Healthcare is an industry associated with high risk1 and while critical care transport (CCT) contributes to this, certain risks attendant to ground critical care transportation are not described well2, 3 and may be appreciated less completely than their rotor-wing counterparts. Yet understanding and inculcating safety in CCT is important and urgent.4
During the period 1992-2011, there were 4,500 crashes involving an ambulance5 in the US (average 225 per year) and while 58% of these crashes occurred during emergency operations, 1% involved at least one fatality.5 It is not clear if these data includes ground critical care transport vehicles. Blumen notes between 1972-2016, emergency medical service helicopters experienced 342 accidents (nearly 8 per year) with 36% involving at least one fatality.6 Many CCT agencies, including MedFlight, have adopted a variety of safety strategies including a philosophy of “three-to-go; one-to-say-no,” fatigue assessments, departure and arrival checklists, written time-out guidelines, and risk assessment (RA) matrices.7
Most often human error emerges from systems with flawed designs.8 Safe patient care, therefore, depends on systems designed around practices that aim to prevent, recognize, and mitigate harm. Building safety into operations is an effective approach to reducing error8 and is achieved, in part, by indoctrinating a just culture,9 incorporating human factors awareness into organizational procedures and individual practices,8 and striving for high reliability. Organizations of high reliability share five characteristics including sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to expertise, and resilience.9, 10 Checklists and risk assessments are tools caregivers can use to help prevent, recognize, and mitigate harm.
In its enduring quest for safer operations, MedFlight began conducting risk assessments at the employee (partner) level in 2008 and includes a requirement for partners to conduct a shift risk assessment and ground transport risk assessment (sensitivity to operations, preoccupation with failure). For rotor-wing helicopter operations, a pilot risk assessment is performed following Metro Aviation, Inc. standards. Metro Aviation is contracted by MedFlight to provide aviation services including operational control (sensitivity to operations, preoccupation with failure, deference to expertise). During the summer of 2017, MedFlight began a process of evaluating and updating its risk assessment matrices for medical crew (sensitivity to operations, reluctance to simplify, preoccupation with failure) with a task force of safety committee representatives including nurses, paramedics, and a safety officer. The task force chose to evaluate MedFlight’s Shift Risk Assessment tool first (Figure 1). Brainstorming followed with sessions on purpose, criteria, language, and weighted values. Risk assessment tools from other CCT programs were reviewed (deference to expertise, reluctance to simplify) and a new tool was developed. MedFlight’s safety committee, risk manager and leadership team approved the deliverable (deference to expertise, sensitivity to operations, reluctance to simplify).
Each MedFlight clinical partner for all modes of transport initiates an electronic risk assessment at the beginning of each 12-hour shift and following each transport throughout the shift (preoccupation with failure, sensitivity to operations, reluctance to simplify, resilience). A new version of this risk assessment tool went into effect November, 2017. The new Personal Risk Assessment tool (Figure 2), replaces the Shift Risk Assessment tool. The task force believes this personal assessment with face validity represents a partner’s own analysis of their own risk based on their own unique features (deference to expertise, sensitivity to operations, reluctance to simplify). Following are changes:
- Criteria captures qualities which contribute to fatigue
- Language written in first-person makes the tool more personal
- New weighted values
- Weighted values calculate in the background by the computer information system
- Asks the partner to rate their activity level during the preceding 10 hours instead of the day before (MedFlight requires a partner to be off at least 10 hours between any and all employment)
- Asks the partner if they feel rested rather than assessing rest in units of time
- Modifies risk associated with number of days in a row the partner has worked to align more closely with the schedule a 12-hour shift worker may experience
- Colorizes gradation of risk. Output of this assessment to the MedFlight partner is a color (green, yellow, red), which corresponds to increasingly more risk. When a partner’s risk is red the partner takes crew rest (crew rest is consistent with long-standing MedFlight policy)
The Personal Risk Assessment tool is integrated into a computerized crew briefing form wherein the partner responds to each of the tool’s four questions. Responses can be amended until the data is saved. Once saved, the partner receives their risk color, their responses are fixed, and no further modifications are possible. While the output to the partner is a color (green, yellow, red), MedFlight’s computer information system captures data in the background so the organization can trend in the aggregate. By comparing risk colors with feelings of tiredness or fatigue, a partner can develop a sense of personal wisdom over time about how to best prepare for a work shift and manage their physical needs during a shift.
Next, MedFlight will revise its ground transport risk assessment matrix (Figure 3) for use by its mobile intensive care unit (MICU) and FlyCar teams and we look forward to sharing this process and tool. MedFlight FlyCars are sport utility vehicles located strategically throughout the state of Ohio and are activated as needed to ensure availability of quality critical care transportation and a timely response. Please look for future installments here…because…Safety Matters.
- Saysana M, McCaskey M, Cox E, Thompson R, Tuttle L, Haut P. A Step Toward High Reliability: Implementation of a Daily Safety Brief in a Children’s Hospital. Journal Of Patient Safety. September 2017;13(3), 149-152.
- Singh J, MacDonald R, Ahghari M. Critical events during land-based interfacility transport. Annals Of Emergency Medicine. July 2014;64(1), 9-15.
- Spradlin W, Kalmar T, McLaughlin D, Bigham M, Volsko T. Use of Ground Risk Assessment to Identify and Mitigate Risks Associated With Ground Critical Care Transport. Air Medical Journal. September 2016;35(5), 287.
- Jaynes C, Werman H, White L. A Blueprint for Critical Care Transport Research. Air Medical Journal. January 2013;32(1), 30-35.
- The national highway traffic safety administration and ground ambulance crashes. National Highway Traffic Safety Administration. April, 2014. https://www.ems.gov/pdf/ GroundAmbulanceCrashesPresentation.pdf. Accessed November 17, 2017.
- Huber M. HEMS industry getting safer. AINonline. 2016. https://www.ainonline.com/ aviation-news/business-aviation/2016-12-22/hems-industry-getting-safer. Accessed November 18, 2017.
- Greene M. 2012 Critical Care Transport Workplace and Salary Survey. Air Medical Journal. November 2012;31(6), 276-280.
- Kohn L, Corrigan J, Donaldson M, eds. To err is human: Building a safer health system. Washington, DC: Institute of Medicine; 1999
- Advice for Hospital Leaders. AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
- Innovation in pursuit of high-reliability culture. Patient Safety Monitor Journal. May 2017;18(5),1-4.