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Monitoring the appropriateness of air medical transports
BRIEF REPORT
Monitoring the Appropriateness of Air Medical Transports Robert J. O'Malley, RN, MS, 1 Margaret Watson-Hopkins, RN, BA 1
1. Patient Care Services, University of California, Davis, Medical Center
Abstract Introduction: With pending changes in the
Key Words: aeromedical, appropriateness
health-care system, there are increasing pressures for each aspect of health care to justify
Address for correspondence: Robert J. O'Malley, RN, MS, University of California, Davis, Medical Center, 2315 Stockton Blvd., Sacramento, CA 95817 Submitted: February 11, 1994 Revised: June 1, 1994 Accepted: June 14, 1994 This abstract was originally presented at the Air Medical Transport Conference, October 1993, St. Louis, Mo.
its use. Several organizations, including the Association of Air Medical Services (AAMS), have published position papers listing appropriate indications for air medical services. Additionally, the Commission on Accreditation of Air Medical Services (CAAMS) specifies that air medical services monitor their flights for appropriateness. The purpose of this study was to determine how often the air medical transports by this program met at least one of the AAMS criteria.
Method: The AAMS position paper was paraphrased into an equivalent checklist and a category, "None of the above criteria met," was added. Immediately after each transport, a flight nurse indicated on the checklist which criteria the patient met supported by documentation in the flight care record.
Results; During a one-year period (March 1, 1992 through February 28, 1993), 558 patients were transported. Of these, 547 (98%) met at least one of the AAMS appropriate-use criteria.
Conclusion; The AAMS "Appropriate Use of Air Medical Services" position paper provides a foundation to monitor the utilization of an air medical transport program, which can be used to meet both government payer requirements for justification and the CAAMS requirement for utilization review.
Introduction Medical organizations have published various guidelines describing the ap: propriate use for air medical transport. 1-3 During 1989 and early 1990, the Medical Advisory Committee of the Association of Air Medical Services (AAMS) created a consensus document regarding the appropriate use of air medical services. After a vote by the medical directors of member programs, the final position paper was approved in July 1990 by the association's Board of Directors and published in September of the same year.4 With pending changes in the healthcare system, there are increasing pressures for each aspect of health care to justify its use. The Medicaid provider in California (Medi-Cal) started to inquire about air medical transports in 1991 and somewhat arbitrarily challenge its use.5 The AAMS position paper was paraphrased into list form, and offered to a representative of Medi-Cal as a resource document. The document was informally accepted for justification of air medical transports in January 1992. The Commission for the Accreditation of Air Medical Services (CAAMS) Standards 6 call for programs to monitor the appropriate use of air medical transport. For the purpose of providing documentation for the Medicaid payer and satisfying the CAAMS standard, our service applied the AAMS appropriate standards to our transports. The purpose of this study was to determine how often the air medical transports by this program met at least one of the criteria. Setting Life Flight is operated by the University
Air Medical Journal 13:8 August 1994
323
of California, Davis, Medical Center. The medical center is located in an urban setting but the program services urban, suburban and rural areas. Life Flight transports 550-650 patients per year, of which about three-fourths are victims of trauma, and about two-thirds are transported directly from the scene. Method The AAMS position paper was paraphrased into an equivalent checklist and a category, "None of the above criteria met," was added (Appendix A). Immediately after each transport, a flight nurse indicated on the checklist which criteria the patient met supported by documentation in the flight care record. During a monthly review meeting, the percent of total transports where at least one criteria was met, was reported and each transport where none of the criteria was met was reviewed individually. Results During a one-year period (March 1, 1992 through February 28, 1993), 558 patients were transported. Of these, 547 (98%) met at least one of the AAMS appropriate-use criteria. Several transports that did not meet any of the criteria were unique situations which, after review, were determined to be appropriate use of air medical transport (see Table 1). Discussion A 90% threshold for review was anticipated to be satisfactory. The experience of 98% provides historical data for this program. There were no specific recommendations from the review of the eleven which met none of the criteria. All of them were transports from scenes, and the judgment for no action was based, in part, on the information the prehospital personnel had at the time of the decision to utilize air medical transport. The prehospital personnel could not project that the vital signs would remain stable dtiring transport after what was perceived to be a significant traumatic event. From the perspective of Medicaid reimbursement, several changes occurred
