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Setting the Standard

By Vertical Mag

Story by Elan Head | Photos by Dan Megna | October 31, 2013

Published on: October 31, 2013
Estimated reading time 20 minutes, 36 seconds.

Relentlessly focused on self-improvement, UC Health University of Cincinnati Medical Center’s Air Care & Mobile Care is striving for new levels of clinical excellence and safety in helicopter emergency medical services.
On an electrocardiogram (ECG), each heartbeat is composed of distinctive waves that are identified by letters: P, Q, R, S and T. The ST segment is a slightly curved line that connects the S and T waves; it corresponds to a period when the heart’s ventricles are contracted, and normally lies along an ECG’s baseline. An ST segment that is higher than usual indicates a particularly severe blockage in the heart — a myocardial infarction, or heart attack — and ST-elevation myocardial infarction (STEMI) patients require immediate medical attention. The American Heart Association generally recommends that no more than 90 minutes elapse between the time a STEMI patient seeks medical attention and the time his or her cardiac blockage is cleared with a balloon — a procedure called percutaneous coronary intervention (PCI), or angioplasty.
PCI is the preferred treatment for most STEMI patients, but relatively few hospitals can perform it (in the United States, roughly a quarter of all hospitals have the capability; in Canada, the percentage is even lower). Consequently, many STEMI patients must be transferred from diagnosing facilities to hospitals where they can receive treatment. This is where helicopter emergency medical services (HEMS) would be expected to shine — time is of the essence for STEMI patients, and HEMS transport is often dramatically faster than transport by ground. Yet a widely cited 2010 study by researchers associated with the UC Health University of Cincinnati Medical Center found that simply adding a helicopter to the mix wasn’t enough to consistently achieve the American Heart Association’s 90-minute “door-to-balloon” standard. The researchers examined medical records for 179 STEMI patients that were transported by a UC Health Air Care & Mobile Care (ACMC) helicopter in 2007; of the 111 who received PCI, only four of them met the 90-minute goal. The median door-to-balloon time for these patients was actually 131 minutes — not because the helicopter was slow, but because it took the referring facilities so long to request a transport.
UC Health decided this wasn’t good enough. Working with other hospitals in the Cincinnati, Ohio area, it developed a “Code STEMI” protocol designed to significantly reduce door-to-balloon times. Previously, referring hospitals wouldn’t request a helicopter until they lined up an accepting cardiologist. Now, ACMC launches a helicopter or mobile intensive care unit ambulance as soon as a STEMI patient is diagnosed; if a specific accepting cardiologist and hospital have not been identified by the time the helicopter arrives at the patient’s location, ACMC will transport him or her back to the University of Cincinnati Medical Center for treatment, provided the patient and referring physician agree. According to UC Health, since the protocol was launched in 2011, Code STEMI has reduced door-to-balloon times by an average of 30 minutes — a tremendous benefit to optimizing the patient outcome, when every minute counts.
Code STEMI is a success story in and of itself, but it also exemplifies many of the things that make UC Health’s Air Care & Mobile Care unique. More than just a medical taxi service, ACMC is part of an integrated health system that leverages its world-class resources as an academic medical center to tangibly improve patient care. UC Health isn’t afraid to look for ways it can do better, and that relentless focus on self-improvement has led to far-reaching changes at the program, particularly in the last few years. Today, ACMC is pursuing its mission with two new, state-of-the-art Eurocopter EC145 helicopters, and a new partnership with Metro Aviation. And it hasn’t stopped striving: its unabashedly ambitious goal is nothing less than to be the recognized world leader in transport medicine; the standard by which others are measured.
A Different Model
UC Health University of Cincinnati Medical Center’s Air Care & Mobile Care was conceived as its founder’s master’s thesis project; it commenced operations in 1984 with a single ambulance and MBB Bo.105 helicopter. From the single-engine Bo.105, the program moved into twin-engine BK117 helicopters, which it operated for many years before bringing its twin-engine, glass-cockpit EC145s online in August and December 2012. Today, it operates the two hospital-owned EC145s and one leased BK117 from three air bases around the Cincinnati area (in addition to leasing a second, back-up BK117). As the most comprehensive air and ground medical transport program in the Greater Cincinnati region, it also offers three levels of ground ambulance transport: Basic Life Support, Advanced Life Support, and Mobile Intensive Care Units. In 2012, its approximately 140 transport specialists transported more than 1,000 patients by helicopter, and more than 10,000 by ground.
Now on the cusp of its 30th anniversary, ACMC has a legacy that stretches back to the early days of the United States HEMS industry. When the program started, “people didn’t know what a helicopter was from the standpoint of medical transport,” recalled Dr. Brian Gibler, who is now a professor of emergency medicine at the University of Cincinnati Medical Center after recently serving as its chief executive officer. From the beginning, ACMC elected to staff its aircraft with an emergency physician and a flight nurse; as a young resident physician, Gibler was the first doctor assigned to an ACMC flight shift.
ACMC’s medical staffing model persists today, even when most HEMS operators in the U.S. have adopted a flight nurse-flight paramedic model. (ACMC medical director Dr. William Hinckley, who is also president of the Air Medical Physician Association [AMPA], said that only six of the hundreds of HEMS programs in the U.S. routinely fly with physicians on board.) Flying with a physician offers clinical advantages in terms of the procedures and medications that can be administered during flight, and is in keeping with ACMC’s mission of bringing the world-class care of the University of Cincinnati Medical Center to the patient through advanced transport medicine. But the model has also become embedded in the Medical Center’s emergency medicine residency training program, the oldest in the world. Resident physicians begin flying with ACMC during the second year of their four-year residency; the unique opportunity attracts talented candidates from across the country, including some who would not otherwise consider Ohio. “Air Care is one heck of a recruiting tool,” said Hinckley, who was himself drawn to the University of Cincinnati Medical Center precisely for the chance to fly. “It provides an opportunity for residents to do something they really can’t do in other emergency medicine residencies.”
