In the first of two articles, James Paul Wallis looks at the role that hospital dispatchers play in the complicated issue of helicopter air ambulance ‘shopping’ in the US healthcare system, a practice that has potentially fatal consequences
Wherever a region is served by more than one helicopter air ambulance provider, there is the possibility for helicopter shopping to occur. Writing in a 2008 position paper for the Indiana Association of Air Medical Services (INAAMS), the Association’s President Rex J. Alexander defined helicopter shopping as: “...the practice of calling, in sequence, various operators until an operator agrees to take a flight assignment, without sharing with subsequent operators the reasons the flight was declined by the previously called operators.”
Although it’s long been discussed as a dangerous practice that puts lives at risk, helicopter shopping continues to be a concern. For example, following the fatal crash of a medical helicopter in January 2019, many commentators were quick to point out that two other providers had turned down the flight before Survival Flight accepted the mission.
In this article, we’ll look at why helicopter shopping may occur, and how helicopter air ambulance providers can work with those requesting flights to try to prevent it.
It’s not difficult to imagine why a first responder or healthcare facility might make multiple calls, trying to find a provider that will take a flight. As an example, the INAAMS paper describes a nurse with a deteriorating patient in ER that needs to be transferred to a higher level of care. The nurse has the numbers for a few providers and tries each in turn until someone takes the flight. There’s no ill intention here, just a desire to help the patient.
As is stated in the INAAMS position paper, the calling of subsequent helicopters is not necessarily a problem. It all comes down to whether or not information is passed on about who has previously turned down the flight and why.
It all comes down to whether or not information is passed on about who has previously turned down the flight and why
“When a sending facility is transparent, informing helicopter air ambulance providers that a request for transport has already been turned down due to weather, this valuable, time-critical information generally prompts pilots to look closer at weather conditions; this scrutiny, in many instances, has proved to be lifesaving,” stated the Air & Surface Transport Nurses Association (ASTNA), the Emergency Nurses Association (ENA), and the International Association of Flight and Critical Care Paramedics (IAFCCP) in a joint position paper issued in March 2019.
Krista Haugen, Co-Founder of the Survivors Network for the Air Medical Community and Director of Patient Safety and Medical Risk Management at Med-Trans Corp, explained why weather information in particular is important: “Weather turn-down is a critical piece of information that must be relayed during any subsequent [helicopter air ambulance] requests so the decision-makers can be fully informed. Even with current weather tools and operational control centres, there are still significant gaps in weather reporting. Reports of previous weather turn-downs add valuable information and greatly enhance the decision-making process.”
Referring to the statement in the INAAMS paper that ‘most hospitals and first responders do not realise the criticality of sharing information regarding flight request turn-downs with subsequently called air medical providers’, Susan Rivers, Programme Director of Carilion Clinic LifeGuard, agreed, saying: “No hospital or first responder agency sets out intentionally to put their patient or medevac providers in harm’s way. I believe they simply lack awareness on the history of the problem of self-induced/competitive pressures to fly.”
In their joint position paper, ASTNA et al made a nuanced argument that callers may fail to pass on information due to trust in the providers in making an informed decision: “Given how charged this topic can become, hospital staff who call more than one [helicopter air ambulance] provider are not wilfully or ignorantly gambling with the lives of flight team members, as has often been the characterisation. Rather, they make requests in the interest of the patient, with the assumption that pilots and flight teams are the experts on transportation safety and will render an expert’s decision about the safety of the flight.”
helicopter air ambulance 2
One course of action, then, would be for air ambulance providers to work with first responders and healthcare facilities to improve education and influence protocols for making medical flight requests. The stated goal of the ASTNA/ENA/IAFCCP collaboration was to educate individuals involved in requesting helicopter ambulance flights, said Sharon Purdom, ASTNA President. In the paper issued by INAAMS, Alexander voiced a similar aim: “It is the goal of [INAAMS] to solicit the co-operation of all hospitals and first responders, to create and adopt weather sharing policies and protocols. By designing and implementing rules and protocols that cover all aspects of air medical transport for your organisation and staff, you can make a significant impact on the ultimate outcome of your patients. Protocols that include the passing of information in regards to flights previously turned down due to weather are paramount in creating a safer environment for everyone. Written protocols and policies that identify who can call for a helicopter, when to call and information required to initiate an air medical transport, have been proven again and again to save time and lives during stressful situations.
Written protocols and policies that identify who can call for a helicopter, when to call and information required to initiate an air medical transport, have been proven again and again to save time and lives during stressful situations
Reflecting on the project today, Rex Alexander told AirMed&Rescue: “On the whole, our experience was very good. It was not a matter of individuals not wanting to help stop this practice as much as it was a need to educate them on what it was, why it was dangerous and what they needed to do to help us curtail it.” This was in part thanks to the fact that INAAMS represented every critical care air and ground medical provider in the State at the time. He added: “It was the fact that we had a unified front and voice that we were so successful. If we had tried this as separate entities, we would not have had the same amount of success. Having the unified front allowed us to have the one voice needed when talking with officials, the State EMS commission, EMS agencies and hospitals in asking for their help to address this problem.”
In it together
However, there is recognition that it’s wrong to solely place responsibility for promulgating good practice on the requesters. Discussing the joint position paper, ASTNA/ENA/IAFCCP said: “...the phrase ‘helicopter shopping’ does an injustice to not only the problem, but also to the hospital and EMS-based staff who request air medical services.” Patricia Corbett of ASTNA explained that a better term would be ‘selective resource management’, which reflects ‘the shared accountability to communicate vital information to mitigate risk’ and ‘emphasises that patient transport is a shared responsibility’.
CAMTS calls for its accredited members to have a written policy to discourage shopping by first responders and other requesting agents. The policy should address ‘how the programme interfaces with other air medical services in the same coverage area to alert them of a weather turn-down’. CAMTS prescribes a number of steps that providers should take that proactively mitigate against the risk of shopping, including specifically asking the requester whether another flight programme has turned down the request.
One answer ... is to have a centralised dispatch centre that first responders and medical facilities contact
Casey Ping, who recently retired as Programme Director at Travis County STAR Flight, commented: “I think we as an industry send mixed messages to the requesters. We routinely tell the requester to just call and we will make a decision about the weather. Call when other programmes have cancelled because we might be able to complete the flight.” He added that the caller’s point of view has to be considered: “We also need to look at this from the requesters perspective. As complex as these decisions are, do we really think we can educate every hospital and EMS requester on when or when not to request a second or third programme? Especially when you consider the frequency of these situations for an individual.”
One answer, mentioned Ping, is to have a centralised dispatch centre that first responders and medical facilities contact: “It’s one phone call and they contact the programmes that offer the best solution to the problem. This also helps with specialised needs (weight, equipment, SAR etc.).”
Perhaps what matters is to think of this education as a continual process. Susan Rivers said: “I believe the burden remains with the medevac providers to ensure that we press on to continue our education efforts for our requesters and our own peer-to-peer notification systems as a safety net in the meantime.”