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National Emergency Air Ambulance

A NATIONAL AIR AMBULANCE NETWORK FOR NEW ZEALAND:A SCOPING REPORT FOR THE ACC AND COMBINED RHAs

PageContents ........................................................................................................................... ....................... 1Listof Tables ..........................................................................................................................................2Listof Figures .........................................................................................................................................3Disclaimer ...............................................................................................................................................4ExecutiveSummary ..............................................................................................................................5Glossaryof Terms .................................................................................................................................81Introduction .......................................................................................................................... 12

1 .1Purpose....................................................................................................................................121.2Background ............................................................................................................................131.3Terms of Reference...............................................................................................................141.4The Project Team ..................................................................................................................151.5The Steering Group ..............................................................................................................151 .6Methodology..........................................................................................................................15

2Current Environment .......................................................................................................... 1 72.1The Health Sector in the 1990s.........................................................................................182.2The Emergency Medical System and the Ambulance Service....................................202.3Air Ambulance Services.......................................................................................................252.4Civil Aviation Responsibilities.............................................................................................392.5Recent Developments/Initiatives ......................................................................................42

3Proposed National Air Ambulance Network ...............................................................563.1Introduction to the Model...................................................................................................563.2Overview Statement.............................................................................................................563.3Service Objectives................................................................................................................563.4The Model...............................................................................................................................573.5Emergency Access to the Network...................................................................................693.6Contracting Arrangements..................................................................................................713.7Key Service Components....................................................................................................76

4High Level Cost Benefit Analysis for the Air Ambulance Network Proposal .....824.1Proposal...................................................................................................................................824.2Methodology..........................................................................................................................824.3Costs ........................................................................................................................................824.4Benefits....................................................................................................................................854.5Costs and Benefits from the ACC Perspective ............................................................... 86

5Implementation Issues .......................................................................................................885.1Issues for Resolution.............................................................................................................885.2Commitment..........................................................................................................................885.3Funding Issues........................................................................................................................885.4Sponsorship &Community Support..................................................................................895.5Contracting.............................................................................................................................895.6Moving Outside the ACC Regulations.............................................................................905.7Implementation Plan ............................................................................................................90

6Recommendations and Conclusion ...............................................................................917References .................................. ........................................................................................... 978Bibliography ..........................................................................................................................98

Page 1

Air Ambulance Network

List of Tables

Table 11

Table 5

Table 6

Table 7

Table 8

Table 9

Table 10

Table 1

Table 2

Table 3

Table 4

Regional Control Rooms

Illustrating the Regional Locations and Number of Operators atEach Location

Fixed Wing Aircraft and Helicopters by Region

Percentage Use of Air Ambulance Services by Case Type andRegion (Helicopter and Fixed Wing)

Estimated Total Cost of Services to the ACC and RHAs (1994/95)

AlA Air Ambulance Categories

The 3 Tier Air Ambulance Model

Proposed Contracting Arrangements

Estimated Cost of Air Ambulance Services in 1995 by Region

Assumed Location and Annual Mission Hours for Designated AirAmbulance Operators

Assumed Percentage Split Between Fixed Wing and HelicopterServices

Page No.

22

25

26

28

34

50

57

73

83

83

84

Table 12Estimated Cost of Air Ambulance Services in 1995 by Region 84

Table 13Potential Benefits and Disbenefits of a National Air Ambulance85Network

Page 2

National Emergency Air Ambulance Network

List of Figures

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

Figure 10

Figure 11

Figure 12

Figure 13

Figure 14

Page No.

27Schematic Representation of Operators who have Registered anInterest or Desire to Provide an Air Ambulance Service (March1996)

Air Ambulance Mission Summary by Region

Estimated Total Cost of Air Ambulance Services by Type of Missionfor Years 1992/93, 1993/94, 1994/95

Proposed Regional Trauma System Model

Pre Hospital Trauma Care Response Model

Schematic Representation of Proposed 1 St Tier Air AmbulanceServices - Helicopter Services

Schematic Representation of Proposed 2' Tier Air AmbulanceServices - Helicopter Services

Schematic Representation of Proposed 1 St & 2 nd Tier Air AmbulanceServices - Helicopter Services

Schematic Representation of Proposed 1 , 2 n & First Response AirAmbulance Services - Helicopter Services

Schematic Representation of Proposed 1st Tier Air AmbulanceServices - Fixed Wing

Schematic Representation of Proposed 1 St & 2nd Tier Air AmbulanceServices Fixed Wing

Schematic Representation of Proposed 1 St & 2nd Tier and OtherOperators Registering an interest - Fixed Wing Air AmbulanceOperators

Access to the National Air Ambulance Network for Non UrgentInter-hospital Air Ambulance Transfers

Response Protocol for Emergency Air Ambulance Helicopters

30

36

47

48

59

ME

61

62

64

65

66

Of

79

Page 3

Air Ambu

Disclaimer

This report has been produced by an independent working group for the Accident andRehabilitation and Compensation Insurance Corporation (ACC) and the combined RegionalHealth Authorities (RHAs).

The views and recommendations contained in the report are the working group's and notnecessarily those of either the RHAs or the ACC. The ACC and the RHAs will consider thereport and make their own decisions on taking forward its recommendations.

Page 4

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Introduction

This report provides recommendations on the establishment andfunding of a cost effective emergency air ambulance service in New

Zealand that will meet the needs of both trauma and seriously ill patients.

There are significant deficiencies in the management, co-ordination andprovision of air ambulance services within New Zealand. The cost of theservice has been increasing: partly in response to the proliferation ofservice providers, and partly in response to new demands arising fromchanges in the provision of health care within New Zealand.

The investment in air ambulance services needs to be managedeffectively to ensure it delivers a satisfactory return to both thepurchasers and users of that service.

The Report'sProposals

The report's proposals have been developed with a view to ensuring theair ambulance network is well integrated with existing road basedambulance services and hospital services. The proposed model alsoaddresses the requirement for better co-ordination and control of inter-hospital transfers.

The recommended 3 tier fixed wing and helicopter air ambulancenetwork model will involve some rationalisation in the delivery of airambulance services, particularly in the North Island. Further developmentwill be required to fill gaps in the ambulance service available in theSouth Island.

The model is broadly based on the principles and recommendationscontained in the Royal Australasian College of Surgeons' trauma careguidelines. It integrates work from later initiatives including the standardsand protocols developed for the ACC Trauma Management Pilot, theSRHA/ACC Ambulance Service contract with the Order of St John, andthe Aviation Industry Association Air Rescue/Air Ambulance Standards.

The report's recommendations are consistent with the findings andrecommendations of both the Emergency Services Review and the CaveCreek Commission of Inquiry.

Page 5


Contractingand InformationRequirements

The two major purchasers of emergency medical services (RHA andACC) in any one RHA region of the country should contract with aprimary provider for road and air ambulance services. The primaryprovider should subcontract for any services (either road or air) they arenot able to deliver themselves. The contracting process should betransparent and contestable. The contracts need to specify detailedservice standards and purchase price arrangements.

Should the RHAs and ACC choose to establish separate contractingarrangements with providers, they should nevertheless agree commonservice standards and contract timeframes.

As in other areas of the health system, better base information needs tobe gathered and evaluated to ensure the system remains well structured,cost effective and responsive to changes in service needs. Thisrequirement needs to be written into contracts between ACC/RHAs andemergency service providers, and into agreements between the RHAsand the CHEs with regard to inter-hospital transfers.

ImplementationThe implementation of this report's recommendations will result in amore cost effective ambulance service and, ultimately, better patientoutcomes. Further efficiency gains are possible if other purchasers ofemergency air transport, such as the Police and the New Zealand FireService, also choose to contract with the preferred providers for airambulance work, for aerial search and rescue and fire suppression tasks.

There are some challenges that need to be addressed if the airambulance network is to be successfully implemented.

The ACC will need to move beyond its current regulatory regime to gainthe maximum benefits from direct contracting arrangements. Morefundamentally, the RHAs and ACC will need to establish a "modusoperandi" that takes account of their differing funding mechanisms andperformance objectives, while aligning their purchasing requirements.

The development and growth of air ambulance services to date has, inlarge measure, depended upon the enthusiasm and support of localcommunities. Major sponsors have welcomed the opportunity to beassociated with a high profile community service. The ACC and theRHAs need to retain and foster the support of local communities andsponsors as they manage the introduction of revised service contractsand arrangements. Effective dialogue and consultation should be afeature of the implementation process.

Page 6


ConclusionIn the final analysis, ACC and the RHAs are responsible for determiningservice requirements and purchasing those services that will deliver costeffective outcomes.

The implementation of a national air ambulance network will result in animproved air ambulance service. The ACC and the RHAs will be betterplaced to manage the cost of the service while ensuring their investment- and that of sponsors and the local communities - reduces the mortalityand morbidity rate associated with accidents and serious illness incidentsin New Zealand.

Page 7

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AA

ACC

Activation time

ADF

AH

AlA

Aircraft

All Weather

ARC!

ATO

ATS

BTS

CAA

Casevac

CASO

CHEs

CMG

CRHA

CO2

Dl

Air Ambulance

Accident & Rehabilitation and Compensation InsuranceCorporation

The time from when the operator is contacted to when theaircraft is airborne with medical or paramedical crew and/orspecialist equipment.

Automatic Direction Finder

Artificial Horizon

Aviation Industry Association

Any machine that can derive support in the atmosphere fromthe reaction of air (otherwise than by reaction of air against thesurface of the earth).

Unless prevented by "Force Majeure", an aircraft equipped,crewed and fuelled to enable it to operate to the lowestapplicable meteorological minima in known or forecasted icingconditions (except helicopters) by day and by night, includingflights in IMC

Accident Rehabilitation and Compensation Insurance

Air Transport Operations

Advanced Trauma Service

Basic Trauma Services

Civil Aviation Authority

Missions for retrieval of acute accident victims in the pre-hospitalemergency situation

Civil Aviation Safety Order

Crown Health Enterprises

Corporate Management Group

Central Regional Health Authority

Carbon Dioxide

Direction Indicator

Page 8


Golden Hour

IMC

lv

Job Cycle Time

Distance Measuring EquipmentDistrict Trauma Service

Booked, or as required

Respond as rapidly as possible

Endotracheal

A power driven heavier than air aircraft deriving it's lift in flightchiefly from aerodynamic reactions on the surface which remainsfixed under the given conditions of flight

A term coined by R Adams Cowley, the "father of traumasurgery", at the Maryland Institute for Emergency MedicalServices Systems (MIEMSS) in the early 1 970s to describe theperiod of time during which the adverse physiologicalconsequences of shock following injury can still be reversed

General Practitioner

Global Positioning System

Helicopters

Horizon Situation Indicator

In Accordance With

Instrument Flight Rules

An aircraft crewed, fuelled and approved for flight in InstrumentMeteorological Conditions

Instrument Meteorological Conditions

Intravenous

The time from receipt of call for assistance until a patient isdelivered to a treatment centre.

DMEDTS

Elective

Emergency

ET

Fixed Wing

GP

CPS

HEL

HSI

lAW

IFR

IFR Capable Aircraft

JESCC Joint Emergency Services Communications Centre Project

Medevac Acute medical evacuations

MRHA Midland Regional Health Authority

MULTI Multi-Engined Aircraft

Page 9


NIBP

Non-Urgent

NRHA

NZFS

OPS

Pin C

Primary Response

PRIME

RACS

RAID ALT

Rapid Response

RCC

Remote Cyeography

Response time

Retrieval

RHA

RNZAF

Rotary Wing

RTMCC

SAR

SP

Non-Invasive Blood Pressure Monitor

Refers to transport that is not time critical and is usually"booked" or "planned" as soon an possible (within 30 minutes)

Northern Regional Health Authority

New Zealand Fire Service

Operations

Pilot in Command

Initial pre-hospital response to assess and manage the injuredpatient in the field

Primary Response in Medical Emergencies

Royal Australasian College of Surgeons

Radar Altimeter

As rapidly as possible

Rescuer Control Centre

Locations from which actual travelling time for the patient to thenearest DTS or ATS by an appropriate mode of transport isgreater than one hour

Response time is the time from receipt of emergency call toarrival at patient accident/illness scene.

The organised transfer of a patient from one facility to anotherwith the resources of the more advanced facility being taken tothe patient

Regional Health Authority

Royal New Zealand Airforce

means a rotocraft that depends principally on power drivenrotors for it's horizontal motion

Regional Trauma Management Co-ordinating Committee

Search and Rescue

Single Pilot

Page 10

National Emergency Air Ambulance N

SRHA Southern Regional Health Authority

Triage A method of determining major trauma or serious illness

Urgent Immediate response

VFR Visual Flight Rules

VHF Very High Frequency

VHF DF Very High Frequency Direction Finding

VMC Visual Meteorological Conditions

VOR VHF Omni-Directional Radio Range

X/C Cross Country Navigation

Page 11

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1.1 Purpose

1.2Background

1.3Terms ofReference

1.4The Project Team

1.5The SteeringGroup

1.6Methodology

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1.1 Purpose

The Report

This scoping report provides recommendations on the establishmentand funding of a cost effective emergency air ambulance network as

part of the emergency medical system that meets the needs of bothtrauma and seriously ill patients.

IncreasingNumbers ofAir Ambulances

Need for Review

In recent years there has been a growth in the number of rescueaircraft and air ambulances operating in New Zealand. Theestablishment of these services does not always appear to have takeninto account patient need or the impact on the overall cost effectivenessof the broader emergency medical services within New Zealand.

The aviation industry has taken steps to establish emergency AirAmbulance standards, operating aircraft standards, equipment, and levelof services provided by operators across the country. However thecontracting arrangements and standards set in place by the purchasersof these services vary from region to region.

There is a need to establish an efficient and cost effective emergency airambulance network for New Zealand. This report recommends:

• preferred locations for a network of first and second tier airambulances;

• appropriate service standards for air ambulance operators;• improved air and road ambulance utilisation which is cost-effective

and achieves optimum patient outcomes;• improved co-ordination of inter-hospital transfers;• appropriate contracting arrangements.

Page 12


1.2 Background

Air ambulances in New Zealand have developed quite rapidly since the1 970s in response to the energy and enterprise of operators and theenthusiasm of local communities and sponsors. Although contractingarrangements are still developing, air ambulance services have been ableto function reasonably effectively, on a "fee for service" basis and withsignificant public support and public expectations.

An EffectiveConsistent with overseas practice, and in accord with the RoyalTrauma SystemAustralasian College of Surgeons (RACS) Trauma Care Guidelines for

New Zealand first published in May 1994, it is recognised that aneffective trauma system which integrates pre-hospital management,hospital treatment, and rehabilitation services will optimise patientoutcomes.

The pre-hospital component of a trauma system needs to provide a rapidretrieval/primary emergency response ambulance service. That service isprovided primarily by road ambulance and emergency medicalhelicopters. Fixed wing aircraft and helicopters are also used for inter-hospital transfers. Emergency air ambulance services, therefore, need tobe well integrated with other pre-hospital emergency medical services,and the hospital-based components of the trauma management system,to obtain optimum patient outcomes.

The "RACS"The RACS Trauma Care Guidelines, commissioned by the Ministry ofReport Health in 1993, provide a solid foundation for the development of a

trauma management system in New Zealand, including the emergencymedical service component of that system.

However, the continued proliferation of air ambulances has given rise toconcerns by the purchasers of healthcare, namely the Accident andRehabilitation and Compensation Insurance Corporation (ACC), and theRegional Health Authorities (RHAs), about the cost effectiveness andquality of the services.

