- Email: [email protected]
Claims cost management for medical repatriation: ADAC insurance companies
missions. In 24,% of this total, the patient suffered injury, and in 41% acute cardiovascular disease. 12% were pediatric patients. 141 patients were dead on arrival at the service or died during prehospital treatment. Further, 58 patients died after arrival at the hospital. Reviews for 357 patients with potential clinical benefit were assessed by the expert panel. The expert panel agreed that, in 80 patients (32 ground missions and 48 air missions), there were life-years gained, 10 patients being pediatric. The median age of these 80 patients was 56 years and 61% were men. 15% were injured patients, and 60% had cardiovascular disease. The panel estimated a total of 640 life-years gained. The life-years gained in 45 of the 80 patients represented 95% of the total life-years gained, and 10 patients represented more than 50% of the total life-years gained. In these 10 patients 4 were severely injured, 3 had cardiac arrest due to arrhythmia, 2 had respiratory arrest due to acute lung disease, and one suffered respiratory arrest due to prolonged general seizures. The clinical benefit was attributed to advanced treatment by the anesthesiologist otherwise not available by local general practitioners or ambulance crews. Conclusion: The number of patients with a clinical benefit in terms of life-years gained was relatively low (9% of the total patient population), but the number of life-years gained was high. The benefit was due to advanced prehospital treatment performed by an anesthesiologist. Our study supports the view that an anesthesiologist-manned air and ground ambulance service has a positive clinical impact on critically ill and injured patients. Could Ambulance Helicopters Be Used More Appropriately? RagnarHotvedt, MD, Institute of CommunityMedicine, University of Tromsfl,Tromsp,NorwayN-9037 Purpose: We estimated the health outcome for patients from a
helicopter program during a 2-year period. We also assessed the health benefits from shortening the response time and to what extent the decisive medical interventions carried out by the flight anesthesiologist could have been managed by a general practitioner (GP). Methods: 370 patients (age O-80 years) transported by helicopter from rural areas to the University Hospital of Tromse were included. Professional assessments of health outcome and management of interventions were done by expert panels using a modified Delphi technique. Results: The most common diagnosis for patients under 15 years was infection (49%); in older patients, cardiovascular disease dominated (50%). 41 patients (11% of the total 370 transported) were deemed to gain in total 290 life-years. 96% of the total life-year gain was achieved in nine patients, six of whom were younger than 7. For patients with cardiovascular problems, the gain was estimated to be 0.04 life-years/patient. A 15minute shorter response time would have increased the total health benefit of the helicopter program by 6%. The helicopter doctor carried out decisive interventions in 29 patients. The panel assessed that a GP could have managed these in 17 (59%) patients. Conclusion: Routine use of helicopters to transfer patients with cardiovascular disease is questionable. For a rural helicopter program serving a nonselected scattered population, the health benefit from a shorter response time is small. In such a program, GPs can manage a majority of lifesaving missions, but the lack of a flight anesthesiologist may imply substantial health losses in a few patients, 148
Helicopter Emergency Medical Services in Finland Matii Martjkainen, MD, Oulu UniversityHospital,00/u Rescue HelicopterSEPE,Kajaanintie 52, 90220 Oulu,Finland
The main principle of modern emergency medical services is to transport the treatment facilities promptly to the sick or injured patient. In Finland, this traditionally has been done by using ground vehicles. The large size of the country (length over 1100 km, area 337,030 km>), the sparse population (approx. 5 million), and the difficult terrain (mires, more than 180,000 lakes, more than 170,000 islands) often make it difficult or even impossible to reach the patient with a ground vehicle. Helicopters were first used experimentally in emergency medical services as early as the 196Os, but they were introduced into regular use only in the early 1990s. At the present, Finland has two full-time medical helicopters (Medi-Heli), which are operating in and around Helsinki and Turku in southern Finland. Apart from Medi-Heli, there are two multipurpose rescue helicopters (SEPE in Oulu and ILMARI in Varkaus). One of these, the Oulu rescue helicopter SEPE,also provides full-time medical services, while ILMARI is paramedic-based. During recent years, there also have been other experimental rescue helicopter services, but none of them has been adopted into full-time use. The helicopters of the frontier guard and the army also have been used for medical purposes, but their alarm-to-departure delay is too long for emergency medical services. An emergency helicopter must be ready to start within a few minutes. Helicopter service is a part of a gradated system of emergency medical services, which