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CAMTS publishes fifth edition of accreditation standards
CAMTS Publishes Fifth Edition of Accreditation Standards Eileen Frazer
T
he Commission on Accreditation of Medical Transport Systems (CAMTS) published the fifth edition of its accreditation standards in January. The commission made some notable changes in format and context, and this article summarizes them. In our efforts to continually improve the format of this document, each standard in the general section is now identified as pertinent to rotor-wing, fixedwing, or ground transport. Also, the standards are boxed so readers can readily identify the main standard and its supporting criteria. An index also is included, with key words and phrases in alphabetical order, so readers can easily reference a topic with its standard and page number. In response to events on September 11, 2001, we included verbiage that a service’s participation in regional disaster planning should include “an integrated response to terrorist events.” The standard that stated carry-on baggage belonging to patients and passengers should be checked for hazardous materials seems to have gained more significance since the attacks. We also added a standard to encourage data collection. CAMTS tracks incidents and accidents (involving aircraft and ambulances) for trending purposes and to evaluate the need to create specific new standards or change existing standards. Air medical personnel are fairly consistent in reporting aviation accidents to the CONCERN Network (sponsored by the Air & Surface Transport Nurses Association), but incidents happen every day, and very few incident May-June 2002
reports are submitted. Ambulance accidents are even harder to track because no organization or government agency has assumed responsibility for tracking accidents involving ambulances. Research by Nadine Levick1 has shown a very dismal morbidity and mortality rate in ambulance crashes. A new standard in the fifth edition “encourages medical transport services to report incidents and accidents to CONCERN.”
Since 1991, when the first edition of the accreditation standards were published, the commission has defined critical care as “the transport of a patient whose condition warrants care commensurate with the scope of practice of a physician or RN.” This definition remains accurate, but we have added an alternate to the team composition standard for critical care. The rationale for this update is included with the standards, but briefly, we are attempting to rede31
fine the team best suited to care for a critical patient during transport based on acuity levels, personnel experience and training, and patient outcome studies rather than just on provider license. As explained in the rationale on page 64: “This change is in response to a national struggle with defining ‘critical care.’ Regional variances (in the U.S.) in training, licensure requirements and practice parameters for paramedics and nurses in particular result in confusion over which providers are best suited for critical care. These variances are even more pronounced outside U.S. borders. As a Board of Directors charged with the responsibility to provide strategic direction to the organization, it is important to redefine team composition and provide a framework to more accurately review the capabilities and limitations of the programs that we accredit.” As such, the alternative to current critical care team composition requires the service to define in detail: 1. Its mission with respect to each category of patient it transports 2. Patient acuity level requests accepted in each category of medical care 3. Patient acuity levels by volume 4. Background and clinical experience of medical personnel 5. Educational requirements for medical personnel (before hire and ongoing) 6. Outcome studies that demonstrate appropriate care is provided by the assigned team Another area we clarify is currency in nationally recognized courses, such as ATLS or equivalent, PALS or equivalent, etc. The “or equivalent” has always led to more questions. In the fifth edition, we added an education matrix that compares each national course and describes the didactic or skills needed to be considered equivalent. As stated by Reneé Holleran, author of this matrix and the ENA representative to the CAMTS board of directors, “No matter what course is chosen—a national course as listed (in the matrix) or a locally developed course—specific objectives, content outlines, and measurable outcomes need to be included in what is developed and must include primary and secondary assessment, advanced physiology, and advanced skills.” 32
Human patient simulators have become highly sophisticated during the past few years. As part of the initial and ongoing training requirements, we state, “Human patient simulators may be considered a substitute for human or cadaver experience requirements if the simulators are dynamic (able to reflect physiologic changes resulting from a performed procedure) and not static.” Another major section with changes is 03.00.00—Medical Configuration. In the design of the ground ambulance services, we added these requirements: 7. Seating should be designed in the ground ambulance so that patient care can be rendered from a seatbelted position. 8. If the ambulance stretcher is floor supported by its own wheels, there is a mechanism to secure it in position under all conditions. These restraints permit quick attachment and detachment for patient transfer. 