Variance ofCurrently, not all callouts for air ambulances are made through the 111Emergencysystem. At times, local Police personnel activate aircraft for searchCall Out and rescue work through their own systems; whilst CHEs arrangeProtocols inter-hospital transfers of patients directly with operators, often local

aero clubs. These situations are compounded by variances inemergency call out procedures between ambulance regions. Moreover,the New Zealand Fire Service utilises aircraft for fire suppression tasks.

Page 13


1.3 Terms Of Reference

The agreed Terms of Reference include the following goals andobjectives. The full terms of reference are set out in Appendix 1. 1.

Goal The Project Team will provide recommendations to ACC and the RHAson the establishment and funding of a cost effective emergency airambulance network as part of the emergency medical system that meetsthe needs of both trauma and medical patients.

ObjectivesThe working group will:

• Confirm the preferred location of a network of first and second tieremergency air ambulances;

• Confirm the aircraft, staffing and medical standards that airambulance providers will be required to meet;

• Establish the service objectives, standards and protocols that shouldbe common to air ambulance service purchase arrangements;

• Estimate the marginal cost benefit of establishing the network;

• - Recommend contracting arrangements for the operation of the airambulance network that will meet the needs of both the RegionalHealth Authorities and ACC; and,

• Establish an implementation plan for introducing the air ambulancenetwork that is accepted by the RHAs and ACC.

Page 14


1.4 The Project Team

It was agreed by the ACC and the combined RHAs that a Project Teamundertake the work required to give operational effect to the "RACS"guidelines as they affect the provision of emergency air ambulanceservices, including the interface with the road-based emergency serviceproviders and the role of the service in undertaking inter-hospital patienttransfers.

A Project Team was established and headed by Tony Cull. The ProjectTeam included:• Tony Cull, (Project Leader)• Jan Cooper, Cooper Associates Ltd• Peter Tranter, ACC/Order of St John• Aviation Technical Advisors: Bernie Lewis

Michael Tournier• Cost Benefit Analysis Advisor: Keith Challands, ACC

1.5 The Steering GroupThe Terms of Reference charged the Project Team with reporting to aSteering Committee comprising of:

• Grant Tweddle, ACC (Convenor)• Russell Worth, Crown Health Enterprises Association• Tony Hacking/Fiona Lindop, Northern RHA• Tony McKewen, Southern RHA• Paul Malpass/Jeanette Black, Midland RHA• Barry Taylor/Michael Quinlivan, Central RHA• Peter Robinson, ACC

1.6 Methodology1. Review of Current Literature

Information was readily available in various specialist documents (SeeBibliography, Section 8). This information was reviewed and has formedthe basis for discussion with key stakeholders. The key documents are:

• Auckland Regional Rescue Helicopter Trials - Review of the AirborneEmergency Medical Services in New Zealand (March 1993)

• Core Health Services Report 1994/95 (August 1993)• Guidelines for a Structured Approach to the Provision of Optimal

Trauma Care - RACS NZ Trauma Committee (May 1994 - "The RACSReport")

• Report of the Working Party to the Midland Regional Health Authorityon Emergency Trauma and Seriously Ill Services in Midland(September 1994)

Page 15


• Pre-Hospital Emergency Care - Primary Response in MedicalEmergencies - Southern RHA (Jul y 1995 -The Prime System)

• Trauma Management in New Zealand, the ACC Perspective 1995• CAA Guidelines (1995)• Report of the Emergency Services Review Task Force (1995)• Commission of Inquiry into the Collapse of A Viewing Platform at

Cave Creek (1995)

2. Initial Consultation Process

Over a period of three months, key stakeholders were consulted. (A listof these personnel and organisations is included in Appendix 1.2)

3. Survey of AlA Registered Air Ambulance Operators

A questionnaire was sent to all registered air ambulance operators so thatbaseline information could be collated to give a true picture of thecurrent situation. (A list of operators ancla copy of the questionnaire isincluded in Appendix 1.3)

4. Analysis of Data

This was undertaken at the end of January 1996. Assumptions for thedata analysis, and the issues related to the validity and reliability of thisdata, are discussed in Appendix. 1.4.

5. Consultation

The draft report was prepared by the working group and was circulatedto interested parties as a "disclosure draft" for comment. A list of theparties who received the report is attached in Appendix 1.5.

6. Analysis of Submissions

Following analysis of the submissions received, the working group soughtthe assistance of technical advisors for specialist issues relating to aviationregulations and aircraft specifications.

7. Publication of Final Report

The working group have prepared a final report for submission to theACC and the combined RHAs for their consideration.

Page 16

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2.1The Health Sectorin the 1990s

2.2The EmergencyMedical System & the

Ambulance Service

2.3Air AmbulanceServices

2.4Recent DevelopmentsInitiatives

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IntroductionT

his section reviews the following current environmental issues. Theseare:

•The Health Sector in the 1 990s;• The Emergency Medical System and Ambulance Service; and,• Air Ambulance Services.

It also takes particular note of the following recent developments andinitiatives

• Core Health Services Report (1993);• The Care of Critically lii Children (British Paediatric Association

1993);• The RACS Trauma Care Guidelines (1994);• The ACC Trauma Management Pilot(1 995);• The SRHA/ACC Contract;• AlA Guidelines (1995);• CAA Regulations Review (1995);• Report of the Emergency Services Review Task Force (1995); and,• Commission of Inquiry into the Collapse of A Viewing Platform at

Cave Creek (1995).

Page 17


2.1 The Health Sector in the 1990s

Change inWithin the last five years the provision and focus of medical care hasFocus changed considerably with a move towards:

• Increasing specialisation and sub-specialisation in many areas ofmedical practice.;

• Centralisation of acute care, with resuscitation/stabilisation andtransportation of patients from smaller centres and definitive carebeing undertaken at larger hospitals;

• Integration of primary and secondary care within the rural healthsector with general practitioners becoming more involved in hospitaland accident services;

• Closure of some country hospitals with restricted secondary servicesbeing provided by others;

• Fewer hospitals and hospital beds generally;• Increasing public expectations of healthcare delivery;• Increased emphasis on preventative and educational health; and,• Increased emphasis on quality, safety, and outcomes.

The HealthThe health reforms have brought a climate of accountability andReforms transparency to the health environment, characterised by an

emphasis on separating the purchaser/provider role. This is seen in amore commercial approach to:• planning;•contestability; and,

contracting,

which have focused on efficiency and effectiveness, ensuring qualityoutcomes and value for money.

Page 18


ImplicationsThe changes in focus of health care and the health environment,for Emergencybrought about by the reforms, have led to changes in theMedical Servicestransportation of patients which in turn has had implications for theand the emergency medical services.Transportation ofPatients There are three factors which are causing an increase in the transport

of ill patients between hospitals:

1. The improvement in pre hospital emergency care facilitated by theavailability of helicopters;

2. The increasing regionalisation of intensive care, trauma management,emergency care, and other specialist services; and,

3. The availability of air transport with the capacity to provide intensivecare in transit.

Small RuralThe changes in the delivery of health care have included aHospitals anddecrease in medical specialities available at smaller hospitals. Due toTransport the ability to transport patients much more quickly and safely to major

hospitals, many small hospitals have lost their expertise to deal with localcrises. This has resulted in a demand for quicker transport of specialisthospital and paramedical staff to emergencies and the retrieval ofpatients to specialist medical facilities.

Page 19


2.2 The Emergency Medical System And The Ambulance ServiceIntroductionThis section reviews the current interface between road and air

ambulance services.

Overview ofCharitable trusts provide the majority of road ambulance services inNew ZealandNew Zealand, notably the Order of St John and the Wellington FreeAmbulanceAmbulance. The New Zealand Ambulance Board co-ordinates, fundsServices and oversees the national ambulance officers training programme and

represents ambulance service operators in discussions with governmentand other national agencies. The Board co-ordinates emergencyambulance service providers nationally and derives its main funding fromlevies on these providers.

RegionalAmbulanceServices

Since the health reforms the trend nation-wide has been for CHEs toexit emergency ambulance services and for the RHAs to contractdirectly with providers.

The Order of St John operates regional ambulance services in:• Auckland (including Northland and Coromandel/Hauraki areas);• Midland;• Hawkes Bay;• Central Districts (based on Palmerston North); and,• South Island based on Christchurch and Dunedin

The Wellington Free Ambulance provides services in the Wellingtonregion.

The only remaining CHE based ambulance services are in Taranaki,Wairarapa and Marlborough.

Ambulance providers now contract with RHAs for emergency and otherpre-hospital services only. A joint contract by ACC and the SRHA withemergency ambulance service providers was signed in 1995. Servicespecifications in this contract have defined and raised standardsparticularly with regard to training, equipment upgrades and crewing(recommended in the RACS NZ Trauma Committee report 1994). Asimilar contract was finalised between North Health, ACC, and the Orderof St John for Northland and was signed earlier this year.

I

Page 20


AmbulanceControl Rooms

111 Ambulance calls delivered by Telecom are processed atAmbulance Control Centres at 6 main centres - Auckland, Hamilton,Palmerston North, Wellington, Christchurch, and Dunedin, and atsecondary ambulance control centres in Napier, Whangarei and NewPlymouth

AmbulanceThe main centre control rooms use a computer aided dispatchRadio Networksystem and during 1995 a new and exclusive nation-wide ambulance

VHF radio network was commissioned. This network included anupgrade of equipment in all ambulance vehicles throughout NewZealand and improved ambulance hospital communications. Theseexclusive nation-wide radio channels enable road ambulances or airambulances operating on this network to communicate with anyambulance or ambulance control room within each region anywhere inNew Zealand. Liaison channels are also available for inter servicecommunications.

Variance inDispatch policies and procedures differ in each ambulance region andDispatch even within individual RHA regions. Methods of telephone triage alsoDecisions differ and this can result in variations in dispatch decision making.

Complete standardisation between each region and even between shiftsin control rooms can never be expected as emergency requests aremore complex than, for example, a request for assistance with a housefire.

At present the underlying philosophy is, if in doubt, dispatch assistance.

The ControlThe public has access to emergency ambulance services inRooms New Zealand via the 111 system. Telecom divert these calls to the

appropriate ambulance regions and these calls are in turn divertedautomatically to other smaller control rooms.

There have been some calls for general practitioners to be able to play amore active and direct role in authorising the callout of air ambulances,particularly in more isolated and rural parts of New Zealand. This viewwas supported by the ACC Regulations Review Panel Report whichrecommended any GP should be able to authorise emergency airtransport.

Page 21


Table 1 - Regional Control Rooms

RHAMain Control Room Secondary Control DiversionRegions(24 Hours)RoomAuckland•St John Whangarei - St John(North Health)Headquarters Mt Headquarters

WellingtonMidland region•St John New PlymouthAfter hours -(Midland RHA)Headquarters - hospital

Hamilton switchboardCentral region•Palmerston NorthMasterton After hours -(Central RHA)•WellingtonNapier hospital

Nelson CHEswitchboardAmbulanceMasterton

Southern•Christchurchregion•Dunedin(SouthernRHAs)

Control RoomLack of formal and inter-regional liaison between ambulanceLiaison control rooms is evident when making dispatch decisions to incidents

that may be better served by the neighbouring ambulance servicebecause their resources, either road or air ambulances, are presently inthat vicinity. Any control room liaison is basically at the discretion ofindividual control room staff.

CHE Air There is no co-ordination of non emergency inter-regional andAmbulanceextra-regional hospital transfers by any agency. Under the presentTransport system the CHEs arrange their own air ambulance transport, in some

regions using the ambulance control room. Generally air ambulanceaircraft are not being used efficiently nationally or even within the sameregion.

It is desirable that the co-ordination of national non-urgent air ambulancetransport be improved.

Air AmbulanceThe variations in dispatch policies and procedures impact on airDispatch ambulance dispatch decision making. Current contractual or budget

holding responsibilities by some ambulance services puts financialrestraints on some decision making. This is the case with acute medicalcases. Conversely, the current ACC fee for service system tends to makeaccident dispatch decision making too easy in some instances.

It has been reported that some ambulance control rooms are reluctant todispatch air ambulance helicopters before the road ambulance staff havelocated the incident to assess patient need. This approach negates anytime advantage helicopter use, as a first response, may have achieved forseriously ill or injured patients.

Page 22


However, other ambulance control rooms routinely activate or place thehelicopter on standby when a possible need for the helicopter isdetermined but not clearly established. This approach enables the crewand aircraft to be readied, and saves valuable time while furtherinformation is gathered so a more informed decision can be made.

Issues AssociatedThe convenience of using air ambulance helicopters instead of roadWith Use of Airambulances, because of patient location and knowing there will be noAmbulances vsimprovement to patient outcome or rehabilitation, is also evident.Road Ambulances

In some cases however, air ambulance helicopter use over roadambulance use may be argued as:

• being a financial saving if staff costs over long periods are considered;

• retaining scarce road ambulance resources within their local area andin some cases lessening the time volunteer staff are away from theiremployment.

Air ambulance use for these reasons over longer distances may well bejustified. Air Ambulances, when relatively short distances are involvedhowever, may not save any noticeable time as there may be delayswaiting for the helicopter, unloading from the road ambulance, handingthe patient over to the air ambulance crew, flight time, unloading in mostcases to another road ambulance and transporting the patient to thereceiving department. The extra patient movement is unnecessary,particularly if no extra patient care procedures are initiated and time wasnot a factor in the patient's outcome.

A balance between these approaches to air ambulance helicopterdispatch decisions, and some questioning of the reasons for using airambulance helicopters when no patient benefits or cost savings can beexpected, is missing.

Page 23

Emergency Air Ambulance

Summary Delivery of care and responses to pre-hospital medical emergenciesof Key Issuesby emergency ambulance services within New Zealand vary, depending

on the ambulance region.

The basic reasons for variations are:

• lack of adequate, or variations between, dispatch procedures;

• lack of protocols or guidelines in some ambulance regions resulting,in some cases, in delays or inappropriate use of ambulancehelicopters and ambulances;

• a need to improve training of ambulance control room staff in thecomplexities of emergency ambulance related telephone triage;

• shortage of road ambulance resources, both vehicles and staff, insmaller remote areas and in large metropolitan areas where singlecrewed ambulances can still attend emergencies;

• training (qualifications) and experience of road ambulance staff,particularly volunteers;

• lack of inter-control room liaison (in some regions), which results inpoor co-ordination and use of resources, and possible delays toincidents occurring near regional boarders;

• lack of national and regional co-ordination of non-emergency airambulance flights (in some regions), resulting in higher costs per tripand less than optimal use of resources;

• lack of protocols or guidelines (in some regions), to ensure patientsare transported to the most appropriate medical facility for thepatient's injury or illness;

• lack of protocols or guidelines (in some regions), to ensure theservices of rural doctors are utilised when necessary; and,

• lack of emergency ambulance service contracts (in some regions)with clear service delivery standards and monitoring and auditingrequirements.

To ensure both air and road ambulances are utilised in a cost effectivemanner that achieves optimum patient outcomes, nationally consistentstandards covering all of these issues are essential.

Page 24


2.3 Air Ambulance Services

IntroductionThis section outlines the current situation of air ambulance services withregard to:

•location;• usage;• response times;• aircraft type/standards;•relationship with medical facilities;• sponsorship and funding; and,• contracting arrangements

Location There are fixed wing and helicopter air ambulance services currentlyoffered from 34 locations. These locations are referred to in Table 2.

