Interfacility Helicopter Transports

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The majority of air medical transports are interfacility. It is surprising to note that there have been few studies on the benefit of interfacility air medical transports. A recent study from Norway on 370 interfacility helicopter transfers found that positive benefit could be judged in only 11 percent of patients, and almost all of the total additional life-years gained from such transport was confined to only 9 patients. 20 Benefits were most often seen in neonates, children with infection, and adults with cardiovascular disease. While some adults with trauma benefited from the interfacility helicopter transfer, the total additional life-years gained was very small. Published studies in the United States have usually focused on acute myocardial infarction and unstable angina. 2122 These studies have not found a positive benefit of interfacility helicopter transfer over ground ambulance.

The Federal Emergency Medical Treatment and Active Labor Act (EMTALA), originally passed in 1985 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) and strengthened through amendment in 1989, directed the Health Care Financing Administration (HCFA) to develop regulations concerning the examination, treatment, and transfer of individuals with emergency medical conditions. The final interim rule issued by the HCFA in 1994 contains a prohibition against the transferring physician's having a patient transported to a medical facility with a lesser or inadequate level of care en route. Thus, if the patient is unstable or requires intensive care during transport, then it is not appropriate to use a BLS ambulance. The position paper from the Air Medical Committee of the National Association of EMS Physicians states: "Reducing out-of-hospital time for these patients seems to be in their best interest. Ground-based out-of-hospital care providers, faced with a patient whose needs obviously exceed their abilities, may wish to access a rotor-wing air medical transport service, especially if they are distant from an appropriate medical facility."18 This position is strengthened by the literature, which suggests that a tertiary center can extend its care out to several hundred miles via rotor- or fixed-wing aircraft with no change in mortality compared with patients transported locally to the same trauma center. 23 However, air medical services may violate certain EMTALA sections by transporting "unstable" patients (as defined by the regulations) and bypassing closer "appropriate" hospitals in order to return to their base hospital.24 The issue is complex, the regulations are vague, and case law is limited to date.

In this regard, then, air medical care and transport protocols should operate to ensure that the patient is transported with the highest appropriate level of service and to the closest appropriate hospital.

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