9. Ambulance equipment must be secured by an appropriate clamp, strap or other mechanism to the vehicle or stretcher/isolette to prevent movement during a crash or abrupt stop. 10.Seat-belt mountings on side-facing benches should be situated in order to restrain personnel/passengers at the pelvic level. Also in this section—for both air and ground transport—a new standard states, “A portable oxygen tank is never to be secured between the patient’s legs while the aircraft or ambulance is in motion.” In the Communications Section— 06.04.00, we upgraded the language and definitions for each timed documentation of a transport with standardized terminology as adapted from research studies2 of the best descriptive terms used primarily by helicopter services. A new standard in the communications section requires “a method to keep noise and other distractions from the communications area while the communications specialist is involved with a medical transport.” Under the Quality Management section—08.00.00, we added, “There is a process to identify, document and ana-
lyze adverse medical events or potentially adverse events (near misses) with specific goals to improve patient safety and/or quality of patient care.” Quality management has always been a weak area for programs applying for accreditation, especially in demonstrating loop closure and outcomes studies. To provide more guidance in developing outcome studies, we added, “Evidence of outcome studies should minimally include airway, fluid resuscitation and adherence to ACLS, PALS and NRP protocols.” We made several changes to the rotor-wing sections—10.00.00 to 16.00.00. Under weather minimums, “night local” increased from a 500-foot to 800-foot ceiling. Pilot in command (PIC) qualifications were changed from 2000 total helicopter flight hours to 2000 total flight hours with a minimum of 1500 helicopter flight hours before assignment with an air medical service with the following stipulations: • Many pilots with recent military training have little experience flying without night vision goggles. Therefore, we now require that the 100 hours of night flight time as PIC be 100 hours of unaided night flight. • Because the total helicopter flight hours were decreased, we also added, “a minimum of 500 hours of turbine time, rather than 1000 hours of turbine time, are strongly encouraged.” We strengthened maintenance standards for both rotor- and fixed-wing transport to address: • Mechanics training. “The mechanic primarily assigned to a specific aircraft must be factory schooled or equivalent in an approved program on the type specific airframe, the powerplant, and all related systems. The primarily assigned mechanic provides direct (on-site during maintenance) supervision to other mechanics who may not have this level of experience or training. All mechanics should receive formal training on human factors and maintenance errors reduction. A policy is written that grants the mechanic permission (without fear of reprimand) to decline from performAir Medical Journal 21:3
ing any maintenance critical to flight safety (that he has not been appropriately trained for) until an appropriately trained mechanic is available to directly supervise or assist.” • Work hours. “It is strongly encouraged that mechanics should not be permitted to work more than 14 continuous hours. Following extended maintenance, such as 12-14 continuous hours, it is strongly recommended that a mechanic should be scheduled for 8 hours of uninterrupted rest.” • Workshop criteria. “Workshop areas should be in close proximity to the helipad/hangar. A workshop area is defined as an area where a desk, shelves, workbench, storage, and telephone are available. Workshop area shall be climate controlled (heated and cooled) to avoid adverse effects of temperature extremes. Appropriate ventilation will be installed to clear the facility of hazardous fumes (such as fuels, solvents, oils, adhesives, cleaners) common to the aviation environment. Workshop area shall be well lit with
an appropriate number of electrical outlets. Floodlights shall be available on the helipad—fixed and/or portable. Hand cleaners, disinfectants, and eye wash bottles are to be available.” • Maintenance distractions. “Policy shall be written and implemented to reduce the likelihood of interruptions and distractions to the mechanic, such as: The mechanic’s phone should have voice mail or messaging. Aircraft tours, public relations events, janitorial services, etc., should be postponed or canceled if involving the aircraft while maintenance is being performed. Mechanic’s work site (hangar helipad) should not be used as a gathering place/social area by the flight team while maintenance is being performed.” The Standards Committee, chaired by site surveyor Laura Lee Demmons, began working on these revisions 18 months ago. Revisions are widely distributed in several draft forms to member organizations and medical transport professionals in general through the
CAMTS website. Comments on the final draft were heard by the board during an open forum meeting during the AMTC in September before they were finally approved in December 2001. The board welcomes comments at any time because the complete accreditation standards is a working document that we revise every 2 to 3 years to keep current with professional practice. Please visit the CAMTS website to review all the changes for 2002, order the standards, complete applications on-line, and view the most current list of accredited services.