Table 2 : Illustrating the Regional Locations and Number of Operators at EachLocation

Northern RH,4Midland RH,4 Central RI-IASouthern RHALocationNo ofLocation No ofLocationNo ofLocationNo ofoperators operators operators operatorsAuckland5Eltham 1Blenheim1Balclutha1Whangarei1Gisborne 3Carterton1Christchurch3

Hamilton 1Hastings2Gore 2New Plymouth1Hawkes Bay2Hokitika1Rotorua 1Nelson 1Invercargill1Ruatoria 1Palmerston5Mosgiel1Taumarunul1Wanganui2Oaniaru1Taupo 2Wellington1Queenstown1Thames 1 2Rakaia 1Waimana 1 Timaru 1Whakatane2 Waikari 1

Wakatipu1

The map overleaf shows the location of all registered air ambulanceaircraft. There are currently 93 aircraft registered as air ambulances.These consist of:

• 27 IFR fixed wing aircraft;• 18 VFR Fixed wing aircraft;• 3 IFR Helicopters; and,• 45 VFR Helicopters

A regional breakdown of this number is offered in Table 3:

Page 25


Table 3: Fixed Wing Aircraft and Helicopters by Region

REGIONFixed Wing #sA/A CategoryHelicopter #sA/A CategoryIFRVFR IFRVFR

Northern RHA10 Not categorised23A x 21 not categorised

Midland RHA45Ax 1 116Ax 4C x 2 BxlD x 1 11 not categorisedE x 34 not categorised

Central RHA91A x 7 11A x 4Cxl B x 2Dxl Cxl1 not categorised 4 not categorised

Southern RHA412A x 4 15B x 5BxlO C x 22 not categorised D x 1

7 not categorisedTOTALS2718 345

45 48(P/ease see Page 50 for A/A Category definitions)

There is no shortage of air ambulance operators or aircraft. Someservices are under utilised with a consequent loss of cost efficiency.

In the last ten years there has been an increase in the number ofcharitable air rescue trusts. Given the high fixed costs associated withthe operation of air ambulances, costs could be driven up as individualhelicopter utilisation rates decline.

There are currently four centres using twin engine helicopters with a 24hour service capability, supported by smaller centres using lesssophisticated aircraft. Those centres with twin engine helicopters are:

• Whangarei• Auckland• Hamilton• Wellington

Page 26

Fig 1. SCHEMATIC REPRESENTATION of OPERATORS who haveREGISTERED an INTEREST or DESIRE to PROVIDE an

A TT A A KTY TV A ASER"II(-Ech 1996)

F ACTION15-120 knots

topography of New Zealand

National Emer gency Air Ambulance N

Use of AirAir Ambulances are currently used for:AmbulanceServices •Casevac (these are missions for the retrieval of acute accident

victims in the pre-hospital emergency situation);

Medevac (these are acute medical evacuations);

• Inter-hospital Transfers (the transfer of seriously ill patients betweenhospitals);

• Search and Rescue Missions (SAR) (these are missions currentlyinitiated by the Police or by CAA via the National Rescue Co-ordinators Centre, for search and rescue of people either on land orat sea); and,

• Other Commercial Work.

At present air ambulance operators are activated by various methods.Activation for casevac and medevac missions are predominantly throughambulance control rooms via the 111 system. However, police in someareas go direct to the air ambulance operator which can result in a lackof co-ordination with the road ambulance and the receiving hospital.CHEs arrange air ambulance transfer of patients in some areas throughambulance control rooms but in many areas deal directly with fixed wingair ambulance operators through aero clubs.

An analysis of 1994-95 missions shows the following percentage use ofair ambulance services by RHA region:

Table 4: Percentage Use of Air Ambulance Services by Case Type and Region (Helicopterand Fixed Wing)

Hell

RH,4 RegionCase vacMedevac Intel-hospital SARTransfers

Northern 29%34%18% 25%Midland 20%17%13% 25%Central 27%9%10% 39%Southern 10%4%1.5% 3%

Fixed Wing

RI-IA RegionCase vacMedevac Inter-hospital SARTransfers

Northern 1% 0%4% 0%Midland 4% 8%14% 1%Central 3% 24%38% 5%Southern 6% 4%1.5% 2%

Page 28


The Central Region has the highest rate of usage of air ambulances(primarily due to the large number of inter-hospital transfers) followed bythe Northern Region, then Midland and finally the Southern Region.

The following graphs also highlight the increased use of air ambulancesover the last three years. These are based on the number of hours flownper region.

Page 29

Central RHA

•Casevac Missions

—U— Medevac Missions

Interhospital Transfers

-- SAR/Other

200018001600140012001000800600400200

01992/931993/941994/95

FIG 2. AIR AMBULANCE MISSION SUMMARY by REGION

200018001600

UCasevac Missions14001200

SMedevac Missions1000

—*— Interhospital Transfers X 800

— SAR/Other 600400200

0

2000Northern RHA

18001600140012001000800600400200

01992/931993/941994/95 1992/931993/941994/95

Midland RHA Southern RHA200018001600140012001000800600400200

0

—U— Casevac Missions

SMedevac Missions

-- Interhospital Transfers

—SAR/Other

1992/931993/941994/95

411-- Casevac Missions

SMedevac Missions

AInterhospital Transfers

4— SAR/Other


From 1992/93 to 1994/95 primary response emergency evacuationmission hours have increased by 30%, with a 93% increase in inter-hospital transfers. The increased usage has arisen largely from thecentralisation of Intensive Care Services and the changing role of smallerhospitals. Air Ambulance data on types of mission, number of patients,and associated hours can be found at Appendix 2.1.

Response TimesThe importance of time in relaying major trauma or serious illnesspatients to the appropriate medical facility is key to patient outcomes(RACS 1994)

Therefore, air ambulance activation and response times are crucial. Thetime from when the operator is contacted to when the aircraft is airbornewith medical or paramedical crew and specialist equipment is theactivation time.

Response time is defined as being the time from receipt of an emergencycallout to location of the patient.

There are many issues which impact on activation times of rotor airambulances. These are:

•aircraft availability;•aircrew availability;• weather suitability;• aircraft being used for other work rather than air ambulance services

when activated; and• availability and location of medical and paramedical crew and/or

specialist equipment.

Dedicated Air Ambulance operators state that they are usually able toactivate within 10 minutes during the day and 20 minutes at night.Those operators whose primary service is commercial activity state thaton average they can be activated within 20 -30 minutes.

Fixed wing aircraft are generally used for inter-hospital transfers and notusually in emergency situations. These services are generally bookedand therefore activation times are not an issue.

Aircraft TypeAppendix 2.2 contains a breakdown of the aircraft types by RHAand Standardsregion.'

Footnote 1:This data relates only to responses received in questionnaires.

Page 31


At present, standards of aircraft vary. The AlA, together with CAAinvolvement, have put together standards for various categories of airambulances (information on these standards can be found in Section 2.4and Appendix 2.3).

The AlA are putting in place auditing procedures to ensure that aircraftregistered in particular categories meet the standards. Currently,operators are not contractually bound to adhere to AlA categories.

Relationship withAs Figure 1 shows, air ambulance services are available in manyMedical Facilitiesareas of New Zealand.

Some operators are already sited in the key locations identified in the"RAGS" report. Currently only two of the proposed advanced traumacentres provide ready access from helicopter to emergency room.

However there are many operators who have developed relationshipswith local CHEs and road ambulance operators with little thought to thecost effectiveness of the total system.

Funding andThe majority of air ambulances are currently funded on a "fee forSponsorshipservice" basis only. Within the last year some road ambulance operators

have had contracts put in place which require them to move tocompetitive tendering for air ambulance services.

The Auckland Rescue Helicopter Trust is subcontracted by Auckland StJohn and The Phillips Search and Rescue Trust is contracted by MidlandRHA to provide specified air ambulance services. Similar arrangementsare being put in place by the Order of St John in the Southern Region.

The cost of using a helicopter is only partially reflected in the feesclaimed. The Project Team has been told by various operators that thereal cost of flying a helicopter is probably 2 or 3 times more costly thanthe fee claimed. Air ambulance services are subsidised by localcommunity support and sponsorship, especially in:

• Whangarei;• Auckland;• Hamilton;• Taupo;• Palmerston North;• Wellington;• Christchurch; and,• Otago/Southland

Page 32


The main sponsors are:

• Westpac;• Trustbank;• Tranz Rail;• New Zealand Post;• Forestry Corporation;• ASB Trust;• North Power;• TV 3;• Lowe Walker;• Speights; and,• Dominion Breweries.

It is estimated sponsorship arrangements provide in excess of $3 millionper year.

A mean charge for helicopters is estimated to be $1,368 per hour andfor fixed wing aircraft, $759 per hour.

Actual charges vary significantly due to the following issues:

• twin engine or single engine aircraft;•size of aircraft;• usage rate;• level of fixed costs and sponsorship;• standby arrangements; and,• whether 'dedicated' to ambulance work.

These mean costs have been established by using the price per hourclaimed by operators from the ACC, RHAs and CHEs.

The range between the lowest and highest price for helicopters is $1,625and for fixed wing aircraft $1,110.

The total mean cost of services nationally for 1994/95 have beenestimated to be $6.8 million. This is certainly an underestimation as thedata supplied to the Project Team is incomplete.

Page 33


Table 5 Estimated Total Cost of Services to the ACC and RHAs (1994/95)

SERVICES $'OOOsHelicopter $4,474Fixed Wing $2,399Total $6,873

If the statements made by operators about the true cost of flying ahelicopter are correct then it can be further deduced that the real cost toNew Zealand of an air ambulance service is currently between $14m-$21m. (More information on the Air Ambulance costs can be found inAppendix 2.4)

Contracting Arrangements

Concerns withAmbulance Operators and Air Ambulance Operators have somePresent Methodsconcerns about the present methods of funding. A number ofof FundingRegional Health Authorities have a capped funding arrangement with

emergency ambulance providers which includes a budgeted amount forair ambulance work. Some air ambulance operators believe that thisfunding arrangement at times governs whether the air ambulance will beused or not.

Some Regional Health Authority funding of emergency ambulanceservices is based on an agreed contract amount for a set period with anescalation clause based on an agreed maximum number of patientsattended or transported.

This method of funding, generally removes the funding or cost criteriafrom ambulance dispatch decisions. An improvement to this systemwould be an escalation clause based only on marginal costs as fixedcosts and overheads should be covered in the base contract amount.

Air ambulance operators have large amounts of capital and fixed costscommitted to ensure their services are available when required. Theoperators have suggested that uncertainty of work and income makes itdifficult for them to plan their business operations.

ACC RegulationsThe Regulations: The ARCI (Cost of Transport Related to Treatment,Service or Physical Rehabilitation) Regulations 1992 establish theconditions under which the ACC contributes to the costs of emergencyair transport for claimants who have suffered personal injury.

The Regulations require the ACC to contribute the lessor of:

a) The amount chargec/by the Crown, the regional health authority, orlicensed hospital for the emergency transport; or,

Page 34


b) The amount that would have been charged ro the Crown, regionalhealth authority, or licensed hospital for the emergency transport ifthe transport had been provided for the claimant in respect of acondition that was not personal injury.

In simple terms the Corporation is unable to pay more for the serviceprovided to its claimant than the lowest rate paid by the RHA or a CrownHealth Enterprise for a similar service. The regulations also place anumber of restrictions on the Corporation's funding of air ambulanceservices:

• Caiout: ACC may only reimburse the costs of emergency transportby air if it is requested by the Police or an ambulance operator;

• 24 Hour Rule: ACC can only pay for emergency inter-hospitaltransport which occurs within 24 hours of the personal injury beingsuffered or the claimant being found, whichever is the later;

• Claimants dead on arrival: The Corporation may not pay for transportwhere an accident victim has died before air ambulance transport hasreached the claimant (The Police pay for the transport of deceasedaccident victims);

• Search and Rescue: ACC is unable to pay for time spent searching foran injured person. The Regulations define transport as flying theaircraft directly from the base to the claimant, transporting theclaimants and returning directly to the base (the Police are responsiblefor funding search and rescue operations).

• Multiple Responses: Where both air and road ambulances aredirected to the scene of an accident, the Corporation is only able topay for the ambulance which actually transports a claimant. While thecosts of cancelled callouts and multiple response can be built intooverheads of regular road and air operators, this arrangement is nottransparent and may present difficulties for operators who are not partof an established preferred provider network.

The Corporation has given effect to these regulatory requirementsthrough the payment of a fee for service through its Branches uponconfirmation that an ACC claimant has been transported in accordancewith the Regulations.

The Amendment Act: The ARCI Act was amended in August 1996. Thepassage of the ARCI Amendment Act No 2 1996 enables the ACC topurchase services through direct contractual relationships where they arecurrently funded pursuant to regulations. The amendments to sections27 and 29a of the ARCI Act, therefore, provide the Corporation with thediscretion to contract directly with providers of road and air transportservices.

Page 35

Interhospital Transfers

1992/931993/941994/95

SARI Others

1992/931993/941994/95

Ii

• Helicopter

EI Fixed Wing

• Helicopter

.J Fixed Wing

20001800160014001200

$ 1000800600400200

0

20001800160014001200

$ 1000800600400200

0

1992/931993/941994/95

• Helicopter

EI Fixed Wing

• Helicopter

J Fixed Wing

Medevac Missions

1992/931993/941994/95

Fig 3. ESTIMATED TOTAL COST of AIR AMBULANCE SERVICES byTYPE of MISSION for YEARS 1992/93, 1993/94, 1994/95.

Casevac Missions2000 1800160014001200

$1000800600400200

0

20001800160014001200

$ 1000800600400200

0


Key IssuesThe following is a summary of the key issues identified during the ProjectTeam's research, consultations, and observations of the industry:

• The proliferation of air ambulance services has resulted in overprovision of services in some areas of the country;

• In some regions resources are used inefficiently and are poorly co-ordinated;

• Variance with callout procedures in some ambulance areas, and areluctance to use air ambulances in some instances, has in turn leadto tensions between road and air ambulances in some parts of NewZealand;

• Transportation of patients, at times, to inappropriate care facilities;

• Lack of accessible, valid and reliable information on which to basedecisions;

• Lack of conclusive research, both nationally and internationally, onpatient outcomes and cost benefit of air ambulance use;

• Lack of common service standards, although recent standards havebeen issued by the AlA;

• Lack of appropriate helicopter access to some major hospitals;

• Fragmentation of purchasing, e.g. RHA payments to ambulanceoperators for emergency medical cases, inter-hospital fee for servicepaid for by CHEs, ACC fee for service for accident cases as requiredby current regulations;

• Limited formal contracting;

• Lack of a review system to audit nationally the use of air ambulanceservices;

• Tensions between operators of helicopter services, especially in ruralareas, as to the choice of operator called out;

• Varying skill mix of attendant services for different levels of missiontraining and credentialling;

• Significant increase in use of air ambulances in recent years, whichhas lead to concern about costs;

• Lack of integration at many levels concerning:- Fixed wing and helicopters- Funding- Emergency services/inter-hospital services- Links between air ambulance services and hospital based

emergency departments and intensive care; and,

Page 37


• Lack of a formally defined relationship between road and airambulance operators.

Page 38


2.4 Civil Aviation Responsibilities

The CAA has responsibility for regulating the aviation environment inNew Zealand and ensuring the continued safe operation of airambulances in New Zealand.

Civil AviationCivil Aviation Authority requirements primarily cover air worthiness andAuthority safe flying practice. Air rescue services encompass a wide range ofRequirementequipment, expertise and operational standards, and there is little in

the way of enforceable standards covering these areas.

In the CAA's view, air ambulances that wish to carry passengers willneed to meet three fundamental requirements:

1. An Air Service Certificate (to be renamed Air Operator Certificatenext year);

2. Aircraft to be correctly equipped to do the job requested. In thisregard they see the AlA standards as applicable; and,

3. Operators to observe CAA rules at all times.

In this respect the revision of Civil Aviation Rules, Part 135 Air TransportRegulations, is of significance as is the CAA's intention to continue topermit, by some form, pilot discretion in genuine emergency situations.

