By Jeff White, M.S., MTSP-C, FP-C
Director of Safety
HealthNet Aeromedical Services
The National EMS Health and Safety Officer committee has been diligently
working for the past year in conjunction with the National EMS Management
Association (NEMSMA) to create a model for EMS agencies to use in selecting
a dedicated safety representative. NEMSMA already has certified and tested
positions for an EMS Director, EMS Manager, EMS Supervisor and has almost
completed the EMS QA/QI position. Now they are moving onto safety. Our
committee currently has the position description and position personal attributes
completed. We are currently in the process of creating the test model and
discussing what materials one might study or learn to achieve this position
We have based our test model on the Board of Certified Safety Professional’s
(BCSP) Associate Safety Professional (ASP) model. We have begun the process
of incorporating EMS specific modalities into this general safety model to make it
relevant for an EMS individual. Many agencies will most likely choose someone
with EMS experience, but others across the country have already begun to
incorporate general industry safety professionals into their system for a broader
look at safety processes. We hope the final model will increase the professionalism
of the position along with the industry.
MedComm: Columbus’ Air Medical “Air Traffic Control”
Amanda Ball, Safety Officer
Columbus, Ohio, is home to several trauma centers, burn centers, hyperbaric chambers, and hospitals offering the best in specialized care. Because of this, air medical traffic in central Ohio is often congested. With 9 helicopter teams positioned throughout Ohio, MedFlight is often in the air across the state and potentially crossing paths with other air medical programs in the area.
Since its inception, MedFlight’s communication center, MedComm, has been proudly located in Columbus. These local and highly-trained experts are available 24/7 for your safety needs and have impressive experience in aviation, 911 dispatching, EMS, military service, nursing, and air medicine.
For decades, MedComm has provided flight-following and flight monitoring services for not only our teams, but for other air medical programs visiting central Ohio hospitals as well. With safety as our top priority, MedComm acts as “air traffic control” for all inbound and outbound aircraft in the greater Columbus region. This initiative began as part of a partnership with the Central Ohio Trauma System to help prevent “traffic jams” over hospital helipads, flight paths crossing, and potential near-misses in an already congested urban airspace.
If you work at an agency that transports into the Columbus area, we ask that you contact MedFlight MedComm so we can not only alert other flight teams and hospital security teams of your intended flight path, but we can keep an eye on YOUR safety as well. This needed communication process is broken down into a few simple steps:
Have your dispatch center call MedComm with your flight path and an ETA. MedComm can be reached 24/7 at 1-800-222-5433.
Once you are 15 minutes away from your Columbus destination, contact MedComm on the radio. Most visiting flight programs contact MedComm on 155.400 PL 141.3, but you are welcome to contact us on MedFlight’s MARCS channel, labeled as MEDFLT. They will relay any air medical traffic you need to look out for in the area during your mission.
Columbus is also home to several touring, media, and law enforcement helicopters, 3 major airports, and visiting air traffic (banner planes, blimps, etc) during special events. Please announce your intended flight path and altitude to air traffic on Unicom 123.025 when you are entering Columbus airspace.
Along with overseeing air medical traffic, MedComm is more than happy to assist your teams with their operational needs, like arranging for extra personnel to be waiting on your arrival for patient unloading, contacting your dispatch center if you are out of range, etc.
With your help, we can maintain a safe flying culture in the Greater Columbus area and around Ohio. #PartnersForLife
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.
In my 16 years in EMS, I have never met a first responder who wasn’t unwaiveringly dedicated to their job and to serving others. Taking that extra 911 call, picking up that extra shift, waking up in the middle of the night when the tones drop, pouring that extra cup of coffee as to prepare for a long transport. I’ve been there myself. And I’ve come home to my family at the end of a long a strenuous shift, kissed my kids, and went to bed… exhausted.
Odd schedules, odd hours, odd circumstances innately lead to odd sleeping patterns. But what about fatigue? What is fatigue? “A subjective, unpleasant symptom, which incorporates total body feelings ranging from tiredness to exhaustion, creating an unrelenting overall condition which interferes with an individual’s ability to function to their normal capacity.” What this translates to: “You are so tired that you are not making great decisions.”
I had never heard of ‘fatigue management’ until I began my career in critical care transport over 12 years ago. There were so many proactive measures and systems in place at MedFlight to respect and PREVENT fatigue that I lost count as I learned them all. Among those is a “Crew Rest” feature, where the team can take themselves out of service for a period of time to rest. We want healthy and alert clinicians taking care of the sick and injured. Listing every fatigue management system at MedFlight would make this article 4 pages long.