324
rable I T r a n s p o r t s Not M e e t i n g A n y of t h e Criteria a) Equestrian accident, fractured pelvis, vital signs stable b) Motorcycle accident, fractured femur, long distance transport, vital signs stable c) Partial entrapment by 2,000-pound burial vault cover, fractured ribs, vital signs stable d) Bicycle accident, questionable loss of consciousness, vital signs stable e) Logging accident, caught between cable and tree, complaint of chest pain, vital signs stable t) Automobile vs. bicycle, amnesiac to event, vital signs stable g) Battered with blows to head and face, vital signs stable h) Automobile rollover with unknown use of seatbelt, vital signs stable i) Assaulted, and jumped from slow-moving vehicle, vital signs stable j)
Spontaneous pneumothorax without history of trauma, left-sided chest pain, vital signs stable except for slight elevation in respiratory rate
k) Motor-vehicle accident, rib fractures, fractured wrist, vital signs stable
in the reimbursement system coincidentally with use of the list including requirements for additional documentation. While the use of the list is not the sole cause, it is the perception of the authors that challenges to the utilization for air transport have all but disappeared. During the data collection period, the program was reviewed and received CAAMS accreditation. The use of the AAMS list to monitor appropriateness and as a screen to identify transports for individual review was noted during the site visit. While collecting data for this report, it became obvious that more useful data could be obtained with no additional effort. Originally, the medical personnel were directed to indicate any of the list of 72 items that were applicable. Some personnel endeavored to find as many as applicable, while others picked one indication. The new practice is for the medical personnel to identify the single most significant indication for the utilization of air medical transport or provide a narrative to why the service was requested. This study may be criticized because the decision as to which of the appropriateness criteria is satisfied is not determined by an independent reviewer. For the purposes described in this report, independent review is not considered necessary.
The authors suggest that a multicenter study be conducted to determine the distribution of the criteria for patients actually transported by air. Results should include percent of transports meeting at least one criteria and the percent of patients transported in each criteria. This information could contribute to the refinement of the appropriateness criteria and provide foundation for determining whether the criteria should be so liberal that all transports would be able to meet at least one criteria. Or it could contribute to determining if a set of criteria should be formulated to allow exceptions that could be reviewed on an individual basis for appropriateness, The 1990 AAMS criteria should only be accepted on an interim basis until they are linked to efficacy or outcomes. This is the only way air medical transport as a medical intervention will establish its place in medical science. Conclusion The AAMS Appropriate Use of Air Medical Services position paper provides a standard by which to monitor the utilization of an air medical transport program.
Air Medical Journal 13:8 August 1994
References 1. American Academy of Pediatrics, Committee on Hospital Care. Guidelines for air and ground transportation of pediatric patients. Pediatrics, 1986;78:943-950. 2. American College of Surgeons Committee on Trauma. Hospital and Prehospital Resources for Optimal Care of the Injured Patient, 1990. [AUTHOR QUERY PAGE NUMBERS?}
3. National Association of Emergency Medical Services Physicians. Air medical dispatch: Guidelines for scene response. Prehospital and Disaster Medicine, 1992;7:75-76. 4. Association of Air Medical Services. Position paper on the appropriate use of air medical services. Journal of Air Medical Transport, 1990;9:29-33.
5. Chanin I: Air ambulance rate study; Draft of proposed new rates. California Department of Health Services, April 18, 1991. (Unpublished.) 6. Commission on Accreditation of Air Medical Services. Accreditation Standards, 1991, pp 26-27.