EmergencyBoth the Civil Aviation Regulations 1953 and the Civil Aviation ActResponse 1990 provide a legal loop hole to enable the Pilot in Command to

carry out any action required, including non-compliance with theassociated rules and regulations, to enable the protection of life orproperty, such as flying VFR in IMC conditions.

The Civil AviationWith the implementation of the Civil Aviation Act 1990, section 13 andAct vs Civilthe revoking of Civil Aviation Regulations 1953, regulation 35 has causedAviation some concern from the aviation industry over the wording and intent ofRegulationsthe new Act.

Civil Aviation Regulations 1953, regulation 35, supported further inregulation 59 (4) and CASO's under Emergency Operations, issued a"blanket coverage" over what actions and when a pilot could draw uponthis legal loop hole, without fear of litigation. The new Civil Aviation Act1990, section 13, however, did not provide such a wide coverage as itspredecessor.

Page 39


Section 13 of the Act has since been amended to clarify its intention,This amendment has yet to be published, but has been made availableby the CAA for this document.

RegulationsCivil Aviation Regulations 1953, regulation 35, states:

35 Emergency Flights - In the case of emergencies necessitating theurgent transportation of persons or medical or other supplies - for theprotection of life or property, the requirements of these regulations orany Civil Aviation Safety Orders regarding type of aircraft, use ofaerodromes, equipment, and meteorological minima to be observedshall not be applicable:Provided that within 48 hours after the completion of the flight theoperator shall submit a report to the Director setting forth the conditionsunder which the flight was made, the necessity for the flight, and list ofthe names and addresses of the crew members and passengers.

Civil Aviation Regulations 1953, regulation 59 (4) states:

59 Responsibility of Pilot in Command(1) In addition to being responsible for the operation andsafety of theaircraft in flight, the pilot in command shall be responsible for the safetyof persons and cargo carried and for the conduct and safety of the crewmembers.(2) The Pilot in Command shall have final authority as to the dispositionof the aircraft while he is in command and for the maintenance ofdiscipline by all persons on board(3) On the permination of a flight the Pilot in Command shall beresponsible for reporting to the operator all defects noted during theflight.(4) The Pilot in Command may follow any course of action he considersnecessary in emergency situations which, in the interests of safety,require immediate decision and action. When any such emergencyauthority is exercised the Pilot in Command shall endeavour to keep theappropriate air traffic control fully informed If the emergency decisioninvolves a deviation from these regulations or from CMIA viation SafetyOrders, or from air traffic control instructions, the Pilot in Command shallnotify air traffic control without delay, and shall, if required, furnish awritten report of any such deviation to the Director.

CAA Amendment Under the CAA Amendment Act, Section 13 of the Civil Aviation ActAct Act has been amended and the insertion of section 1 3A has been issued

to clarify issues in the use of emergency air ambulance and air rescuewithin section 13A (3)-(6). These provisions permit an operator tobreach certain rules where:

• The emergency involves a danger to life or property, and• The extent of the breach of the prescribed requirements goes only as

far as is necessary to deal with the emergency, and

Page 40


There is no other reasonable means of alleviating, avoiding, orassisting with the emergency, andThe degree of danger involved in deviating from the prescribedrequirement is clearly less than the degree of risk in failing to attendthe emergency.

The rules permitted to be breached do not include any aircraftregistration requirements (CAR part 47), airworthiness requirements(assorted rules in CAR, Part 21, sub-part H and Part 91, sub-parts B, F, G)or personnel licensing requirements (CAR part 61).

Section 1 3A replaces regulation 35 of the Civil Aviation Regulations1953. This regulation expires on 31 March 1997. Section 13A takes adifferent approach to regulation 35. Instead of prescribing the rules thatmay be breached, it prescribes those rules that cannot be breached.These core rules shall not, in the interest of safety, be breached in anysituation.

The industry has prepared a collective submission to CAA to permitsingle engine operations under Visual Flight Rules (VFR) at night, as thereis debate about the precise place of IFR flying in helicopters. Most twinengined craft in New Zealand will require two pilots to fly IFR and this isseen as an expensive requirement (one aircraft has an approved autopilot and can fly single pilot [IFR}).

CAA intends to retain provision for pilots to be able to exercisediscretion in emergency situations, but in doing so are concerned toensure this applies only to genuine emergency situations.

Contracts for air ambulance services will need to take into account anychange the CAA regulations, or their interpretation, in the future.

Page 41

National Emergency Air Ambu

2.5 Recent Developments/Initiatives

IntroductionThe following section reviews recent developments and initiatives byvarious organisations who have interests in either air transportation or theimprovement of patient outcomes following trauma or serious illness.

The recommendations and guidelines presented by each initiative in thissection have been taken into account by the Project Team whendeveloping its' recommendations for a national air ambulance network.

2.5.1 Core Health Services Report

The first report of the National Advisory Committee on Core Health andDisability Support Services (31 October 1992) reported its expectationsof an emergency ambulance service as:

'The co-ordination of publicly funded and voluntary ambulance servicesto provide emergency services which allow accessible land, sea and airambulance coverage across the country, with fair access to regional andrural areas. Services should include the provision of an emergencyresponse to any situation where it is believed that a person requires pre-hospital emergency care; assessment, treatment and transport ofpatients; and the operation of a comprehensive and integrated 24 hourcommunications system, including 111, emergency service responsefacilities '

2.5.2 The Care of Critically Ill Children (British Paediatric Association 1993)

Experience within the UK, North America and Australia have establishedthat transfers of critically ill children are best provided by a dedicatedpaediatric emergency team.

Air transport is key to the transfer of critically ill children within NewZealand. The role of the transport team is to travel as quickly as possibleto the requesting hospital to perform on site assessment and pre-transferstabilisation, and to begin treatment as necessary. Return to the treatinghospital should be accomplished as a planned, unhurried procedure afterstabilisation.

It is recommended at least one medical member of the team be anexperienced paediatrician or anaesthetist of senior registrar or consultantstatus with training in paediatric intensive care. The second member ofthe team should be an experienced paediatric nurse.

Page 42


2.5.3 The RACS NZ Trauma Committee Guidelines

Clear GuidelinesThe Royal Australasian College of Surgeon's New Zealand TraumaCommittee report was published in May 1994 and provided clearguidance to purchasers of trauma services on the appropriate (includingintensive care and support) services required to deliver the best patientoutcomes. It made recommendations as to draft national guidelines fortrauma care services for New Zealand.

This was based on the following elements:• Pre hospital care;• Hospital care;

- Emergency Department-Intensive Care-Definitive Surgical & Medical Care; and,

•Rehabilitation.

This report has been distributed to purchasers by the Ministry of Healthfor their consideration and implementation.

Recommendations In regard to transport, the report states:associated withTransportation"Transport of the injured patient requires timelines, ongoing care, and

the use of the appropriate mode of transport. This applies both withregard to the primary transport from the field and any secondary, inter.hospital transfer. An important principle is that transport of the criticallyill should be aimed at achieving impro ved patient care. The quality ofmanagement during inter-hospital transport must be equal to or betterthan that at the point of referral"

That the referral systems should be based on:

• "24 hour/7 day emergency ambulance helicopters be based onadvanced trauma services in Auckland, Hamilton, Wellington,Christchurch and Dunedin.

• primary response crewing of ambulance helicopters be thecombination of doctor/paramedic personnel

• retrievals/inter-hospital transport of the critically ill be crewec/by theperson deemed appropriate by the unit carrying out the service

• access to local emergency ambulance helicopters be available inWhangare4 Hastings, Palmerston North, Nelson, Greymouth andIn vercargill

• local emergency ambulance helicopters be crewed for primaryresponse by ambulance personnel but doctors with appropriatetraining be included when and where necessary.

Page 43


• Queenstown maintain a local emergency ambulance helicoptercapability.

• there is a suitable fixed wing service to cover the West Coast and toprovide transport to an advanced trauma service or tertiary referralservice."

2.5.4 The ACC Trauma Management Pilot

An ACC Trauma Management Pilot has been set up to test the conceptof a regional trauma system based on the RACS guidelines. It willdetermine whether a trauma system will:

• improve patient outcomes;• reduce the overall cost of injury to ACC; and• create more efficient and effective use and co-ordination of health

services for ARCI claimants.

Outline of aThe pilot regional trauma management system has been agreedRegional between the ACC, Capital Coast Health, Wellington Free Ambulance,Trauma SystemOrder of St John (Hawkes Bay), and Healthcare Hawkes Bay.

In line with the "RACS" Report the pilot regional trauma system willcomprise:

A centrally located Advanced Trauma Service (ATS) based aroundWellington Hospital capable of treating all severe trauma with theexception of specific types of injury for which a specialist unit isrequired;

• District Trauma Service (DTS) based around Hastings Hospitalcapable of treating the majority of major trauma patients;

• Basic Trauma Services (BTS) located throughout the region andcatering for minor injuries; and,

• The pre-hospital emergency services including effective air and roadambulance services.

Co-ordination of the regional trauma system is being undertaken by aRegional Trauma Management Co-ordinating Committee (RTMCC).The function of the RTMCC is to:

• provide a discussion forum for ACC, the Service Providers and otherstakeholders;

• co-ordinate trauma research;• development of common protocols and guidelines;• development of common trauma data collection systems;• establishment of system performance standards and performance

indicators as audit filters;• ensure outcome reviews are undertaken;

Page 44


• ensure peer reviews are undertaken; and,• assist generally in promoting the effectiveness of the trauma system

(See Figure 4).

2.5.5 Southern Regional Health Authority / ACC EmergencyAmbulance Service Agreement

During 1995 the Southern Regional Health Authority and ACC workedtogether to develop an emergency ambulance service agreement withthe Order of St John.

The process enabled the ACC and the SRHA to confirm common servicestandards and align their purchasing requirements in a manner that mettheir respective needs.

The Southern Regional Health Authority was already actively upgradingemergency ambulance services throughout the South Island, and thejoint initiative enabled emergency ambulance services to be improvedfurther.

The agreement covered the South Island (excludingNelson/Marlborough) and included requirements for:

• the Ambulance Service to provide air ambulance services whichmeet a specified standard including emergency ambulancehelicopters, (this requirement may be sub-contracted by acompetitive tendering process); and,

• improvements to staffing and the double crewing of ambulancesattending emergencies;

• a well defined role for rural general practitioners providingemergency medical services in conjunction with the ambulanceservices.

The agreement also specified:

• air ambulance and road ambulance activation times;

• job cycle times (time from dispatch until the patient has beendelivered to a medical treatment centre);

• air ambulance crewing standards;

• a requirement for agreed call out protocols to be developed by a setdate, and

• a requirement for the ambulance service to co-ordinate the PRIMEcommittees;

Page 45


and requirements for:

• medical audit;• communication systems;•inter-agency liaison;•training;• quality assurance;• records; and,• performance reports

Under this arrangement ACC agreed to pay on a "fee for service" basisin accordance with the Accident Rehabilitation and CompensationInsurance (Costs of Transport Related to Treatment Services or PhysicalRehabilitation) Regulations 1992. The SRHA continued to 'bulk-fund' theservices.

Page 46

Fig 4. PROPOSED REGIONAL TRAUMA SYSTEM MODEL

I

\̂̂, ACCESSto

o TRAUMA

I-I SYSTEM(eg /a

q u,u,•IIIIu uuulullIluu 1.111111 IP

Tertiary ReferralService (TRS)

2hhhhhhhhhhhhhhhhhhhhhlu

[1$ ii?i?ationAdvance Trauma --AdvanceServiceHome

•u.u...... NationalRehabilitation EUnit (NRU)

District TraumaService (DTS)

ReferralReturn

..rrtn

/IuuIIIIuuII.uIIlII.u.I.uIl

NOTE:1. Each service facility will also function as a lower level facility for its catchment e.g. an ATS facility as a DTS or BTS2. Pre- hospital triaging may also occur at DTS or BTS for self presented patients

TriageCommunicate !;Communicate- Treat

LU>0=

Fig 5. PRE-HOSPITAL TRAUMA CARE RESPONSE MODEL

Form ofrL Transport

i-AirSea

- Road

I1LOCALITY

PERSONNEL -1

1

—JLU

COMMUNICATION - Ambulance OfficerAMBULANCE CONTROL - Other Emergency Services- Hospital

CASE/SYSTEM AUDITTelecom/Ambulance Control Ambulance- Ambulance Officer Ambulance Officer/PatientAmbulance Officer/ HospitalPublic / Telecom Ambulance Control/Mobilise DecisionControl- Hospital

- Other emergency servicesC PERSOPINEL& QUALIFICATIONS_

2 Crew Paramedic- Ambulance Officer

[ThESPONSE TIMESTotal elapsed time =1 hour for 98%

ACTIVATION RESPONSE Rural80% within 10 minsRoad 95% within 3 mins Metropolitan80% within 10 mins 95% within 20 minsAir95% within 10 mins 95% within 20 mins

EQUALITYMANAGEMENTTools (T)Response times IOfficer training I Medical Audit T

Indicators (I)Activation time I Skills use I System Audit TTotal elapsed time IHospital admissions I Clinical Audit T

Hospital notifications time I


2.5.6Aviation Industry Association Air Rescue / Air Ambulance Standards(1995)

The AlA Air Rescue/Air Ambulance Standards were published inSeptember 1995 and have been endorsed by the CAA. They definestandards for air rescue/air ambulance aircraft and helicopters.The standards establish six categories of air rescue/ air ambulanceaircraft, each with specifications for aircraft equipment, medicalequipment, attendants and pilots. The standards were developed by theAlA in consultation with ACC, Health and Ambulance Authorities, SARAgencies and AlA Divisional Members to support the RAGS TraumaGuidelines.

There is widespread support for these standards and the industry is to becommended for arranging for these standards to be audited. TheAviation Industry Association Air Rescue/Air Ambulance Standards lendthemselves readily to incorporation in contracts.

(See Appendix 2. 3 for A/A Standards)

Page 49

National Emerg ency Air Ambulance Network

Table 6: AlA Air Ambulance Categories(Categorisation of Air Ambulances has been in process since 1973. In September 1995 the following key categories were defined):

Category A Category B Category C Category D Category E Category FIntensive Care AirRapid Response AirStretcher Care AirSeated Care AirIndependent Patient Air Search & RescueAmbulance Ambulance Ambulance Ambulance Transport (I/FR//FR)AircraftAr) 'Intensive Care AirA "Rapid Response AirA "Stretcher Care AirA "Seated Care AirIndependent Patient AirA search and rescue aircraftAmbulance' shall be usedAmbulance" shall be usedAmbulance" shall be usedAmbulance shall be used to Transport aircraft may bemay be fixed or rotary wingto transport patients whoto transport patientsto transport patientstransport patients who areused to transport patientssuitably equipped withmay require continuousneeding intensive care andneeding to be transferredsemi-mobile, perhapswho do not require an airnavigation,attachment to a ventilator,continuous treatmenton a stretcher and needingconvalescent (or a walkingambulance or attendant.communications andother means of life supportand/or monitoring prior tosome medical attention, but casualty) and who mayNo wheelchair is neededrescue capabilities and mayand/or physiologicalinitial hospitalisation, andnot intensive care duringneed to be embarked /during embarkation /include any category of airmonitoring throughout theusually needing flight. Some monitoringdisembarked using adisembarkation ambulance.flight emplacement at or near the might be required. Thewheelchair or other forms

site of an accident soonpatient would usually beof assistance. There is littleafter its occurrence,transferring from oneneed for on-going care, but

hospital to another.a risk of some form ofincapacitation during flightcould arise. Seated carepatients include post-operative stable patientstransferring betweenhospitals.

• There is still some discussion as to the differences between Category A: Intensive Care and Category B: Rapid Response. The consensus view is that Category Bshould be only marginally less well set up than Category A.

