Model State Guidelines

First edition Table of Contents

Introduction ��3

2 Definitions / Acronyms ��5

Administration / Management ��7

Medical Program Operations ��9

Medical Control ��15

Utilization ��17

Quality Management ��18

Safety ��20

Communication ��22

Multijurisdictional Air Provider ��27

References / Additional Resources ��27

Background The National Association of State EMS Officials (NASEMSO) was asked to participate as an Orga- In 2007, the Air Medical Task Force was formed nizer as well. NASEMSO agreed to participate in the of representatives from the National Association process but as an observing organization only. of State EMS Officials (NASEMSO), the National Association of EMS Physicians (NAEMSP), and Other organizations that were invited were: the Association of Air Medical Services (AAMS), Air and Surface Transport Nurses Association and published a paper in the journal Pre-Hospital (ASTNA) Emergency Care. This paper, entitled“Air Medical Services: Future Development as an Integrated Compo- Air Medical Operators Association (AMOA) nent of the Emergency Medical Services (EMS) System,” Air Medical Physician Association (AMPA) 3 (Initial Air Medical Task Force Paper) was intended Association for Critical Care Transport (ACCT) to be a guidance/resource document for state EMS leaders, planners and regulators to help in under- Commission on Accreditation of Medical Trans- standing and appreciating the development, integra- port Systems (CAMTS) tion and regulation of air medical services, as well as International Association of Flight & Critical the similarities/differences between the ground and Care Paramedics (IAFCCP) air components of most EMS systems. National Association of Air Medical Communi- This paper provided a look at the way air ambulances cation Specialists (NAACS) are regulated at the state and federal levels. It also National EMS Pilots Association (NEMSPA) outlined some of the core components of current National Association of State EMS Officials state regulation, identified outstanding licensing (NASEMSO)—Observing role issues, and discussed different approaches to integrating air medical services into a state EMS system. National Association of EMS Physicians (NAEMSP) Model Air Medical State Guidelines Industry National Association of EMT’s (NAEMT) Task Force (MASGIT) American College of Emergency Physicians (ACEP) At the time of publication, the members of the task force discussed the need for a second effort based Objective around the development of model state guidelines or regulations for air medical services. To fulfill that The objective of the MASGIT group was to create a vision, the Model Air Medical State Guidelines Task consensus document outlining the core components Force or MASGIT was born. and potential language of model regulation that could be shared with State EMS officials and oth- There were four core organizing groups representing ers interested in State-level oversight of air medical special market segments of the air medical and criti- transport. cal care transport field that encouraged the development of the MASGIT. They were: Association of Air Medical Services (AAMS) American Ambulance Association (AAA) International Association of Fire Chiefs (IAFC) Airborne Law Enforcement Association (ALEA) How the work was accomplished term “related to” has been interpreted broadly by the courts as extending to all state laws “having a connec- A select task force of representatives from the above- tion with or reference to” airline prices, routes, or ser- named organizations met over the course of 9 vices. Morales v. Trans World Airlines, Inc., 504 U.S. months to develop a draft document. The task force 374, 384 (1992). Further, the courts have affirmed started with the work of the Initial Air Medical Task matters governing aviation safety, including aircraft, Force Paper, and referred to other nationally-recog- aircraft equipment, aircraft operation, and pilot nized patient care standards published by National qualifications are the exclusive jurisdiction of the Highway Traffic Safety Administration (NHTSA), FAA and also preempted by federal law. On the other NAEMSP, AMPA, AAMS, AAA, and others. When hand, various courts and the DOT have clarified that appropriate, the task force sought advice from key state laws and regulations serving “primarily a patient stakeholders in government and industry including care objective” are properly within a state’s regulatory the Federal Aviation Administration (FAA), National authority. Med-Trans Corp. v. Benton, 581 F. Supp. Transportation Safety Board (NTSB), and CAMTS. 2d 721 (E.D.N.C.) (2008). Consequently, these 4 The task force also took into consideration the Guidelines acknowledge specific aviation economic findings of the Government Accountability Office and safety issues regulated by the Federal government (GAO) in its study about state oversight of air medi- and focus on issues of patient clinical care properly cal services. the responsibility of states.

The task force began its work in January 2011 and In several states, both private sector entities and completed its task in September 2012. government entities provide air medical services. Private sector air medical services are always regulated Purpose and Scope by the DOT and FAA on aviation matters and by state authorities on medical care matters; government The Model State Guidelines should be viewed as a entities, (federal, state, or local governments or other tool in the collective effort to advance the level of public services), on the other hand, may or may not clinical care for patients transported by air. They are be certificated by the FAA or licensed by the state in intended to assist in the development of more com- which they operate. These Guidelines are intended as prehensive and consistent state standards governing a resource for state application of the same compre- licensing of the medical services provided to these pa- hensive clinical care standards to all air medical patients and the continued oversight of those services. tient transport regardless of the status of the provider. The Guidelines are mindful of the preemptive role Throughout, these Guidelines recognize the impor- of the Federal government in regulating the aviation tance of the state’s role not only in regulating but aspects of an air medical service. The operator of an also facilitating patient medical care. To this end, the air medical service is an air carrier for purpose of the Guidelines highlight the need for communications federal preemption provisions in federal law. Those capabilities among medical personnel involved in air provisions prohibit a state from enacting or enforcing and ground medical transport services and multistate any requirement “related to the price, route, or ser- license reciprocity. vice of an air carrier.” 49 U.S.C. §41713(b)(1). The Section 2—Definitions & Acronyms

AAA—American Ambulance Association any other parenteral pharmaceutical unique to the patient’s special health care needs or special moni- AAMS—Association of Air Medical Services tors or procedures such as mechanical ventilation, ACCT—Association of Critical Care Transport multiple monitors, cardiac balloon pump, external cardiac support (Ventricular assist devices, etc.) or ACEP—American College of Emergency Physicians any other specialized device or procedure beyond the DOT minimum standard for EMT-Paramedic, ACNP—Advanced Care Nurse Practitioner certified by the referring physician as unique to the Air medical services—ambulance services provided patient’s health care needs, commensurate with the scope of practice of a clinician with specialty care or using aircraft such as helicopters and fixed wing 5 (airplane) aircraft board certification. Deemed Status ALEA—Airborne Law Enforcement Association —Recognition by a state licensing body that certification by a specific professional ALS (Advanced Life Support)—Medical transport review organization is a sufficient basis for state that includes medical care procedures commensu- licensure. rate with the DOT minimum standard for EMT- DOT Paramedic, including advanced airway management, —U.S. Department of Transportation parenteral fluids and medications, and cardiac EMS—Emergency Medical Services monitoring. EMTALA—Emergency Medical Treatment and Ac- AMOA—Air Medical Operators Association tive Labor Act

AMPA—Air Medical Physician Association FAA—Federal Aviation Administration

AMTF—Air Medical Task Force FAR—Federal Aviation Regulations

ASTNA—Air and Surface Transport Nurses Associa- FCC—Federal Communications Commission tion Flight crew—includes the personnel responsible for BLS (Basic Life Support)—Medical transport that aircraft operations during transport. includes medical care procedures consistent with the EMT-Basic skill set. GAO—Government Accountability Office

