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Journal of the Royal Society of Medicine Volume 84 April 1991
Report
Medical helicopter systems - recommended minimum standards for patient management Keywords: audit; helicopter; monitoring; training-, transport
Working party composition Dr A Bristow Barts Careflight (Chairman) Dr P Baskett Association of Anaesthetists Dr M Dalton London Hospital Helicopter Service Mr P Ediss Department of Health Capt I Evans Barts Careflight.Dr R Harris British Paediatric Association Mr M Leighton Civil Aviation. Authority Dr L Martin Department of Health Dr I Perry British Helicopter Advisory Board Mr G Roberts Chief Ambulance Officer, Essex Ambulance Service Mr J Scurr Royal College of Surgeons Mr D Skinner British Association of Accident & Emergency Medicine Capt J Strong Civil Aviation Authority Dr N Toff BAMPA Mr A Wilson London Hospital Helicopter Service General The following recommendations are designed to provide a minimum acceptable standard of safety for patients, staff and the community in respect of medical helicopter operations. These recommendations should be read in conjunction with the guidelines set down by the Civil Aviation Authority ('Requirements document/Helicopter emergency medical services'). Definitions Medical helicopter systems may be involved in primary or secondary transfers. A primary transfer is a flight by a helicopter, the purpose of which is t facilitate emergency medical treatment of one or more persons by carrying medical personnel and/or medical supplies to an emergency site or carrying one or more persons requiring emergency medical treatment toa treatment site. A secondary transfer is the movement of a patient, normally between hospitals, that does not fulfil these criteria. A secondary transfer may still need to be undertaken with a degree of urgency. Organization All equipment should be physically checked by. medical, nursing or paramedical personnxel at the start of their period on call, and no mission should commence until this has been done. The acceptance of a mission should be undertaken separately by both the aviation and medical side. Both sides should have the absolute right to refuse a mission. The doctor or senior paramedic retains absolute right to terminate a mission on medical grounds, and the pilot on aviation grounds.
Except for evacuation from the scene of injury or illness, the medical person in charge of the mission should receive a medical briefing prior to starting the flight' The decision to transfer a patient between hospitals should be that of the responsible consultant in the sending hospital, made following discussion with his colleague in the receiving hospital. The helicopter medical" staff should accept this decision and limit their consideration to whether they have the facilities to undertake the transfer. A formal' method of despatching for all primary systems must be established with the local ambulance control. A high quality of despatcher is paramount. To avoid the hazardous consequences of a 'free for all' competition between helicopter operators pursuing work' produced by accidents,- the geographical areas of responsibility should be clearly defined. Helicopter operators will establish contracts to reflect this. This will not preclude back-up cover by another scheme provided a suitable priority call out 'system is established. All staff should wear suitable clothing when flying. The minimum would be overalls and sensible footwear. There should be aduate procedu for dealing with infected cases and guarding against cross infection.' The escorting team should accompany the patient throughout the transfer, including any part of the transfer within a hospital or by ambulance. The escorting team -should receive a formal hand over- of each patient together with all notes and investigations for all inter hospital transfers. They should hand over all patients to a named doctor at the receiving hospital. There should be adequate insurance cover for medical, nursing and paramedical staff to provide for death or injury in the event of an aircraft accident.
ItVeUIiuI UIreVIor A named medical practitioner ould be involve in each medical helicopter system. He or she should be either a consultant or equivalent, andhave experience of such systems. His roles should be defined, and include: Approval of selection of maedical, nursing and paramedical staff Approval of medical equipment Approval of drugs and disposables Approval of medical management protocols Designation of destination hospitals He should supervise medical taining, clinical practice
and audit, and should have designated sessions or periodsof time for this work. He will normally be the consultant responsible for the patient whilst outside a hospital. There should be a named deputy medical director to provide cover in the absence ofthe medical director. Doctors All doctors should be from a specialty relevant to the patients carried and of adequate seniority (registrar status or above).
