311November-December 2013

ASTNA

Farewell

Greetings everyone! The time has come to write myfinal column for Air Medical Journal as president ofASTNA. The year has really flown by!

As I look back, I see many great things that have hap-pened this year, not because I am the president, butbecause I have a great group to work alongside. TheASTNA board is a group of professionals that words can-not describe. They, along with Karen and Amanda fromthe ASTNA office, ensure that you, the member, are takencare of as best as possible. Long meetings, long conferencecalls, and behind-the-scenes work ensure that ASTNAwill live long into the future.

Membership has been my theme. I am proud to say thatour membership is diverse, but there is still work to do. Wemust band together to make sure that our profession has thelegitimacy and stature that it needs to function at a peerlevel with any group of industry professionals. There isalways strength in numbers, and by being an ASTNA mem-ber, you stand shoulder to shoulder with transport nursesfrom around the globe. Safety and great patient care mustcontinue to be our focus. Without getting to and from amission safely or giving safe care, we will not be effective. Iencourage and implore all of you to please dedicate as muchenergy as possible to safe care and transports.

I am honored to have received your trust to be presi-dent of ASTNA. In my entire professional career, I havenever been as honored as I am to have been elected byyou to serve as a board member and then president. I amproud to have followed people that have been the presi-dent that I admire and respect. The list of past presidentsis long, with names on it that immediately equate to pro-fessionalism and also exemplify and embody what trans-port nursing is all about.

The baton now gets passed to Steven Neher. Steve is agreat leader who will definitely make the organizationshine. Steve has a long lineage of involvement and hasmade every project that he has been involved with shine.The ASTNA luncheon at Air Medical TransportConference has been his project for years, and he hastaken it leaps and bounds from what we had in the past.His dedication and professionalism will serve us all well.

In closing, I thank each of you, the board, the officestaff, the committees, and Past President Sandy Correiafor all of the support and mentoring. I also thank my 2sons, Mason and Jacob, for their understanding of whyDad was on the phone or gone to a conference.

With the utmost respect.Jim Mobley, President

IAFCCP

Parting Words

The end of 2013 is swiftly approaching, and theIAFCCP has again passed the leadership torch to a succes-sor. Over the past year, we have made commitments toimprove your association and have responded to yoursuggestions and commentary. The IAFCCP has embracedits international membership and is working to ensurereliable consistency in communications and member serv-ices for all members, regardless of country of origin. TheIAFCCP has polled our members for suggestions forimproving our value to members, and we are pushing for-ward with measures, based upon your comments. Wecontinue our efforts to support worthwhile education cur-ricula and resources, and we encourage further inputfrom you on how to do this. We have also kept a steadyeye on monitoring legislative and regulatory issues thataffect our members, and we will ensure a high level ofsurveillance in the future.

I wish to thank you for your support of my leadershipover the past year, and I encourage you to speak up andshare thoughts with our new president, RichardChildress. I encourage you to get involved as well. Inaddition to commentary, we need your activity. Ourstrength is the sum of our membership effort, so step upand be active.

Lastly, as IAFCCP past-president, I ask you as a member toreflect on the following. Regardless of your business modelor employer, no one is immune from the consequences ofthoughtless behavior or reckless disregard. You have aresponsibility to yourself, your family, your team, youremployer, and your patients to ensure that each and everywork activity, transport or otherwise, is done in a safe man-ner. If you believe that it simply “won’t happen” to you, youare making a dangerous wager against the odds. If youbelieve that you have no ability to control your circum-

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stances and that “these things happen,” ask yourself, “Who isit ok for ‘these things’ to happen to?” The answer is no one. Ifyou believe otherwise, please work hard toward a moreresponsible perspective. You should be going home aftereach shift in the same (or better) condition.

The medical transport community needs no moreaccidents, air or ground. We need no more heroes, mar-tyrs, or names emblazoned on bricks. We need you.

Commit yourself to examining the behaviors of yourteam and yourself. Set the example for ownership ofsafety and do not allow others to be complacent or dis-engaged from their responsibility for safety for yourteam, your equipment, and your patients. Step up andown this responsibility.