efficiently supplements the ground-operated units by bringing the emergency physician and services quickly to the acutely ill or injured patient. After that, it is often possible to use a ground vehicle to transport the patient to a hospital or other medical unit. The Finnish government does not directly contribute to the cost of rescue helicopters, which have been financed so far by various associations. The funds have.been raised by local sponsoring groups, which acquire funding from the Finnish Slot Machine Association (the main source of funding), the Flight Rescue Centre, the Social Insurance Institution, or insurance companies. Requests for funding also have been presented to municipalities but without much success so far. The support organizations raise a large part of the money from voluntary sources and by selling their own products. The Finnish Ministry of Social Affairs and Health commented on the status of rescue and medical service helicopters in their reports of 1995 and 1997. According to them, Finland would need 5 or 6 full-time rescue helicopters. Of these, 1 or 2 could be used exclusivelyfor medical purposes in the densely populated parts of southern Finland, while the others could be multipurpose helicopters serving the more sparsely populated parts of the country. The latter could be used for a variety of purposes to improve basic safety in society. Apart from emergency medical services, these purposes include extinguishing forest fires, searching for lost people with the help of a thermocamera, and sea rescue operations. The helicopters should be based at the five university hospitals, which would guarantee high-quality aftercare for victims. Claims Cost Management for Medical Repatriation: ADACInsurance Companies WalterHolzhammer,ADAGSchutzbriefUersjcherungs-AG,Am Westpark8, Miinchen, Germany81373 Purpose: In addition to the activities in the field of primary mis-
sions of the ADAC Airmed Services, over 10,000 patients are transported annually on behalf of the ADAC insurance compaOctober-December
2000
19:4
Air Medical
Journal
nies, some 4200 of which by ambulance aircraft or airliner. The total cost of medical repatriation amounted to more than DM 50 million with DM 42.5 million alone for patients brought home by air. In order to finance such services, an effective cost management is absolutely essential. Methods: The following measures should be the basis of effective medical repatriation cost management (outline): Precise medical analysis of transport requirements: commercially trained physicians answering calls, availability of medical network for local verification of indication, dispatch of physician to hospital for local verification, and ongoing optimization of the call center Selection of suitable transport mode in terms of medical and commercial aspects: determination of ground transportation/airliner/air ambulance, selection of suitable aircraft (rotorcraft or various jets) based on mission profile (medical requirements, route, and distance), adaptation of fleet to changing conditions, chartering additional bigger aircraft in the event of disasters, definition of interface special flight/stretcher depending on carrier Determination of transportation schedule in terms of costefficiency: combined transportation, flexible handling of waiting times, maximum use of existing transportation capacity, consistent mission schedule, minimization of alert takeoffs, comparison of hospital costs/transportation costs (particularly USA, Japan) Arrangements ensuring economic efficiency: purchase/operation of own air transport company (Aero Dienst), ensuring cost price operation, surplus capacity use/additional income through executive or charter operations; high service readiness of fleet ensured by own maintenance operation (overnight maintenance) and thus high utilization; medical networks in Germany to minimize flight days and travel costs; international cooperations for volume synergism; network (“patient exchange”) on the Internet; advance booking of certain airline routes to ensure transport capacity, agreement of special conditions with airlines; setting up own IATA agency for airline booking and generating commissions; restrictive entitlement verification (exclusions, such as gross negligence) Installation of valid up-to-date reporting: ongoing review of cost development (per patient, transport mode, country of claim) Results: Through efficient cost management, the ADAC insurance companies have saved several million DM in medical repatriation over the last few years. Conclusion: Medical repatriation from all over the world is an integral part of the security scheme for tourists and business travelers. In view of the constantly increasing use of this benefit due to a booming tourism industry, effective claims cost management is a vital requirement Report about the Cooperation between Rescue Helicopter Station “Christoph One” and the Police Helicopter Squadron of Bavaria Bernd Liiffler, MD, M. Ku/beck,Luftrettungsstation Christoph, SttidtischesKrankenhaus,Miinchen, Germany,Sanatoriumsplatz 2, 8 1545 Miinchen, Germany
This cooperation has existed since 1991 and includes the following items: Emergency rescue training of police officers * Regularlyscheduledflight of the police officerson ChristophOne Use of the standard configuration of the police helicopters, especially rescue winch, emergency case, rescue stretcher l