Ryan Gerecht, a fourth-year resident who is also ACMC’s assistant medical director, agreed: “Air Care is often referred to as the gem of the residency,” he said. Resident physicians bring not only clinical authority, but also enthusiasm and recent exposure to the very latest in medical technology and research. However, many of them also lack previous exposure to pre-hospital caregiving, which is where ACMC’s knowledgeable flight nurses come in. As some of the most experienced flight nurses in HEMS, ACMC’s nurses are able to fill in the residents’ knowledge gaps in the realm of providing critical care outside the hospital, while also gaining insights from their recent medical-school training. Said Hinckley, “The learning that goes both ways in that relationship is a very special thing.”
An exception to ACMC’s physician-nurse staffing model is made at the program’s third air base, east of Cincinnati, which will soon expand its operations from 12 hours per day to 24. Because of their other duties, the 52 residents currently in the University of Cincinnati Medical Center’s emergency medicine residency program weren’t sufficient to fully staff the helicopter at that base. So, Air Care 3 instead flies with a medical crew comprising a flight nurse and an advanced practice nurse, such as a nurse practitioner. The advanced practice nurse’s additional training brings with it additional clinical privileges, allowing ACMC to continue to offer an exceptionally high level of care. This staffing model is also fairly unique: ACMC is only the third program in the nation to utilize advanced practice nurses as a primary care provider on adult patient flight missions.
Guiding Principles
According to ACMC program director Teri Grau, ACMC has two guiding principles: “What is the safest way to accomplish this?” and “What is best for the patient?” As she explained, “If you follow these two guiding principles in your decision-making, you can’t go wrong.”
The question of what is best for the patient has guided the program’s clinical development in obvious ways, from its medical staffing model to the care it provides to patients. ACMC carries blood and hypertonic saline on every flight, and is continually adding new technologies, such as a portable ultrasound machine that helps crewmembers diagnose and monitor patients in the air. “There is no status quo to the care we give to our patients,” said Gerecht. “We carry medications that six months ago we didn’t carry, because we knew it was right for the patient.”
Yet this focus on patient care has also done much to shape the aviation side of the program, where it goes hand in hand with the emphasis on safety (as the safest way to accomplish something is almost always in the patient’s best interest, too). The dual concern for safety and patient care is the reason why ACMC has for many years flown larger, twin-engine helicopters, which offer both the security of an extra engine, and room for additional medical equipment and an extra caregiver or family member, as required. UC Health’s priorities are especially obvious in its new EC145s. Not only do these top-of-the-line aircraft incorporate safety-enhancing technology such as helicopter terrain awareness and warning systems (HTAWS) and traffic collision avoidance systems (TCAS), their medical interiors, completed by Metro Aviation, are nothing short of world-class. Fully customized, the interiors were designed with significant input from ACMC’s flight nurses and physicians, incorporating their collective years’ worth of insight into what works and what doesn’t in the back of a medical helicopter.
In addition to completing ACMC’s new EC145s, Shreveport, La.-based Metro Aviation now operates them, too. When UC Health recently put its aviation services contract up for re-bid, the winner was Metro, which began providing aviation services to ACMC on May 1, 2012. So far, UC Health is more than satisfied with the arrangement, seeing Metro as a “partner” that can help the program achieve its ambitious goals. “They are very closely aligned with our values,” Grau said of Metro, praising the company’s commitment to safety, service and industry leadership. “They have the same mission and vision.”
Bob Francis is Metro Aviation’s site manager at ACMC, having started with the program five years ago as a line pilot. He said that Metro’s experience and support are proving invaluable as the program pursues its next step toward enhancing safety and patient care: transitioning to instrument flight rules (IFR) operations. “Metro has a great training program in that respect,” said Francis, noting that ACMC’s pilots have been cycling through IFR simulator training with Metro at FlightSafety International’s Dallas, Texas, Learning Center. ACMC is pursuing the transition to IFR carefully and deliberately, but hopes to have an IFR program in place within the next year.
Although IFR operations are likely to enhance patient care by increasing the availability of the Air Care service, Grau said the primary driver for the move is safety. And there have been many other instances in which the question “What is the safest way to accomplish this?” has guided ACMC’s decision-making. For example, the program has been operating with night vision goggles (NVGs) since 2008, but a couple of years ago its BK117s (along with many other HEMS aircraft across the country) were temporarily barred from NVG operations when the Federal Aviation Administration discovered deficiencies in their NVG cockpit completions. Rather than simply returning to unaided night scene flights, as many programs did, ACMC worked with local first responders to identify and prepare designated landing zones for patient transfers at night. Recalled Grau, “We asked ourselves, how can we still do the mission in a way that doesn’t compromise air safety?” Ultimately, the program decided that taking the extra steps to mitigate risk was the best choice for patients as well as crews.