Be safe.Chris Hall, President

NEMSPA

Seeking Solutions

On September 5 and 6 somewhere between 30 and 40safety professionals from the nationwide air medicaltransport community gathered in Washington, DC, forthe 2013 Air Medical Safety Summit. The attendeesincluded key leaders involved in the air medical industrywho are each dedicated to the campaign to stop thestream of tragic and preventable crashes that continue toplague the nation’s air medical transport industry.

The presentations and discussion on the first day of theSafety Summit focused on the complex structure of the airmedical transport system and the need for communica-tion and cooperation between the various entities thatdeliver, support, oversee, and legislate the system. Therelationships between distinct elements of the system areboth horizontal and vertical, and effective coordinationbetween them is 1 of the greatest challenges facing theindustry. (In fact, the topic of my presentation at the AirMedical Transport Conference this year was a discussionof the implications of the hierarchical structure of this sys-tem on the implementation of safety management systemswithin air medical provider organizations.)

By the end of the first day, 4 areas of emphasis emergedthat became the focus for Day 2:

1. Technology2. Training3. Safety culture4. Human factorsThe attendees broke into 4 groups, with each person

choosing the group that he or she would join. Each groupwas tasked to identify the essential factors in their area

that had an influence on operational safety. Then theysuggested some strategies (industry-level) and tactics(organization-level) to best mitigate the risks associatedwith each of the 4 areas. The next step will be to focusmore closely on the best tools to use to manage thoserisks at the appropriate levels of the air medical transportsystem. Because of time constraints inherent in a 2-daymeeting, there will be a delay before the final report of the2013 Air Medical Safety Summit is finalized and sharedwith the air medical transport community.

In my view, efforts like this Safety Summit are essentialfor the health of our industry. It signals a determination tomobilize internal resources to address problems withsafety, rather than relying on government agencies to dic-tate the solutions. This is not to say that state and nationalgovernment agencies have no role in addressing challengesto operational safety. An additional presentation on Day 2of the summit was provided by a representative from theFederal Aviation Administration who updated us on thenew air ambulance rules that are in the final stages of con-sideration and are expected to be implemented soon.

The final presentation of the summit was provided byKrista Haugen, representing the AAMS SurvivorsNetwork. This organization is an advocate for the manysurvivors of air medical crashes, as well as for the familiesand loved ones of those who did not survive. Kristashared words and images with us that reminded us ofhow important it is that we follow through on the discus-sions of those 2 days.

Bill Winn, General Manager

AAMS

Continue the Progress

At the time of this Forum publication, I will have movedto the position of AAMS Past Chair and the new chairman ofthe board will have taken the helm. Organizational changesthat occurred in the year before my board chairmanship cul-minated over my term in several notable accomplishmentsthat I’d like to mention. These include:

• In December, AAMS hosted a timely and successfulCapitol Hill “Fly-In” to raise Congressional aware-ness of MedPAC recommendations that couldadversely affect our membership. This was followedby the AAMS Spring Conference in March, duringwhich almost 100 meetings were conducted with

313November-December 2013

Congressional leaders and key Congressional staff.As a result of these combined legislative efforts, ourkey advocacy wins this past year include:•• Critical drug shortages: AAMS’ advocacy efforts,

in conjunction with several other associations’,resulted in Congress passing legislation reautho-rizing the Food and Drug Administration andsupporting language that requires drug manufac-turers to report to the government any disrup-tion in the production of critical life-saving andEMS drugs. Added to the list of drugs thatrequire such notification are those used in emer-gency medicine and all sterile injectables.

•• Air ambulance rural zip code “hold-harmless”provision: AAMS’ major year-end advocacyefforts resulted in Congress extending the AirAmbulance “Hold Harmless” agreement for 6months and the 2% urban and the 3% rural andthe super rural Medicare add-on payments forground ambulance for 1 year.

• AAMS and Helicopter Association International peti-tioned the FAA to extend Exemption NO. 6002, whichallows properly trained pilots to remove and reinstallliquid oxygen system containers in their aircraft. Theexemption will now run until January 31, 2015.

• AAMS conducted its first Net Promoter Survey withthe intent to measure membership satisfaction andloyalty and help guide future activities.