l
Air Medical
Journal
19:4
October-December
2000
l
Professional first aid and call for the right rescue means by the police officers Twice a year common winch and mountain rescue training Additional assistance by Police Helicopters: Supply of a pediatrician trained in baby rescue Equipment and rescue staff transportation at disasters Primary transportation of seriously injured people, accompanied by an emergency doctor Secondary transportation of seriously injured people (accompanied by ED) under IFR conditions Searches for missing people by using the FLIR (forward looking infrared) camera Night rescue missions in combination with FLIR camera and night vision goggles All the actions of cooperation are in agreement with the Bavarian Police Law. Due to the necessary “special equipment,” night rescue missions in the near and middle future will be possible only by using police helicopters. The cooperation has proved successful and is recommended to other rescue and police helicopter units. l
TeleTriage-A Tool to Improve Air Medical Retrieval? Andrew Berry,MD, NETS,P.O.Box563, Wentworthville,NSW, Australia2145 Purpose: Changes to the organization and pediatric retrieval
services in 1995 included the introduction of a single statewide service and a “single phone call” system. We describe the features of a model in which clinical call processing by conference call is used to triage and support referring doctors prior to and during critical care transportation. Methods: Since it was agreed to amalgamate several retrieval services for pediatrics in the state of NSW, trends in calling pattern and outcome have been monitored. All calls are recorded on digital audiotape, a multi-part paper record is completed, and details are logged in an electronic database. Communications technology includes a digital PABX using 30 ISDN and 5 PSTN trunks for incoming and outgoing calls. A conference “bridge” permits an unlimited number of call participants (maximum determined by number of trunks) in up to 6 simultaneous conferences. The system is readily scalable. Conference participants connect by fixed phone, DECT, GSM, CDMA, or satellite. Staff rotate between retrieval team duties and clinical coordination. Results: The referring doctor is transferred to a “conference room.” The clinical coordinator contacts the duty retrieval consultant who dials directly into the “room” to act as “chairman.” As requested, the coordinator contacts and places other specialistsinto the “room.” The referring doctor explains the problem and discusses immediate management with a panel of specialistsin one phone call. Although the referring doctor is askedto state a destination preference, there is no discussion about “bed” availability. In parallel with this process, a retrievalteam is activated by helicopter, plane, or road ambulance. Further discussions are held in the conference room as required during dispatch and patient stabilization.The bed is organizedoff-line from the referring doctor. Since late 1996, total call numbers have risen from 1470 to 2252. The proportion of calls translating into retrievals has dropped from 83% to 71%, despite an increase in case severity. For preterm newborns, there has been a 45% fall in retrievals despite total births being stable. This is attributable to transfer in-utero being negotiated by clinical conference. Conclusion: Greater selectivity of patients for retrieval, improved telephone access to expert advice, and a reduction in 149
helicopter program during a 2-year period. We also assessed the health benefits from shortening the response time and to what extent the decisive medical interventions carried out by the flight anesthesiologist could have been managed by a general practitioner (GP). Methods: 370 patients (age O-80 years) transported by helicopter from rural areas to the University Hospital of Tromse were included. Professional assessments of health outcome and management of interventions were done by expert panels using a modified Delphi technique. Results: The most common diagnosis for patients under 15 years was infection (49%); in older patients, cardiovascular disease dominated (50%). 41 patients (11% of the total 370 transported) were deemed to gain in total 290 life-years. 96% of the total life-year gain was achieved in nine patients, six of whom were younger than 7. For patients with cardiovascular problems, the gain was estimated to be 0.04 life-years/patient. A 15minute shorter response time would have increased the total health benefit of the helicopter program by 6%. The helicopter doctor carried out decisive interventions in 29 patients. The panel assessed that a GP could have managed these in 17 (59%) patients. Conclusion: Routine use of helicopters to transfer patients with cardiovascular disease is questionable. For a rural helicopter program serving a nonselected scattered population, the health benefit from a shorter response time is small. In such a program, GPs can manage a majority of lifesaving missions, but the lack of a flight anesthesiologist may imply substantial health losses in a few patients, 148
