Presentation to CAAC – May 2010

1. Presentation to CAAC – May 2010

2. Mission and Vision Mission Statement CAMTS is a peer review organization dedicated to improving patient care and transport safety by providing a dynamic accreditation process through the development of standards, education, and services that support our vision. Vision Statement All patients are transported safely by qualified personnel using the appropriate mode of transport.

3. VALUES Fair Ethical Consistent Accountable Patient and Safety Focused

4. Charter Members –1990 AAMS ACEP NAACS NEMSPA NFNA NAEMSP Now 19 member organizations In this great diversity of experience lies its strength An Organization of Organizations

5. AsMA AMPA ASTNA AAP AACN AARC AAMS ACEP ACS AMOA ENA NATA NAACS NAEMSP NANN NASEMSD NEMSPA NFPA US Transcom Ad Hoc & JHSIT MEMBER ORGANIZATIONS in 2009

6. EMS Helicopters in 1981

7. There were NO STANDARDS There Were & Are FARs to address pilots/maintenance/a/c

8. And There Were and Are Patient Care Guidelines from Many Sources

9. 1970s and 1980s There were NO Air Ambulance STANDARDS

10. And there were crashes accidents

11. U.S. HEMS Accidents and Fatal Accidents *Dedicated and dual-purpose

12. CAMTS Standards Bring These Professions Together There were grey areas untouched by regulations and patient care guidelines That affected or had the potential to affect safety and patient care during the transport process. For example:

13. Stretchers must be STCd but no FAA requirement for rigidity to do CPR, elevation of headrest etc.

14. - No regulation to require a barrier to protect the pilot, controls and radios from interference by patient or crew or equipment and supplies.

15. No regulation to protect the pilot’s night adaptation vision from crew lighting necessary for patient care.

16. Medical Crew Training and Appropriate dress

17. MEDICAL CONFIGURATION - Seating be designed so that patient care can be rendered from a seat- belted position. Head Strike area is padded or clear All equipment and supplies are secured

18. Education and Processeshallmarks of CAMTS accreditation • Initial and ongoing education • SMS which includes a non punitive hazard reporting system • QM medical –operations -communications • UR to determine transport appropriateness

19. Aircraft Issues Not required by FAA Interior of the aircraft should be climate controlledto avoid adverse effects on the patients and personnel on board – AS: 05.07.00 Aircraft should be equipped with a functioning radar altimeter AS: 05.01.01 Aircraft must be equipped with a functioning emergency locator transmitter (ELT)AS: 05.02.00 – Not required for all make/model a/c by FAA

20. Rotorwing and Fixed Wing Sections • All “Patient Mission Flights” must be conducted under FAA Part 135 regulations • Higher Weather Minimums • Pilot pre-hire qualifications

21. Pilot Qualifications – FW • 2000 airplane flight hours prior to assignment with a medical service with the following stipulations: • At least 1000 of those hours must be as PIC in an airplane. • At least 500 hours must be multi-engine airplane time as a PIC. • At least 100 hours must be night flight time as PIC. • PIC must be ATP rated. SIC is strongly recommended to be ATP rated.

22. Pilot training – also includes: • Part 135 instrument proficiency check (135.297) • Infection control (for pilots and mechanics) • Medical systems and loading and unloading • AMRM - Communications Processes & Decision Behaviors - Team Building and Maintenance - Workload management and situational awareness

23. Communications Centers Policies, Procedures, Training

24. Communications • “Sterile cockpit” not required by FAA • Time between communications shall not exceed 15 minutes • Backup emergency power source for communications equipment

25. Air to air communications, Common frequencies 123.025

26. Procedures that coordinate arrivals and departures from hospital helipads with other air medical services in the region and pre-arranged communication agreements with hospitals.

27. Refueling policies required by CAMTS • Refueling with Patient on board requires at least one transport person remain with the patient at all times during refueling or stopover. AS: 04.01.06 • A policy requires that the pilot or designee stay with the aircraft when refueling to verify fuel type and quantity received. AS: 15.01.00

28. Standard changes as a result of 2008 accidents • More stringent rest and duty time policies • Require education on sleep deprivation, sleep inertia, circadian rhythms and recognizing signs of fatigue. • Added a fatigue factor to risk assessment tools

29. Where We are Today? • Currently there are 155 accredited services: • 30% are RW only • 14% are FW only • 02% are CCG only • 54% are combination Of the approximately 300 RW programs in the U.S we have accredited about 50%. But those programs operate about 70% of the total number of helicopters operating in the U.S.

