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Remarks to the American College of Emergency Physicians Meeting, Boston, MA
Robert L. Sumwalt
Boston, MA

I want to thank ACEP for the invitation for me to speak to you today about the National Transportation Safety Board’s activities and recommendations related to the Helicopter EMS (HEMS) industry.

I want to begin by first highlighting the good news: HEMS operators safely transport nearly 400,000 patients annually across the United States. They provide a vital function within our health care system, providing critical care to victims of trauma, transferring at-risk patients between institutions, and transporting medical personnel to facilitate life-saving organ transplants.

The HEMS industry’s current record for safety, however, is simply unacceptable. In the last six years, 85 HEMS accidents have occurred, resulting in 77 fatalities. 2008 itself was the deadliest year on record for HEMS fatalities, as 29 individuals lost their lives. It’s clear that a paradigm shift within this industry is needed.

We were optimistic that we had turned a corner of sorts, as we saw 49 weeks elapse without a fatal HEMS accident. - until two weeks ago. On September 25th, a Eurocopter AS-350 crashed in my home state of South Carolina as it attempted to divert after encountering inclement weather. All three crew members aboard – a pilot, flight nurse and paramedic – were killed.

In 2006, the NTSB undertook a Special Investigation Report on accidents involving aviation EMS operations. We analyzed 55 accidents: 14 fixed-wing aircraft flights, and 41 helicopter flights. Our investigators determined that 29 of the 55 accidents analyzed could have been prevented, if the corrective actions recommended in the report had been implemented. These tragic accidents, and the lives lost because of them, were preventable.

As a result of the Special Investigative Report, the NTSB made four recommendations to the FAA. These recommendations called on FAA to require that all legs of EMS flight missions conducted under the enhanced safety regulations of Part 135; that all EMS missions undertake a formalized flight risk evaluation, and utilize flight dispatch procedures; and, that all EMS operators equip their aircraft with Terrain Awareness and Warning Systems (TAWS). Last year, the issue area of HEMS safety was added to the NTSB’s “Most Wanted List” of transportation safety improvements, and with that addition, these recommendations were added to the list.

In February of this year, I had the privilege of serving as Chairman of an unprecedented four-day public hearing by the NTSB into the safety of HEMS industry operations. We heard from 41 witnesses from across a broad spectrum of industry stakeholders: HEMS operators, industry associations, manufacturers, and health care professionals like you.

This hearing resulted in the Safety Board adopting 21 additional safety recommendations last month. Of these 21 recommendations, 10 were issued to FAA, two to Federal Interagency Committee on EMS (FICEMS), five to 40 publicly-operated HEMS organizations. While these recommendations included many vital safety enhancements – such as the use of night vision imaging systems and autopilot technology – it was the four recommendations issued to the Centers for Medicare and Medicaid Services (CMS) on which I’d like to focus right now.

The NTSB recommended that CMS evaluate the HEMS reimbursement rate structure to determine whether rates should differ according to the level of HEMS transport safety provided. Even further, we recommended that minimum safety accreditation standards for HEMS operators be developed and that Medicare reimbursement be provided only to those operators who meet the standards. CMS accreditation would by no means be required for HEMS operators to conduct business; but it would serve as a precondition to transporting and caring for patients participating in the Medicare program.

These recommendations represented new territory for the NTSB; never before had we issued recommendations to a health care organization that cut to the heart of its system of reimbursement. We recognized, however, the shocking disparity in HEMS safety that exists from operator to operator across the country. Not every HEMS operator is created equally: a city – or even a single hospital – may be served by multiple HEMS providers, each of whom operate aircraft that differ widely in age and equipment, and employ flight crews that differ in experience and training. Despite this divergence in the level of service, though, current Medicare reimbursement rates are the same for all operators. I think you will agree that every Medicare patient deserves the same basic guarantee of safe transport; CMS, as the federal agency acting on their behalf, deserves to require such a guarantee of every operator making a claim on the federal reimbursement dollar.

More importantly, these recommendations were a recognition of the daunting obstacles posed by the bureaucracy of the federal regulatory process. While the FAA is certainly empowered to mandate the NTSB’s recommendations of safety technologies and practices for all HEMS operators, it is not required to do so. Moreover, even those recommendations that the FAA chooses to implement face a prolonged process of rulemaking, public comment and rewriting - a process that can extend for many years. In the interim, Medicare patients would remain at the mercy of HEMS operators to simply comply with basic Federal Aviation Regulations (FARs), a level that is represent a ceiling on their commitment to safety. CMS is in a position to effect immediate change, outside the lengthy rulemaking process.

CMS, however, is not the only party empowered to bring about a higher level of HEMS safety. Medical professionals who fly on, dispatch or administer HEMS programs – many of you in this very room – are stakeholders in safety just as much as the patients they fly. Faced with traumatic accidents and injuries, your patients cannot make informed choices about which HEMS operators transport them to you; they rely on you to make those choices for them, and in this case, knowledge is power. You can demand that your practice, your hospital, your organization work only with operators who have committed to implementing the highest degree of safety. Certainly, you can expect resistance: the common refrain that it’s “just too expensive” to outfit EMS aircraft with autopilot or TAWS technology. Think for a moment, though, about the costs associated with just one accident: the loss of lives, both patients and emergency personnel; the loss of aircraft; the loss of your ability to provide emergency services to your community. It is crucial that you collectively send a message to your health care administrators, that you will no longer accept the status quo.

It is a false choice to pit safety against costs, especially in the field of emergency medicine. While the safety procedures and equipment recommended by the NTSB can be adopted voluntarily right now, HEMS operators recognize that within a matter of years, they will be mandatory.

There are several standards to which every EMS operation can hold itself. “Standard practices” are the bare minimum, embodied in the HEMS industry by mandatory compliance with the FARs. “Best practices” go further, effectively managing recognized challenges, threats and risks. “World class” standards are the most stringent and proactive, positioning an organization well ahead of future challenges, threats and risks.

Toward which standard do you want your operation to strive?

Thank you and I look forward to your questions and discussion on this important topic.