CRITERIA FOR ALL TRAUMA PATIENTS [] [] [] [] [] [] [] [] [] [] []
Lengthy extrication with severe injuries Motor vehicle accident with structural intrusion into patient's space in the vehicle Motor vehicle accident with ejection from vehicle Motor vehicle accident with another person in the same vehicle died Motor vehicle accident with patient a pedestrian struck by a vehicle traveling more than 20 mph Motor vehicle accident with patient not weadng a'seat-belt in a car which overturned Motor vehicle accident with front bumper of vehicle displaced to the rear by more than 30 inches Motor vehicle accident with front axle displaced to the rear Patient was thrown from a motorcycle traveling more than 20 mph Fallfrom a height greater than 20 feat Penetrating injury anywhere on the body between the mid-thigh and the head
[] [] []
[] [] [] [] []
Amputation or near-amputation Scalping or degloving injury Severe hemorrhage, with systolic blood pressure less than of 90 mmHg or requiring blood transfusion 15% or greater body surface burns Major burns of the face, hands, feet, airway, or perineum Experienced, or had great potential to experience to experience, injury to the spinal cord, spinal column, or neurologic deficit. Face or neck injury with unstable or potentialIy unstable airway which might require advanced airway procedure CRAMS score of 8 or less Age less than 5 years with multiple traumatic injuries Age greater than 55 years with multiple traumatic injuries Respiratory rate less than 10 or greater than 30 breaths per minute Heart rate less than 60 or greater than 120 beats per minute
[] [] [] [] [] [] [] [] []
Systolic blood pressure Child 6-12 years less than 80 mmHg Near-drowning with signs of hypoxia or altered mental statue Statis epilepticus Acute bacterial meningitis Acute renal failure Unstable toxicological syndrome Reye's syndrome Hypothermia Multiple trauma
[] [] [] []
CRITERIA FOR PEDIATRIC PATIENTS - []
[] [] [] [] [] []
Experienced or at risk for developing cardiac dysrhythmias or cardiac pump failure that requires intervention not available at the referring hospital Experienced or at risk for developing acute respiratory failure or respiratory arrest and is not responsive to initial therapy Invasive airway procedure with assisted ventilation Respiratory rate less than 10 or greater than 60 breaths per minute Systolic blood pressure Neonate less than 60 mmHg Systolic blood pressure Infant (<2 years) less than 65 mmHg, Systolic blood pressure Child 2-5 years less than 70 mmHg
GENERAL CRITERIA []
[] [] []
Required critical care life support (monitoring, personnel, medication, or specific equipment) during interfacility transport that is not available from the local ground ambulance service. Clinical condition required that the time spent between hospitals (out of the hospital environment) to be as short as possible. Specific or timely treatment required not available at the referring hospital. Condition requires care by receiving hospital's physicians intimately
CRITERIA FOR MEDICAL PATIENTS [] [] [] [] [] [] [] [] [] [] [] [] [] [] []
Respiratory arrest within the past 12 hours Cardiac arrest within the past 12 hours Acute respiratory failure net responsive to initial therapy Continuous intravenous vasoactive medications. Medication: Mechanical ventricular assist Continuous intravenous anti-dysrhythmia medication. Medication: Cardiac pacemaker Mechanical ventilator support Risk of having an unstable airway Acute deterioration in mental status Invasive therapy for hypothermia Intra-aortic balloon pump Arterial Line Indwelling pulmonary artery catheter Intracranial pressure monitor
[]
NONE OF THE ABOVE CRITERIA ARE MET
Air Medical Journal
13:8
August 1994
[] [] [] [] [] [] [] [] [] [] [] [] [] []
familiar with the patient's history, chemotherapy, or previous extensive invasive procedures Use of local ground transportation would leave the local area without adequate EMS coverage. Potential delays associated with ground transport (road obstacles and traffic) is likely to worsen clinical condition. Area was inaccessible to regular ground traffic. Respiratory rate less than 10 or greater than 30 Heart rate less than 50 or greater than 150 Systolic blood pressure less than 90 mmHg or greater than 200 mmHg Acidosis with pH less than 7.2 Transport in a critical care environment to a medical center that can perform organ transplantation or procurement Acute myocardial infarction that requires therapy or diagnostic procedures not available at the referring hospital Dissecting or leaking aneurysm that requires therapy or diagnostic procedures not available at the referring hospital Cerebrovascular accident in evolution that requires therapy or diagnostic procedures not available at the referring hospital Seizure not controlled at referring hospital High-risk obstetrical condition None of the above conditions are met.