Let’s look at fatigue from a different angle:
A friend of mine, who does not work in this industry, just had his NORMAL work week increased to 72 hours a week, indefinitely. Six 12-hour shifts in a row, with one day off inbetween (and he is asked weekly to work that day as well). He works in an industrial setting working with very large machinery. As he talked about it, I found myself drawing a lot of parallels to OUR industry and how fatigue, burn out, and the drive to “get more done, place production over safety” can quickly threaten the well-being of medical transport crew members.
Talk with your teams: Could this lead to fatigued decision making? Could this lead to machinery failure? Could this lead to injury, or worse?
What would the potential risks be if we required our crews to work a similar schedule? What tools are in place at YOUR organization to mitigate against fatigue and burn-out? Which of those practices could proactively be placed in my friend’s work setting that would mitigate fatigue and potential errors?
Take time to review the safety measures at your organization that discuss fatigue and burn-out. In addition to having systems, practices, and beliefs in place that promote a safe working cultures, The Commission on Accreditation of Medical Transport Systems (CAMTS) recommends ongoing training on the topics of sleep deprivation, sleep inertia, circadian rhythms and recognizing signs of fatigue.
We work in an industry that needs us at our healthiest so we can help those who need us most. In addition to that, we have families at home who depend on us. Respect your fatigue level, and find a balance that maintains your health and well-being…it’s a matter of safety.
“Evidence-Based Guidelines for Combatting Fatigue in EMS”, Daniel Patterson, PhD, MPH, MS, NRP
“Fatigue: A concept analysis. Int J Nurs Stud.”, Ream E, Richardson
CAMTS Standards and Policies, 10th Edition. http://www.camts.org
It’s 0800 hours… You are starting your shift on this cold, bitter morning. You
call the Communications Center to let them know the crew is in for the day.
The communicator advised it looks like it is going to be a busy day.
After your morning brief, you and your crew head out the door for your first flight request. You quickly check the equipment, do your walk-around, and are on your way.
The day is very busy, and eventually, you find yourself on the way back to base after trip number seven. And it’s only midnight.
Five minutes out from base, you hear the familiar voice on the radio with
another request, and off you go again. You look at your watch and notice that it’s
going on 0020; This trip seems like it will take forever. You look out your window,
and everything goes dark.
Wakening up covered with debris, still strapped to your seat, in the woods, darkness all around, silence surrounding you. You don’t know where you are or how you got there. You check your body, luckily no major injuries. You look around trying to figure out what happened. “Why am I in the middle of the woods sitting in a seat with no sign of anybody, just pieces of the wreckage?” You call out, getting no response from anyone.
You start to panic, your breathing labored, trying to get up out of your seat, realizing that you’re still strapped in. You get unbuckled and crawl from the debris… Still trying to comprehend, asking the same question “What happened?!” over and over in your mind.
As you’re calling out for your crew, you notice the time:
0045. You need to get help and fast. You try your cell phone, no service. Radios are broken. Twenty minutes goes by without word from your crew. You are desperately trying to get help with no success. “Boy it’s getting cold out here” you tell yourself while panicking and heart racing, still looking for your crew. Is anyone coming? Does anyone know where we are? What happened? Where is the survival pack?
This story has two endings, one with the program director telling your family
the bad news, and one with a story of survival. You have the choice!
Let’s seewhat happens with the first ending.
You can’t find the survival pack or your crew. You don’t carry anything in your pockets except medical equipment. The sounds of a helicopter emerge overhead, but they are unable to see you. Two days later, you’re found frozen to death… fifty feet from your crew. Days later, at your services, the person chosen to give your eulogy stands up and quotes a line from Prince: “Dearly beloved, we are gathered here today to celebrate this thing called life.” Not a very good outcome. Let’s try the second ending and see what happens.
You reach into your pocket and pull out your personal survival kit, locating your flashlight and your crew. Your crew is alive, but injured. You are able to get a fire started with your fire starter to keep warm. As you start walking around to gather more
firewood, you find the vehicle survival pack hanging in the trees. Returning to build a shelter to protect yourself and your crew from the weather, you hear a helicopter emerge overhead. It’s time to put your signaling skills to work. As you make the fire bigger, your crew uses the flashlight to signal the aircraft. Ten minutes later, rescue crews arrive to prepare you and your crew for transport to the ER for treatment. Do these scenarios make you think? It has all happened before, you know!