0141-0768/91/
040242-03/$02.00/0 © 1991 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 84 April 1991
All doctors who transport patients in helicopters should receive specific trainingthat;includes relevant aspects of aviation medicine, resuscitation, loading and unloading, and safety aspects of the aircraft. These aspects should be formally reexamined every 13 months. All doctors should be responsible to the consultant involved in the scheme. There should be a mehanism for continual cover and periodic audit.
Nursing and paramedical staff Nurses and paramedical staff on medical helicopter systems should be of adequate seniority and experience. They should undergo training and e amintion in the same areas as the medical st-a. In terms of medical care, they should be responsible to the same named medical practitioner as the doctors. If senior nursing or ambulance personnel are involved in the project, they too should be named.
Equipment The equipment should be selected for the types of -patients that are to be carried.- Nopatient should be acoepted if, in the opinion ofthe accompanying doctor, there is insufficient equipment. The installation of all equipment must be approved by the CAA and the carriage of other equipment should be exceptional. In such cases,- the CAA should be consulted -whenever possible. Only 'installed' equipment can be so cleared. The minimum acceptable equipment is: ECG Pulse oximetry Blood-pressure measurement Positive pressure ventilation
Defibrillator Oxygen Suction
Facilities for endotracheal intubation Intravenous fluid administration Appropriate drugs for resuscitation Pilots The transfer of a patient between hospitals should The relevance of their flying techniques together with i nunloading in l n ad uonly be undertaken where the level of monitoring is "m 1oafrequt their frequent involvemienttheir dnnggand make t for pilots to have aa basic under - ofMonitoring an order thatshould does notbeplace the patient in jeopardy. makes itidesirable bedside/ from continuous basing proble ofithe standing of the clinical problems of transporting roadside to bedside, so all relevant equipment should patients. All schemes should have a mechanism be easily removable from the aircraft. whereby pilots are exposed to relevant ;hospital There should be adequate oygen and power to departments and receive basic traiung in lifting for the use ofALL equipment throughout the Of transport. techniques and the meclconsequencestehiusadtemdclallow transfer, as well as for a reasonable-margin of safety. There should be a system for maintenance and Staffing procedures servicing of equipment All medical, paramedical and nursing personnel should be rostered to the system in advance, and have Neonatal transfers All receiving hospitals should have -designated no other conflicting duties for their period on call. At least one medical, nursing or paramedical member- level I neonatal intensive care cots. of staff is required for each patient. No interhospital Neonatal transfers should be organized between referring consultant paediatrician, receiving consulttransfers should be undertaken without a doctor. ant neonatal paediatrician or paediatric cardiologist etc, and the medical director of the transferring Training helicopter system. Medical directors lacking the All doctors, nurses and paramedics should receive necessary neonatal expertise and experience may training under each of the following items that could wish to appoint a neonatal transport adviser. apply to their operation: The minimum accompanying medical team should Aviation medicine Pathophysiology of movement consist of one doctor who should be a neonatal Attitude and acceleration paediatrician or paediatric anaesthetist (either of Temperature and vibration whom should have training and expertise of helicopter Monitoring Altitude transport systems) and one nurse who should be either a neonatal nurse with experience of helicopter ACLS Resuscitation transport systems or a flight nursing sister with ATLS neonatal nursing experience, or equivalent. Paediatric The minimum acceptable equipment is: Loading/unloading Theory and practice Transp;ort incubator with internal, lighting Setting up the helicopter Safety aspects Neonatal ventilator CAA regulations Temperature monitor Evaciation diill with and Pulse oximeter or without patient Umbilical artery catheter oxygen monitor Overwvater drill Non invasive blood pressure monitoring Medical General ITU ECG monitoring Burn managementSpinal injury management Suction Oxygen Neonatal ITU Air supply Surgery General medicine Syrinie pump or infusion pump Facilities for endotracheal intubation Anaesthesia To some extent previous experience will dictate the 1Drugs- fot resuscitation aid continuing management as appropriate type of training required in post, but all appointees All equipment should.bean -integral part of, or require experience in the, early management of trauma or other life-threatening problems with which fiurmly affixed to thetransort incubator. Installationof al equipment must- be appwed bythe CAA. they may be presented.