325
Monitoring the Appropriateness of Air Medical Transports Robert J. O'Malley, RN, MS, 1 Margaret Watson-Hopkins, RN, BA 1
1. Patient Care Services, University of California, Davis, Medical Center
Abstract Introduction: With pending changes in the
Key Words: aeromedical, appropriateness
health-care system, there are increasing pressures for each aspect of health care to justify
Address for correspondence: Robert J. O'Malley, RN, MS, University of California, Davis, Medical Center, 2315 Stockton Blvd., Sacramento, CA 95817 Submitted: February 11, 1994 Revised: June 1, 1994 Accepted: June 14, 1994 This abstract was originally presented at the Air Medical Transport Conference, October 1993, St. Louis, Mo.
its use. Several organizations, including the Association of Air Medical Services (AAMS), have published position papers listing appropriate indications for air medical services. Additionally, the Commission on Accreditation of Air Medical Services (CAAMS) specifies that air medical services monitor their flights for appropriateness. The purpose of this study was to determine how often the air medical transports by this program met at least one of the AAMS criteria.
Method: The AAMS position paper was paraphrased into an equivalent checklist and a category, "None of the above criteria met," was added. Immediately after each transport, a flight nurse indicated on the checklist which criteria the patient met supported by documentation in the flight care record.
Results; During a one-year period (March 1, 1992 through February 28, 1993), 558 patients were transported. Of these, 547 (98%) met at least one of the AAMS appropriate-use criteria.
Conclusion; The AAMS "Appropriate Use of Air Medical Services" position paper provides a foundation to monitor the utilization of an air medical transport program, which can be used to meet both government payer requirements for justification and the CAAMS requirement for utilization review.
Introduction Medical organizations have published various guidelines describing the ap: propriate use for air medical transport. 1-3 During 1989 and early 1990, the Medical Advisory Committee of the Association of Air Medical Services (AAMS) created a consensus document regarding the appropriate use of air medical services. After a vote by the medical directors of member programs, the final position paper was approved in July 1990 by the association's Board of Directors and published in September of the same year.4 With pending changes in the healthcare system, there are increasing pressures for each aspect of health care to justify its use. The Medicaid provider in California (Medi-Cal) started to inquire about air medical transports in 1991 and somewhat arbitrarily challenge its use.5 The AAMS position paper was paraphrased into list form, and offered to a representative of Medi-Cal as a resource document. The document was informally accepted for justification of air medical transports in January 1992. The Commission for the Accreditation of Air Medical Services (CAAMS) Standards 6 call for programs to monitor the appropriate use of air medical transport. For the purpose of providing documentation for the Medicaid payer and satisfying the CAAMS standard, our service applied the AAMS appropriate standards to our transports. The purpose of this study was to determine how often the air medical transports by this program met at least one of the criteria. Setting Life Flight is operated by the University
Air Medical Journal 13:8 August 1994
323
of California, Davis, Medical Center. The medical center is located in an urban setting but the program services urban, suburban and rural areas. Life Flight transports 550-650 patients per year, of which about three-fourths are victims of trauma, and about two-thirds are transported directly from the scene. Method The AAMS position paper was paraphrased into an equivalent checklist and a category, "None of the above criteria met," was added (Appendix A). Immediately after each transport, a flight nurse indicated on the checklist which criteria the patient met supported by documentation in the flight care record. During a monthly review meeting, the percent of total transports where at least one criteria was met, was reported and each transport where none of the criteria was met was reviewed individually. Results During a one-year period (March 1, 1992 through February 28, 1993), 558 patients were transported. Of these, 547 (98%) met at least one of the AAMS appropriate-use criteria. Several transports that did not meet any of the criteria were unique situations which, after review, were determined to be appropriate use of air medical transport (see Table 1). Discussion A 90% threshold for review was anticipated to be satisfactory. The experience of 98% provides historical data for this program. There were no specific recommendations from the review of the eleven which met none of the criteria. All of them were transports from scenes, and the judgment for no action was based, in part, on the information the prehospital personnel had at the time of the decision to utilize air medical transport. The prehospital personnel could not project that the vital signs would remain stable dtiring transport after what was perceived to be a significant traumatic event. From the perspective of Medicaid reimbursement, several changes occurred