• Category E is for patients who do not require an attendant at all. This category was added to clarify the scenario of a patient transfer being made without anyattendant. Therefore it is inappropriate to "refer to this as being an air ambulance operation", and should not be mistaken or cloud the responsibilities of the pilot.

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2.5.7 Report of the Emergency Services Review Taskforce

The report of the Emergency Services Review Taskforce has been takeninto account by the Project Team. Careful consideration has been givento the Taskforce View on Emergency Medical Services, in particular:

Ambulance Services

41. The powerful voice ofpub/ic interest in urban areas had led to theperceived need for this air ambulance capability being satisfiedThe same has not been true in the country, where arguably theneed for wide ranging rapid response aero-meclical evacuationservices is greater. The growth of tourism in rural areas is anothersignificant factor.

42. It is the Task Force view that there is a need for an integratedambulance service which incorporates all emergency medicaltransport needs. Such a service should be funded/n such a way asto recognise:

a) the difference between non emergency medical transportand emergency ambulance services;

b) the actual costs of the ambulance operators, (Le. for serviceswhere the victim dies or when multiple vehicles are called);

c) the value of "snatch and grab" operations that can best beundertaken by commercial operators within relative proximityto the accident sites and their local know/edge; anci

d) the value of the fully equipped dedicated operation.

43. The service should:

a) have operational standards;b) be properly audited; ana'c) be funded on a national basis, largely by A CC.

44. It should be noted that this does not imply a common provider,however, it does imply a common management system so that thevehicle dispatched is based on the most appropriate response andnot the ownership of the vehicle.

45. The Task Force has not undertaken an analysis of the Cave Creektragedy. This is currently the subject of a Commission of Inquiryand not the domain of the Task Force. However, in the course ofthe Inquiry, concerns have been expressed as to the level ofhelicopter coverage on the West Coast. One such statement wasmade by Mr Worth, Director of Medical Services with the RNZAFand Director of Trauma Services with the Capital Coast CHE It is

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reported that he said helicopter rescue operations have not beendeveloped systematically and that, "This has resulted in patchycoverage of New Zealand."

2.5.8 Commission of Inquiry into the Collapse of a Viewing Platformat Cave Creek

Judge GS Noble, the Commissioner for the Inquiry into the collapse of aviewing platform at Cave Creek near Punakaiki on the West Coastrecommended:

1. That the Government initiate and implement appropriate steps toinstitute a combined regional disaster and trauma plan for the WestCoast.

2. That such a process should invite and involve wide participation fromevery relevant rescue and trauma care organisation or party.

3. The object of the plan should be to deliver timely, effective andseamless trauma care from accident site to the appropriate hospital.

4. Among other matters, the plan should provide for:

a) Unambiguous overall leadership, including the prior resolution of1all likely conflicts, and the co-ordination of all services

b) Unambiguous medical leadership

c) Mobilisation of resources on a worst-case scenario basis, withprogressive scaling down as appropriate.

d) Clear and well-planned lines of communication, both personal,and by means of technology, between all the various arms of therescue services.

e) Optimisation of resources, including a determination of thecommunity's ability to support, and the location of, a dedicatedrescue helicopter.

f) The manning of ambulances by two well-trained andappropriately qualified officers, and with provision for therecording and passing on of patient notes.

g) Where practicable, the introduction of pre-hospital triageperformed by suitably qualified officers on patients perceived tobe high-risk, and before they are moved.

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h) Appropriate categorisation of hospitals, with Grey Base Hospitalbeing appropriately designated and a trauma service directorappointed, and with pre-planned hospital designations allocated.

i) The instigation of continuing trauma treatment training forinterested general practitioners.

j) Identification of responsibility for notifying families of bothinjured and deceased victims and the adoption of appropriateguideline procedures to achieve a sensitive and timelycommunication of information.

k) An overall programme of continuous education and trainingaimed at maintaining a co-ordinated overall response.

2.5.9 Other Emergency Services

Airborne Support Significant increases in helicopter usage by the New Zealand Police andthe New Zealand Fire Service have occurred in recent years. In addition,future methods of New Zealand Fire Service operations place significantemphasis on researching and developing airborne support protocols fora much wider range of operations, including:

• building evacuation and victim rescue;• personnel movement (structural and rural firefighting, extrication,

national structural rescue team, rural firefighting);• equipment movement;• incident command and control; and,• rural firefighting (of which some 1,700 flying hours have been utilised

in the last five years by various fire authorities).

The increasing use of airborne support is not a new venture for NewZealand Fire Service operations and this approach has been significantlyincreased internationally. Overseas documentation shows that extensiveprogress has been made in improving emergency managementefficiencies and life saving capabilities through better utilisation ofairborne resources in carrying out the above tasks.

On an economic basis alone the use of airborne support needs to bevigorously explored if the emergency services are going to truly practicean integrated emergency management approach in New Zealand.

CommunicationsThere are mutual benefits to purchasers and providers of air ambulanceservices and related emergency services to more closely examine newtechnology that is soon to be available in New Zealand.

This particular issue was emphasised in both the Cave Creek Inquiry andthe Emergency Services Review, with the latter identifying that:

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"there are clear advantages to be gained by the co-location and perhapssharing of operational facilities and dispatch systems between theprincipal service deliverers. Common communications systems, or moreproperly /nteroperab///ty of systems and protocols should be vigorouslypursued."

The New Zealand Fire Service / Police Joint Emergency ServicesCommunication Centre Project (JESCC) initiative, is a significant steptowards achieving the recommendations of the Task Force.

One of the concerns of the Task Force related to the perceived currentinability to confidently, efficiently and economically dispatch theappropriate mix of expensive resources (including new generationtechnology such as helicopters) to incidents. The JESCC developmentaddresses this concern and could result in joint Emergency ServiceCommunication Centres in Auckland, Wellington and Christchurch from1 July 1997.

These developments suggest there are significant opportunities availablefor closer co-operation between Emergency Services in the co-ordinationand use of airborne services.

SummaryOur analysis of recent developments and initiatives that report onemergency and air ambulance services suggests:

• accessible land, sea, and air ambulance coverage is considered to bea core health service;

• the RACS Trauma Care Guidelines provide a framework and arebroadly accepted within the community and provide a sound basis fordeveloping an air ambulance network;

• the ACC Trauma Pilot has translated the RACS Guidelines into apractical working model with protocols that can be adapted fornational use;

• recent joint contracting initiatives between ACC and RHAs provide anearly prototype for a possible ambulance service contracting model;

• the AlA Standards are broadly accepted and are used as a basis fordetermining air ambulance standards in contracts;

• both the Emergency Service Review and the findings of the CaveCreek Commission of Inquiry underpin the importance of progressingthe development of an integrated air and road ambulance service aspart of a wider trauma management system.

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• the increasing use of airborne support by other emergency serviceproviders, together with recent initiatives by the NZFS and Police toexplore the establishment of communication systems, suggestsopportunities for closer co-operation between the emergency servicesin the co-ordination and use of airborne services.

ConclusionDelivery of care and responses to pre-hospital medical emergencies byemergency ambulance services within New Zealand vary, depending onthe ambulance region. To ensure both air and road ambulances areutilised in a cost effective manner that achieves optimum patientoutcomes nationally, consistent standards covering all of these issues areessential.

Accessible land, sea and air ambulance coverage is considered to be acore health service. Air ambulance services should be based on theRACS Trauma Care Guidelines, underpinned by the AlA standards whichshould be used as a basis for contracting and auditing services. Anintegrated air and road ambulance service needs to be considered aspart of a wider trauma management system.

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\

CIS a

1]'!!A1

-1

3.1 Introduction

3.2Overview

3.3ServiceObjectives

3.4The Model

3,5Access to theNetwork

3.6ContractingArrangements

3.7Key ServiceComponents


3.1 Introduction to the Model

Qur proposals for an air ambulance network for New Zealand takeaccount of the trends of increased utilisation of the services and the

recommendations and guidelines from the various reports and initiativesdetailed in Section 2.4. It is a refinement of existing arrangementsdesigned to support the implementation of the RAGS Trauma CareGuidelines.

3.2 Overview Statement

The proposed network will use the resources and skills of current airambulance operators, and aims to better co-ordinate air and roadambulance services. It will also improve inter-hospital air ambulance co-ordination.

The proposed network will, however, redistribute the workload in someareas.

3.3 Service Objectives

It is envisaged that the proposed network will provide an efficient allweather, 24 hour air ambulance service (fixed and rotary wing) whichsupports, and is integrated with, road based ambulance services andhospital services in providing emergency medical services within NewZealand by ensuring that:

• agreed aircraft staffing, medical standards and call-out protocols aremet for those services designated:

-first tier - servicing advanced trauma centres-second tier - servicing district trauma centres-third tier - "first response" services in areas not readily

accessed by first or second tier services;

• all services, for whatever designation, transport patients to the mostappropriate medical facility within accepted timelines.

This will ensure:

-optimal patient outcomes-reduction of the overall cost of injury-improved use and co-ordination of health services for both

serious illness and major trauma patients.

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3.4 The ModelTo achieve the service objective the following model has beendeveloped:

Table 7: The 3 Tier Air Ambulance Model

Helicopter

TierAvailabilityMinimum A 1Activation TimesTypes of MissionCategory

1st Tier24 Hours A 10 mins - day CasevacAll Weather Multi-Engined20 mins - night Medevac

FR Inter-hospitalSAR

2nd Tier24 Hours B 10 mins - day Casevac

VFR20 mins - night MedevacInter-hospitalSAR

3rd TierFirst Response PreferredAs soon as possibleCasevacEmergency Only B Medevac

VFR SAR

Fixed Wing

TierAvailabilityMinimum A 1Activation TimesTypes of MissionCategoty

1St Tier24 Hours AAs soon as possible inPredominantly inter-All Weather Multi-Enginedconjunction with roadhospital with some

Pressurisedambulance casevac and medevacDeiced

I FR2nd Tier24 Hours AAs soon as possible inPredominantly inter-

Multi-Enginedconjunction with roadhospital with some

FRambulance casevac and medevac3rd TierFirst Response BAs soon as possible inPredominantly inter-

Emergency Only VFRconjunction with roadhospital with someambulance casevac and medevac

This network of three tiers of rotary and fixed wing will ensure better airambulance utilisation within New Zealand.

3.4.1 Rationale: First Tier Helicopter Air Ambulances

The location of first tier helicopter air ambulances has been determinedby identifying centres of population, consideration of geographic factors,the location of specialist medical facilities, the availability of ambulanceresources to crew the air ambulances, and the location of supportingservices for the air ambulance operator.

The Royal Australasian College of Surgeons Trauma Care Guidelinesidentified five major trauma centres. That report also recommendedtwenty four hour air ambulance services be available to service thesetrauma centres. The Project Team supports this rationale.The minimum requirements for a first tier helicopter air ambulance arethat it conforms to AlA Standard A, is Multi-Engined and [FR. It should be

Page 57


available 24 hours, all weather and must be able to be activated within10 minutes during the day and within 20 minutes during the night.

The Project Team has recommended that first tier air ambulancehelicopters be multiengined to conform to CAA regulations for landingon helipads situated on top of buildings.

Location ofAnalysing current workload figures and forecasting potential futureEmergency Airworkloads there is justification for siting first tier emergency airAmbulanceambulance helicopters at the following advanced trauma centreHelicopterslocations:

• Auckland;• Hamilton;• Wellington;• Christchurch;• Dunedin. (*See note page 74)

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- - EJ

Fig 6. SCHEMATIC REPRESENTATION of PROPOSEDI st TIER AIR AMBULANCE SERVICES

ter Services

WELLINGTON

CHRISTCHURCH

30 MINUTE RADIUSOF ACTION1 HOUR RADIUSOF ACTIONHelicopter Air Speed115-120 knots

es do not take account of\Jew Zealand

WHANGAREI

wHA\

II I

OAREI I

I/

--

30 MINUTE RADIUS OFACTION\5•_!

QUEEN

C

Fig 7. SCHEMATIC REPRESENTATION of PROPOSED2nd TIER AIR AMBULANCE SERVICES

- - -.. - Helicopter Services

TAUPO IROTORUA

•,' / -(

ROTORUA J)

-.1I(3AUPO

-.7kJ

i 1- S - -- - - • • 1HASTINGS

I

S 1'HASTINGS

NB: These circles do not take account oftopography of New Zealand

Fig 8. SCHEMATIC REPRESENTATION of PROPOSEDI st & 2nd TIER AIR AMBULANCE SERVICES

:

- Helicopter Services

ANo

/HAMIL 0

ROTORUA

"IHASTINGS-

/I

/'PALMER ON NS -,-

//

/

CS.

S.

/

/

I

I GREYMOUTH I

I/'F

-. - - - CHRISTCHURCH

'F SS.

S.

I

• I

QUEENSTOWN I

DUNEDIN

1st Tier30 MINUTE RADIUSOF ACTIONHelicopter Air Speed115-120 knots

2nd TierI 30 MINUTE RADIUS

OF ACTIONHelicopter Air Speed115-120 knots


,NEW PLYMOUTH

(

Rotorua

/

PALMER ON N.•

7INC

>111

Fig 9. SCHEMATIC REPRESENTATION of PROPOSEDI st, 2nd & First Response

AMBULANCE SERVICES- Helicopter Services

Xe

bon.

/

1st Tier Air Ambulance Services30 MINUTE RADIUSOF ACTIONHelicopter Air Speed115-120 knots

BQ2nd Tier Air Ambulance Services30 MINUTE RADIUSOF ACTIONHelicopter Air Speed115-120 knots

GlacieroG Ze, 4J..ep

Region

OUEENSTOW

-/3rd Tier

- -First Response Providers

SoMced out ofTo Amu S



3.4.2 Rationale: Second Tier Helicopter Air Ambulances

The Project Team considered the RACS Trauma Care Guidelines, theproposed District Trauma Centres and the need for secondary services tobe available as backup to the 24 hour, all weather services. On the basisof this analysis, second tier air ambulances should be available to servicethe district trauma centres. It is proposed that second tier helicopter airambulances should be located in the following regions:

• Northland (Whangarei)• Hawkes Bay (Hastings)• Manawatu (Palmerston North)• Bay of Plenty (Taupo or Rotorua)• West Coast (Greymouth)• Otago (Queenstown with backup from Te Anau)

A second tier service for Taranaki will be justified in the future. Atpresent, the utilisation of helicopter services does not warrant a fullydedicated second tier service, and there are restraints on the provision ofthis level of service. However, the geographical isolation of the region,and the likelihood of increasing utilisation of the service, indicates theappropriateness of a dedicated second tier service in the future.

It is the opinion of the Project Team that Nelson should also beconsidered for a second tier service in the future.

In most cases first tier air ambulances can be located within anacceptable time to backup the provision of additional treatment andtransport from secondary centres.

It is proposed that one second tier service cover the Taupo/Rotoruaregion. Like Queenstown, the region has unique topography whichattracts large numbers of tourists involved in high risk recreationalactivities all year round, i.e. skiing, tramping and hunting.

This is in addition to the recommendations within the RACS report, asutilisation rates within the Midland region justify the siting of a helicopterat this location. This helicopter can service the district trauma service atRotorua and the Advanced Trauma Centre in Hamilton within the RACSspecified timeframes.

The minimum requirements of a second tier helicopter air ambulance arethat it conforms to AlA Category B and is VFR. It should be available 24hours a day and must be activated within 10 minutes during the day and20 minutes during the night.

