your AMTC travel plans, think about arriving in scenic Phoenix a day or two early. Imagine the advantages - You'll be able to plot strategic air conditioning respites throughout downtown. Precon weekend is a great time to meet other providers and actually have time to talk with them. (Don't worry - your peers are easy to pick out of a crowd of locals. Just look for the flight team logos.) Not sure how to strike up a conversation that doesn't include, “How long have you had this pain?” try, “How do you like your airframe?” “Does your program use subscriptions?” or “ Are your program intubation stats any better than those in recently published studies?” All are sure to get rousing responses!
Or, after a brief introduction, ask some variant of:
Again, you are sure to get some interesting and passionate answers.
How do you answer those five questions? Is leadership something you spend a lot of time thinking about? I believe leadership is a lot like field medicine. There are basic universal truths to both.
Great leaders make it look easy. Ever work with someone who seems to only work the most messed-up calls? Great experience, right? Every time they leave base, they end up with the story of a lifetime. Lucky devils! All you seem to get are regular, simple, noncatastrophic missions. But wait a minute - can anyone really be that much of a black cloud? Is each and every call they go to that messed up before they arrive—or just after? Great leaders, just like great field providers put on a calm, controlled show for the public. It's that “never let them see you sweat” adage. If you're good, you make things better, not worse. No medical or management stories of a lifetime lately? Congratulations!
The person sitting on the couch uses the biggest words. Just like in field medicine, couch-sitters have lots of “could've,” “should've,” “would've” advice. They always seem to have an opinion, exact diagnosis, and precise path of treatment without ever doing a patient assessment, gathering a patient history, or touching anything other than the remote. Only when you are up to your elbows in blood or alligators do you truly know what happened on a call or in a management decision. I propose a new rule: If your posterior is still on the couch, you're not allowed to opine. If you feel passionately about a subject, move muscles other than your jaw.
You're only as good as your team. In medicine and management, it's all about the team. We've all been on calls where we pick up some slack. (I'll take time right now to thank my buddies who've picked up slack for me.) Most of us are good enough to even carry the team for a shift or two. But working with great partners, in medicine or in management, is absolute bliss. I'm talking about true roll-up-your-sleeves, you-go-we-go teamwork here. Differentiate that from political maneuvering! There is a synergistic effect that makes the group far better than the sum of the parts. Time spent building or working on your medical or management team is as important as readying aircraft or equipment.
Situational awareness is a crucial element. You can call it situational awareness, critical thinking, maturity, experience, empathy, or all those rolled into one. Whatever you call it, it differentiates good field providers and leaders from truly great ones. Learn to trust intuition and listen to gut feeling. It takes effort to open your mind to all the clues your patient or your surroundings give you. Tunnel vision is easy—one path, one option. But intuition leads us to those aha! moments of medical or management clarity and vision.
Some things you can teach. Some things you can't. Until this point, I have used leadership and management somewhat interchangeably. In truth, I believe they are significantly distinct. Management is the art of doing things right. You can teach management principles: HR rules, accounting, economics, contracting. The sheepskin on the wall lets people know you know your stuff. Leadership, on the other hand, is doing the right thing. The right thing is not always easy or popular or good for your career. The “right thing” is nebulous and tough to teach. It just seems some people get it and some people don't.
This is where you have a leg up on other professionals. You've spent years discerning and doing the right thing. In the sleet and mud, it hasn't been easy. Middle-of-the-night patient advocacy isn't always popular. You've read the studies that show your dedication to excellence isn't always good for you. You know leadership. We just want to take this opportunity to give you some management principles you can use to build on that foundation.
By the nature of what you do, you are already leaders in your communities. As a critical care or air medical provider, pilot, communicator, or administrator, you are already a leader in your profession. In the true interest of teamwork and community, we have designed this course to be inclusive of all leaders: paramedics, physicians, nurses, therapists, pilots, communicators, and administrators. To that end, member registration rates are extended to all members of AMTC-sponsor associations.
I hope to see you leaders at AMTC a little early this year. I'll share my air conditioning map if you'll share yours!