Helicopter Emergency Medical Services in Finland Matii Martjkainen, MD, Oulu UniversityHospital,00/u Rescue HelicopterSEPE,Kajaanintie 52, 90220 Oulu,Finland
The main principle of modern emergency medical services is to transport the treatment facilities promptly to the sick or injured patient. In Finland, this traditionally has been done by using ground vehicles. The large size of the country (length over 1100 km, area 337,030 km>), the sparse population (approx. 5 million), and the difficult terrain (mires, more than 180,000 lakes, more than 170,000 islands) often make it difficult or even impossible to reach the patient with a ground vehicle. Helicopters were first used experimentally in emergency medical services as early as the 196Os, but they were introduced into regular use only in the early 1990s. At the present, Finland has two full-time medical helicopters (Medi-Heli), which are operating in and around Helsinki and Turku in southern Finland. Apart from Medi-Heli, there are two multipurpose rescue helicopters (SEPE in Oulu and ILMARI in Varkaus). One of these, the Oulu rescue helicopter SEPE,also provides full-time medical services, while ILMARI is paramedic-based. During recent years, there also have been other experimental rescue helicopter services, but none of them has been adopted into full-time use. The helicopters of the frontier guard and the army also have been used for medical purposes, but their alarm-to-departure delay is too long for emergency medical services. An emergency helicopter must be ready to start within a few minutes. Helicopter service is a part of a gradated system of emergency medical services, which efficiently supplements the ground-operated units by bringing the emergency physician and services quickly to the acutely ill or injured patient. After that, it is often possible to use a ground vehicle to transport the patient to a hospital or other medical unit. The Finnish government does not directly contribute to the cost of rescue helicopters, which have been financed so far by various associations. The funds have.been raised by local sponsoring groups, which acquire funding from the Finnish Slot Machine Association (the main source of funding), the Flight Rescue Centre, the Social Insurance Institution, or insurance companies. Requests for funding also have been presented to municipalities but without much success so far. The support organizations raise a large part of the money from voluntary sources and by selling their own products. The Finnish Ministry of Social Affairs and Health commented on the status of rescue and medical service helicopters in their reports of 1995 and 1997. According to them, Finland would need 5 or 6 full-time rescue helicopters. Of these, 1 or 2 could be used exclusivelyfor medical purposes in the densely populated parts of southern Finland, while the others could be multipurpose helicopters serving the more sparsely populated parts of the country. The latter could be used for a variety of purposes to improve basic safety in society. Apart from emergency medical services, these purposes include extinguishing forest fires, searching for lost people with the help of a thermocamera, and sea rescue operations. The helicopters should be based at the five university hospitals, which would guarantee high-quality aftercare for victims. Claims Cost Management for Medical Repatriation: ADACInsurance Companies WalterHolzhammer,ADAGSchutzbriefUersjcherungs-AG,Am Westpark8, Miinchen, Germany81373 Purpose: In addition to the activities in the field of primary mis-
sions of the ADAC Airmed Services, over 10,000 patients are transported annually on behalf of the ADAC insurance compaOctober-December
2000
19:4
Air Medical
Journal
nies, some 4200 of which by ambulance aircraft or airliner. The total cost of medical repatriation amounted to more than DM 50 million with DM 42.5 million alone for patients brought home by air. In order to finance such services, an effective cost management is absolutely essential. Methods: The following measures should be the basis of effective medical repatriation cost management (outline): Precise medical analysis of transport requirements: commercially trained physicians answering calls, availability of medical network for local verification of indication, dispatch of physician to hospital for local verification, and ongoing optimization of the call center Selection of suitable transport mode in terms of medical and commercial aspects: determination of ground transportation/airliner/air ambulance, selection of suitable aircraft (rotorcraft or various jets) based on mission profile (medical requirements, route, and distance), adaptation of fleet to changing conditions, chartering additional bigger aircraft in the event of disasters, definition of interface special flight/stretcher depending on carrier Determination of transportation schedule in terms of costefficiency: combined transportation, flexible handling of waiting times, maximum use of existing transportation capacity, consistent mission schedule, minimization of alert takeoffs, comparison of hospital costs/transportation costs (particularly USA, Japan) Arrangements ensuring economic efficiency: purchase/operation of own air transport company (Aero Dienst), ensuring cost