Page 63

AUCKLAND

Fig 10. SCHEMATIC REPRESENTATION of PROPOSED I st TIERAIR AMBULANCE SERVICES

- Fixed Wing

WELLINGTON

CHRISTCHURCH

- 1 HOUR RADIUS OFACTIONFixed Wing Air Speed 170knots

Fig 11. SCHEMATIC REPRESENTATION of PROPOSED I St & 2ndTIER AIR AMBULANCE SERVICES

- Fixed Wing

AUCKLAND

WELLINGTON

CHRISTCHURCH

1st TIER1 HOUR RADIUS OF ACTFixed Wing Air Speed 17(knots

2nd TIER1 HOUR RADIUS OF ACTIFixed Wing Air Speed 170knots

Fig 12. SCHEMATIC REPRESENTATION of PROPOSED I st & 2nd TIERand Other Operators Registering an Interest

- Fixed Wing Air Ambulance Operators

AUCKLAND

WELLINGTON

CHRISTCHURCH

1st TIER1 HOUR RADIUS OF ACTIONFixed Wing Air Speed 170knots

2nd TIER1 HOUR RADIUS OF ACTIONFixed Wing Air Speed 170knots

Other Operators InterestedAIR AMBULANCEFixed Wing


3.4.3 Rationale: Third Tier "First Response" Helicopters

The Project Team has been unable to justify any 24 hour dedicatedsecondary tier contracted service in areas with workloads of less than150 incidents per annum where air ambulances may be required.

Therefore, the Project Team recommends a preferred provider systemwith helicopter operators in these areas. This preferred provider list ofcommercial helicopter operators would have standardised call outmechanisms accessed through the 111 system. Although they would notoffer dedicated services, the operators would be contracted by the primeambulance service to provide their services on an as required basis, andin accordance with agreed minimum standards, as a first response andbackup to first or second tier services.

This form of arrangement is desirable in areas with a more limited needand where access to first tier or second tier services is not readilyavailable. These regions are Nelson, Gisborne, Taranaki, and theSouthern West Coast.

To ensure these operators remain familiar with the interface withambulance services they should participate in joint meetings with ruralgeneral practitioners, Police and other emergency service personnel.

The requirements for the non-dedicated third tier "first response"helicopters are that they are available for emergencies only, and can beactivated as soon as possible. They should be AlA rated, preferably toCategory B standards although this standard may not be achievable in allcircumstances.

Air Ambulance specifications, crewing, activation times, communicationsand response protocols are detailed in the contract section of this report.

3.4.4 Rationale: First Tier Fixed Wing Air Ambulances

First tier fixed wing air ambulances must be available to service advancedtrauma centres, and be able to transport retrieval teams from theadvanced trauma centres to the hospital of the patients admission. Firsttier fixed wing operations may be separate to those of first tier helicopterservices.

The minimum requirements for first tier fixed wing air ambulances arethat they conform to AlA Category A, are Multi-Engined, deiced andpressurised to enable altitude sensitive patients to be transported. Firsttier fixed wing aircrafts must be available 24 hours a day, in all weatherand must be able to be activated as soon as possible in conjunction withroad ambulance services.

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3.4.5 Rationale: Second Tier Fixed Wing Air Ambulances

Second tier fixed wing air ambulance services should be available toservice district trauma centres where there is a high need not adequatelymet by first tier fixed wing air ambulances, and for time critical patientsnot requiring advanced trauma centre retrieval teams. --- -

Taking into account curreht workloads and perceived need,- the ProjectTeam woUld propose that second tier, fixed . wing services be offered out ofManawatu/Wanganui, Hawkes Bay,-Southland and Central Otago.

The minimum requirements for second tier fixed wing air ambulances arethat they conform to AlA Category A, are Multi-Engined and IFR. Secondtier fixed wing aircrafts must be available 24 hours a day and must beable to be activated as soon as possible in conjunction with roadambulance services.

3.4.6 Rationale: Third Tier Fixed Wing Air Ambulances

The services of third tier fixed wing aircrafts are seen as being utilised asan emergency "first response" on those limited occasions where a first orsecond tier operator is not available. A list of preferred providers atoptimum sites should be available to all emergency services so that theseaircraft can be activated as need requires.

The minimum requirements for third tier fixed wing air ambulances arethat aircraft and operations conform to AlA Category B and are VFR.

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Air Ambulance

3.5 Emergency Access to the Network

Access to the National Air Ambulance Network for emergencies mustcontinue through the 111 system. Callout protocols recognising thespecific needs of SAR operations, which may require an aircraft to beretasked from a search to an ambulance role mid-operation, need to bedeveloped. Appropriately trained and qualified doctors, which includesappropriately qualified rural GPs, should also be able to accessemergency air transport through the 111 system.

Access to theThere may be merit in designating one control room as the nationalNational Airco-ordinator or the inter- hospital system. The ACC and the RHAsAmbulanceshould initiate talks with the New Zealand Ambulance Board with aNetwork - view to designating one control room for this role.Non Urgent

In the meantime, effective co-ordination and control of limited resourcesmeans access to Air Ambulances for non urgent inter hospital transferscan best be achieved regionally through the 0800 system. One controlroom in each RHA region should be designated as the answering anddispatch point. In the longer term, there would be merit in designatingone control room as the national co-ordinator of the inter-hospitalsystem. Figure 10 provides an overview of how an effective regionallybased system might be achieved.

An alternative option the ACC/RHAs and ambulance service providersmay wish to consider, is utilising the existing 0800 service provided bythe Auckland Air Rescue Trust. Well defined callout and referralprotocols would need to be developed and agreed by ACC/RHAs andCHEs, perhaps through a body such as a National Trauma ManagementCo-ordinating Committee.

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HOSPITAL & MEDICAL STAFF

REGIONAL 0800 NUMBER

Take booking & establish location and destination ofpatient and requirements for staff, equipment, timing, road

ambulances etc.

Co-ordinate air ambulance request with otherknown national air ambulance bookings

Confirm flight times etc with air ambulanceoperator

Confirm arrangements to requesting agent

Arrange road ambulances for pickup point anddestination ensuring that equipment or special

needs are catered for

Confirm booking to air ambulance operatorand advise of pickup point, destination and

of any backloads


3.6 Contracting Arrangements

The health service environment is now one in which contracts areestablished to agree purchase prices, provide clarity of relationships,clarity of responsibilities, and clarity of accountability. It is in the bestinterests of purchasers, providers, trauma and serious illness patients, thatcontracts for air ambulance services be established.

The National Air Ambulance Network model and its associated standardsand specifications should be incorporated into contracts with providers.

The Purpose ofContracting

Contracting will ensure Air Ambulance services are accessible,responsive, needs based, of a high quality and cost effective.

These objectives can best be realised by ACC and the RHAs establishingcommon service standards and requirements for these services.

Contracts should be let by ACC and the RHAs, by 1998 or before,through a competitive tendering process within each RHA areaconsidering:

•regional utilisation and requirements;• use of helicopter versus fixed wing requirements;• the huge increase in CHE related inter-hospital transfers.

ProposedPrinciples forContracting

The following principles are recommended to ensure the contractingprocess should be transparent and contestable.

• ACC and each RHA jointly contract for emergency ambulanceservices - both road and air;

the contracting between RHAs and CHEs should take account of theneed for CHEs to use the proposed contracted air ambulanceservices for inter-hospital transfers, taking into account thespecifications and standards recommended for first and second tierair ambulances as recommended within this report. This will ensurefull use and viability of contacted first tier services at the best price;

• contracts must reflect any changes to the CAA regulations;

• all contracts be contestable through a competitive tendering process;

• first and second tier operations be tendered for separately with aregionally staged implementation;

• separate contracts be developed for rotary and fixed wingoperations;

• the successful tenderer also competitively tender any services thatare to be sub-contracted;

Page 71


• contracts be awarded in alignment with other purchaser contractingarrangements (NB: 3 year term would be desirable);

• first and second tier ACC contracted operations be funded by amonthly payment to the contracted operator for an agreed minimumnumber of hours plus marginal costs. There should be provision forrenegotiation if the minimum number of hours is significantlyexceeded;

• third tier operations (first response services) remain on a "fee forservice" basis.

• ACC and combined RHAs enter into dialogue with New ZealandPolice/New Zealand Fire Service on arrangements for use ofcontracted air ambulances for SAR and other missions on a "fee forservice basis".

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Table 8: Proposed Contracting Arrangements

TierContractorContractBudgetSubMinimum A 1Type of ContractHolderHolderContractorCategoryMinimum # of Fee For Service Types of

Hours & ContractedMarginal Costs Missions

1st TierACC & ambulanceambulance1st tier operatorA (fixed wing) / Casevaccombined RHAsoperatoroperatoreither fixed wingIFR Multi-Engined Medevac

or helicopterpressurised, deicedA (helicopter)

FR Multi-EnginedCHEs CHEs 1st tier operatorA (fixed wing) /Inter-hospital

either fixed wingIFR Multi-Engined Transfersor helicopterpressurised, deiced

A (helicopter)FR Multi-Engined

Police Police 1st tier operatorA (fixed wing) SAReither fixed wingIFR Multi-Enginedor helicopterpressurised, deiced

A (helicopter)IFR Multi-Engined

2nd TierACC & ambulanceambulance2nd tier operatorA (fixed wing) / Casevaccombined RHAsoperatoroperatoreither fixed wingIFR Multi-Engined Medevac

or helicopter(helicopter)B VFR

CHEs CHEs Either fixed wingA (fixed wing) VInter-hospitalor helicopter Transfer

Police Police 2nd tier operatorIFR Multi-Engined "SAR(helicopter)

B VFR3rd TierACC & ambulanceambulance3rd tier operatorB (fixed wing) /Casevac"First combined RHAsoperatoroperatoreither fixed wingVFR MedevacResponse" or helicopterPreferred B

(helicopter)VFR

Police Police 3rd tier operator /SAReither fixed wingor helicopter

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First Tier First tier providers of air ambulance services should offer acomprehensive helicopter and fixed wing service for each RHA area.Due to regional differences in utilisation, it is recommended that eachRHA, in conjunction with ACC, set the number of minimum hoursrequired to be purchased for helicopter and fixed wing services forCasevac, Medevac and Inter-hospital Transfer Services.

Helicopters will not replace the requirement for fixed wing airambulance operations in New Zealand. Fixed wing services can operatemore cost effectively. There is significant over capacity and the use ofthese services can more readily be scheduled because they are utilisedmostly for inter-hospital transfers.

The Project Team sees value in contracting fixed wing services alongsidehelicopter services in the first tier. However, contracts can be tenderedfor separately with different operators jointly providing a comprehensiveservice. Helicopter and fixed wing aircraft operate in a complementaryfashion. Fixed wing aircraft are, for example, often used if retrievaldistances are in excess of 100km, when a suitable fixed wing landingarea is available, or weather is adverse for helicopters. There is also somecapacity for backloading. Value is perceived in attaching fixed wingaircraft operations to the first tier with its focus on specialist services andthe associated training environment. There are undoubtedly economiesof scale to be realised with fixed wing aircraft, to the extent of makingpressurised aircraft cost competitive.

An important principle in retrieval services is that a team from the referralcentre (the advanced trauma centre) is dispatched to pick up patientsrequiring specialist care (e.g. neonates, intensive care patients). Thusfixed wing aircraft need to be associated with the advanced traumacentres as part of the first tier provider.

Fixed wing aircraft need to meet the appropriate AlA standards anddefined response times, and should be pressurised and have deicingcapabilities, allowing for 24 hour all weather operation.

To ensure continuity of service, first tier operators should be required toensure they have appropriate helicopter backup arrangements in place,should their primary machine be non-operational or already respondingto another emergency callout.

First tier services should conform to the AlA definition of intensive careair ambulance. The Project Team considers that, as a general rule, firsttier helicopters should be twin engined and fully IFR.

*Note: Dunedin is a special case. The use of (FR in Otago/Southland willnot always increase available flight times. This is mainly due to weatherand geographical conditions around Dunedin. Further considerationwould need to be given to the cost effectiveness of purchasing an LFRcapable rotary wing service for Otago/Southland.

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National Emerencv Air Amb

It is recommended that an IFR approach to Dunedin Hospital isdeveloped as a priority, and put in place before an IFR service ispurchased within the Dunedin region.

As the first tier will provide the core of New Zealand's air ambulancenetwork, it should be able to provide the maximum availability and safetypermitted in weather extremes. For this reason the use of IFR willbecome increasingly common.

Second TierIt is recommended that second tier helicopter and fixed wing airambulance services be tendered for separately.

Third Tier There is a need to protect the capacity of "first response" helicopterswho, because of location or specialised local knowledge, are able toprovide emergency services rapidly in remote locations. It isrecommended that third tier services for helicopter air ambulances besub-contracted to prime ambulance contract holders, to deliver serviceson an "as required" basis under the present "fee for service" paymentsystem. Third tier operators would not normally provide dedicatedaircraft, or be contracted to provide a service outside of the isolatedareas identified above. They could, however, provide a backup service tofirst and second tier operators on an "as required" basis.

Funding needs to be reserved and protected to finance the utilisation ofthese first response services. This funding should be placed with theregional ambulance operator to pay fee-for-service (hourly rate) to anyoperator called upon by them to deal with sick or injured people. Theprinciple role of the third tier is to provide immediate service, and thento link with the formal air ambulance services and the appropriatemedical staff to hand over the care of the sick or injured person.

Police/Fire/SARThe Project Team's discussions with the Police, the NZ Rescue CentreMissions and the New Zealand Fire Service (NZFS) suggest that these bodies will

not be seeking any immediate change in the way they acquire or pay forservices. They are, however, open to exploring effective options forimproving the co-ordination and delivery of emergency services.

There will always be situations where the roles and responsibilities of theemergency services overlap. Rather than attempting to strictly defineand adhere to agency specific roles and responsibilities, a better solutionmay be to ensure close co-operation and consultation between allemergency services at the policy formulation, control room and fieldoperations levels.

Where another emergency service becomes aware of injured or illpersons, it should (the urgency of the situation allowing) consult withambulance personnel about the most appropriate means of providingassistance to that person.

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To be effective, and appropriately meet current and future risks, jointemergency service operations need to co-ordinate and share, wherepossible, available resources for both practical and economic reasons.

Time-sharing, and multi-party base cost funding of approved and selectedoperators, would assist in reducing overall costs (particularly applicableto IFR related costs), as well as giving operators more flying timeexperience.

It is clear that there is a significant increase in the use of airborne servicesby the emergency services. The ACC and RHA institutions will ensure amore co-ordinated approach to future air ambulances operations, whichshould be to the benefit of all emergency service organisations.

Discussions should, however, be held between the ACC/RHAs, the NZFire Service, the Police and the Rescue Control Centre (RCC) with a viewto exploring the options for the shared use of contracted providers ofemergency air ambulances, and co-ordinating and rationalising commandand contract arrangements between the emergency services.

3.7 Key Service Components

Air Ambulance Specifications

It is recommended that aircraft to be used be registered as airambulances with AlA and meet the following AlA aircraft categories foreach tier of the network:1St TierCategory A - Fixed Wing IFR

Category A - Helicopter IFR2nd TierCategory A - Fixed Wing IFR

Category B - Helicopter VFR3rd TierCategory B - Fixed Wing VFR

Preferred Category B - HelicopterVFR

First tier and second tier providers must operate helicopters that providesufficient space for access by the attendant to, at least, the patient'shead.

Air AmbulanceFirst and second tier air ambulances must be capable of maintainingVoice voice contact with ambulance regional control centres, and voiceCommunicationscontact with third tier services is also recommended.

Air AmbulanceThe crewing requirement for air ambulances in first tier (AdvancedCrewing Trauma Service) areas must be a minimum of a doctor, paramedic

and/or an ambulance officer.

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For second and third tier call outs to emergencies that may require pre-hospital patient care, at least one crew member is required to be either:

• paramedic ambulance officer and/or• suitably trained doctor or an Ambulance Officer qualified to the level

most appropriate for the incident.