References 1. Levick NR, Donnelly BR, Blatt A, Gillespie G, Schultze M. Ambulance crashworthiness and occupant dynamics in vehicle-to-vehicle crash tests: preliminary report, enhanced safety of vehicles. Technical paper series Paper #452. May 2001. Available at www-nrd.nhtsa.dot.gov. 2. Thompson C, Schaffer J. Minimum data set development: air transport time-related terms. January 18, 2002. Unpublished.
Eileen Frazer is the CAMTS executive director. She can be reached (864) 287-4177 and E-mail [email protected]. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 4534350; reprint no. 74/1/124216 doi:10.1067/mmj.2002.124216
Continued from page 25
CFRN Examination Review Answers 1. B. Dressler’s syndrome Dressler’s is a postinfarction syndrome. Brun’s is a syndrome of intermittent headaches, vertigo, vomiting, and visual disturbances. Evan’s is a syndrome of acquired hemolytic anemia and thrombocytopenia. 2. C. Deviation of the head and eyes to the right Right-left confusion, dysphasia, and right hemiplegia are symptoms of left hemisphere stroke. 3. C. Spinal shock Neurogenic shock is characterized by loss of sympathetic vasomotor function. The loss of sympathetic tone and uninhibited parasympathetic responses cause extreme vasodilation in the systemic vasculature, producing a maldistribution of the circulating volume.
4. A. Elevated pH with hyperemia Called a “pink puffer,” the patient usually presents with tachypnea, a normal PaO2, and low PaCO2. Emphysema is a disorder of impeded expiration caused by overdistention of air spaces, alveolar wall destruction, partial airway collapse, and loss of elastic recoil of the lungs. 5. C. Clubbing of fingers and toes With a right to left shunt, blood passes directly to the systemic circulation without being oxygenated. The patient is hypoxic, and you will gradually see clubbing of fingers and toes. A gallop rhythm is seen in myocarditis. Expiratory grunting and crackles are found in pulmonary edema. Mottled skin with pale color indicates poor perfusion. doi:10.1067/mmj.2002.124227
May-June 2002
33
T
he Commission on Accreditation of Medical Transport Systems (CAMTS) published the fifth edition of its accreditation standards in January. The commission made some notable changes in format and context, and this article summarizes them. In our efforts to continually improve the format of this document, each standard in the general section is now identified as pertinent to rotor-wing, fixedwing, or ground transport. Also, the standards are boxed so readers can readily identify the main standard and its supporting criteria. An index also is included, with key words and phrases in alphabetical order, so readers can easily reference a topic with its standard and page number. In response to events on September 11, 2001, we included verbiage that a service’s participation in regional disaster planning should include “an integrated response to terrorist events.” The standard that stated carry-on baggage belonging to patients and passengers should be checked for hazardous materials seems to have gained more significance since the attacks. We also added a standard to encourage data collection. CAMTS tracks incidents and accidents (involving aircraft and ambulances) for trending purposes and to evaluate the need to create specific new standards or change existing standards. Air medical personnel are fairly consistent in reporting aviation accidents to the CONCERN Network (sponsored by the Air & Surface Transport Nurses Association), but incidents happen every day, and very few incident May-June 2002
reports are submitted. Ambulance accidents are even harder to track because no organization or government agency has assumed responsibility for tracking accidents involving ambulances. Research by Nadine Levick1 has shown a very dismal morbidity and mortality rate in ambulance crashes. A new standard in the fifth edition “encourages medical transport services to report incidents and accidents to CONCERN.”
