Transport Program Standards and Law

In depth

The one-page summary above is what the PDF prints. These sections go further.

Accreditation: what it is and what it is not

CAMTS describes itself as a peer review organization. Its standards are voluntary, a surveyor compares the program with them on a site visit, and the decision rests on substantial compliance rather than meeting every criterion. A program is judged against its own mission statement and scope of care, whether that is BLS, ALS, critical care or specialty care.

Accreditation sits on top of the law rather than replacing it. The program still needs state licensure (or the local authority having jurisdiction) for each vehicle, and the aircraft operator still works under FAA rules; CAMTS notes that its standards often go further than what the authority having jurisdiction requires.

Crew composition and experience

A CAMTS critical care team has at least two licensed clinicians at the patient, plus the pilot or driver. At least one of them brings 3 full-time years of critical care experience, which CAMTS counts as at least 4,000 hours in an ICU or emergency department, and each clinician must already have training or experience with the drugs and interventions within the program's scope before hire.

The medical director and clinical leaders qualify each applicant and can set higher minimums for their own scope of service. The transport certification is required after hire, not at the time of hire.

Fatigue and shift length

CAMTS treats crew fatigue as a safety hazard. Whatever the shift length, a crew member who judges himself or herself, or a partner, too tired to work safely can stop for rest, and the program may not punish or pressure that person. Managers watch call volume and how often time outs are used, and the program has a fatigue-risk management system.

A base that is busy (1 or more transports a day), close to where crews live, or that gives less than 10 hours of rest does not qualify for routine shifts longer than 24 hours, even if it meets the 12-hour rules.

Communications center and flight following

Requests for a transport, whether from a 911 center, another agency or a hospital, go to the program's communications center. A program may not self-dispatch, and a caller should not ring a base directly for a response. A crew member who gets such a call redirects the caller to the communications center, which documents the initial coordination (time of the request, the requesting agency and its phone number, patient age and problem, referring and receiving physicians and facilities, acceptance and bed availability) and then runs flight following.

The center records all phone and radio traffic in both directions, time-stamped and available for instant replay. CAMTS requires keeping recordings at least 90 days and strongly encourages 2 years, because complaints, reviews and claims often arrive months later. Meeting minutes have a separate rule: kept at least 3 years.

Each program has a post-accident/incident plan for an overdue or missing aircraft and drills it at least every 6 months, with at least one daytime and one nighttime drill each year.

Medical direction and crew scope

The medical director answers for the clinicians' competence and has to understand their scope of practice and the regulations that govern it. The program designates and orients on-line medical direction physicians, who can be reached at any hour and must know enough to guide care for each kind of patient the program accepts.

When the on-line physician lacks experience in an area (an LVAD or ECMO patient, for example), CAMTS expects prompt consultation with a suitable designated physician or the receiving attending physician, rather than improvising from a general protocol.

A transport clinician works within his or her license, credentialing and the program's protocols, even when a sending physician asks for more. The usual step is to explain the limit and contact on-line medical direction to agree on a plan (an alternative within protocol, a different crew, or a sending clinician who travels with the patient), and to document the consultation. Under EMTALA the sending physician decides the mode, equipment and attendants, so a mismatch between the patient's needs and the crew's scope is worked out between physicians.

Patient care standards on long transports

For transports longer than 2 hours, CAMTS asks programs to have written policies to prevent pressure ulcers or limit their impact. Skin is checked and the findings recorded before departure, during the trip and after arrival, with padding, positioning or other pressure relief used as needed. A recorded baseline before departure shows whether an injury existed before the flight; checks during the flight find pressure from tubes, straps and cuffs.

Utilization review, briefings and debriefs

Utilization management asks whether the patient needed this mode and team; quality management asks whether the care was good. CAMTS encourages a structured periodic review of transport appropriateness, which may be prospective, concurrent or retrospective, with feedback to requesting agencies.

• Discharged home directly from the emergency department
• Moved with no IV access and no oxygen
• Already in cardiac arrest with CPR under way at the referring site
• Scheduled (non-urgent) rotor-wing flights
• A second transport for the same illness or injury within 24 hours
• Scene flights for patients who fall outside the applicable triage guidelines
• Patients treated by the team but not carried
• Interfacility flights to a hospital offering no higher level of care

These are examples from the longer CAMTS list of findings that may prompt a review of whether a transport was medically appropriate; others include an inappropriate vehicle or team for the patient. Emergency transports do not need a guaranteed payment first; for non-emergency requests, callers are helped with cost, insurance and cheaper equally appropriate options.