Another AMTC is here. Another week of dozens of meetings, classes, discussions, debate, and of course the M.A.S.H. Bash, all intended to better air medical operations. The AMTC is only a small piece of a very large pie, albeit the most visible piece. During the other 51 weeks of the year, a great deal of work is done by those who continue to strive for a better industry. Although things are highlighted on a national level during the conference, operations exist at the local level.
Long time Speaker of the House, Tip O'Neil once said, “All politics is local.”I would like to apply that analogy to air medical operations: “All operations is local.”
We, as an industry, can attack problems and come up with solutions on as large a scale as we can create, but it will all mean nothing if we don't get things done on the local level. We can spend hours, days, and weeks in meetings, discussing problems and solutions, but if the word doesn't make it to the folks on the line, we are wasting our time. The people making fatal operational mistakes aren't usually sitting behind a desk. They are most often found in or around the wreckage of an aircraft. Too often, in my humble opinion, we as an industry look for blanket-type answers to local or isolated problems. A crew getting caught in bad weather did not get there because someone sitting behind a desk planted them there. They got there because they made a decision to accept a flight and take off. It doesn't get any more local than that.
Now if a company supports, encourages, or demands that type of operation, it can expect problems. If a company fails to make its safety policies clear all the way down to the crew level, it is guilty of passive support for unsafe behavior. There have been many articles and discussions regarding pressure to fly, so I don't need to mention those subtle pressures that tend to push crews into bad situations. I would recommend that those at the highest level of management get face to face with their mission flying staff and make clear that we aren't about taking risk, we are about transporting critically ill patients. That means face to face with every crewmember.
I can't say how many negative comments I've listened to regarding AMRM, risk assessment, and the alphabet groups, just to name a few. Sometimes I've explained a position, and sometimes I knew it would be a waste of breath. In many cases it seemed to be just a matter of education or stating a problem in different terms. To many people, the problems exist in other programs and regions, not with them. They are doing everything as safe as can possibly be done, therefore, they don't need anyone telling them how to operate. Good for them! For the rest of us who realize our mortality and our ability to make mistakes, we need to continue to look at ourselves and others so we may learn better ways to do things.
I have a friend who, after looking at some new regulations, stated that he hated to see what air medicine would be like in 10 years. I understand his feelings. There are a lot of changes coming—some good, some not so good. Some will have a positive effect, others may do more harm than good. Personally, I rather look forward to seeing what our industry will look like in 10 years.
During the past 2 years serving as president of NEMSPA, I have made my feelings pretty clear about aviation decisions being left to aviators. I have no problem with input from others, but aviation decisions should be made by the guys flying. Although I think we have made a little headway in that area, we need to make much more. That won't happen unless more pilots are actively and vocally involved at all levels of this industry. Of course it begins at the local level.
My term as president ends in Phoenix. I can say that, of the goals I started with, some things have been successful and some haven't. Some things are ongoing. Gary Sizemore, the new president, will continue to fight for those things NEMSPA finds important. I look forward to helping him and the board of directors accomplish our mission, which is to make air medical operations as safe as they can be.
The AAMS and FARE board of directors participated in an all-day strategic planning meeting on June 10 in Washington, DC. While AAMS has certainly been strategically driven, with an environmental check-in at many of our board meetings, this was the first time in many years that we had a whole day dedicated to strategic planning. The board obtained input from a number of our members through work by our regional directors and Dawn Mancuso and I with the large multi-state operators. That input was used in developing our strategic plan. We will also be working with the entire air medical community. The five initiatives are:
GAO investigation of air medical safety
The General Accounting Office (GAO) is continuing its investigation into air ambulance safety at the request of Congressman Jerry Costello (D-Illinois), a member of the U.S. House of Representatives Transportation and Infrastructure Committee. AAMS supplied a number of key contacts in our community, and they have all been notified of possible contact by members of the GAO. One of the areas being assessed is the need for regulatory or legislative action to address ambulance safety.