CAMTS—Commission on Accreditation of Medical IAFC—International Association of Fire Chiefs Transport Systems IAFCCP—International Association of Flight & Climate control—ability to alter the ambient tem- Critical Care Paramedics perature in the patient compartment via heating or ICS cooling. —Incident Command System (as defined by the National Incident Management System) CON—Certificate of Need IFR—Instrument Flight Rules Critical Care—Medical transport that includes MASGIT specialized medical interventions such as IV infu- —Model Air Medical State Guidelines sions including vasopressors, vasoactive compounds, Industry Task Force antiarrhythmics, fibrinolytics, tocolytics, and/or MD—Medical Doctor Medical crew—the personnel responsible for patient NTSB—National Transportation Safety Board care with sufficient training as applicable to the scope of service required during transport via ground, rotor Part 135 Operator—A direct air carrier certified by or fixed wing ambulance. the FAA and operating under the requirements of 14 CFR 135 NAACS—National Association of Air Medical Com- munication Specialists PNP—Pediatric Nurse Practitioner

NAEMSP—National Association of EMS Physicians RN—Registered Nurse

NAEMT—National Association of Emergency RT—Respiratory Therapist Medical Technicians Scope of service—The number, type, and intensity NASEMSO—National Association of State EMS or complexity of patient care services being provided. Officials Sterile cockpit—requirement for flight crew to 6 NEMSPA—National EMS Pilots Association refrain from non-essential communications during critical phases of flight NHTSA—National Highway Traffic Safety Admin- istration VFR—Visual Flight Rules

NNP—Neonatal Nurse Practitioner Section 3—Administration & Management

1. Identification of Air Medical Service a. The identity of the Part 135 Operator pro- State regulations should require the following viding the air transportation is evident to the information at the time of application for EMS public. licensure as an air medical service within the b. Actual types of aircraft utilized by the Part State: 135 Operator are used in materials. a. Corporate entity and headquarters informa- c. Level of licensure being sought is congruent tion including contact information, lead with advertised services. contact for organization, CEO/Board names. 4. Subscription & Membership Programs b. Part 135 Operator information including a The State guidelines should require the applicant copy of the FAA-issued operating certificate. to disclose the use of any subscription or mem- 7 c. Information on any additional bases/loca- bership programs. The State should ensure that tions of operations to be covered under the the membership program is congruent with the license. DOT ruling. The State should confirm: d. Service area designation. a. The program is easy to understand for the e. Scope of Service (BLS, ALS, Critical Care/ general public. Specialty Care, etc.) consistent with State b. Disclosures are made concerning require- licensure requirements. ments to receive services. f. Identification of the air medical service’s c. The applicant demonstrates a written plan of medical director(s). action should the applicant cease business. 2. Insurance d. The applicant is able to provide services as The US Department of Transportation (DOT) described in the membership region. requires direct air carriers, like Part 135 Op- 5. Hiring & Credentialing erators, to have hull and liability insurance for The State guidelines should require the applicant aviation aspects of the air medical operation. to provide/demonstrate the following: Those requirements are found in 14 CFR Part a. A job description for each clinical position 205 (reference Attachment A). The State regula- including any fitness for duty requirements. tions should dictate the amount of professional b. A process that screens applicants to ensure liability insurance that needs to be carried by the they meet the qualifications and assessment air medical service concerning medical malprac- of their knowledge, skills, and experience. tice, medical liability and worker’s compensation. c. An orientation process that meets the scope These amounts should be comparable to what is of service of the provider. required of the ground services in the State. d. A process for ongoing competency evalua- Public safety operators should demonstrate hull tions. and liability insurance coverage congruent with 6. Program Administrative Oversight Part 205 requirements. State guidelines should require the following: 3. Advertising a. A business plan that includes scope of service The State guidelines should be congruent with and service area. each air medical service’s mission profile. The b. An organizational chart that demonstrates a State should confirm that the applicant will have clear line of authority and responsibility. a license for all modes of transport being ad- c. A copy of all patient care protocols and poli- vertised within the State. In addition, the State cies be provided to the State at the time of should confirm: licensure application and are made available to all of the air medical service’s staff. d. A demonstration of the ability to provide an “…a state, political subdivision of a state, or politi- aircraft the majority of the time to respond cal authority of at least two states may not enact or to transport requests within the program’s enforce a law, regulation or other provision having service area exclusive of automatic aid, mu- the force and effect of law related to a price, route, tual aid, weather, and maintenance. or service of an air carrier that may provide air e. Policies addressing these subject areas: transportation under this subpart.” 49 U.S.C. Sec- i. Disciplinary process. tion 41713(b). ii. Procedure for documenting meeting However, should states or local governments minutes. wish to directly purchase services from an air car- iii. Marketing. rier in the capacity of a “customer”, rather than iv. QA process to include a review of ap- as a “regulator”, they are free to contract directly propriateness of transports. with one or more air carriers. v. Compliance with State reporting requirements. States should work with air medical services 8 vi. Corporate compliance. within the state to provide coverage to under- vii. Ethical conduct and practices. served areas. This can be accomplished through agreements that allow shared costs/subsidies. 7. Data Reporting / Patient Reporting 11. Notification of changes The applicant should be required to demonstrate the ability to comply with all required State The state should provide a process for notifica- data reporting requirements that are currently tion of changes at the air medical service. This in place. While much of this may mirror other should be comparable to what is required of EMS service requirements, additional manda- ground services and include changes in: tory reporting is within the ability of the State to a. Ownership. require and may include but is not limited to: b. Base locations. a. Number of patients flown. c. Medical Director. b. Hours flown. d. FAA Part 135 Operator Certificate (including any suspensions, if applicable). 8. Patient Privacy e. Number of vehicles. The State should require the applicant to dem- f. Level or scope of service. onstrate compliance with patient privacy laws 12. License Duration / Renewal as in any other EMS service. Business Associate Agreements may be necessary between the appli- The duration of licensure should be commensurate cant and the Part 135 Operator if not operated to the requirement for ground EMS services in the directly by the applicant. state. 9. Deemed Status 13. Frequency of review, air medical regulations

States may recognize an air medical service’s States should review their air medical licensure stan- accreditation from a national accrediting body dards at least every 7 years. as assurance of at least partial compliance with appropriate state rules. Additional requirements 14. Facilities standards may be imposed if state standards exceed those Buildings and facilities used by air medical services set by the accrediting body. fall under state and local regulations related to build- 10. Access to Services ing and fire codes, as well as federal regulations cover- States and local governments have been advised ing workplace safety requirements. Federal aviation that limiting or restricting competition of air car- safety regulations and guidance regarding airports, riers, including by a certificate of need (CON) heliports, helipads, and other landing areas also may process, is prohibited due to the preemption be relevant. clause of the Airline Deregulation Act (ADA). ADA (49 U.S.C. Section 41713) states in pertinent part: Section 4—Medical Program Operations