• AAMS, National Association of State EMS Officials,and National Association of Emergency MedicalTechnicians petitioned the General ServicesAdministration (GSA) to extend their support forthe KKK-1822 Ground Ambulance Standards untilSeptember 20, 2015. AAMS’ efforts were successfulas the GSA granted the extension that will allowmore time for AAMS and industry partners to ana-lyze and come to a consensus on the standards forground ambulances.

• AAMS awarded the 2013 AAMS Excellence inCommunity Service Award to its first internationalrecipient, CareFlight, Westmead NSW, Australia.

• AAMS held the largest Medical TransportLeadership Institute School in the history of theinstitute, hosting 213 attendees.

• AAMS launched Patient of the Month stories to bet-ter educate the public on the value of air medicaltransport.

• AAMS secured Rep. Gregory Meeks, D-NY, to co-chairthe Congressional Air Medical Caucus with our long-standing co-chair, Rep. Pete Sessions, R-TX.

• AAMS secured an excellent lineup of AMTCkeynote presentations, including popular story-teller Connie Merritt, BSN, RN, PHN; the USArmy Aeromedical Research Laboratory (Ft.Rucker, AL); and 1 of the most prominent combatcommanders in American history, Gen. David H.Petraeus (US Army, Ret.).

• AAMS continues strengthening internationalconnections through new agreements withAeromedical Society of Australasia, Society ofAeromedicine Malaysia, and European HEMSand Air Ambulance Committee and by gainingnew international members.

• AAMS conducted a campaign to promote fixed-wing services to social workers and case managers.

• AAMS hosted an air medical safety summit inWashington, DC, to provide industry stakeholderswith a fresh perspective on safety programs andchallenges and reach consensus toward measurablegoals that improve the overall safety of the air med-ical community.

In closing, I would like to recommend that each of ourmembers consider getting involved with the association,whether as a board, committee, or subcommittee member oras an active member in 1 of our sections or special interestgroups. The voluntary service is personally rewarding andbeneficial to the community.

As I step down from the chair position, I want toexpress my gratitude to the members and the associationfor allowing me to serve. It has been both an honor andan extremely meaningful experience that will remain withme long into the future. The course has been set andAAMS has taken new direction, with strong and definitiveleadership in place. Let’s continue to work together to doour best as an association to support the community inproviding the highest level of safety and excellence inpatient care in an efficient manner.

Gerry Pagano, Chairman

AMPA

Utilization Review: The Hardest Part of CCTM Medical Direction?

“In the end you should always do the right thing, even if it’shard.” Nicholas Sparks

This certainly is a crazy business we’re in, in whichdoing business correctly involves teaching people whennot to buy what we’re selling. After all, I don’t seeMcDonald’s teaching me that today’s probably not a good

day for me to buy a Big Mac. Steve Jobs never once toldme I didn’t need another Apple device. Nike would thinkit’s perfectly reasonable for me to decide to fill my closetwith 100 pairs of sneakers.

In our case, where the “product” is a critical care trans-port mission, there are 3 huge differences. First, our price

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tag is much greater. Second, the person who makes thedecision to buy is almost never the person left holding thebill. Third, occasionally when someone who doesn’t needus buys us, someone else who does need us dies becausewe weren’t available at that time.

I’m not only a flight doc, medical director, and acceptingemergency physician. I sometimes work in a suburbancommunity emergency department (ED), where I’m a refer-ring physician for critical care transport medicine (CCTM).Let me be clear: I have a great respect for the immenselychallenging decision-making process involved in trying todecide when to pull the trigger on calling for a helicopter ora mobile intensive care unit (MICU), when the stakescouldn’t be higher, time is critical, and precious informa-tion is limited. And I think that, despite those challenges,most people do it remarkably well, again and again, and forthe right reasons, from a patient-first mindset.

However, I also understand that many forces arealigned to incentivize overutilization of medical heli-copters in America. True critical care ground resourcesare precious and rare, because MICU runs don’t paythat well, and states disincentivize or fail to recognizecritical care ground teams. So, when it comes toCCTM, the only tool that many regions have is a ham-mer—the helicopter. Both EMS/fire chiefs and referringhospitals are often interested in getting resource-inten-sive patients out of their hair as soon as possible, andunloading that patient with relatively stable, non-STEMI or partial pinky amputation or 12% burn with-out airway involvement 15 minutes sooner sounds likea tantalizingly great idea. Call in the big guns, and therest of the shift flows so much more easily. Doesn’tDanny’s brother work for those guys? He’ll have fun withthis one. And truthfully, the rest of the patients in thereferring ED, or the rest of the county’s populationserved by the referring EMS department, will be just alittle bit safer because of it.