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Journal of the Royal Society of Medicine Volume 84 April 1991
All neonates should have intravenous access in situ prior to transfer. All other minimum standards applicable to helicopter transfer of paediatric and adult patients should be met in neonatal cases. Medical directors should draw up protocols for specific clinical situations such as cyanotic congenital heart disease, diaphragmatic hernia, pneumothorax. Protocols There should be a written protocol book. The headings should include the following: Introduction Definitions Personnel Daily set up mechanism Coordination and accepting missions Primary missions Secondary transfers Medical protocols Standing orders Communications Major disasters Inventories Hospital details Check lists Audit A permanent clinical record sheet should be kept for each patient, and this should be securely stored for a minimum period of 7 years. In view of the small numbers of patients transferred by helicopter, data should be freely shared between schemes subject to normal restraints of confidentiality. The following is the minimum data that should normally be recorded: Patient information (name, age, sex) Clinical information (history, investigations, examination) Indication for call Timings Pick up and disposal points Accident scene details
Letters to the Editor Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 300 words and should be typed double-spaced.
Myocarditis - a controversial disease I read with interest the editorial on myocarditis by Peters and Poole-Wilson (January 1991 JRSM, p 1). It was a comprehensive review of a rather controversial subject. Unfortunately they left out sarcoid myocarditis, an important entity well described by their compatriot H A Fleming'. Sarcoid myocarditis is commoner than recognized clinically2. It is a difficult diagnosis to make even at autopsy, unless thorough sampling included the upper portion of the ventricular septum and the conduction system3. During life myocardial biopsy has been relied upon almost exclusively for making a definitive
Treatment and procedures in transit Clinical parameters every 15 minutes in transit Complications Follow up Trauma, sickness or APACHE II scores The medical data should be audited by the medical director, who should also debrief the team following a proportion of flights, either by means of individual debriefings or regular audit meetings. Any audit that is in progress elsewhere in the health authority should apply to this scheme if appropriate.
Major disasters Each helicopter scheme should be part of its region's major disaster plan. Confidentiality The importance of medical confidentiality should be recognized by everyone involved in a system. The level of medical confidentiality should be that laid down in HC (FP) (87)9. Any research should be subject to approval by the appropriate ethical committee. Appendices The following documents may be of assistance to those involved in medical helicopter systems: Guide lines for requesting HEMS (available from The London Hospital Department of Accident & Emergency Medicine) Aviation medicine handbook for patient transfer by air (available from Dr I Perry, British Helicopter Advisory Board). Careflight - information for senior medical staff (available from Department of Anaesthetics, St Bartholomew's Hospital). A Bristow Department of Anaesthetics St Bartholomew's Hospital West Smithfield, London EClA 7BE
diagnosis of sarcoid myocarditis. Its value, however, is rather limited, because of the patchy distribution of the disease. Furthermore, a deliberate attempt is usually made to avoid both the upper septum and the conduction system during myocardial biopsy2. Myocardial biopsy in the diagnosis of myocarditis is a tricky matter. Both false positives and false negatives have been reported4. Whereas sampling errors account for most false-negative diagnoses, falsepositive diagnoses may result from misinterpretation of non-inflammatory cells as lymphocytes and from clinical bias56. Whereas only positive findings are regarded as diagnostic, negative findings do not exclude the possibility that myocarditis exists elsewhere beyond the reach of the bioptome. Because of the high incidence of sudden death7, all patients with myocardial sarcoidosis should be aggressively treated with corticosteroids and closely monitored8. T 0 CHENG
Department of Medicine Division of Cardiology The George Washington University Medical Center 2150 Pennsylvania Ave, NW, Washington DC 20037, USA
Journal of the Royal Society of Medicine Volume 84 April 1991
Report
Medical helicopter systems - recommended minimum standards for patient management Keywords: audit; helicopter; monitoring; training-, transport