The applicant’s mission statement and scope of care a. A single medical attendant should have should be defined by the applicant and the applicant knowledge and medical equipment to ad- should demonstrate that its aircraft are configured equately care for the patient. The decision to in such a way that the medical transport personnel transport with only one medical attendant can provide patient care consistent with that mission should require medical control physician ap- statement and scope of care of the medical transport proval. service. The scope of care is commensurate with the b. Quality management activities are in place qualifications and level of initial and ongoing educa- that regularly review the patient care pro- tion required for medical personnel. vided by only one medical attendant and the patient’s status at the time of arrival at the Medical Team make-up and number of practitioners arranged destination facility. 9 shall be defined by each applicant and included in c. Given the medical condition of the patient, the business plan. Staffing should be commensurate no other more suitable transport team is with the mission statement and scope of care of the available at the time of transport that would air medical service. It can be defined as, but not be more appropriate for delivering the level limited to the following, RN/RN, RN/RT, RN/MD, of care the patient requires. RN/Paramedic, NNP/RT, ACNP/RN, PNP/RT, d. A mechanism should be in place to require Paramedic/Paramedic or alternative team composi- reporting these events to appropriate State tion in accordance with the scope of service of the regulators for review. program. The air medical service’s Medical Director, in conjunction with clinical management, will be Medical equipment & patient compartment responsible for the determination of the appropriate medical team configuration. Medical supplies and equipment must be consistent with the air medical service’s mission statement and On an emergency/unanticipated/infrequent basis, scope of care. The medical supply and equipment list non-scheduled personnel can be added as a team is a direct responsibility of the air medical service’s member according to the protocols of the air medi- Medical Director and a minimum equipment list cal transport service as long as orientation/training should be provided to the State at time of applica- includes in-transport treatment protocols, general tion. All medical supplies and equipment should be aircraft and ambulance safety, emergency proce- covered for utilization in the patient care protocols. dures, operational policies and infection control. The Additionally, the applicant must demonstrate that aircraft, by virtue of medical staffing and retrofitting the aircraft is configured for CPR and the follow- of medical equipment becomes a patient care unit ing equipment is on the aircraft and available for all specific to the needs of the patient. Critical Care or ALS Providers. Under certain conditions, the weight of a second 1. Cardiac monitoring capabilities: medical person or equipment could potentially a. Cardiac monitor, defibrillator, and external impact the performance of the aircraft and safety of pacemaker are secured and positioned so the mission. This situation and the pilot’s authority that displays are visible. and responsibility to make this determination are b. Extra batteries or power source are available governed by applicable federal aviation safety require- for cardiac monitor/defibrillator or external ments and the program should have a policy making pacemaker. that clear. Under these conditions, if only one medical person can accompany the patient, the following should occur: 2. Defibrillator: 6. Devices for decompressing a pneumothorax and a. Defibrillator is secured and positioned for performing an emergency cricothyroidotomy easy access. available if applicable to scope of care of the air b. Semiautomatic or automatic external medical transport service defibrillator may be required for some BLS Providers (where permitted as scope of care Aircraft Standards for EMT-B). c. Pediatric paddles/pads available if applicable Operational standards such as aircraft configuration to the scope of care of the medical transport should be consistent with the air medical service’s service. scope of service and shall not compromise patient stability in loading, unloading, or in-flight opera- 3. External pacemaker on-board or immediately tions. Medical transport personnel must have access available as a carry-on item to the patient in order to begin and maintain basic 4. Advanced airway and ventilatory support equip- and advanced life support treatment. The applicant 10 ment: must demonstrate: a. Laryngoscope and tracheal intubation sup- 1. The aircraft has an entry that allows loading and plies, including laryngoscope blades, bag- unloading without excessive maneuvering (e.g., valve- mask and oxygen supplies, includ- no more than approximately 45 degrees about ing PEEP valves; appropriate for ages and the lateral axis and 30 degrees about the longitu- potential needs of patients transported. dinal axis) of the patient, and does not compro- b. A mechanical ventilator and circuit appro- mise functioning of monitoring systems, intrave- priate to age and scope of care should be on nous lines, and manual or mechanical ventilation board for critical care transports as pertinent to the scope of care of the medical transport 2. The provision of a minimum of one stretcher service. that can be carried to the patient c. Equipment for alternative air and protocol a. Aircraft stretchers, including issues of for management of missed airway attempts. maximum gross weight and the means of d. Two suction units, one of which is portable securing in-flight, are regulated by the FAA and both of which must be required to de- and required to meet federal aviation safety liver adequate suction. requirements. e. Pulse oximetry on-board for critical care b. The stretcher should be large enough to car- missions or immediately available for ALS. ry at least the 95th percentile adult patient, f. End-tidal CO2 continuous wave-form full length in the supine position. (Estimated monitoring capabilities available. 95th percentile adult American male is 6 ft. g. If inhaled nitric oxide or other inhaled gases and 232 lbs.). are used, policies address the following: c. The stretcher should be sturdy and rigid Monitoring, Cylinder safety, Transporta- enough that it can support cardiopulmonary tion regulations, Occupational exposure, resuscitation. If a backboard or equivalent Equipment issues, Weight, Mounting in device is required to achieve this, such device the vehicle, Delivery of the drug, Emer- will be readily available. The head of the gency procedures (for example trouble- stretcher is capable of being elevated at least shooting for battery failure, delivery 30 degrees for patient care and comfort. fault, system failure). d. If the stretcher is floor-supported by its own wheels, there is a mechanism to secure it 5. Automatic blood pressure device, sphygmoma- in position under all conditions, consistent nometer, doppler or arterial line monitoring with the FAA’s requirements. The restraints capability on-board or immediately available should permit quick attachment and detach- ment for patient transfer. 3. The ability to properly secure the patient 5. Electric power outlet will be provided with an a. Patient restraints are regulated by the FAA inverter or appropriate power source of sufficient and must meet federal aviation safety re- output to meet the requirements of the complete quirements. specialized equipment package without com- b. Patients transported by air are restrained promising the operation of any electrical air- with a minimum of three cross straps. Cross craft/ambulance equipment. Extra batteries are straps are expected to restrain the patient at required for critical patient care equipment. Any the chest, hips and knees. supplemental power source or amplified power c. Patients that are loaded head forward must source installed or transported in an aircraft must also be restrained with a shoulder harness meet applicable federal aviation safety require- restraint. ments. d. Patients under 40 pounds (18kg.) should 6. Medical transport personnel will ensure that be provided with an appropriately sized all medical equipment is in working order and restraining device (for patient’s height and all equipment/supplies are validated through weight), which is further secured by a lock- documented checklists for both the primary and 11 ing device. backup aircraft/ambulance. i. All patients less than 40 pounds must be a. Equipment must be periodically tested and secured in a five-point safety strap device inspected by a certified clinical engineer. that allows good access to the patient b. Equipment inspections and records of from all sides and permits the patient’s inspections are maintained according to the head to be raised at least 30 degrees. program’s guidelines. Velcro straps are not encouraged for use on pediatric devices. 7. The floor, sides and ceiling in the patient cabin ii. Any car seat used on board an aircraft is of the aircraft or ambulance are of a surface ca- required by the FAA to comply with fed- pable of being cleaned and disinfected in accor- eral aviation safety requirements and by dance with national health and safety regulations the DOT to carry a certification sticker with the appropriate disinfectant. identifying it as safe for aircraft use. e. Isolette: There must be some type of restrain- Scenes, inter-facility, ambulance intercept ing device within the isolette to protect the There should be policies from Air Medical Service infant in the event of air turbulence. Isolette Providers to integrate with hospitals and ground must be capable of being opened from its EMS for emergency response, if the air medical ser- secured position to provide full access to the vice is involved in pre-hospital emergency responses infant in the event of complicated airway (note: some air medical services may only provide problems or extrication from the isolette inter-facility transportation). becomes necessary. 4. Supplemental lighting system will be installed in State rules should not prohibit nor impede the ability the aircraft in which standard lighting is insuffi- of air medical crew members from providing patient cient for patient care. Any supplemental lighting care services in a ground ambulance when conditions system or source installed or transported in an preclude air medical transport. aircraft must meet applicable federal aviation States should ensure that their rules covering ground safety requirements ambulance services and first responder agencies a. A self-contained lighting system powered by require a plan for integrating air medical transport a battery pack or a portable light with a bat- into emergency operations, including protocols for tery source must be available. intercept, scene flights, and the transport of air medi- b. There must be adequate lighting for patient cal crews based, at least in part, on ICS principles. care: Use of red lighting or low intensity lighting in the patient care area is acceptable if not able to isolate the patient care area from effects on the cockpit or on a driver. Hazardous materials recognition A record of patient care is completed, and a copy remains (electronic or other format) at the receiving The DOT/FAA regulates the transportation of facility for appropriate continuity of care. hazardous materials. The air medical service has and demonstrates a process to identify and manage haz- 1. A policy outlines minimal documentation re- ardous materials and its risks as they pertain to the quirements based on the transport service’s scope mission of the program. A written policy to address of care and should include: response to hazardous materials requests or unan- a. Purpose of the transport. ticipated contact with hazardous materials should b. Treatments, medications, intake and output, include the following elements: vital signs and patient’s response to treatments and medications. 1. There is an outlined plan of action according to c. Ventilator setting and change in ventilator pre-established policies with appropriate training settings are recorded. of the medical transport team d. Documentation of pertinent radiologic and 12 2. A plan for patient decontamination procedures laboratory findings on inter-facility trans- prior to transport, including removal of patient ports. clothing and other decontamination procedures e. Signature of each care provider and clar- for saturation of gasoline or other hazardous ity about what care was performed by each chemicals provider (administering medications and performing procedures) and indicates who 3. The medical transport team must be fully actually documented patient information. informed about the nature of the hazardous f. Transport facilities (to and from) and to materials whom report was given to at the receiving 4. A list of contaminated materials, which could facility. pose a threat to the medical transport team or g. Patient condition at certain predetermined render transport inappropriate, must be readily altitudes. available 5. The Landing Zone (LZ) or aircraft operational Drugs and IV Fluids area must be a safe distance to avoid any down- wind danger when approaching or departing Medications that are consistent with the service’s scope of care are accessible for patient care. 6. A policy addressing carry-on baggage of patient or passenger that must be physically inspected 1. The transport service has a method of assuring for hazardous materials that could endanger the that all medications and intravenous fluids are medical transport team or compromise safety appropriately calculated. Examples of effective (such as weapons, sharp objects, chemicals, and methods include the use of drug calculation lists; obvious contaminated materials) before loading internet based programs and pre-programmed on the transport aircraft/ambulance drug delivery systems such as those found in medication pumps 7. A policy addressing the presence of firearms on the transport vehicle 2. Medications are easily accessible 3. The transport service has a procedure for con- Medical documentation firmation of medication and dose between the medical crew members to reduce the risk of Medical documentation ensures that patient care medical error records and policies and procedures are stored according to hospital or agency policies, and HIPAA or privacy regulations are indicative of the individual medical transport service’s sensitivity to patient confidentiality in accordance with local and national standards. 4. Controlled substances are in a locked system Bariatric patients and kept in a manner consistent with local and national regulations. For services that transport Air medical services should have strict policies ad- medications between bases, a policy exists that dressing weight limitations consistent with federal assures safe and secure transport of medications aviation safety requirements. The policy will indicate between bases that is consistent with state and/or the maximum gross weight allowed on the stretcher federal laws. In the U.S., there is a DEA license (inclusive of patient and equipment) as consistent required for each base that stores and dispenses with manufacturer’s guidelines. In the event that the narcotics (for example, a hospital pharmacy that patient’s weight exceeds the maximum gross weight stocks controlled substances for various locations guidelines, a policy should exist that addresses alter- needs a terminal distribution license) nate modes of transportation/resources for patients who are too heavy to transport by the available assets. 5. Storage of medications allows for protection The program should have a policy that addresses from extreme temperature changes if environ- transporting patients of unusual size, including their ment deems it necessary weight and size limitations. 13 6. There is a method to check expiration dates of medications and supplies on a regular basis Transporting Multiple Patients