price operation, surplus capacity use/additional income through executive or charter operations; high service readiness of fleet ensured by own maintenance operation (overnight maintenance) and thus high utilization; medical networks in Germany to minimize flight days and travel costs; international cooperations for volume synergism; network (“patient exchange”) on the Internet; advance booking of certain airline routes to ensure transport capacity, agreement of special conditions with airlines; setting up own IATA agency for airline booking and generating commissions; restrictive entitlement verification (exclusions, such as gross negligence) Installation of valid up-to-date reporting: ongoing review of cost development (per patient, transport mode, country of claim) Results: Through efficient cost management, the ADAC insurance companies have saved several million DM in medical repatriation over the last few years. Conclusion: Medical repatriation from all over the world is an integral part of the security scheme for tourists and business travelers. In view of the constantly increasing use of this benefit due to a booming tourism industry, effective claims cost management is a vital requirement Report about the Cooperation between Rescue Helicopter Station “Christoph One” and the Police Helicopter Squadron of Bavaria Bernd Liiffler, MD, M. Ku/beck,Luftrettungsstation Christoph, SttidtischesKrankenhaus,Miinchen, Germany,Sanatoriumsplatz 2, 8 1545 Miinchen, Germany
This cooperation has existed since 1991 and includes the following items: Emergency rescue training of police officers * Regularlyscheduledflight of the police officerson ChristophOne Use of the standard configuration of the police helicopters, especially rescue winch, emergency case, rescue stretcher l
l
Air Medical
Journal
19:4
October-December
2000
l
Professional first aid and call for the right rescue means by the police officers Twice a year common winch and mountain rescue training Additional assistance by Police Helicopters: Supply of a pediatrician trained in baby rescue Equipment and rescue staff transportation at disasters Primary transportation of seriously injured people, accompanied by an emergency doctor Secondary transportation of seriously injured people (accompanied by ED) under IFR conditions Searches for missing people by using the FLIR (forward looking infrared) camera Night rescue missions in combination with FLIR camera and night vision goggles All the actions of cooperation are in agreement with the Bavarian Police Law. Due to the necessary “special equipment,” night rescue missions in the near and middle future will be possible only by using police helicopters. The cooperation has proved successful and is recommended to other rescue and police helicopter units. l
TeleTriage-A Tool to Improve Air Medical Retrieval? Andrew Berry,MD, NETS,P.O.Box563, Wentworthville,NSW, Australia2145 Purpose: Changes to the organization and pediatric retrieval
services in 1995 included the introduction of a single statewide service and a “single phone call” system. We describe the features of a model in which clinical call processing by conference call is used to triage and support referring doctors prior to and during critical care transportation. Methods: Since it was agreed to amalgamate several retrieval services for pediatrics in the state of NSW, trends in calling pattern and outcome have been monitored. All calls are recorded on digital audiotape, a multi-part paper record is completed, and details are logged in an electronic database. Communications technology includes a digital PABX using 30 ISDN and 5 PSTN trunks for incoming and outgoing calls. A conference “bridge” permits an unlimited number of call participants (maximum determined by number of trunks) in up to 6 simultaneous conferences. The system is readily scalable. Conference participants connect by fixed phone, DECT, GSM, CDMA, or satellite. Staff rotate between retrieval team duties and clinical coordination. Results: The referring doctor is transferred to a “conference room.” The clinical coordinator contacts the duty retrieval consultant who dials directly into the “room” to act as “chairman.” As requested, the coordinator contacts and places other specialistsinto the “room.” The referring doctor explains the problem and discusses immediate management with a panel of specialistsin one phone call. Although the referring doctor is askedto state a destination preference, there is no discussion about “bed” availability. In parallel with this process, a retrievalteam is activated by helicopter, plane, or road ambulance. Further discussions are held in the conference room as required during dispatch and patient stabilization.The bed is organizedoff-line from the referring doctor. Since late 1996, total call numbers have risen from 1470 to 2252. The proportion of calls translating into retrievals has dropped from 83% to 71%, despite an increase in case severity. For preterm newborns, there has been a 45% fall in retrievals despite total births being stable. This is attributable to transfer in-utero being negotiated by clinical conference. Conclusion: Greater selectivity of patients for retrieval, improved telephone access to expert advice, and a reduction in 149