324
rable I T r a n s p o r t s Not M e e t i n g A n y of t h e Criteria a) Equestrian accident, fractured pelvis, vital signs stable b) Motorcycle accident, fractured femur, long distance transport, vital signs stable c) Partial entrapment by 2,000-pound burial vault cover, fractured ribs, vital signs stable d) Bicycle accident, questionable loss of consciousness, vital signs stable e) Logging accident, caught between cable and tree, complaint of chest pain, vital signs stable t) Automobile vs. bicycle, amnesiac to event, vital signs stable g) Battered with blows to head and face, vital signs stable h) Automobile rollover with unknown use of seatbelt, vital signs stable i) Assaulted, and jumped from slow-moving vehicle, vital signs stable j)
Spontaneous pneumothorax without history of trauma, left-sided chest pain, vital signs stable except for slight elevation in respiratory rate
k) Motor-vehicle accident, rib fractures, fractured wrist, vital signs stable
in the reimbursement system coincidentally with use of the list including requirements for additional documentation. While the use of the list is not the sole cause, it is the perception of the authors that challenges to the utilization for air transport have all but disappeared. During the data collection period, the program was reviewed and received CAAMS accreditation. The use of the AAMS list to monitor appropriateness and as a screen to identify transports for individual review was noted during the site visit. While collecting data for this report, it became obvious that more useful data could be obtained with no additional effort. Originally, the medical personnel were directed to indicate any of the list of 72 items that were applicable. Some personnel endeavored to find as many as applicable, while others picked one indication. The new practice is for the medical personnel to identify the single most significant indication for the utilization of air medical transport or provide a narrative to why the service was requested. This study may be criticized because the decision as to which of the appropriateness criteria is satisfied is not determined by an independent reviewer. For the purposes described in this report, independent review is not considered necessary.
The authors suggest that a multicenter study be conducted to determine the distribution of the criteria for patients actually transported by air. Results should include percent of transports meeting at least one criteria and the percent of patients transported in each criteria. This information could contribute to the refinement of the appropriateness criteria and provide foundation for determining whether the criteria should be so liberal that all transports would be able to meet at least one criteria. Or it could contribute to determining if a set of criteria should be formulated to allow exceptions that could be reviewed on an individual basis for appropriateness, The 1990 AAMS criteria should only be accepted on an interim basis until they are linked to efficacy or outcomes. This is the only way air medical transport as a medical intervention will establish its place in medical science. Conclusion The AAMS Appropriate Use of Air Medical Services position paper provides a standard by which to monitor the utilization of an air medical transport program.
Air Medical Journal 13:8 August 1994
References 1. American Academy of Pediatrics, Committee on Hospital Care. Guidelines for air and ground transportation of pediatric patients. Pediatrics, 1986;78:943-950. 2. American College of Surgeons Committee on Trauma. Hospital and Prehospital Resources for Optimal Care of the Injured Patient, 1990. [AUTHOR QUERY PAGE NUMBERS?}
3. National Association of Emergency Medical Services Physicians. Air medical dispatch: Guidelines for scene response. Prehospital and Disaster Medicine, 1992;7:75-76. 4. Association of Air Medical Services. Position paper on the appropriate use of air medical services. Journal of Air Medical Transport, 1990;9:29-33.
5. Chanin I: Air ambulance rate study; Draft of proposed new rates. California Department of Health Services, April 18, 1991. (Unpublished.) 6. Commission on Accreditation of Air Medical Services. Accreditation Standards, 1991, pp 26-27.