No one believes it will happen to them. Do you carry a personal survival kit? Do you know how to use it? How about the vehicle survival kit, do you know what’s in it and how to use it? What would happen if you crashed, do you have on your person what you need to survive?
Now is a good time to check your survival kit. See what you have to work with, and be sure you check all the contents of the pack on a routine basis. If it doesn’t work, it will not do you any good. If you do not have a personal survival kit… then get one. Only plan on what you have on your person to survive.
Well what do you think? Are you prepared for a survival situation? Will you
Between a Rock and a Hard Place: Integrating Change Across the Healthcare Industry Jeff White, M.S., MTSP-C, FP-C Director of Safety, HealthNet Aeromedical Services
Attempting to get in front of the coming changes to EMS as an industry and implement safety regulations from aeromedical, general industry, transport and healthcare is no easy feat.
We have faced a multitude of challenges attempting to change the culture and mindset of EMS providers being guided by the National Strategy for an EMS Safety Culture released in 2013 by NHTSA and NEMSAC. It appears that EMS, as an industry, is going to be required to lead the charge in evolving the mindset and culture of hospitals and the insurance industry to advance all the needed safety and operational changes for EMS providers.
When EMS began, it was merely a transport service with very little focus on bettering patient care. Over the last 40 years, our mission and responsibilities have dramatically changed and continue to grow. While our operational scope has changed, the insurance industry and hospitals view of us has changed very little.
We must get them to invest in our process as we begin molding our industry into mainstream healthcare and away from just strictly transport. This will ensure a
strong working partnership that will ultimately benefit our patients and EMS field
The other hurdle we will face is regulation. There is no single agency governing EMS. We as an industry must come together and assist in the development of a governing body before it is done for us. Among the organizations trying to take the lead are AAMS, NAEMSMA, NAEMT and NREMT. The challenge is getting all these agencies on the same page. We need to find a way to take care of ourselves which will lead to even better care of our patients. Isn’t that why we all got into this?
Karen Swecker, RN, CIC Exposure Control Liaison, MedFlight
An important part of safety operations is keeping patients safe from easily transmitted bacteria. The aircraft, just like the ambulance, becomes easily contaminated with many different potentially pathogenic bacteria: MRSA, VRE, C. difficile, and all the other multi-drug resistant organisms (MDROs). It is important to decontaminate the aircraft after
each patient transport as well as complete weekly deeper cleans.
Decontamination means the removal of or neutralizing bacteria from surfaces and objects. The decontamination process starts by wiping all surfaces to physically remove any debris. It is important to read the labels to ensure the products used are safe for the surfaces. For example, saline could be used to wipe down surfaces, but it is damaging to instruments.
A surface that isn’t cleaned, but is wiped down with a disinfectant, is not decontaminated. If a blood glucometer is not cleaned of dried blood and just wiped down with a disinfectant, it can still cause potential infections. Hepatitis B remains infectious in dried blood for at least seven days. Surfaces must be thoroughly cleaned before any disinfectant is applied.
Have someone observe your process. Were you wearing gloves to provide patient care and then touched the radio control knobs or control box to give a report? If so, you have just contaminated the radio with bacteria from the patient. Gloves, like bare hands, easily transfer pathogens from surface to surface. After transfer of a patient, make
sure to wipe all surfaces not in direct contact with the patient such as door handles, sled knobs, chin straps and the sides of helmets.
When choosing a disinfectant, make sure to thoroughly read the instructions to ensure you are properly using the product. Labels will list what type of disinfectant is in the product, what type of bacteria is killed and how long it takes to kill. A product listed as tuberculocidal will kill Mycobacterium within the time limit listed. While Mycobacterium is not transmitted from surfaces; these bacteria are very hard to kill.
The standard is if Mycobacteria is killed, all other bacteria will also be eliminated within the same time frame.
The one exception to this is highly transmissible Clostridium difficile (C. diff). Hand sanitizer is not effective; therefore, care providers must wash hands with soap and
water. A bleach product must be used to effectively kill C. diff on surfaces. Unfortunately, bleach is very corrosive to many surfaces and care should be taken. Check equipment manufacturers before using a bleach product. Bleach products should NOT be used on surfaces in aircraft. When transporting a patient with diarrhea, make sure to
change gloves frequently and do not touch any surface with gloves used for patient care.
A few resources available for reference: The Guide to Managing an Emergency Service Infection Control Program, U.S. Fire Administration http://www.usfa.fema.gov/publications Infection Prevention and Control Guidance for EMS Providers, Metropolitan Chicago Healthcare Council http://www.APIC.org