Shift briefings at the start of each shift bring clinicians, pilots or drivers, communications and maintenance together. Every transport ends with a debrief; the communications specialist joins when communication was part of the problem and maintenance when the vehicle was, and the debrief is saved on paper or electronically and tied into the quality reporting system. An informal hangar conversation with no record and no communications specialist does not meet that standard.

EMTALA: who owes what

EMTALA duties fall on hospitals that participate in Medicare, including critical access hospitals. A hospital with a dedicated emergency department must give anyone who comes to it a medical screening examination and, if an emergency medical condition exists, stabilizing treatment within its capability or an appropriate transfer. The transport team carries out the transfer; the sending hospital remains responsible for making it appropriate.

A hospital may follow reasonable registration, including asking whether the patient is insured and with whom, as long as the question does not delay screening or treatment and does not discourage the patient from staying. It may not seek insurer authorization until after the screening examination and the start of stabilizing treatment. CAMTS holds the same line for transport: emergency transports do not require a guaranteed payment.

CMS interpretive guidance adds that a hospital whose helipad is used only as a transit point does not take on an EMTALA duty, unless the patient deteriorates there and the accompanying crew asks for help, and that a receiving hospital may not make acceptance depend on a particular transport service: the sending physician chooses it.

EMTALA: transferring an unstabilized patient

Stabilized has a legal meaning: within reasonable medical probability, no material deterioration is likely to result from or occur during the transfer. It is a judgment about the trip, not a cure. Once a patient is stabilized, EMTALA's transfer restrictions no longer apply, so a splinted fracture with normal perfusion and vital signs can be moved at the patient's request without a certification.

For a pregnant woman having contractions, an emergency medical condition exists when there is not enough time for a safe transfer before delivery or the transfer may threaten her or the fetus. Labor runs from the latent phase through delivery of the placenta, so she is stabilized only after the child and placenta are delivered; an earlier move is an unstabilized transfer and needs the crew and equipment to manage a delivery en route.

The patient's informed written request is a separate ground from physician certification, so it does not depend on a physician agreeing that benefits outweigh risks; the transfer must still meet the appropriate-transfer conditions. The CMS guidance notes that EMTs are not always qualified personnel for a given patient; the sending physician decides who must go.

EMTALA: when it starts, ends and is reported

If the hospital screens a patient, finds an emergency medical condition and admits the patient as an inpatient in good faith to stabilize it, its EMTALA duty ends. Care and any later transfer of that inpatient are governed by the hospital conditions of participation (42 CFR part 482), not by EMTALA, and a specialized receiving hospital's duty to accept does not cover inpatients of another hospital. Observation status is not an inpatient admission.

A hospital with specialized capabilities or facilities, such as a burn unit, shock-trauma unit, NICU or rural regional referral center, may not refuse an appropriate transfer of a patient who needs those capabilities when it has the capacity to treat the patient, whether or not it has an emergency department. Payment source plays no part. Capacity includes staff, beds, equipment and the hospital's past practice of making room.

A hospital may not penalize a physician or qualified medical person who refuses to authorize an unstabilized transfer, or any employee who reports an EMTALA violation. Separately, a hospital that has reason to believe it received a patient transferred in an unstable condition in violation of the rule must report it to CMS or the state survey agency. HIPAA permits disclosures to health oversight agencies for investigations authorized by law.

Consent and surrogates in transport

When a decision is urgent, the patient cannot take part and no surrogate is available, treatment can start without prior consent. That presumed consent is a bridge, not a substitute: the patient or surrogate is told at the earliest opportunity and consent is obtained for ongoing treatment. In flight this can mean a phone or radio patch with a family member who arrives at the sending hospital, routed through medical direction, with the time, the explanation and the decision documented.

The agent the patient named in a durable power of attorney for health care comes first, then family or others as state law and policy allow. The surrogate is owed the same respect as the patient, and clinicians give the surrogate advice, guidance and support.

A contemporaneous decision by a patient with capacity outranks an older advance directive or POLST. The California POLST form, for example, lets a patient with capacity revoke it at any time by any means that shows the intent to revoke, so a new form is not needed first; the crew confirms capacity, follows the current wish, documents the revocation and tells medical direction and the receiving team. States differ in the details.