Support From the Top
According to program clinical manager Matt Gunderman, ACMC strives to maintain a non-punitive, safety-supportive “just culture” of shared accountability. It also encourages staff-driven safety efforts, and its many and varied safety initiatives reflect employee engagement at all levels of the program. For example, Gerecht, a recent MedEvac Foundation International scholarship winner, drew on his experiences at the Medical Transport Leadership Institute to help create a safety award that recognizes the outstanding safety commitment of two ACMC team members annually. Gerecht was also behind the creation of a publicly displayed safety declaration, which is voluntarily signed by ACMC team members as a reiteration of their dedication to the program’s core value. And flight nurse Dennis Schmidt, who is chair of the ACMC safety committee, researched, developed and implemented an employee safety perceptions survey, which he will be presenting at this year’s Air Medical Transport Conference in Virginia Beach, Va.
But while safety may bubble from the bottom up at UC Health, it also flows from the top down. Generally speaking, it’s rare for health systems executives higher than program directors to take much interest in HEMS operations, but University of Cincinnati Medical Center chief nursing officer (CNO) Jen Jackson was one of several senior leaders who made a point of talking to Vertical about ACMC. Since she assumed responsibility for the program three years ago, Jackson has invested long hours in learning its ins and outs — and with that has come a commitment to making its operations as safe as possible. Recalling her first ride-along with Air Care, to a scene call, Jackson said, “It was very overwhelming and eye-opening that first flight. . . . My world pre-Air Care and post-Air Care is totally different.” Now, she said, “I feel like I’m part of it — I’m not some senior leader, I’m not some CNO. I’m part of their team.”
That type of high-level interest and passion has been key to ACMC’s aviation and clinical advancement, which in recent years has been rapid — and accelerating. ACMC lead mechanic and longtime Cincinnati resident Jaison Kinser observed the program from afar for over a decade before joining it, and noted, “For years it seemed like the program was status quo. . . . There’s so much forward thinking now. Everyone is on board with the progression.” Not only does the program have new aircraft and a new aviation vendor, it is actively expanding its reach. ACMC will soon be moving the EC145 that is based at the University of Cincinnati Medical Center to a new base farther south, which will shorten response times for patients in the program’s current service area, as well as allow it to serve new patients in northern Kentucky. Additionally, UC Health recently started flying medical crews from Cincinnati Children’s Hospital Medical Center — ranked as the number three children’s hospital in the nation — to better serve the region with pediatric and neonatal transport services.
UC Health is also looking beyond its own program, seeking ways to help promote safety and clinical excellence in the community and in the HEMS industry at large. ACMC has always had a strong tradition of community service: last year alone, its special event crew provided more than 2,100 hours of non-subsidized medical services at 150 events; and its flight physicians serve as medical directors for more than 20 regional fire and EMS departments, conducting hundreds of hours of medical education per year. ACMC personnel are also active in many industry organizations, with Grau, for example, serving as a Commission for the Accreditation of Medical Transport Systems (CAMTS) site surveyor, and clinical manager Ruda Jenkins acting as the vice president of the Ohio Association of Critical Care Transport (OACCT). Recently, Hinckley has been active in a project to develop benchmarks for the HEMS industry that can be used to identify and refine clinical best practices. “Right now there really don’t exist any significant clinical, apples-to-apples benchmarks — that’s a problem for our industry,” he said. “I do think that this AMPA Metrics Project will have far-reaching implications that will help our patients.”
All of these activities support the University of Cincinnati Medical Center’s overarching mission, which is to deliver life-changing patient care. And, as an integral part of the UC Health system, ACMC has the luxury of evaluating its clinical and financial success in a broader context than individual transports. “The thing that I think is special about this program is that it’s very medically focused,” said Diana Deimling, a flight nurse who has been with the program since it started, in 1984. “There’s never been a clinical decision I’ve made that’s been financially based.”
That legacy, combined with current levels of institutional support and the enthusiasm of its management and staff, bodes well for ACMC as it pursues its goal of becoming the standard by which other HEMS programs are measured. “We’ve come a long way, but there’s much more to be done,” said Hinckley. “I couldn’t be more excited about it. In a lot of ways, we’re just getting started.”

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