Wing-to-wing transfers and the need for strong partnerships

Claudia Schmiedhuber, Managing Director, EURAMI, said that for global wing-to-wing missions, EURAMI-accredited providers are being held to the same strict expectations that apply to themselves. “In the newly launched Fixed Wing V. 6.0. Standards, EURAMI has dedicated a whole subsection to the selection of wing-to-wing partners, to ensure that these missions are performed safely and carefully,” she said. “The wing-to-wing standards must be fulfilled by providers to pass (re)accreditation, as EURAMI demands from accredited providers to not only carefully select aeromedical programmes to work with, but also ensure that a suitable collaboration agreement is in place and that both companies apply the utmost diligence and care to their mutual missions. Generally speaking, we are aware that these types of missions are performed quite frequently and, so far, EURAMI’s accredited membership has been selecting wing-to-wing partners very carefully and in accordance with our standards,” Schmiedhuber concluded.

EURAMI’s accredited membership has been selecting wing-to-wing partners very carefully and in accordance with our standards

Patient care and safety

Eileen Frazer, RN, CMTE, Executive Director, CAMTS, is unequivocal on its relevance: “Accrediting agencies rely on established standards that address quality of care and safety. There may be variables, but if a service is accredited by CAMTS Global or EURAMI, at least an auditing process is assured. For example, an aeromedical transport service may tell you they meet compliance with the standards of CAMTS Global or EURAMI, but unless these were tested and reviewed by an outside agency, the quality of patient care and safety is questionable.”

An aeromedical transport service may tell you they meet compliance with the standards of CAMTS Global or EURAMI, but unless these were tested and reviewed by an outside agency, the quality of patient care and safety is questionable

Frazer continued: “Accreditation is no guarantee that there will never be an accident or misstep in patient care. However, standards are created to address what we have learned through a robust quality management process, often going above and beyond government regulations that address basic and minimal criteria. A review of patient care, operations, accidents and incidents by outside experts is a learning experience, even if accreditation is not achieved at first. Specific guidance for areas needing improvement is provided to all accreditation applicants and fulfils the mission of both accreditation agencies – to improve the quality of patient care and safety.”  

Mike Black, Chief Operating Officer, AMREF Flying Doctors, pointed out the specific benefits of shared accreditation, particularly given that these standards are regularly audited: “The same accreditation gives a level of comfort that both partners have the same minimum standards, wherever they are based. Wing-to-wing partnerships assume the partners are in different parts of the world and, by working together, can provide a service that neither could individually. Having the same accreditation is important, as it gives both parties the comfort that they meet minimum prescribed medical and aviation standards, and these are regularly audited – i.e. consistently maintained,” Black concluded.

Words of wisdom

Salinas explained that experience is paramount and provided some insight into Jet Rescue’s important partnerships: “I have personally been involved in the air ambulance industry for over 25 years, as a living witness to the development of the industry as a whole. I have seen companies come and go and there is no substitute for experience. Over the years, we have developed relationships with other air ambulance vendors that are professional and trustworthy. They were not always accredited by a third party, but are among the most respected air ambulance carriers in the world,” Salinas said. For Redstar Aviation, the message is simple: “We expect our partners to commit to delivering the same standards that we offer to our customers.”

Redstar Aviation said that there are additional relevant considerations: “Besides EURAMI accreditation, criteria such as fleet size and type, medical capabilities in terms of staff and equipment, and case management experience for specialised cases such as ECMO. Also, overall insurance, reputation and reliability play a role in the wing-to-wing operator determination process. References given by mutual customers are also contributing factors. We evaluate potential operators in terms of these criteria and conduct desktop audits.”

Delving deeper, Frazer said: “Interfacility transports should be bedside to bedside, and wing-to-wing if possible, but in both cases ground transport is involved, however brief. One of the standards (07.01.10) addresses the use of ground transport requirements to ensure safe and appropriate flight line and air-to-ground transfer as follows:

• A checklist to verify the necessary onboard equipment is in working order and oxygen is sufficient for the length of the transport
• Stretchers can be secured in a locked position to prevent movement during transport
• Seatbelts are required for operator and attendants
• Operator uses lights and sirens only when requested by the clinical crew
• Operator uses a hands-free communication system.