Working party composition Dr A Bristow Barts Careflight (Chairman) Dr P Baskett Association of Anaesthetists Dr M Dalton London Hospital Helicopter Service Mr P Ediss Department of Health Capt I Evans Barts Careflight.Dr R Harris British Paediatric Association Mr M Leighton Civil Aviation. Authority Dr L Martin Department of Health Dr I Perry British Helicopter Advisory Board Mr G Roberts Chief Ambulance Officer, Essex Ambulance Service Mr J Scurr Royal College of Surgeons Mr D Skinner British Association of Accident & Emergency Medicine Capt J Strong Civil Aviation Authority Dr N Toff BAMPA Mr A Wilson London Hospital Helicopter Service General The following recommendations are designed to provide a minimum acceptable standard of safety for patients, staff and the community in respect of medical helicopter operations. These recommendations should be read in conjunction with the guidelines set down by the Civil Aviation Authority ('Requirements document/Helicopter emergency medical services'). Definitions Medical helicopter systems may be involved in primary or secondary transfers. A primary transfer is a flight by a helicopter, the purpose of which is t facilitate emergency medical treatment of one or more persons by carrying medical personnel and/or medical supplies to an emergency site or carrying one or more persons requiring emergency medical treatment toa treatment site. A secondary transfer is the movement of a patient, normally between hospitals, that does not fulfil these criteria. A secondary transfer may still need to be undertaken with a degree of urgency. Organization All equipment should be physically checked by. medical, nursing or paramedical personnxel at the start of their period on call, and no mission should commence until this has been done. The acceptance of a mission should be undertaken separately by both the aviation and medical side. Both sides should have the absolute right to refuse a mission. The doctor or senior paramedic retains absolute right to terminate a mission on medical grounds, and the pilot on aviation grounds.
Except for evacuation from the scene of injury or illness, the medical person in charge of the mission should receive a medical briefing prior to starting the flight' The decision to transfer a patient between hospitals should be that of the responsible consultant in the sending hospital, made following discussion with his colleague in the receiving hospital. The helicopter medical" staff should accept this decision and limit their consideration to whether they have the facilities to undertake the transfer. A formal' method of despatching for all primary systems must be established with the local ambulance control. A high quality of despatcher is paramount. To avoid the hazardous consequences of a 'free for all' competition between helicopter operators pursuing work' produced by accidents,- the geographical areas of responsibility should be clearly defined. Helicopter operators will establish contracts to reflect this. This will not preclude back-up cover by another scheme provided a suitable priority call out 'system is established. All staff should wear suitable clothing when flying. The minimum would be overalls and sensible footwear. There should be aduate procedu for dealing with infected cases and guarding against cross infection.' The escorting team should accompany the patient throughout the transfer, including any part of the transfer within a hospital or by ambulance. The escorting team -should receive a formal hand over- of each patient together with all notes and investigations for all inter hospital transfers. They should hand over all patients to a named doctor at the receiving hospital. There should be adequate insurance cover for medical, nursing and paramedical staff to provide for death or injury in the event of an aircraft accident.
ItVeUIiuI UIreVIor A named medical practitioner ould be involve in each medical helicopter system. He or she should be either a consultant or equivalent, andhave experience of such systems. His roles should be defined, and include: Approval of selection of maedical, nursing and paramedical staff Approval of medical equipment Approval of drugs and disposables Approval of medical management protocols Designation of destination hospitals He should supervise medical taining, clinical practice
and audit, and should have designated sessions or periodsof time for this work. He will normally be the consultant responsible for the patient whilst outside a hospital. There should be a named deputy medical director to provide cover in the absence ofthe medical director. Doctors All doctors should be from a specialty relevant to the patients carried and of adequate seniority (registrar status or above).