Since 1991, when the first edition of the accreditation standards were published, the commission has defined critical care as “the transport of a patient whose condition warrants care commensurate with the scope of practice of a physician or RN.” This definition remains accurate, but we have added an alternate to the team composition standard for critical care. The rationale for this update is included with the standards, but briefly, we are attempting to rede31
fine the team best suited to care for a critical patient during transport based on acuity levels, personnel experience and training, and patient outcome studies rather than just on provider license. As explained in the rationale on page 64: “This change is in response to a national struggle with defining ‘critical care.’ Regional variances (in the U.S.) in training, licensure requirements and practice parameters for paramedics and nurses in particular result in confusion over which providers are best suited for critical care. These variances are even more pronounced outside U.S. borders. As a Board of Directors charged with the responsibility to provide strategic direction to the organization, it is important to redefine team composition and provide a framework to more accurately review the capabilities and limitations of the programs that we accredit.” As such, the alternative to current critical care team composition requires the service to define in detail: 1. Its mission with respect to each category of patient it transports 2. Patient acuity level requests accepted in each category of medical care 3. Patient acuity levels by volume 4. Background and clinical experience of medical personnel 5. Educational requirements for medical personnel (before hire and ongoing) 6. Outcome studies that demonstrate appropriate care is provided by the assigned team Another area we clarify is currency in nationally recognized courses, such as ATLS or equivalent, PALS or equivalent, etc. The “or equivalent” has always led to more questions. In the fifth edition, we added an education matrix that compares each national course and describes the didactic or skills needed to be considered equivalent. As stated by Reneé Holleran, author of this matrix and the ENA representative to the CAMTS board of directors, “No matter what course is chosen—a national course as listed (in the matrix) or a locally developed course—specific objectives, content outlines, and measurable outcomes need to be included in what is developed and must include primary and secondary assessment, advanced physiology, and advanced skills.” 32
Human patient simulators have become highly sophisticated during the past few years. As part of the initial and ongoing training requirements, we state, “Human patient simulators may be considered a substitute for human or cadaver experience requirements if the simulators are dynamic (able to reflect physiologic changes resulting from a performed procedure) and not static.” Another major section with changes is 03.00.00—Medical Configuration. In the design of the ground ambulance services, we added these requirements: 7. Seating should be designed in the ground ambulance so that patient care can be rendered from a seatbelted position. 8. If the ambulance stretcher is floor supported by its own wheels, there is a mechanism to secure it in position under all conditions. These restraints permit quick attachment and detachment for patient transfer. 9. Ambulance equipment must be secured by an appropriate clamp, strap or other mechanism to the vehicle or stretcher/isolette to prevent movement during a crash or abrupt stop. 10.Seat-belt mountings on side-facing benches should be situated in order to restrain personnel/passengers at the pelvic level. Also in this section—for both air and ground transport—a new standard states, “A portable oxygen tank is never to be secured between the patient’s legs while the aircraft or ambulance is in motion.” In the Communications Section— 06.04.00, we upgraded the language and definitions for each timed documentation of a transport with standardized terminology as adapted from research studies2 of the best descriptive terms used primarily by helicopter services. A new standard in the communications section requires “a method to keep noise and other distractions from the communications area while the communications specialist is involved with a medical transport.” Under the Quality Management section—08.00.00, we added, “There is a process to identify, document and ana-
lyze adverse medical events or potentially adverse events (near misses) with specific goals to improve patient safety and/or quality of patient care.” Quality management has always been a weak area for programs applying for accreditation, especially in demonstrating loop closure and outcomes studies. To provide more guidance in developing outcome studies, we added, “Evidence of outcome studies should minimally include airway, fluid resuscitation and adherence to ACLS, PALS and NRP protocols.” We made several changes to the rotor-wing sections—10.00.00 to 16.00.00. Under weather minimums, “night local” increased from a 500-foot to 800-foot ceiling. Pilot in command (PIC) qualifications were changed from 2000 total helicopter flight hours to 2000 total flight hours with a minimum of 1500 helicopter flight hours before assignment with an air medical service with the following stipulations: • Many pilots with recent military training have little experience flying without night vision goggles. Therefore, we