Texting is prohibited while the ambulance is in motion, ground ambulance EMS licence by state or the authority having jurisdiction (AHJ) is provided, while EVOC or equivalent training is required initially and at least every two years for vehicle operators.” Frazer concluded that, ultimately, the patient’s needs must be met with the same level of care providers, supplies and equipment by the receiving transport service.

Black expanded further on certain expectations: “Key medical standards beyond acceptable international air ambulance accreditation are the signing of a formal and legal wing-to-wing agreement by the parties, with an up-front quality review carried out by AFD on the proposed partner’s air ambulance medical service provider background and history. This also includes medical protocols, quality and safety standards, staff qualifications and training and medical equipment.

“Additionally, the comparison and alignment of standard operating procedures (SOPs) for medical, ops and communication, and research of the air ambulance market for feedback on the proposed partner’s reputation and medical standards. Regular intercompany, medical team online meetings (quarterly or half-yearly) to review cases and discuss new developments are a given, for both medical and aviation. And a detailed discussion/exchange of patient details, condition and required treatment between Medical Director – including FTF status – on a mission by mission basis. Finally, ongoing updates between the medical teams on the patient condition and treatment, up to and including the handover at the destination, with post-flight medical case reviews.”

Black went on to list the necessary aviation standards:

• Aircraft fleet composition and size, aviation quality and safety standards complied with, history of aircraft operational incidents or accidents
• Pilot employment, training, compliance standards
• Regular quality and safety-specific aviation audits carried out by AFD or third-party auditors on the aviation component if necessary
• Review of aircraft maintenance standards and individual aircraft size, cabin configuration, speed, range.

Due diligence discussions

To ensure a prospective partner meets the necessary criteria to be successful long term, it is important to conduct due diligence when establishing a new wing-to-wing relationship. Salinas said: “Our process includes the type of aircraft, AOC authority (domestic, regional, global), medical capacity – including crew configuration – and onboard equipment, safety record and cost.” Reflecting on the due diligence process and what it should cover, Black underlined the importance of ‘mission availability; mission pricing; client acceptance of the wing-to-wing concept and partner chosen; medical and aviation insurances in place; and aircraft suitability for the specific mission’.

Schmiedhuber highlighted the importance of reviewing important documentation, which will lead to the development of a suitable written agreement: “Whenever choosing a new wing-to-wing provider, EURAMI providers must look into essential documents such as insurance, operations, medical and aviation staff training and qualifications, as well as operational capabilities of the partner-to-be,” she said. “A written collaboration agreement, regulating duties and liabilities – coupled with a clear line of responsibility and communication – is a must. It is also essential that providers ensure their equipment is compatible, guaranteeing a seamless chain of care at all times, especially during the critical handover phase.”

A written collaboration agreement, regulating duties and liabilities – coupled with a clear line of responsibility and communication – is a must

She added: “EURAMI also requires evidence of written consent from the client/patient before a wing-to-wing mission. This ensures that all parties involved are aware of the details and in agreement. Furthermore, EURAMI requires proof of suitable insurance – both medical and aviation – from the wing-to-wing partner.”

The bottom line

When it comes to contract details, Salinas said: “This should include exact services to be provided, route, aircraft type, onboard medical staff, times, dates and extra costs not included.”

Black said: “The contract should include service levels subscribed to, pricing and quoting mechanism and procedure, individual partner’s legal liability clarification and acceptance, plus acceptable insurance coverage – medical and aviation. Add to this, both partners’ obligations/responsibilities, risk management/control and accountability clearly defined, with communication procedures, protocols and channels. Also, patient medical data protection protocols, procedures covering unexpected aircraft technical issues, financial, administrative and payment criteria and obligations, with legal dispute resolution procedure.”

Considering the complexity of wing-to-wing transfers, it makes sense that the process of establishing a partnership is rigorous. Thorough due diligence ensures a prospective partner upholds the same levels of care and safety. Only trust and shared standards can deliver efficient and effective end-to-end patient transfer.