Air AmbulanceThe following activation times are proposed:Service LevelsActivationFirst Tier and Second Tier HelicoptersTimes • Between 0700 hours and 1800 hours - within 10 minutes of

dispatch time (assigned by ambulance control);

• between 1800 hours and 0700 hours - within 20 minutes of dispatchtime (assigned by ambulance control) NB: It is recognised thatconsideration needs to be given to the response time of flightcommencing late in the evening and through the night, as additionaltime is required to prepare for such flights.

3rd Tier• As soon as possible.

All fixed wing aircrafts are reliant on road ambulance services and shouldbe activated in a timely fashion in conjunction with these services.

Callout ProtocolsCall-out protocols for Air Ambulance Services, includingfor Air Ambulance emergency ambulance helicopters, should be introducedServices as soon as possible based on the following principles.

Use of emergency ambulance helicopters should be considered:

• for all accident and sudden illness calls where life is at risk or wheninformation received cannot exclude life being at risk; and/or;

• the patients condition and/or outcome is dependent on time-criticalmedical intervention; providing,

• road transport response time is greater than 30 minutes;

• the retrieval of a patient to a suitable medical facility will otherwiseexceed 60 minutes; after considering,

• the patient's medical condition will not be adversely affected by airtransport, and/or,

• when a possible improvement to the patient's outcome orrehabilitation can be realistically assumed

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Allowance should be made for Air Ambulance response time. Secondtier operators should ensure that they can maintain the agreed level ofservice as required by the prime contractor. This may require helicopteroperators with only one aircraft to establish backup arrangements. Thesebackup aircraft must be capable of meeting appropriate AlA standards.

Callout protocols and other operating standards should be reviewedregularly by a Regional Trauma Management Co-ordinating Committee.

The next section details the proposed response protocol for EmergencyAir Ambulance Helicopters (Figure 14).

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Fig. 14. RESPONSE PROTOCOL for EMERGENCY AIRAMBULANCE HELICOPTERS

The following protocols are a guide and require Ambulance Service Staff to take responsibility for the use of expensiveair ambulance resources, so that the best outcomes for patients are achieved, without unnecessary costs.

1For all accident and sudden illness calls where life is at risk or frominformation received cannot exclude life being at risk,

and/or2For all patients whose condition and/or outcome is dependent on

critical medical intervention

A. Road transport response time is greater than 30 minutes (for anambulance to locate at patients meeting criteria 1 or 2 above and anair ambulance can locate quicker than a road ambulance)

DESPATCH AIR AMBULANCE

B. The retrieval time of a patient (meeting criteria 1 or 2 above) to a suitablemedical facility will exceed 60 minutes and air ambulances use will reduce thistime significantlyDESPATCH AIR AMBULANCE

A.-J

andB.

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A patient's medical condition will not be adversely affected by airtransport,

A possible improvement to the patient's outcome or rehabilitation canbe realistically assumed.

Allowance should be made for Air Ambulance response time

j NOTE: Time, traffic conditions, terrain, climatic conditions and access

) \' are not automatic reasons for air ambulance use.These factors should be considered in relation to serious illness orserious injury, form information received.

Three methods to assist to determine major trauma or serious illness:• Physiological• Anatomical• Mechanism

Physiological triage is based on the present state of vital signs andlevel of consciousnessEXAMPLES• respiratory rate less than 10 or greater than 30• systolic blood pressure less than 90• pulse greater than 130• difficulty of arousal or falling level of consciousness

In children and the elderly the same principles apply but physiologicalcriteria must be taken in context of both age or size.

If any of these physiological factors are recognised in relationship to illnessor injury, then the patient should be regarded as having potentially majortrauma or serious illness. The patient should be transported directly to a districtor advanced trauma. This may require bypassing other medical facilities unlessthe ambulance officer or ambulance crew are unable or concerned about theirability to maintain or improve the patient's condition. In such cases the servicesof a local GP or medical facility should be used or medical assistance broughtto the patient.

In all other cases, patients should be transported to the closest appropriatedesignated medical facility.

Anatomical CriteriaSpecific examples:• Penetrating injury to head, neck chest, abdomen, peritoneum, or back• Head injury with coma, a dilated pupil, open head injury, or severe

facial injury. Chest injury with flail segment or subcutaneous emphysema• Abdominal injury with distension and/or rigidity• Spinal injury with weakness and/or sensory loss• Limb injury involving vascular injury with ischaemia of the limb,

amputation, crush injury of the limb or trunk, or bilateral fractures ofthe femur

• Burns partial of full thickness, more than 20% in adults, or more than10% in children.

If any of these anatomical factors are recognised then the patient should betransported directly to a district or advanced trauma service. This may requirebypassing other medical facilities unless the ambulance officer or ambulancecrew are unable or concerned about their ability to maintain or improve thepatient's condition. In such cases the services of a local GP or medical facilityshould be used or medical assistance brought to the patient.

In all other cases patients should be transported to the closest appropriatedesignated medical facility.

The following mechanisms, which imply high energy transfer, shouldtrigger very careful evaluation of patients.• Vehicle crash over• major deformation of the vehicle• fatality in the same vehicle• ejection from the vehicle• unrestrained child in a motor vehicle crash• cyclist or pedestrian hit by a motor vehicle crash• fall over 5 metres• any mechanism that causes injuries to multiple body regions.


Contract All contracts with air ambulance operators should cover the followingSpecificationspoints:

Operational requirements for specific tiers

• Quality systems to ensurestandardised protocols

O benchmarksO best practice protocolsO appropriate helicopter access to medical facilitieso continual service improvement proceduresO audit proceduresO outcome studiesO review systems that link with the Regional Trauma Management

Co-ordinating Committees

• Data collection systems to collect, store and analyse0 mission dataO response timesO activation times0 management dataO cost dataO outcome data

• Reporting requirements0 regular reports, as agreed, that analyse the data collected

• Communication systems0 between land ambulance and air ambulance0 between road and air ambulance services and other emergency

servicesO between air ambulance operators and Crown Health Enterprises

• Financial management systems which identify0 Fixed and marginal costsO the cost of casevac missionsO the cost of medevac missionsO the cost of inter hospital transfers

• Contractual management systemsO standardised schedules for the contracts

• Training systems toO identify staffing needso need for training programmes0 establishing and implementing training programmeso ensure staff are adequately trained to operate from air

ambulances

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4.1Proposal

4.2Methodology

4.3Costs

4.4Benefits-

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4.1 Proposal

This paper's preferred model would establish a co-ordinated networkof dedicated first and second tier ambulance service providers, to

replace the current ad hoc arrangements.

In general terms the main rationale for implementing this change are to:

improve emergency response times and service standards, therebyimproving the medical outcomes for hospital patients and accidentvictims; and,take advantage of any economies of scale associated with the movefrom a wide diversity of service providers to a smaller number ofpreferred providers.

4.2 Methodology

The proposed model has been evaluated from a national economicperspective, and compares the marginal (additional) costs and benefitsthat will be incurred as a result of this initiative.

From the results so far obtained, there is a strong likelihood that thisproject could be justified simply on the grounds that it will generate areduction in costs. This is an attractive proposition in that it avoids thenecessity of having to quantify a number of benefits that, whilst real, aredifficult to measure, in order to evaluate the options.

4.3 Costs

Establishment costs, in the form of the cost of bringing operators'equipment up to the new standards that are envisaged, are not explicitlyincluded in this analysis for two reasons:

nationally, the cost of bringing air ambulance operators' equipmentup to the new standards is likely to be minimal, particularly in theNorth Island as sufficient numbers of operators are already meeting orexceeding the envisaged standards; and,the establishment costs, where they exist, are reflected in/recoveredin the charge out rates used to estimate the costs of the new system(Table 12).

The national cost of Air Ambulance Services for 1995 (the currentscenario) has been calculated using mission hours and average operatingcost information supplied by industry participants in response to asurvey. These figures have been adjusted upwards by a factor of 30% toallow for annual growth in air ambulance usage based on current trends.The results obtained are summarised in Table 9.

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Table 9:Estimated Cost of Air Ambulance Services in 1995 by Region

NorthernMidlandCentralSouthernRegionRegionRegionRegionTotal

Casevac 460,881583,343441,129293,6471,779,000Medevac 205,876309,945384,60382,577983,001Inter-hospital Transfers 759,4531,019,2921,81 1,853124,4023,71 5,000SAR/Other 267,941156,069233,41345,578703,001Sub-total 1,694,1512,068,6492,870,998546,2047,180,002Growth Adjustment 508,245620,595861,299163,8612,154,000TOTAL 2,202,3962,689,2443,732,297710,0659,334,002

These figures have been derived from the information contained in Appendices 2.1 and 2.4

Table 10 sets out the assumed number of hours per annum that are likelyto be flown by the first and second tier designated air ambulanceoperators. First tier operations will involve both helicopter and fixedwing services, and the assumed split between these for each region is setout in Table 11.

Table 10:Assumed Location and Annual Mission Hours for Designated Air AmbulanceOperators

15t Tier Minimum No. of Hours forHelicopter and Fixed Wing

Auckland 800Hamilton 800Wellington 800Christchurch 400Dunedin 400

Second TierIt is assumed that the minimum number of hours for helicopter andOperationsfixed wing aircraft will be 400 /200 hours for those services designatedAssumptionssecond tier operations, for the North Island or South Island

respectively.

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Table 11:Assumed Percentage Split Between Fixed Wing and Helicopter Services

Fixed Wing % Helicopter %Northern Region 15 85Midland Region 48 52Central Region 69 31Southern Region 49 51

These percentage splits are derived from the percentage use by each RHA for the 1994/95 year.

The above figures have been applied to the operating costs of industryparticipants, using the formulas set out below to derive the likely cost ofa first and second tier air ambulance network.

North IslandFirst tier• 800 hours divided into percentage of fixed wing or helicopter• Fixed wing hours costed at $759 per hour• Helicopter hours costed at $2033 per hour (mean helicopter price) at

present. three first tier locations - Auckland, Hamilton, Wellington)

Second tier. 400 hours costed at mean helicopter rate of $1368 per hour

South IslandFirst tier• 400 hours divided into percentage of fixed wing or helicopter use

(Table 11)• Fixed wing hours costed at $759 per hour• Helicopter hours costed at $2033 per hour (as for North Island).

It is estimated that first and second tier operations constitute 80% of theair ambulance requirements for New Zealand. The cost of first andsecond tier operations have in turn been factored up by 25%, to allowfor the costs of the third tier operators. The derived total costs for aNational Air Ambulance Network are summarised in Table 12.

Table 12:Estimated Cost of Air Ambulance Services in 1995 by Region

NorthernMid/andCentralSouthernRegionRegionRegionRegionTotal

1st Tier Services 1,8425001,421,2501,153,7501,407,5005,825,0002nd Tier Services 683,750683,7501,367,500685,0003,420,000TOTAL COSTS 2,526,2502,105,0002,521,2502,092,5009,245,000

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A comparison of Tables 9 and 11 indicates that the annual cost of aNational Air Ambulance Network is $89,000 less than the costs of thepresent system. As this amount represents less than 1 percent of thecosts involved, it seems reasonable to conclude that the marginal costsof this initiative as it stands are nil.

4.4 BenefitsTable 13 below contains a qualitative summary of the potential benefitsand costs associated with this type of proposal.

Table 13Potential Benefits and Disbenefits of a National Air Ambulance Network

Trauma Patient MedicalSocietyACCRI-IAPatients

Potential• Reduced risk • Reduced risk •Lower• Lower• LowerBenefitsof deathof death "mortality"disabilitydisability

• Lower risk of• Lower risk ofcosts: slInnrrt cos ts ,r,r,-srt

permanentdisability

•Earlier returnto pre-accidentstatus

• Shorterlength of stayin hospital

• Reducedpain andsuffering

permanentdisabilityEarlier returnto pre-illnessstatusShorterlength of stayin hospitalReducedpain andsuffering

Loss ofcreative andeconomiccontributionLoss ofinvestmentin educationand welfarePain andsuffering offamilies

Lowerrehabilitationcosts perpatientImprovedpatientoutcomesImprovedpatient care

Lowerrehabilitationcosts perpatientImprovedpatientoutcomesImprovedpatient care

Lower disabilitycosts:• Income

support• Welfare and

otherbenefits

Potential • More• MoreDisbenefits survivors ofsurvivors of

trauma illnessrequiringrequiringcare care

To place this proposal in context, the air ambulance network should beseen as part of a broader trauma management system.

International experience indicates that regional trauma systems canlower mortality rates for patients with severe trauma from 30-35 percentto 5-10 percent'.

1 See among others, West JG et al, Impact of Regional isation: The Orange County Experience, Archives ofSurgery, Vol 118, 1993.

Page 85

More importantly from the perspective of the air ambulance network,studies indicate that death is potentially preventable in at least 40 percent of those who die from accidental injury before they reach hospital,with response time being a key variable2.

One of the more significant benefits associated with this project is thereduced mortality rates, which are likely to arise from the improvedresponse times that will accompany the move towards designatedservice suppliers. If a typical trauma victim is a male aged 25, the value oflifetime earnings discounted over a 40 year working life amounts toapprox $375,000.

If, as seems likely from the literature available, the additional downstreamtreatment costs that accompany reduced mortality and morbidity rates,are matched by downstream benefits of reduced injury severity andlength of time taken to return to independence; then this initiative onlyneeds to result in the avoidance of one preventable pre hospital traumadeath per annum to generate a positive return.

4.5 Costs and Benefits from the ACC Perspective

ACC expenditure on air ambulances was $1.6 million in the 1995financial year. For the first 9 months of the 1996 year the correspondingfigure is $1.8 million which equates to an annualised figure of $2.4million. These figures indicate that the cost to ACC of air ambulanceservices is only increasing in direct proportion to the general increase indemand for such services. If these trends continue then the marginal costto ACC of this initiaitve appears to be minimal.

As the "value of life benefits" of this proposal accrue to the individualrather than ACC, the relative size of the additional downstream costsassociated with reduced morbidity, compared to the savings arising fromreduced injury severity, becomes a critical factor.

If the ACC and the RHAs proceed with this report's proposal, carefulevaluation will be required to ensure that these potential benefits arerealised.

ConclusionsAn integrated air ambulance network has the potential to make a realcontribution to the favourable outcomes associated with a broadertrauma management system.

2 See among others, Hussain LM and Redmond AD, Are prehospital deaths from accident injurypreventable? BMI Vol 308, April 1994

Page 86

This analysis indicates that these benefits could be obtained with little orno increase in overall expenditure by the ACC and RHAs, assumingcurrent levels of community and sponsor support. The validity of thisanalysis will only be fully tested during contract negotiations withpotential providers. Specifically, if-the ACC and the RHAs proceed withthis proposal a critical early step in implementation will be firmingestimates of the true costs of operation.

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Issues forResolution

Commitment

Funding Issues

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5.1 Issues for Resolution

To be able to successfully implement this new national air ambulancenetwork the following issues must be resolved:• Commitment• Funding• Sponsorship and Community Support• Contracting• CAA Regulations

5.2 Commitment

A formal commitment of support for the proposed national airambulance service by the main users and purchasers is essential:

• ACC;• Regional Health Authorities;• Crown Health Enterprises;• NZ ambulance services.

Initially, a commitment and agreement by the main funders, ACC andRHAs, to purchase air ambulance services is essential for theestablishment of a national air ambulance network.

The RHAs and ACC should also take the lead on facilitating discussionswith the CHEs to progress the implementation of a more efficient andeffective integrated interhospital transfer system.

ACC and RHAs will need to facilitate talks with the Police and NZ FireService on how the best use can be made of contracted air ambulanceproviders for Search and Rescue and Fire suppression tasks in anintegrated emergency management network.