Maintaining IV Fluids If the air medical service’s mission and statement of care includes the ability to transport two or more pa- 1. Hangers/hooks are available that secure IV solu- tients, it should also demonstrate that this transport tions in place or a mechanism to provide high will not compromise the airway, patient stabilization flow fluids if needed or the ability to perform emergency procedures on 2. All IV hooks are padded, flush mounted, or so any on-board patient. located to prevent head trauma to the medical 1. The aircraft should have access for simultane- transport personnel in the event of a hard land- ous airway management if there is a two-patient ing in the aircraft or emergency maneuver of the configuration aircraft 2. For all transports, there are written guidelines 3. Glass IV containers are not used unless required describing types of patients that can be trans- by specific medications and are properly secured ported in a two patient stretcher configuration if 4. A minimum of three IV infusion pumps or the aircraft configuration does not allow for full channels are on the aircraft or immediately avail- access to the second patient able for critical care transports and, as appropri- 3. For all transports, strict policies will address ate, to the scope of care weight limitations, patient condition based on anticipated needs, and patient position in the Blood products aircraft The air medical service has policies for utilization of 4. Policies will be written and adhered to for one or blood products, storage, and disposal of blood prod- more patient transports if the interior configura- uct materials as pertinent to the scope of service. tion of the aircraft does not allow for access to 1. Blood specimens or other potentially infectious one or more patients while enroute. Policies will materials should be placed in a leak proof, sealed address under what circumstances two critical container during transport patients may or may not be transported, including staffing and equipment 2. Disposal of contaminated materials from the aircraft or ambulance meets federal OSHA Guide- lines Environmental controls (air conditioning or Incident command heating) Air medical services should be integrated with and be The interior of the aircraft should be able to maintain able to communicate with other public safety agen- climate control in order to avoid adverse effects on cies, including ground emergency service providers. patients and personnel on board. In the event that This may include participation in regional quality climate controls are not utilized, available, or ad- improvement reviews, regional disaster planning and equate, the air medical service must have a policy to mass casualty incident drills that include an integrat- compensate for adverse effects on the patient (warm- ed response to terrorist events. Air medical services ing or cooling measures). should have, within their scope of serve: 1. Cabin temperatures must be measured and 1. A response plan to all types of disaster, including documented every 15 minutes during a patient weapons of mass destruction, terrorist events, transport until temperatures are maintained and natural disasters within the range if 50-95 degrees F (10-35 C) 14 2. A policy that prohibits “freelance responses” for aircraft (responding without being specifically requested) 2. The program has written policies that address to disasters measures to be taken to avoid adverse effects of 3. Programs to ensure their personnel are familiar temperature extremes on patients and personnel with the plan to respond to disasters on board 4. Training with FEMA or other Emergency Man- 3. In the event cabin temperatures are less than 50 agement classes for scene and disaster response degrees (F) or greater than 95 degrees (F), the program will require documentation be flagged 5. Interface of the medical team with other regional for the QM process to evaluate what measures resources were taken to mitigate adverse effects on the pa- a. For air medical services that respond to in- tient and personnel and what outcomes resulted cident scenes and support disaster response, staff has completed the Federal Emergency Management Agency Independent Study Courses on Incident Command. (IS-100, IS-200). b. For air medical services that are involved in national disaster response, management staff should also have completed IS-800.—Na- tional Response Framework, An Introduc- tion. Section 5—Medical Control

