Steve Sittig, RRT, RRT-NPS, FAARC 2020-10-27 16:43:46
As a component of medical care today, medical transport occurs 24 hours a day, 7 days a week, 365 days a year. According to the Association of Air Medical Services (AAMS), around 550,000 patients are transported by air in the United States every year (https://aams.org, Accessed October 2, 2020). The bulk of these transports occur without any incidents, but unfortunately serious incidents and fatal accidents occur despite improving technology and the addition of night vision goggles and the Helicopter Terrain Avoidance Warning Systems. In 2008, the medical transport industry experienced its worst year of accidents, losing 29 flight crew colleagues. There has been spikes in accidents over the years since the record high in 2008. In 2010 there were 16 fatalities, and in 2013 there were 12 fatalities in emergency medical services helicopter operations.1 While ground ambulance accidents do not often receive the local or national news like helicopter accidents, they also have risk. On average, 2,600 people are injured in 1,500 ambulance accidents each year. Fatalities via ground transport occur most frequently in individuals occupying the passenger compartment who were not properly restrained.2
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While technology has improved, we still must acknowledge that human factors are a serious contributing factor in accidents and incidents.3 Being a part of the medical transport industry since 1986, I have observed where this human factor component may play a part. As humans, it is possible for us to fall into complacency, thinking we are so particularly good at what we do that everything is almost automatic. A transport program may go years without an incident or serious accident. Nevertheless, programs do realize that something may go seriously wrong at some point, so they have developed post-accident incident plans (PAIP) as a response to serious events. The PAIP may often remain on a shelf or on a computer for years before it is needed.
CAMTS
The Commission on Accreditation of Medical Transport Services (CAMTS) is non-profit organization dedicated to improving the quality and safety of medical transport services, with 21 current member transport specialist organizations, each of which sending one representative to the CAMTS Board of Directors. CAMTS was initially formed in 1991, and the AARC was one of the original members to join in 1991. The Commission offers a program of voluntary evaluation of compliance with accreditation standards demonstrating the ability to deliver service of a specific quality. The Commission believes that the two highest priorities of an air medical or ground inter-facility transport service are patient care and safety of the transport environment.
According to the CAMTS standards, a drill should be conducted semi-annually (one in daytime and one at night) to exercise the PAIP. This drill must include pilots, medical personnel, communications personnel, mechanics, and administrative personnel. Written debriefing and critique of PAIP drills must be shared with all staff members. A full drill must test each of the modes of transport (if the program has rotorwing, fixed wing, or surface capabilities, or a combination thereof) within a three-year time frame. This standard does not differentiate between an accident and an incident, but there is a difference. An accident is defined as an unexpected event that may result in property damage and does result in an injury or illness to an employee. An incident, on the other hand, is an unexpected event that may result in property damage but does not result in a significant injury or illness. An incident may also be called a close call, a near miss, or a near hit.
PAIP Testing and Assessment
A general rule for any emergency response plan is that it should be periodically tested and updated. This need is not different than a hospital conducting scheduled fire or severe weather drills. The PAIP must be part of the transport program’s protocol so that appropriate search and rescue efforts may be initiated in the event the aircraft or surface ambulance is overdue, radio communications cannot be established, or location can’t be verified. There must be a written plan to initiate assistance in the event the aircraft or ambulance is disabled. PAIPs should be easily identified, readily available, and understood by all program personnel; at a minimum, it should include a list of personnel (with current phone numbers) to notify in order of priority in the event of a program incident or accident (for air or surface). CAMTS has frequently noted as missing in program’s family assistance plan is the coordination of family needs immediately after the event, such as transportation, lodging, memorial/burial service, condolences, and initial grief support services or referrals for such services, usually through the appointment of a family liaison. Another frequent issue is that, while the program may have tested scenarios concerning aircraft and ground ambulances, they may overlook drills involving the communications center, such as an evacuation drill for a fire or an intruder while still maintaining operations.3
Drills should be planned so that only limited administration staff are aware of it before it is activated. The drill should involve a scenario as close to reality as possible to evaluate the process and the performance of staff. A detailed tracking of responses to scenario situations should be compiled to analyze and assess areas for improvement from any lessons learned. A “tabletop” drill is an informal training tool managed by a facilitator and is not a true assessment of emergency drill process. There is no hands-on practice or field work by the staff. It is basically a drill on paper without really testing the drill’s effectiveness. Once the actual drill is completed, a thorough analysis of any findings and lessons learned must be communicated to all staff. Any changes suggested in the analysis should then be implemented to improve the program’s PAIP. A more complete list of items to consider including in your program’s PAIP drills can be found in the CAMTS standards.4
A PAIP Drill Example
There are many ways to conduct a good PAIP drill, but one of the best I have seen was focused on the transport team’s actions during the drill. The drill began with a page out by rotor (i.e., a call for a helicopter) for a 6-year-old who nearly drowned about 40 miles away. The dispatched team was the pediatric critical care team, composed of the pediatric transport respiratory therapist (RT) and pediatric ICU registered nurse (RN), along with the pilot and the flight RN. Shortly after liftoff, the flight RN, who was also the safety officer, passed a note to the RT sitting in the helicopter’s airway seat. The note was the scenario drill and spelled out what was going to be tested from the pediatric transport team’s perspective. The scenario was this: assume that the helicopter had come to a running stop (i.e., a transition from forward flight to a landing on the surface when there may not be sufficient power available to sustain a hover) in an open field at the rescue site, and that the flight RN was dead and the pilot was incapacitated and unconscious. The pediatric critical care team was to exit the aircraft with the survival gear, shut the helicopter down, and call in for support.
As soon as the helicopter landed, the drill was activated. The first task was to shut down the helicopter engines, so the RT entered the cockpit and pulled the engine controls past the detent position to shut the engines down and slow the rotors. Next, the RT and the RN extracted the pilot and placed him a safe distance away from the helicopter. Then they took out the cell phone and handheld GPS from the survival bag and contacted the communications center with their location. Local law enforcement and emergency medical services were directed to find the team.
What was incredibly unique about this exercise was that it was videotaped for presentation to the entire program staff during the debrief session. As the debrief session was conducted, team members could easily imagine themselves in the scenario to see how they were expected to respond.
One can only hope your program’s PAIP will never need to be activated, but one never knows when it may be needed. It is important to know how your PAIP plan is structured and to test it with drills and analysis to be certain it is effective for the transport program and does as much as possible for the staff and their families.
REFERENCES
1 Aerossurance. US HEMS Accident Rates 2006-2015. Available at: http://aerossurance.com/helicopters/us-hems-accident-2006-2015. Accessed September 5, 2020.
2 de Anda HH, Moy HP. EMS ground transport safety. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2020.
3 Elliott M, Page K, Worrall-Carter L: Reason’s accident causation model: Application to adverse events in acute care. Contemporary Nurse ;43(1):22-8.22-28 | 2014
4 Commission on Accreditation of Medical Transport Services. CAMTS Eleventh Edition Accreditation Standards. Available at: https://www.camts.org/wp-content/uploads/2017/05/CAMTS-11th-Standards-DIGITAL-FREE.pdf. Accessed September 5, 2020.
about the author…
Steve Sittig, RRT, RRT-NPS, FAARC, currently serves as AARC representative to the Commission on Accreditation of Medical Transport (CAMTS) Board of Directors. He also serves on the CAMTS Executive Committee as secretary.
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