0141-0768/91/
040242-03/$02.00/0 © 1991 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 84 April 1991
All doctors who transport patients in helicopters should receive specific trainingthat;includes relevant aspects of aviation medicine, resuscitation, loading and unloading, and safety aspects of the aircraft. These aspects should be formally reexamined every 13 months. All doctors should be responsible to the consultant involved in the scheme. There should be a mehanism for continual cover and periodic audit.
Nursing and paramedical staff Nurses and paramedical staff on medical helicopter systems should be of adequate seniority and experience. They should undergo training and e amintion in the same areas as the medical st-a. In terms of medical care, they should be responsible to the same named medical practitioner as the doctors. If senior nursing or ambulance personnel are involved in the project, they too should be named.
Equipment The equipment should be selected for the types of -patients that are to be carried.- Nopatient should be acoepted if, in the opinion ofthe accompanying doctor, there is insufficient equipment. The installation of all equipment must be approved by the CAA and the carriage of other equipment should be exceptional. In such cases,- the CAA should be consulted -whenever possible. Only 'installed' equipment can be so cleared. The minimum acceptable equipment is: ECG Pulse oximetry Blood-pressure measurement Positive pressure ventilation
Defibrillator Oxygen Suction
Facilities for endotracheal intubation Intravenous fluid administration Appropriate drugs for resuscitation Pilots The transfer of a patient between hospitals should The relevance of their flying techniques together with i nunloading in l n ad uonly be undertaken where the level of monitoring is "m 1oafrequt their frequent involvemienttheir dnnggand make t for pilots to have aa basic under - ofMonitoring an order thatshould does notbeplace the patient in jeopardy. makes itidesirable bedside/ from continuous basing proble ofithe standing of the clinical problems of transporting roadside to bedside, so all relevant equipment should patients. All schemes should have a mechanism be easily removable from the aircraft. whereby pilots are exposed to relevant ;hospital There should be adequate oygen and power to departments and receive basic traiung in lifting for the use ofALL equipment throughout the Of transport. techniques and the meclconsequencestehiusadtemdclallow transfer, as well as for a reasonable-margin of safety. There should be a system for maintenance and Staffing procedures servicing of equipment All medical, paramedical and nursing personnel should be rostered to the system in advance, and have Neonatal transfers All receiving hospitals should have -designated no other conflicting duties for their period on call. At least one medical, nursing or paramedical member- level I neonatal intensive care cots. of staff is required for each patient. No interhospital Neonatal transfers should be organized between referring consultant paediatrician, receiving consulttransfers should be undertaken without a doctor. ant neonatal paediatrician or paediatric cardiologist etc, and the medical director of the transferring Training helicopter system. Medical directors lacking the All doctors, nurses and paramedics should receive necessary neonatal expertise and experience may training under each of the following items that could wish to appoint a neonatal transport adviser. apply to their operation: The minimum accompanying medical team should Aviation medicine Pathophysiology of movement consist of one doctor who should be a neonatal Attitude and acceleration paediatrician or paediatric anaesthetist (either of Temperature and vibration whom should have training and expertise of helicopter Monitoring Altitude transport systems) and one nurse who should be either a neonatal nurse with experience of helicopter ACLS Resuscitation transport systems or a flight nursing sister with ATLS neonatal nursing experience, or equivalent. Paediatric The minimum acceptable equipment is: Loading/unloading Theory and practice Transp;ort incubator with internal, lighting Setting up the helicopter Safety aspects Neonatal ventilator CAA regulations Temperature monitor Evaciation diill with and Pulse oximeter or without patient Umbilical artery catheter oxygen monitor Overwvater drill Non invasive blood pressure monitoring Medical General ITU ECG monitoring Burn managementSpinal injury management Suction Oxygen Neonatal ITU Air supply Surgery General medicine Syrinie pump or infusion pump Facilities for endotracheal intubation Anaesthesia To some extent previous experience will dictate the 1Drugs- fot resuscitation aid continuing management as appropriate type of training required in post, but all appointees All equipment should.bean -integral part of, or require experience in the, early management of trauma or other life-threatening problems with which fiurmly affixed to thetransort incubator. Installationof al equipment must- be appwed bythe CAA. they may be presented.