Medical Control shall include: j. Is considered to be a part of the high-level 1. Medical Director—An air medical service should management team for the service, even for have the medical components of the service non-medical operations. directed by a physician, licensed and authorized 2. Utilization Review—The medical director shall to practice in the location in which the medical supervise a process for prospective, concurrent transport service is based, and who is responsible and/or retrospective trending and tracking of and accountable for supervising and evaluat- requesting and receiving providers for evaluat- ing the quality of medical care provided by the ing appropriate use of air medical resources and medical personnel. Further the medical director personnel (see Utilization section) should: 3. Destination protocols—The air medical service 15 a. Practice and have expertise in emergency, will develop and maintain guidelines for trans- critical care and/or critical care transport and port of patients to the most appropriate receiv- education and expertise for specific popula- ing institutions, with consideration of Federal tions identified by scope of service (i.e. pe- EMTALA regulations, timeliness, distance and diatric, neonatal, trauma, etc.) or designate capabilities and by the most appropriate means and ensure availability of specialty specific (i.e. fixed wing, rotor wing, or ground) with ap- consultants for these populations. propriate crew configuration for patient specific b. Maintain a leadership role in the service’s needs regardless of transport modality. Protocols Quality Management Program. will include mechanisms for real time communi- c. Set and review written guidelines for cur- cation with sending and receiving destinations rent accepted medical practice for all service medical personnel. 4. Protocol administration & oversight—The air d. Be actively involved in the hiring, training medical service, under the supervision of the and continuing education of all medical medical director and other service leadership, personnel. will set, review and update medical program e. Orient and provide additional quality protocol management for any additional physicians a. Protocol revisions will be evaluated to deter- providing on-line/ in-transport medical mine relative benefit. direction as to the policies, procedures and b. Protocol compliance will be monitored and patient care protocols of the service. documented. f. Establish protocols and practices for medical c. A process for remediation or dismissal for care under standard operating procedures service personnel not in compliance with and define circumstances requiring on-line protocols will be established and maintained. medical control. 5. Professional development program—Continuing g. Ensure that any ancillary ground transport education and staff development must be pro- is safe and appropriate for specific patient vided and documented for all air medical service medical needs. medical care providers. These should: h. Set and maintain policies that insure compli- a. Be specific and appropriate for the mission ance with federal EMTALA regulations and statement and scope of care of the medical other relevant federal, state, and local laws. transport service. i. Maintain communications with referring b. Include maintained currency in required and accepting physicians and service medical credentialing as defined by federal, state, and personnel and be accessible for any concerns service regulation. regarding patient management. c. Be based on quality improvement and focus 6. Transfer of care—The air medical service, under on reinforcement and expansion of skills of the supervision of the medical director, should individual providers. establish and be in compliance with medical care d. Include a focus on Safety and Risk Manage- protocols for receiving patients from sending ment including but not limited to: institutions, first responders, or ground units and i. Human Factors—Crew Resource Man- for transfer of care to any additional transport agement. units or receiving institutions ii. Infection control and Hazardous Mate- a. Medical director and service personnel will rials. communicate protocols with associated insti- iii. Emergency Safety Procedures. tutions. iv. Stress and fatigue recognition. b. Protocols will be in compliance with federal e. Be regularly repeated by service designated EMTALA and HIPAA laws. schedule. 7. Online medical control—The air medical service, under the supervision of the medical director, 16 will establish and maintain protocols for on-line medical direction by the medical director or appropriately trained and designated physicians a. Medical director will ensure defined schedule and ensure availability for on-line medical control via the communication center or other appropriate means. Section 6—Utilization

States should develop evidence-based medical 2. A patient has significant potential to require a protocols to define parameters for the request of air time-critical intervention and an air medical medical resources. Organizations can request, not transport will deliver the patient to an appropri- dispatch, air medical services. The Part 135 Operator ate facility so much faster than ground transport providing the air transportation has the exclusive au- that improved outcome could be reasonably thority to dispatch aircraft after careful consideration expected of the conditions of each flight. 3. A patient is located in a geographically isolated States should develop regional care plans based on area that would make ground transport impos- the capacity of facilities and patient care needs re- sible or greatly delayed gardless of political boundaries and sub-divisions. 4. Local EMS resources are exceeded or are un- 17 available to transport to the closest appropriate Some of the situations where utilization of air medi- facility without compromising response to the cal transport or evacuation would be appropriate primary service area include: 5. Organ and/or organ recipient requires air trans- 1. A patient has a significant need of equipment or port to the transplant center in order to maintain medical personnel for critical care (i.e., to pre- viability of time-critical transplant vent or manage ongoing deterioration that is an imminent threat to life, limb, or organ) available from an air medical transport and which cannot be provided via ground transport Section 7—Quality Management