30. Number and Types of Surveys • We did 69 site visits, 10 supplemental visits, 7 consult visits and 5 monitoring visits last year. • Trends include: - International interest - More specialty teams - More consultation visits - More complex visits

31. Changing Landscapeof CAMTS Accredited Services

32. 1st Accredited Service Outside of North America SOS Air Rescue in South Africa achieved full accreditation in June 2007. Flight Nurse/physician teams – many patients flown through contracts with Fortune 500 companies, the U.S.DOD and major universities.

33. CAMTS is Voluntary but Required??? • DOD (contracting with civilian services) • Indian Health Services • Some States and local entities • Some insurances will give a preferred status to CAMTS accredited services

34. State Licensing • All states have licensure for ground ambulances. • Five states do not have licensure for air ambulance • “Deemed Status” – CAMTS White Paper • Some states require CAMTS for air ambulance licensure: Colorado Maryland Massachusetts Michigan New Hampshire New Mexico Rhode Island Utah Washington Counties in California and Nevada

35. Challenges with States using CAMTS standards or requiring accreditation. • Some States simply use CAMTS standards as State guidelines– but our standards are dynamic and ever changing – revised every 2-3 years. • States that require accreditation – conflict with policies such as eligibility requirements • Must be in business for 1 year before the service can submit a PIF. • Must do at least 12 transports in a year. • What if a program is suspended or withdrawn?

36. Federal preemption • FAA Act of 1958 created the FAA to have full responsibility and authority for the advancement and promulgation of civil aeronautics including enforcement of safety regulations. • 1978 – Congress passed the Airline Deregulation Act (ADA). The primary focus was on the competitive market environment for air carriers.

37. Federal preemption • 1978 – Congress passed the Airline Deregulation Act (ADA). The primary focus was on the competitive market environment for air carriers. • 2009 – HB 978 – Altmire Bill –challenging the extent to which States can be prohibited by the ADA to oversee air medical services and States role in protecting public health.

38. Preemption rule –part of the ADA • To insure that States would not undo federal deregulation with regulation of their own, Congress included a preemption provision that states: “ A State, political subdivision of a state, or political authority of at least 2 states, may not enact or enforce a law, regulation, or other provision having the force or effect of law related to price, route, or service of an air carrier that may provide air transport.”

40. Since 1978, it is reported that over 1,600 lives have been lost in ground ambulance crashes Department of Labor statistics indicate that emergency medical service (EMS) employees have fatality rates twice that of other occupations. Seventy-four percent of these fatalities are associated with transportation. • July 20, 2007, a volunteer ambulance with five crewmembers and two patients aboard collides with a tractor-trailer rig in rural Antwerp, Ohio killing all but one - 3 volunteer crewmembers and an elderly husband and wife.

41. ATS Task Force • Developed as an ad hoc group after the Antwerp accident. 1. We need a national data collection center Wrote to NTSB for assistance in developing national data collection and investigation of fatal and serious accidents that resulted in an out of service ambulance (which can effect an entire community). 2. Engineering design specifications

42. Ambulance Design

43. Ambulance Safety Summit Co Chair of the The Subcommittee on EMS Transportation Safety of the National Academies Transportation Research Board

44. EDUCATION Role • Education materials and presentations for Air & Ground Medical Transport Services: • JUST CULTURE (David Marx and Scott Griffith) • AMRM • Threat and Error Management • Companion Publication on Culture and QM • Hazards of Helicopter Shopping • Best Practices

45. Medicine and Transport – Rely on standardized processes and procedures. Striving to meet compliance with standards propels a service into a dynamic flow of performance improvement and benchmarking.

46. CAMTS Website • www.camts.org - Order Standards and “Best Practices” - Download standards & Policy Manual - Complete application on-line • Office – 864 287-4177 • FAX – 864 287-4251 • Email – efrazer@aol.com

47. Fixed Wing Accidents – 6 in 2004 of a total of 19 EMS accidents 2 of 11 in 2005 2 of 8 in 2006 3 of 9 in 2207 1 of 11 in 2008 0 0f 10 in 2009

48. Helicopters make News especially in 2008. . . . .

49. Feb 2009 NTSB Hearings EmphasisRecommendations – Fall 2009 • Operational Structure/Business Models (Competition/Helicopter Shopping) • Flight Ops (risk tools, SMS) • Equipment (NVGs, HTAWS) • Training (Simulator, AMRM) • FAA Oversight (135 or separate regulations)

50. Terrain Avoidance Warning System (TAWS) NTSB Recommendation to Prevent Controlled Flight Into Terrain From Jan 2002 to Jan 2005, 17 of 55 HEMS Accidents May Have Been Prevented If TAWS Equipped