now require that the 100 hours of night flight time as PIC be 100 hours of unaided night flight. • Because the total helicopter flight hours were decreased, we also added, “a minimum of 500 hours of turbine time, rather than 1000 hours of turbine time, are strongly encouraged.” We strengthened maintenance standards for both rotor- and fixed-wing transport to address: • Mechanics training. “The mechanic primarily assigned to a specific aircraft must be factory schooled or equivalent in an approved program on the type specific airframe, the powerplant, and all related systems. The primarily assigned mechanic provides direct (on-site during maintenance) supervision to other mechanics who may not have this level of experience or training. All mechanics should receive formal training on human factors and maintenance errors reduction. A policy is written that grants the mechanic permission (without fear of reprimand) to decline from performAir Medical Journal 21:3
ing any maintenance critical to flight safety (that he has not been appropriately trained for) until an appropriately trained mechanic is available to directly supervise or assist.” • Work hours. “It is strongly encouraged that mechanics should not be permitted to work more than 14 continuous hours. Following extended maintenance, such as 12-14 continuous hours, it is strongly recommended that a mechanic should be scheduled for 8 hours of uninterrupted rest.” • Workshop criteria. “Workshop areas should be in close proximity to the helipad/hangar. A workshop area is defined as an area where a desk, shelves, workbench, storage, and telephone are available. Workshop area shall be climate controlled (heated and cooled) to avoid adverse effects of temperature extremes. Appropriate ventilation will be installed to clear the facility of hazardous fumes (such as fuels, solvents, oils, adhesives, cleaners) common to the aviation environment. Workshop area shall be well lit with
an appropriate number of electrical outlets. Floodlights shall be available on the helipad—fixed and/or portable. Hand cleaners, disinfectants, and eye wash bottles are to be available.” • Maintenance distractions. “Policy shall be written and implemented to reduce the likelihood of interruptions and distractions to the mechanic, such as: The mechanic’s phone should have voice mail or messaging. Aircraft tours, public relations events, janitorial services, etc., should be postponed or canceled if involving the aircraft while maintenance is being performed. Mechanic’s work site (hangar helipad) should not be used as a gathering place/social area by the flight team while maintenance is being performed.” The Standards Committee, chaired by site surveyor Laura Lee Demmons, began working on these revisions 18 months ago. Revisions are widely distributed in several draft forms to member organizations and medical transport professionals in general through the
CAMTS website. Comments on the final draft were heard by the board during an open forum meeting during the AMTC in September before they were finally approved in December 2001. The board welcomes comments at any time because the complete accreditation standards is a working document that we revise every 2 to 3 years to keep current with professional practice. Please visit the CAMTS website to review all the changes for 2002, order the standards, complete applications on-line, and view the most current list of accredited services.
References 1. Levick NR, Donnelly BR, Blatt A, Gillespie G, Schultze M. Ambulance crashworthiness and occupant dynamics in vehicle-to-vehicle crash tests: preliminary report, enhanced safety of vehicles. Technical paper series Paper #452. May 2001. Available at www-nrd.nhtsa.dot.gov. 2. Thompson C, Schaffer J. Minimum data set development: air transport time-related terms. January 18, 2002. Unpublished.
Eileen Frazer is the CAMTS executive director. She can be reached (864) 287-4177 and E-mail [email protected]. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 4534350; reprint no. 74/1/124216 doi:10.1067/mmj.2002.124216
Continued from page 25
CFRN Examination Review Answers 1. B. Dressler’s syndrome Dressler’s is a postinfarction syndrome. Brun’s is a syndrome of intermittent headaches, vertigo, vomiting, and visual disturbances. Evan’s is a syndrome of acquired hemolytic anemia and thrombocytopenia. 2. C. Deviation of the head and eyes to the right Right-left confusion, dysphasia, and right hemiplegia are symptoms of left hemisphere stroke. 3. C. Spinal shock Neurogenic shock is characterized by loss of sympathetic vasomotor function. The loss of sympathetic tone and uninhibited parasympathetic responses cause extreme vasodilation in the systemic vasculature, producing a maldistribution of the circulating volume.
4. A. Elevated pH with hyperemia Called a “pink puffer,” the patient usually presents with tachypnea, a normal PaO2, and low PaCO2. Emphysema is a disorder of impeded expiration caused by overdistention of air spaces, alveolar wall destruction, partial airway collapse, and loss of elastic recoil of the lungs. 5. C. Clubbing of fingers and toes With a right to left shunt, blood passes directly to the systemic circulation without being oxygenated. The patient is hypoxic, and you will gradually see clubbing of fingers and toes. A gallop rhythm is seen in myocarditis. Expiratory grunting and crackles are found in pulmonary edema. Mottled skin with pale color indicates poor perfusion. doi:10.1067/mmj.2002.124227
May-June 2002
33