Quality Management programs should fall under tort f. Encourage reporting of clinical care adverse protection for medical quality improvement pro- events, including sole source events, without grams as specified under state law. punitive actions beyond what is proscribed 1. An air medical service shall have a written quality for licensing, credentialing, or legal require- management (QM) plan that includes: ments. a. Business plan including service area and g. Include regularly scheduled meetings to scope of care. provide personnel, from all service aspects, b. Diagram or similar charting of QM organi- the opportunity to participate continuously zational structure with clear assignments of in QM. accountability and links to safety organiza- h. Generate a regular report, an annual sum- 18 tional tools. mary at a minimum, that is available to all c. A process to identify, record, and evaluate air medical service personnel. sentinel events, adverse medical events, or i. Drive education and training needs to main- potentially adverse events with specific goals tain an instructional, non-punitive purpose to improve the quality of patient care. to action plans. d. Identified thresholds for performance of 3. As part of a Quality Management Program, clini- the clinical care, ideally based on published cal and operational data shall be collected and standards or established best practices. available for review to analyze service perfor- e. Methodology of data collection and employ- mance and establish benchmarks. Examples of ment of the QM process. possible data collected in such a program could f. Continuous evaluation of the QM process. include but would not be limited to: 2. The Quality Management program shall: a. Accurate time of request, dispatch, and ar- a. Monitor and attempt to identify improve- rival to patient; transport times; and times ments in all important clinical care out- for conclusion of care and service re-entry. comes, including but not limited to, medical b. Referring and receiving locations. operations, medical control, clinical care, c. Reason for transport (integrated with utiliza- utilization, communications, and safety. tion review). i. Objective measures are utilized where d. Mechanism of patient injury or illness. achievable. e. Medical interventions instituted or main- ii. Communications and clinical documen- tained with accurate times and patient tation should allow structured review of responses. important aspects of service and clinical f. Change in patient condition during trans- care. port. b. Assemble representatives from all aspects of g. Patient condition at time of arrival. the service to identify any areas for improve- h. Issues of integration with referring or receiv- ment in clinical care in a continuous man- ing institutions. ner. i. Number of completed transports. c. Record and maintain evidence of actions j. Number and type of aborted and cancelled taken in problem areas. transport requests, with times, reasons (i.e. d. Monitor and be able to demonstrate effec- weather, maintenance, patient condition, tiveness of actions taken in the QM program etc.) and disposition of patients as appli- with finite timelines to achieve loop closure. cable. e. Be integrated with risk management and utilization review. 4. If the service has a sponsoring institution or i. Specialized equipment and expertise agency, then the Quality Management and Utili- available during transport that is not zation Review programs shall: otherwise available to the sending insti- a. Report results through an established organi- tution. zational structure to the service’s sponsoring ii. Utilization of regional resources. institution or agency. iii. EMTALA obligations of sending and b. Directly integrate transport service activities receiving institution. with the sponsoring institution or agency. iv. Time dependency of medical condition. 5. The medical director and other relevant manage- v. Cost of transport. ment shall ensure a utilization process through • Emergency transports do not re- trending and tracking requests which shall con- quire guaranteed payment. tain at least the following: • Agents calling for non-emergent a. Regular, documented, structured review to transports should be assisted with determine: alternative, appropriate modes of i. Appropriateness of transfer from a scene transport. 19 or requesting institution to a receiving • Requests that are outsources or institution; and subcontracted shall be reviewed for ii. That the mode of transport enhances appropriateness. medical outcome or cost effectiveness e. Where appropriate, the air medical ser- over other modes of transport. vice should promote a timely feedback to b. Structured, confidential feedback between referring agency, facility or physician about the air medical service and requesting agents patient outcome and treatment rendered and receiving facilities. before, during and after transport. c. Utilization review may be prospective, con- f. Patients transferred from air to ground current or retrospective. transport units (at sending and receiving d. Reviews of appropriateness of transport and destination) shall have the same or higher mode of transport may consider but are not level ground personnel as that provided by limited to: air transport personnel. Section 8—Safety

Air medical services operate at the junction of the 4. Patient Loading and Unloading. The State guide- aviation and medical industries. Because of that, lines should require the applicant to provide aviation, workplace, and clinical/medical safety information about its procedures for maintain- programs should not operate in isolation. With the ing the safety of the medical personnel and development of model state guidelines, states should patients during loading & unloading operations encourage Part 135 Operators and Medical Direc- (whether or not the aircraft engine is running), tors to review their programs, jointly, to enhance the in accordance with applicable federal aviation industry’s overall safety effort. requirements. Further, the State should require 1. Helicopter/weather “shopping.” The State guide- all applicants to have policies and procedures used to assure the safety of non-air medical 20 lines should require that the applicant utilizes a methodology to inform other surrounding service personnel assisting in loading/unload- helicopter programs of when they have declined ing of the aircraft if such personnel are utilized a flight. The sharing of this information will in this capacity. These policies and procedures assist in mitigating a helicopter requestor from should contain, at a minimum, the safe approach “shopping” for a helicopter to complete a trans- zones for the aircraft, the known danger areas of port when they have already been informed that the aircraft and direction to never approach the weather will not allow for safe flight. Further, the aircraft until directed to do so by a member of State guidelines should require that the applicant the crew provides education to their service areas on the 5. Medical Personnel rest requirements. The State dangers of Helicopter/weather “shopping” guidelines should require the applicant to have a 2. Pre-established landing areas. The State guide- defined policy outlining the minimum hours of lines should require the applicant to report to the uninterrupted rest required of medical personnel state any pre-established landing areas (improved before reporting for a regularly scheduled shift or unimproved) which may be used as intercept 6. Shift length requirements. The State guidelines points with ground ambulances. State guidelines should require the applicant to have a defined should encourage the use of such pre-established policy outlining the maximum hours of sched- areas for helicopter patient transports. The goal uled shift length for the medical personnel. For of these actions is to decrease the time to defini- shifts of 24 hours or greater, the applicant must tive care for patients by facilitating rendezvous provide adequate facilities for medical personnel between ground and air ambulances rest 3. Hot refueling. The State guidelines should require the applicant to provide information about its procedures for maintaining the safety of the medical personnel and patients, in accordance with applicable federal aviation safety requirements; in the event that the applicant will be conducting hot (engine(s) remain running) refueling operations 7. Workplace safety. Public education and prevention a. The State guidelines should require the applicant to have a defined policy outlining To facilitate public awareness, the air medical service the minimum required immunizations and shall provide information about its safety program to post-exposure prophylaxis that should be public safety/law enforcement agencies and hospital made available to the applicant’s clinical care personnel who interface with the medical service. employees. Many of these safety program areas are governed by b. The State guidelines should require the ap- federal aviation safety requirements. The information plicant to have a policy defining the use of should include: personal protective equipment to include 1. Identifying, designating and preparing an appro- at a minimum, fire-resistant or natural fiber priate LZ uniforms, sturdy over the ankle footwear, 2. Personal safety in and around the aircraft for all and the use of helmets for helicopter opera- ground personnel tions. The State should require the applicant to provide and have a policy governing the 3. Procedures for day/night operations, conducted 21 use of disposable exam gloves, eye protection by the medical team, specific to the aircraft: and other body fluid barriers as necessary for a. High and low reconnaissance. the mission profile. b. Two-way communications between the c. The State guidelines should require the ap- aircraft and ground personnel to identify plicant to have a policy defining what medi- approach and departure obstacles and wind cal conditions may limit the medical crew direction. member’s ability to perform the required c. Approach and departure path selection. job tasks. This includes but is not limited d. Procedures for the pilot to ensure safety to height and weight considerations, acute/ during ground operations in a LZ with or chronic illness and pregnancy. without engines running. 8. Sterile cockpit. Federal Aviation Regulations 4. Crash recovery procedures specific to the aircraft require the maintenance of a sterile cockpit in make and model should minimally include: certain conditions so that the pilot is able to a. Location of fuel tanks. transmit and receive vital information and to b. Oxygen shut-offs in cockpit and cabin. minimize distractions during any critical phase of c. Emergency egress procedures. flight. No external communications are permit- d. Aircraft battery—stay away from it., and ted by the medical team and no patient informa- e. Emergency shut-down procedures. tion is transmitted at this time unless radios for 5. Education regarding weather-based helicopter medical report are isolated “shopping” should be included 6. Education regarding the appropriate utilization of the air medical asset in the context of the regional EMS system 7. Records are kept of initial and recurrent safety training of pre-hospital, referring and receiving ground support personnel Section 9—Communications