Truth-telling and ethics consultation

Outside an emergency in which the patient cannot make an informed decision, withholding information from a patient without her knowledge or consent is ethically unacceptable, even at a family member's request. Disclosure can come over time, matched to what the patient wants to know and can take in, and a patient may ask not to be told certain things. The transport clinician asks how much she wants to know, answers truthfully within his or her knowledge, and may leave detailed prognosis and surgical risk to the treating specialist.

An ethics committee or other institutional resource is consulted when no surrogate is available, when there is a dispute over who the surrogate is, when disagreement about treatment cannot be resolved, or when the clinician judges that a surrogate's decision clearly departs from what the patient would have chosen, is not in the patient's best interest, or mainly serves someone else. AMA guidance likewise sends a conflict between an advance directive and the surrogate's wishes to an ethics committee. A request for a transport that the patient's own directive refused is such a case: consult before arranging the flight, rather than simply obeying the agent or overriding him.

Transport documentation

CAMTS sets a minimum for what the patient care record contains, and the receiving facility keeps a copy for continuity of care. In summary:

• Why the patient is moving, the history and the exam
• Vital signs on arrival and repeatedly through the trip; with an advanced airway, waveform EtCO₂ is part of every set; temperature, pain score and other assessments as the program specifies
• What was given or done, fluids in and out, and how the patient responded
• Ventilator settings at the start and each time they change
• Relevant imaging and lab results on interfacility transports
• Signatures of all clinicians, which clinician gave each drug and did each procedure, and which one wrote the entries
• Sending and receiving facilities and the name of the person who took report
• The patient's condition at altitude checkpoints set by the program

EtCO₂ values belong in each set of periodic vital signs for an intubated patient, not only at tube confirmation. One crew member may act as recorder, but each entry must show who did the work; a co-signature or a note that care was shared does not meet the standard.

Care is documented when it is given, never before. A late entry carries the date and time it is written and its author, states when the care was actually given, and is permanently marked as a late entry; writing it into an earlier time slot makes the record misleading. CMS review guidance also flags excessive late entries and obliterated or altered entries as warning signs. A dose given just before handoff is also passed to the receiving nurse, because it affects the next dose.

Records are stored by hospital or agency policy and privacy rules. CAMTS favors a permanent electronic record and accepts scanned paper, so downtime paper charts are scanned into the permanent record. Re-typing a chart and shredding the original removes what was written at the time of care.

Splitting the intervals shows where time is lost: a long bedside time points to packaging and preparation; a long at-patient interval points to getting from the vehicle to the patient.

Quality improvement tools

IHI's own balancing examples: when shortening time on the ventilator after surgery, watch reintubation; when shortening length of stay, watch readmissions. Data are plotted over time.

Error analysis can look back or ahead. Root cause analysis looks back at a serious event to find the underlying system problems rather than blaming individuals. Failure mode and effects analysis (FMEA) looks ahead: the team maps every step of a new process, asks how each step can fail, how likely the failure is to be caught and how much harm it would cause, and redesigns the riskiest steps before patients are exposed. FMEA fits a new process such as carrying whole blood; run charts and peer review come after launch.

Reading research

Evidence-based practice means decisions based on the best available, current, valid and relevant evidence, informed by the knowledge and experience of the clinicians and made with the patient's values and preferences, within the resources available. It is not following the newest study regardless of context, a director's preference, or rigid protocol. Its five steps: ask an answerable question, find the best evidence, appraise it for validity, relevance and applicability, apply it, and evaluate the result.

Number needed to treat (NNT) is 1 divided by the absolute risk reduction (the difference in event rates between groups), and by convention it is rounded up to the next whole number. A risk difference of 0.12 gives 1 ÷ 0.12 = 8.3, so NNT 9. It is the expected number of patients treated with the intervention rather than the comparator for one more patient to avoid the event over a stated time frame, so report it with the time frame and comparator.

Read the effect estimate together with its 95% confidence interval. The interval excludes the null value (a relative risk of 1.0) only when P is below 0.05. A large P value is often misread as proof of no effect: an interval running from a useful benefit to a small harm means the effect is uncertain, not that the treatments are equal. Equally, a small P value does not by itself mean the benefit is important.

Under the Common Rule (45 CFR 46.116), research consent begins with concise key information and includes that the study is research, its purpose, duration and procedures, foreseeable risks, expected benefits, alternatives, confidentiality, whom to contact, and that participation is voluntary, that refusing carries no penalty or loss of benefits, and that the participant may stop at any time. Consent may not contain language that waives the participant's rights or releases investigators from liability for negligence, and it is sought when the person has enough time to consider and the chance of coercion is small.