Meanwhile, the non-STEMI patient is wondering whyshe was flown at 130 mph to be dropped off in an ICUand get the same heparin and GP2b3a drip she was get-ting at the referring ED for the next 8 hours until shefinally meets the accepting cardiologist. The partial ampu-tation patient ponders how much he really cares whetheror not his pinky fingertip is salvageable but can’t bear toconsider how much all this commotion is going to costhim. The 12% burn patient is confused by the inconsis-tency of having been hot loaded and unloaded from a hel-icopter in order to meet a burn surgeon who casually tellshim he’s OK to go home tonight on some Percocet andB&A dressing changes.

Let’s not forget the matter of the feedback that the folkswho called the helicopter for these patients will receive.Oh yes, there will be feedback from us CCTM programs.Most of the time, that feedback will be unopposedly posi-tive, without any direct education whatsoever with regardto room for improvement in the realm of appropriate uti-

lization decision-making, and let’s leave it at that. Ourcompetitive environment creates immense financial pres-sure that assures that’s the case. If you work in CCTM inAmerica, you have felt this pressure, and it’s not subtle.No margin, no mission.

This discussion is an oversimplication, of course.Obviously, without some overtriage, patients will be hurtby being denied the thing that could save their lives:CCTM. Furthermore, there is no doubt that, in manyother circumstances, for entirely different reasons, under-utilization of CCTM resources is a significant problem aswell. But I’ve got to focus, given the limited space gener-ously granted me. If our community doesn’t aggressivelyregulate itself to curb overutilization, somebody else will,and I doubt we’ll like it.

Here are some of my ideas of how we can start:• As AMPA founder Dr. Frank Thomas loves to say,

“You can’t manage what you can’t measure.” As a partof its Metrics Project, AMPA is drafting a definition ofa metric to measure a program’s performance withregard to appropriate utilization. A daunting task,absolutely. I don’t yet know how we’ll do it. If you’vegot a great idea, I’m all ears.

• Commission on Accreditation of Medical TransportSystems standards are fairly specific on which mis-sions that medical directors are expected to reviewfor appropriateness. They are, however, quite vaguewith regard to expectations regarding feedback andeducation that we are supposed to provide to ourcustomers in this area. The standards need to be spe-cific and quantifiable (ie, “There is evidence of directfeedback from the medical director to the requestingagents on X percent of CCTM missions, at least halfof which must be missions deemed by the medicaldirector to involve inappropriate utilization.”).

• We need to be transparent with regard to what wecost. Most of the folks that call us, I believe, have noidea. We can pretty easily let them know.

• So many critically ill patients can be cared for justas awesomely in an ambulance as they can in a hel-icopter. If states would recognize critical careground transport as unique from advanced lifesupport across the board, and payors would betterreimburse for it, many regions that have only ahammer would expand their toolbox, creating lessneed for excessive use of hammers.

• There is no certificate of need (CON) process for hel-icopters in most states. It goes without saying thatthis situation has created an uber-competitive marketthat incentivizes good people to encourage helicopteroverutilization, because our margin depends on vol-ume. States need to have the right to create a CONprocess for helicopters if they so choose.

• Mechanism of injury alone should not be reasonenough to request a helicopter. For trauma patients,we need to focus on physiologic criteria.

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I believe that doing utilization review right, locally, isthe hardest part of my job as a CCTM medical director.Changing overutilization patterns nationally will be evenharder. AMPA is addressing the challenge head-on with ajoint task force with American College of EmergencyPhysicians, American Academy of Emergency Medicine,and National Association of EMS Physicians, admirably

led by Dr. Doug Floccare, which has already authored theposition statement (available on ampa.org) “Appropriateand Safe Utilization of HEMS.” An accompanying whitepaper, paving the path to national utilization guidelines, isforthcoming. Our patients desperately need us to do theright thing, even though it’s so damn hard.

William Hinckley, President