The FAA Part 135 Operator has the responsibility for 5. The Communications Center contains a system dispatch, operational control, flight following, and for recording all incoming and outgoing tele- all flight release decisions. The FAA and the FCC phone and radio transmissions with time record- regulate the operation and capability of radios on ing and immediate playback capabilities. Record- board aircraft. An air medical service should provide ings must be kept for a minimum of 90 days information confirming it is in compliance with 6. The Communications Center contains a capabil- FAA and FCC regulations regarding communica- ity to immediately notify the medical transport tions and operational control. An air medical service team and on-line medical direction (through must provide information confirming its ability to radio, pager, telephone, etc.) meet communications requirements, consistent with 22 federal aviation safety requirements, either directly 7. The Communications Center contains a status or through contracted services with regional com- display with information about pre-scheduled munication centers, aviation operators, or others, flights/patient transports, the medical transport including: team on duty, weather and maintenance status as pertinent to the scope of service Communications Equipment—Rotary Wing 8. Current local aircraft service area maps and and Emergent Fixed Wing navigation charts are readily available for aviation operations. Mapping software could supplement (Emergent Fixed Wing services operate in a manner current charts similar to rotory wing services, responding immediately or on-demand to emergent transport requests Communications Specialists from an emergency department or scene response using a ground ambulance intercept) 1. A Communication Specialist or other designee must be assigned to receive and coordinate all 1. All communications equipment is in full oper- requests for the medical transport service ating condition and in good repair. Radios on a. Scheduling and individual work schedules aircraft (as range permits) are capable of trans- demonstrate strategies to minimize duty- mitting and receiving the following: time, fatigue, length of shift, number of a. Medical direction. shifts per week and day-to-night rotation. b. Communications center. b. Call volume and other required duties are c. Air traffic control (aircraft)., and considerations in the number of communi- d. Emergency Services (EMS, law enforcement cation specialists on duty at any one time. agencies, fire, etc.) where it meets the scope (Programs should be able to demonstrate of service. how they assign staffing levels, for example, 2. The pilot is able to control and override radio number of Communication Specialists on transmissions from the cockpit in the event of an duty per shift relevant to the number of emergency situation vehicles and teams in service.). c. There are relief personnel with the appropri- 3. The medical team is able to communicate with ate training available for periodic breaks. each other during flight. Helmets with commu- d. Personnel must have at least eight hours of nications capabilities are required on helicopters rest with no work-related interruptions prior 4. The Communications Center contains at least to any scheduled shift of twelve hours or one dedicated phone line for contacting the more. The intent is to preclude back-to-back medical transport service shifts with other employment, commercial or military flying, or significant fatigue-caus- ing activity prior to a shift. e. On-site shifts are routinely scheduled for a k. Stress recognition and management to include period not to exceed 18 hours. Twenty-four resources for Critical Incident Stress Debrief- hour shifts are not acceptable. In addition: ing or other type of post critical incident i. Personnel must have the right to call counseling. “time out” and be granted a reasonable l. Customer service/public relations/phone rest period if a team member deter- etiquette. mines that he or she is unfit or unsafe m. Quality management. to continue duty, no matter what the n. Crew Resource Management (CRM) perti- shift length. There should be no adverse nent to communications. personnel action or undue pressure to o. Computer literacy and software training. continue in this circumstance. p. Emergency Incident Plan (also known as ii. Management should monitor flight Post Accident/Incident Plan or PAIP). volumes and personnel’s use of the “time 3. There is evidence of recurrent training and of out” policy to ensure that communica- training as policies and equipment changes occur tions personnel utilize the right to call 23 “time-out” appropriately. 4. Certifications (such as EMT-B, EMD, NAACS Certified Flight Communications Course or 2. Training of the appropriate, designated com- equivalent), if required by position description, munication specialist or other design should must be current be commensurate with the air medical service’s scope of service and should include: Communications Policies a. Medical terminology and obtaining patient information. 1. Must be in writing and include the following: b. Knowledge of EMS—roles and responsibili- a. Communications policy and procedures ties of the various levels of training –BLS/ manual. ALS, EMT/ EMT-Paramedic. b. A method to keep noise and other distrac- c. State and local regulations regarding EMS. tions (traffic) from the communications d. Familiarization with equipment used in the area while the communications specialist is field and/or inter-facility setting, based on involved with a medical transport mission. scope of service. c. An evacuation plan that provides for con- e. Knowledge of federal aviation regulations tinuous communications with transport and FCC regulations or equivalent as perti- personnel in the event there is a need to nent to medical transport service. evacuate the communications center. f. General safety rules and emergency proce- d. There is a written policy that at the time of dures pertinent to medical transportation a request, the pilot is not informed of the and flight following procedures. patient condition or age unless there are g. Navigation techniques/terminology, flight operational considerations (for example: following and map skills. This should in- weight, extra equipment etc.). clude an understanding of GPS navigation e. Emergency incident plans (also known and approaches. as post-accident/incident plans) are easily h. Understanding weather interpretation identified, readily available, and understood and how to retrieve current and forecasted by all program personnel. For RW aircraft weather to assist the pilot during a transport or FW aircraft on a VFR flight plan, ap- if other means are not in place within the propriate search and rescue efforts should be organization. initiated in the event the aircraft is overdue, i. Types of radio frequency bands used in radio communications cannot be established medical and ground EMS. nor location verified. These plans should j. Assistance with the hazardous materials minimally include: response and recognition procedure using appropriate reference materials.