243
244
Journal of the Royal Society of Medicine Volume 84 April 1991
All neonates should have intravenous access in situ prior to transfer. All other minimum standards applicable to helicopter transfer of paediatric and adult patients should be met in neonatal cases. Medical directors should draw up protocols for specific clinical situations such as cyanotic congenital heart disease, diaphragmatic hernia, pneumothorax. Protocols There should be a written protocol book. The headings should include the following: Introduction Definitions Personnel Daily set up mechanism Coordination and accepting missions Primary missions Secondary transfers Medical protocols Standing orders Communications Major disasters Inventories Hospital details Check lists Audit A permanent clinical record sheet should be kept for each patient, and this should be securely stored for a minimum period of 7 years. In view of the small numbers of patients transferred by helicopter, data should be freely shared between schemes subject to normal restraints of confidentiality. The following is the minimum data that should normally be recorded: Patient information (name, age, sex) Clinical information (history, investigations, examination) Indication for call Timings Pick up and disposal points Accident scene details
Letters to the Editor Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 300 words and should be typed double-spaced.
Myocarditis - a controversial disease I read with interest the editorial on myocarditis by Peters and Poole-Wilson (January 1991 JRSM, p 1). It was a comprehensive review of a rather controversial subject. Unfortunately they left out sarcoid myocarditis, an important entity well described by their compatriot H A Fleming'. Sarcoid myocarditis is commoner than recognized clinically2. It is a difficult diagnosis to make even at autopsy, unless thorough sampling included the upper portion of the ventricular septum and the conduction system3. During life myocardial biopsy has been relied upon almost exclusively for making a definitive
Treatment and procedures in transit Clinical parameters every 15 minutes in transit Complications Follow up Trauma, sickness or APACHE II scores The medical data should be audited by the medical director, who should also debrief the team following a proportion of flights, either by means of individual debriefings or regular audit meetings. Any audit that is in progress elsewhere in the health authority should apply to this scheme if appropriate.
Major disasters Each helicopter scheme should be part of its region's major disaster plan. Confidentiality The importance of medical confidentiality should be recognized by everyone involved in a system. The level of medical confidentiality should be that laid down in HC (FP) (87)9. Any research should be subject to approval by the appropriate ethical committee. Appendices The following documents may be of assistance to those involved in medical helicopter systems: Guide lines for requesting HEMS (available from The London Hospital Department of Accident & Emergency Medicine) Aviation medicine handbook for patient transfer by air (available from Dr I Perry, British Helicopter Advisory Board). Careflight - information for senior medical staff (available from Department of Anaesthetics, St Bartholomew's Hospital). A Bristow Department of Anaesthetics St Bartholomew's Hospital West Smithfield, London EClA 7BE
diagnosis of sarcoid myocarditis. Its value, however, is rather limited, because of the patchy distribution of the disease. Furthermore, a deliberate attempt is usually made to avoid both the upper septum and the conduction system during myocardial biopsy2. Myocardial biopsy in the diagnosis of myocarditis is a tricky matter. Both false positives and false negatives have been reported4. Whereas sampling errors account for most false-negative diagnoses, falsepositive diagnoses may result from misinterpretation of non-inflammatory cells as lymphocytes and from clinical bias56. Whereas only positive findings are regarded as diagnostic, negative findings do not exclude the possibility that myocarditis exists elsewhere beyond the reach of the bioptome. Because of the high incidence of sudden death7, all patients with myocardial sarcoidosis should be aggressively treated with corticosteroids and closely monitored8. T 0 CHENG
Department of Medicine Division of Cardiology The George Washington University Medical Center 2150 Pennsylvania Ave, NW, Washington DC 20037, USA