CRITERIA FOR ALL TRAUMA PATIENTS [] [] [] [] [] [] [] [] [] [] []
Lengthy extrication with severe injuries Motor vehicle accident with structural intrusion into patient's space in the vehicle Motor vehicle accident with ejection from vehicle Motor vehicle accident with another person in the same vehicle died Motor vehicle accident with patient a pedestrian struck by a vehicle traveling more than 20 mph Motor vehicle accident with patient not weadng a'seat-belt in a car which overturned Motor vehicle accident with front bumper of vehicle displaced to the rear by more than 30 inches Motor vehicle accident with front axle displaced to the rear Patient was thrown from a motorcycle traveling more than 20 mph Fallfrom a height greater than 20 feat Penetrating injury anywhere on the body between the mid-thigh and the head
[] [] []
[] [] [] [] []
Amputation or near-amputation Scalping or degloving injury Severe hemorrhage, with systolic blood pressure less than of 90 mmHg or requiring blood transfusion 15% or greater body surface burns Major burns of the face, hands, feet, airway, or perineum Experienced, or had great potential to experience to experience, injury to the spinal cord, spinal column, or neurologic deficit. Face or neck injury with unstable or potentialIy unstable airway which might require advanced airway procedure CRAMS score of 8 or less Age less than 5 years with multiple traumatic injuries Age greater than 55 years with multiple traumatic injuries Respiratory rate less than 10 or greater than 30 breaths per minute Heart rate less than 60 or greater than 120 beats per minute
[] [] [] [] [] [] [] [] []
Systolic blood pressure Child 6-12 years less than 80 mmHg Near-drowning with signs of hypoxia or altered mental statue Statis epilepticus Acute bacterial meningitis Acute renal failure Unstable toxicological syndrome Reye's syndrome Hypothermia Multiple trauma
[] [] [] []
CRITERIA FOR PEDIATRIC PATIENTS - []
[] [] [] [] [] []
Experienced or at risk for developing cardiac dysrhythmias or cardiac pump failure that requires intervention not available at the referring hospital Experienced or at risk for developing acute respiratory failure or respiratory arrest and is not responsive to initial therapy Invasive airway procedure with assisted ventilation Respiratory rate less than 10 or greater than 60 breaths per minute Systolic blood pressure Neonate less than 60 mmHg Systolic blood pressure Infant (<2 years) less than 65 mmHg, Systolic blood pressure Child 2-5 years less than 70 mmHg
GENERAL CRITERIA []
[] [] []
Required critical care life support (monitoring, personnel, medication, or specific equipment) during interfacility transport that is not available from the local ground ambulance service. Clinical condition required that the time spent between hospitals (out of the hospital environment) to be as short as possible. Specific or timely treatment required not available at the referring hospital. Condition requires care by receiving hospital's physicians intimately
CRITERIA FOR MEDICAL PATIENTS [] [] [] [] [] [] [] [] [] [] [] [] [] [] []
Respiratory arrest within the past 12 hours Cardiac arrest within the past 12 hours Acute respiratory failure net responsive to initial therapy Continuous intravenous vasoactive medications. Medication: Mechanical ventricular assist Continuous intravenous anti-dysrhythmia medication. Medication: Cardiac pacemaker Mechanical ventilator support Risk of having an unstable airway Acute deterioration in mental status Invasive therapy for hypothermia Intra-aortic balloon pump Arterial Line Indwelling pulmonary artery catheter Intracranial pressure monitor
[]
NONE OF THE ABOVE CRITERIA ARE MET
Air Medical Journal
13:8
August 1994
[] [] [] [] [] [] [] [] [] [] [] [] [] []
familiar with the patient's history, chemotherapy, or previous extensive invasive procedures Use of local ground transportation would leave the local area without adequate EMS coverage. Potential delays associated with ground transport (road obstacles and traffic) is likely to worsen clinical condition. Area was inaccessible to regular ground traffic. Respiratory rate less than 10 or greater than 30 Heart rate less than 50 or greater than 150 Systolic blood pressure less than 90 mmHg or greater than 200 mmHg Acidosis with pH less than 7.2 Transport in a critical care environment to a medical center that can perform organ transplantation or procurement Acute myocardial infarction that requires therapy or diagnostic procedures not available at the referring hospital Dissecting or leaking aneurysm that requires therapy or diagnostic procedures not available at the referring hospital Cerebrovascular accident in evolution that requires therapy or diagnostic procedures not available at the referring hospital Seizure not controlled at referring hospital High-risk obstetrical condition None of the above conditions are met.
325