i. List of personnel (with current phone iii. Consecutive guidelines to follow in at- numbers) to notify in order of priority tempts to: (for communication specialist to acti- • Communicate with the aircraft. vate) in the event of a program incident/ • Initiate search and rescue or ground accident (for air or ground). This list support. should minimally include sponsoring • Have a back-up plan for transport- organization individuals where appli- ing the ground ambulance patient cable, risk management attorney, family in the event of an incident or members of team members, family of accident and/or the ambulance is patient, referring hospital, receiving inoperable. hospital, security (as applicable), human • Have an individual identified from resources (as applicable), media relations the Part 135 Operator as the scene or pre-identified individual who will coordinator to coordinate activities be responsible for communicating with at the crash site. 24 the media, state health department and iv. Preplanned time frame to activate the other team members. emergency incident plan (also known ii. Notification plans include appropriate as a post-accident/incident) for overdue family members and support services aircraft or ambulance. to family members following a tragic v. A method to insure accurate informa- event. There must be timely notification tion dissemination. of next of kin. Next of kin is no longer vi. Coordination of transport of injured strictly defined at the federal level so the team members to higher level of care if crew member determines this on a data needed and/or back to local area. sheet and reviews annually. It is strongly vii. Procedure to document all notifications, recommended that: calls, and communications and to secure • Family assistance includes coordina- all documents and tape recordings re- tion of family needs immediately lated to the particular incident/accident. after the event e.g. transportation, viii. Procedure to deal with releasing infor- lodging, memorial/burial service, mation to the press. condolences, initial grief support ix. Resources available for CISD or other services/referrals, (usually through counseling alternatives. appointment of a family liaison). x. Process to determine whether the pro- • Continuity includes follow through gram and/or component of the program with the family after the event (e.g. will remain in service. If it is determined submission of crew to national EMS that the program or a component of the memorial service, the continuation program will go out of service, other of grief counseling and support regional transport services, primary cus- referrals, the inclusion of families in tomers, EMS, public service groups and decision-making on anniversaries/ other applicable groups are advised. memorials, and check-ins following xi. An annual drill is conducted to exer- release of NTSB reports, or equiva- cise the emergency incident plan (also lent, etc.). known as a post incident/accident plan). This drill should include pilots, medical personnel, communications personnel, mechanics and administrative personnel. Written debriefing and critique of PAIP drills should be shared with all staff members. xii. A full drill must test each of the modes g. Ground transportation coordination at send- of transport (if the program has RW, ing and receiving areas. FW and G or combination thereof) h. The time medical personnel are notified within a three year time frame. flight is approved, post pilot’s OK of flight). xiii. An actual incident may be used, as i. Time depart base (Time of lift-off from base appropriate, if documented and docu- or other site). mentation includes loop closure. A table j. Number and names of all personnel on top drill—defined as a drill where there board the aircraft. are position challenges between the pilot k. Number and names of patient(s) on board and the communications specialist only (for inter-facility requests). and not covering all the components l. Estimated time of arrival (ETA). and disciplines listed in the PAIP is not m. Time arrive location (Time aircraft/ambu- considered a full drill. lance arrives at landing zone, helipad, airport 2. A general test of all emergency procedures to or referring area). include fire drill, intruder on premises, cata- n. Time depart location (Time aircraft/ambu- 25 strophic failure of the communications center, lance lifts off from landing zone, helipad, or helipad mishaps, forces of nature etc. will also be airport or leaves referring area). conducted on an annual basis o. Time arrive destination (Time patient transferred to receiving clinical team; in unusual 3. A disaster preparedness drill should be part of circumstances, this may not be at a health- the general test of all emergency procedures or care facility). conducted separately as an annual drill p. Time depart destination (Time left patient destination. This will be recorded for trans- En Route Communications ports not ending at base). q. Time arrive base (Time arrive base after call The FAA Part 135 Operator has the responsibility for completed)., and/or dispatch, operational control, flight following, and r. Time aborted (Time authorized transport is all flight release decisions. The Part 135 Operator aborted/canceled after dispatch). may choose to enter into contractual arrangements for individuals not directly employed by the Part 135 Operator to provide these duties under the oversight Criteria for non-emergent or pre-scheduled and responsibility of the Part 135 Operator. Ad- Fixed Wing ditional Information for clinical care needs may be (Fixed wing services considered non-emergent or pre- requested, to include: scheduled transport between facilities typically under 1. Initial coordination to include communication non-emergent situations (not from an emergency and documentation of: department) or as a transport that has been requested a. The time of the request call (Time request/ in advance at a specified date and time) inquiry received). 1. For a fixed wing service that flies only pre-sched- b. The name and phone number of requesting uled flights, an answering service may serve as agency. the receiving point for requests for service c. The age, diagnosis, or mechanism of injury. a. Answering service personnel must be trained d. The referring and receiving physician and to obtain specific information when receiv- facilities (for inter-facility requests) as per ing a request to schedule fixed wing patient policy of the medical transport service. transportation. e. Verification of the acceptance of the patient and verification of bed availability by referring physician and facility (for inter-facility requests). f. Previous turn-downs of the mission (i.e. helicopter shopping). b. The items should include but not be limited Coordination of Communications Capabilities to: i. Name and telephone number of caller The FAA Part 135 Operator has the responsibility for ii. Patient type/condition dispatch, operational control, flight following, and iii. Date and time call received all flight release decisions. With the development of iv. Anticipated or scheduled date/time of the Model State Guidelines, states should work to fa- departure cilitate medical communications capabilities between v. Location of patient and destination air and ground services. Air and ground medical transport services should provide direct communica- 2. Specific methods must be used by the answering tion capabilities for medical personnel and ground service for contacting the medical service coordi- ambulance providers, to ensure rapid dissemination nator (or designee) to relay request information, of information, coordination of efforts, and problem i.e., pager numbers, telephone and/or cellular solving. Direct contact between the parties should be numbers established whenever possible as follows: 26 3. Destination airport, refueling stops (if necessary), 1. There is a written policy that addresses direct location of transportation exchange and hours of or relayed communications to communications operation (FW) center (while in motion) specifying locations and 4. Guidelines of timely notification (less than thirty ETA’s, and deviations, if necessary minutes) should be established. Alternate pro- 2. Time between each communication cedures for notification must be in place in case a. Time between each communication should the coordinator is not available to receive the not exceed 10 minutes while in flight unless request/information a system of continuous automatic position 5. An on-call roster of the medical team must be tracking is utilized. provided to the answering service. The roster in- b. There is a policy to address continuous cludes a priority phone list of personnel to notify automatic position tracking, if utilized; the in the event of an emergency policy should ensure there are also verbal communications at predetermined times. c. Alternate agencies are used to relay communications when direct contact is not possible. 3. There is a written policy that while the aircraft is on a mission, a dedicated communicator assigned to flight follow will be present at all times. (RW) Section 10—Multijurisdictional Air Provider

With the development of model state guidelines, should seek to establish national-level guidelines for states should work on compacts that offer license license reciprocity for long-range (i.e. fixed-wing) air reciprocity for providers and medical crews, provided medical services that could also provide a framework those providers and/or medical crew members are for inter-state compacts for local ground and air licensed in their home state. State EMS Officials medical services.

Section 11—References

A. Air & Surface Patient Transport: Principles & Additional Resources Practice [Hardcover] A. DOT insurance requirements for direct air carri- Renee S. Holleran RN PhD CEN CCRN ers (http://www.gpo.gov/fdsys/pkg/CFR-2012-ti- CFRN CTRN FAEN (Author), ASTNA (Au- tle14-vol4/xml/CFR-2012-title14-vol4-chapII. thor), 3rd edition xml) B. Federal Aviation Administration. (2011). Title B. Air Medical Task Force paper (http://www.aams. 14 of the Code of Federal Regulations. Retrieved org/AAMS/PublicationsProducts/AMTF_Fi- from http://rgl.faa.gov/Regulatory_and_Guid- nal_Paper1.aspx) ance_Library/rgFAR.nsf/MainFrame C. Government Accountability Office (GAO) C. Commission on Accreditation of Medical Report (http://www.gao.gov/products/GAO-10- Transport Systems. (2011). 8th Edition Standards. 907) Retrieved from http://www.camts.org/component/option,com_docman/task,cat_view/gid,17/ D. Department of Transportation (DOT) opinion Itemid,44/ letters (available upon request) D. National Association of EMS Physicians. (2011). Guidelines for Air Medical Dispatch. Retrieved from http://www.aaem.org/positionstatements/ helicopterdispatch.pdf

CAMTS has agreed to grant permission and acknowledges limited use of the CAMTS logo and reference to the 8th Edition Accreditation standards herein the AAMS Model State Guidelines. Association of Air Medical Services www.aams.org MedEvac Foundation International www.medevacfoundation.org

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