IOM study released
The Institute of Medicine released their reports “Emergency Medical Services: At The Crossroads,” “Hospital Based Emergency Care: At The Breaking Point,” and “Emergency Care for Children: Growing Pains” this month. The reports are still not finalized—they are in uncorrected copy—but still very good reads. You can purchase copies at National Academy Press' website (www.nap.edu). While I was interested in all the reports, since my career has been centered around both prehospital and in-hospital emergency care, the specific recommendations on air medicine included that states assume regulatory oversight of the medical aspects of air medical services, including communications, dispatch, and transport protocols. Specifically, the FAA's regulatory authority should extend to helicopters, fixed-wing aircraft, pilots, and company sponsors; however, the state should regulate the medical aspects of the operation, including personnel on board (nurses, paramedics, and physicians), the medical equipment, and the transport protocols regarding hospitals and trauma centers. In addition, states should establish dispatch protocols for air medical response and should incorporate air medical providers into the broader emergency and trauma care system through improved communication. The reports concluded that these are essential to more coordinated and efficient use of air capacity.
AAMS was actively working with the state EMS medical directors on a task force even before these recommendations so that air medical services can be better coordinated at the state level. The task force is developing an interrogatory paper that will form the basis of providing recommendations and some standardization across all states.
Disaster preparedness news
We were informed in early July that the Department of Health and Human Services (HHS) is requesting a contractor to coordinate air and ground medical services for disaster response. AAMS learned that something was possibly being announced in June, so we put together a task force chaired by AAMS Treasurer Tim Pickering. At this point HHS just wants comments back on issuing the solicitation, which we did along with other organizations.
With Hurricanes Katrina and Rita, we learned that there are many services that want to respond, but we need to coordinate better so that we do not leave our regular service areas without access to care. As of this writing, HHS desires a single source contract for both air and ground, but since they are not providing upfront development money, it will be hard for any one source contractor to provide and coordinate all services.
Safety technology in the spotlight
I just attended the AAMS Technology Conference in Dallas, Texas, and am happy to report that we had another great year. I was not able to get down to the conference until Tuesday because of my older son's graduation from high school, but sitting in the 2nd day sessions and hearing feedback from attendees from the first day was all quite positive. A survey will be sent to the 70-plus attendees in the near future so we will have a more detailed response. Thanks to the AAMS Safety Committee and staff for putting on a great conference.
AAMS' Political Action Committee
I want to talk in this column about the AAMS Political Action Committee and the importance of supporting it. For years, AAMS has effectively lobbied Congress in support of issues that directly impact the air medical community. As AAMS takes on new issues that have significant impact, on both the medical community and aviation, it has become increasingly important to support election and re-election campaigns for congressional members who support and champion the cause of air medicine.
Political action committees (PACs) have become an important part of nearly all association government activity. There are literally thousands of PACs in Washington and hundreds of state PACS supporting state elections across the country. PAC contributions are meticulously monitored by the Federal Election Commission to ensure that these dollars are spent on campaign finance and that the limits on both contributions and expenditures are respected. AAMS works tirelessly to inform and educate members of Congress on these and many other issues; your PAC support will aid in that effort.
Some important points to keep in mind:
I encourage you to take full advantage of this opportunity to ensure the future of air medical services. With your support, AAMS will have a stronger voice in Washington, a voice that continues to speak for the needs of the air medical community. For more information about the AAMS PAC, call Chris Eastlee at (703) 836-8732 or via e-mail at ceastlee@aams.org.
Elections
The AAMS board of director elections are going on as of this writing, and there are contested elections in Regions II and V. In June I made appointments for two vacant positions: Jerry Pagano from Trauma Hawk in West Palm Beach, Florida, is our new Region VI director, and Ian Badham from NRMA Careflight in Australia is the new Region VIII director. They are both running unopposed in their respective regions this election period.
Vision Zero White Paper
Remember that the Vision Zero White Paper has been published at visionszero.aams.org. Please take the time to read this important work as it outlines our efforts to improve safety. Many thanks go to the Vision Zero Steering Committee with the development of this paper and also in their continued efforts with Vision Zero. Wear that bracelet if you are not already doing so!
Volunteers
AAMS, in collaboration with all the associations in the critical care transport community, continues to add value to your individual programs. Be a part of things as we are always looking for volunteers for committees. Contact the AAMS office at (703) 836-8732 because we need your expertise and assistance.
PII: S1067-991X(06)00225-2
doi:10.1016/j.amj.2006.07.003
© 2006 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