5.3 Funding Issues

It has become clear through the Project Team's research that there isconsiderable use of air ambulances for inter-hospital transfers. Thedefinitive size of this market is unknown.

To identify the expenditure associated with inter CHE air ambulanceRHAs will require usage data to be collected by each CHE over thecoming financial year (See Appendix 3).

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5.4 Sponsorship & Community Support

The large contribution from sponsorship and community support tothe capital and operating costs, particularly of emergency helicopters,should not be underestimated.

This support is essential if good quality, cost effective air ambulanceservices are to be made available for all population centres in NewZealand.

Effective dialogue between ACC, the RHAs, and sponsors is required toensure sponsors continue to target and support services that areessential to the delivery of a cost effective network, and to ensure thatsponsors' interests are taken into account as the service model isimplemented.

5.5 Contracting

Contracts for the provision of air ambulance services within thisproposed new national air ambulance network should be tendered.

The following issues will impact on the timing of new contracts:

• current contractual arrangements of air ambulance operators;• current contractual arrangements of emergency ambulance services;

and• current sponsorship arrangements.

We have recommended ACC develop joint contracting arrangementswith the RHAs under the clauses 27 and 29a of the ARC! Act inaccordance with the guidelines contained in this paper.

Should the ACC and the RHAs chose to establish separate (as opposedto joint) contractual arrangements with ambulance service providersindependently of one another, we recommend that they agree commonservice standards and maintain similar contracting timeframes to facilitatethe coherent development of emergency ambulance services in NewZealand.

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5.6 Moving Outside the ACC Regulations

To give effect to the recommendations contained in this report, the ACCwould need to move outside the bounds of the current ARCI (cost ofTransport for Treatment, Service or Physical Rehabilitation) Regulations1992.

5.7 Implementation PlanTo give effect to our recommendations we have set out the followinghigh level implementation plan:

1. ACC and RHAs to consider report and agree implementationplanning arrangements.

2. ACC/RHAs to complete consultation process with stakeholders onthe report and proposed implementation arrangements.

3. ACC/RHAs to commence competitive tendering process forAmbulance Services on a region by region basis as RHA contractswith prime ambulance service providers fall due:

• Midland RHA for Midland region (30 June 1997)

• Southern RHA/ACC for South Island (excludingNelson/Marlborough) (30 September 1997)

• Central RHA for Wellington, Hawkes Bay, Central (PalmerstonNorth / Manawatu), and Nelson Marlborough (30 June 1997).

• Northern RHA/ACC for the Auckland Region (excludingNorthland) (To be advised).

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6.1 Recommendations

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6.1 Recommendations

The following recommendations are made:

6.1.1 National Trauma System

• The ACC and the combined RHAs, in association with the Ministry ofHealth, should facilitate the formation of a National Regional TraumaManagement Co-ordinating Committee and five Regional TraumaManagement Co-ordinating Committees linked to Advanced TraumaServices, to ensure a co-ordinated national approach to traumamanagement and the integration of pre-hospital emergency servicesinto that system:

Objectives for these committees should include:

O the implementation of a National Trauma Management system inaccordance with the RACS Trauma Guidelines;

o take account of the results of the ACC Wellington/Hawkes BayTrauma Pilot;

O make changes, as required, to the trauma system network inrelation to the outcomes of the Wellington/Hawkes Bay TraumaPilot; and,

0 consider RHA initiatives for wider adoption.

The Regional Committees should include representatives from ACC,RHAs, Trauma Directors and ambulance service providers.

6.1.2 Air Ambulance Network

• Create and implement a network of air ambulance services whichare fully integrated with road ambulance services and reflect theneeds of a New Zealand Trauma System. This network should consistof the following three tiers:

First Tier- Contracted air ambulance services, as dedicated preferredproviders, associated with the five advanced trauma services.

Second Tier - Contracted dedicated district air ambulance services whichact as back up to the first tier services and carry out local work asdeemed appropriate.

Third Tier - Preferred providers of local air ambulance services used as anon-dedicated "first response" on an "as required" basis.

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6.1.3 The Call Out!Activation System

• The 111 Emergency Service Response System be the route forcallouts in emergency situations;

• Air ambulances be activated by the Ambulance Control Roomsaccording to agreed protocols;

• There be a designated ambulance control room in each RHA regionfor the co-ordination of non urgent CHE air ambulance transport.

• Clearer callout protocols need to be developed taking into accountclinical need, weather and flight conditions.

6.1.4 Audit and Review

Regional Trauma Management Co-ordinating Committees should:

• further develop and monitor callout protocols;

• Review utilisation of air ambulances on a quarterly basis; and,

• Review all issues relating to operational activities.

6.1.5 ProposedPrinciples forContracting

The following contracting principles are recommended:

• ACC and each RHA should establish common service standards andrequirements as a basis for contracting emergency ambulanceservices;

• Contracting between RHAs and CHEs should include a requirementfor Crown Health Enterprises to contract with identified preferredproviders of air ambulance services for inter hospital transfers, and toaccess these services through the ambulance command and controlinfrastructure;

• Contracts must reflect any changes to the CAA regulations;

• For the purposes of contracting, wherever possible it is desirable toseparate the provider of the air ambulance service from thecharitable/private trust. The trusts should ideally be set up to co-ordinate community support and the raising of funds/sponsorship insupport of the actual service provider;

• All contracts should be contestable through a competitive tenderingprocess;

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• First and second tier, both fixed wing and helicopter, operationsshould be tendered for separately;

• The successful tenderer also competitively tender any services thatare to be sub-contracted;

• Contracts should be awarded for three years;

• First and second tier contracted operations be funded by a monthlypayment to the contracted operator for an agreed minimum numberof hours plus marginal costs;

• A "drop down" rate should be negotiable if the number of hours isexceeded;

• Third tier operations (first response services) should remain on a "feefor service" basis;

• ACC and the combined RHAs should enter into dialogue with Policeand the New Zealand Fire Service on arrangements for use ofcontracted air ambulance services for SAR and other missions on a"fee for service" basis.

6.1.6 Access/Three of the Advanced Trauma Centres need to review their helipadEnvironmentlocations. Only Wellington and Hamilton hospitals provide ready access

from helicopter to emergency room. At Auckland Hospital, ChristchurchHospital, and Dunedin Hospital the access is inadequate. Hospitalsinvolved in changing or locating helipads should work closely with theCAA and AlA to seek guidance with regard to suitable specifications'.

IFR approaches should be developed for all advanced trauma centres assoon as possible. IFR approaches for District Trauma Centres should bedeveloped as soon as the Advanced Trauma Centres' approaches areimplemented.

6.1.7 RetrievalServices

All Advanced Trauma Centres should be required to provide anappropriate retrieval service.

Refer to CAA Manual No. 13-908 and No. 15-701).

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6.2 Conclusions

This report provides recommendations on the establishment and fundingof a cost effective emergency air ambulance service in New Zealand thatwill meet the needs of both trauma and seriously ill patients.

There are significant deficiencies in the management, co-ordination andprovision of air ambulance services within New Zealand. The cost of theservice has been increasing: partly in response to the proliferation ofservice providers, and partly in response to new demands arising fromchanges in the provision of health care within New Zealand.

The investment in air ambulance services needs to be managedeffectively to ensure it delivers a satisfactory return to both thepurchasers and users of that service.

The report's proposals have been developed with a view to ensuring theair ambulance network is well integrated with existing road basedambulance services and hospital services. The proposed model alsoaddresses the requirement for better co-ordination and control of inter-hospital transfers.

The recommended 3 tier fixed wing and helicopter air ambulancenetwork model will involve some rationalisation in the delivery of airambulance services, particularly in the North Island. Further developmentwill be required to fill gaps in the ambulance service available in theSouth Island.

The model is broadly based on the principles and recommendationscontained in the Royal Australasian College of Surgeons' trauma careguidelines. It integrates work from later initiatives including the standardsand protocols developed for the ACC Trauma Management Pilot, theSRHA/ACC Ambulance Service contract with the Order of St John, andthe Aviation Industry Association's Air Rescue/Air Ambulance Standards.

The report's recommendations are consistent with the findings andrecommendations of both the Emergency Services Review and the CaveCreek Commission of Inquiry. They also take account of tasks in the useof airborne services by other emergency services.

Page 94

lance Network

The two major purchasers of emergency medical services (RHA andACC) in any one RHA region of the country should jointly contract witha primary provider for road and air ambulance services. The primaryprovider should subcontract for any services (either road or air) they arenot able to deliver themselves. The contracting process should betransparent and contestable. The contracts need to specify detailedservice standards and pricing arrangements.

Should the RHAs and ACC chose to separately contract with providers,they should nevertheless agree common service standards and align theircontracting timeframes. This would facilitate the cohesive developmentof emergency air ambulance services in New Zealand.

As in other areas of the health system, better base information needs tobe gathered and evaluated to ensure the system remains well structured,cost effective and responsive to changes in service needs. Thisrequirement needs to be written into contracts between ACC/RHAs andemergency service providers, and into agreements between the RHAsand the CHEs with regard to inter-hospital transfers.

The implementation of the model will result in a more cost effectiveambulance service and, ultimately, better patient outcomes. There areeconomies of scale to be realised with fixed wing aircraft to the extent ofmaking pressurised aircraft cost competitive. Further efficiencies arepossible if the RHAs and ACC can establish mutually beneficialarrangements with other users of emergency air transport, such as thePolice, New Zealand Fire Service, and the Rescue Co-ordination Centrein Wellington, on the use of preferred providers for air ambulance work,aerial search and rescue and fire suppression tasks.

There are some challenges that need to be addressed if the airambulance network is to be successfully implemented.

The ACC will need to move beyond its current regulatory regime to gainthe maximum benefits from contracting. More fundamentally the RHAsand ACC will need to establish a "modus operandi", that takes accountof their differing funding mechanisms and performance objectives whileobliging their purchasing requirements.

The development and growth of air ambulance services to date has, inlarge measure, depended upon the enthusiasm and support of localcommunities. Major sponsors have welcomed the opportunity to beassociated with a high profile community service. The ACC and theRHAs need to retain and foster the support of local communities andsponsors as they manage the introduction of revised service contractsand arrangements. Effective dialogue and consultation should be afeature of the implementation process.

In the final analysis the ACC and the RHAs are responsible fordetermining service requirements and purchasing those services that willdeliver cost effective outcomes.

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The implementation of a national air ambulance network will result in animproved air ambulance service. The ACC and the RHAs will be betterplaced to manage the cost of the service while ensuring their investment- and that of sponsors and the local communities - reduces the mortalityand morbidity rate associated with accidents and serious illness incidentsin New Zealand.

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1. ACC (1995) Trauma Management in NZ: The ACC Perspective

2. AlA Guidelines (1995)

3. British Paediatric Association (1993) The Care of Critically Ill Children

4. CAA (1995) Civil Aviation Rules, Part 135, Air Transport O perations - Helicopters and SmallAeroplanes

5. CAA (1995)Concepts in Safe Administration of Air Ambulance Operations

6. Core Health Services Report (1993)

7. RACS NZ Trauma Committee (1994) Guidelines For A Structured Approach To TheProvision Of Optimal Trauma Care, Trauma Proiect for the Ministry of Health

8. Report of the Emergency Services Review Task Force, November 1995.

9. The ACC Trauma Management Pilot (1995)

10. The Department of Internal Affairs (1995) Re port of the Inquiry into the Collapse of aViewing Platform at Cave Creek Near Punakaiki on the West Coast.

11. The SRHA/ACC Emergency Ambulance Service Contract

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8. BIBLIOGRAPHY

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-----JMULANC/ bWORK

ational Emergency Air Ambulance Network

Articles:

1. Baxt WG, Berry CC, Epperson MD, Scalzitti V (1989), The Failure of Prehospital TraumaPrediction Rules to Classify Trauma Patients Accurately, Annals of Emergency Medicine, Vol18, No. 1, pp 1/8/21-28.

2. Baxt WG, Jones G, Fortlage D (1990), The Trauma Triage Rule: A New, Resource-BasedApproach to the Prehospital Identification of Major Trauma Victims, Annals of EmergencyMedicine, Vol 19, No. 12, pp 73-78/1401/1406.

3. Cadigan RT, Bugarin CE (1989), Predicting Demand for Emergency Ambulance Service,Annals of Emergency Medicine, pp 618+620

4. Cameron PA, Flett K, Kaan E, Atkin C, Dziukas L (1993), Helicopter Retrieval of PrimaryTrauma Patients by a Paramedic Helicopter Service, Australia & New Zealand lournal ofSurgery, Vol 63, pp 790-797.

5. Clawson J (1985), Dispatch Priority Training: Strengthening the Weak Link, lournal of theBritish Association of Immediate Care, Vol 8, pp 6-11.

6. Coats TJ, Newton A (1994), Call Selection for the Helicopter Emergency Medical Service:Implications for ambulance control, Journal of the Ro yal Society of Medicine, Vol 87, pp208-210.

7. Hanman BL, Cue JI, Miller FB, O'Brien, DA, Polk HC, Richardson, JD, (1991) HelicopterTransport of Trauma Victims: Does a Physician make a Difference? The Journal of Trauma,Vol 3, No. 4, pp 490-494

8. Lindbeck GH, (1993) Reimbursement Patterns in a Hospital based Fixed-wing AeromedicalService, American lournal of Emergency Medicine, Vol 11, No. 6, pp 586-589.

9. Low S, (1995) Helicopter retrievals, how sick are the patients? New Zealand MedicalJournal, Vol 28, pp 300.

10. Maher G (1994), A New Approach at Erlanger, Rotor & Wing, pp 20-27.

11. Malacrida RL, Anselmi LC, Genoni M, Bogen M, Suter PM, (1993) Helicopter mountainrescue of patients with head injury and/or multiple injuries in southern Switerland 1980-1990, Iniury : International lournal of Care of the lniured, Vol 24, No. 7, pp 451-453

12. Moylan JA, (1988) Impact of Helicopters on Trauma Care and Clinical Results, Annals ofSurgery, Vol 208, No. 6, pp 673-678

13. Nicholl JP, Beeby NR, Brazier JE, (1994) A comparison of the costs and performance of anemergency helicopter and land ambulances in a rural area, Iniur y : International Journal ofthe Care of the Iniured, Vol 25, No. 3, pp 145-153.

Page 98


14. Nichol[ JP, Beeby NR, Brazier JE, (1994) Authors' Reply, Injury: International lournal of theCare of the Injured, Vol 25, No 10, No. 3, p 690 (re: A comparison of the costs andperformance of an emergency helicopter and land ambulances in a rural area).

15. Nicholl JP, Brazier, JE, (1995) Effects of London helicopter emergency medical service onsurvival after trauma, British Medical lournal, Vol 311, pp 217-222.

16. Nocera A and Dalton AM, (1994) Disaster Alert! The role of physician-staffed helicopteremergency medical services, The Medical journal of Australia, Vol 161, No. 11/12, pp 689-692

17. Rinke, CM, (1986) Quality Assurance in Prehospital Care, Medical Control, Concepts inEmergency and Critical Care, IAMA, Vol 256, No 8, pp 1027-1031

18. Sasada M, (1994) Letter to the Editor, International Journal of the Care of the Iniured, Vol25, No. 10, pp 689-690 (re: A comparison of the costs and performance of an emergencyhelicopter and land ambulances in a rural area).

19. Schmidt U, Frame SB, Nerlich ML, Rowe DW, Enderson BL, Maull KI, Tscherne H, (1992)On-Scene Helicopter Transport of Patients with Multiple Injuries - Comparison of a Germanand an American System, journal of Trauma, Vol 3, No. 4, pp 548-553

20. Schwartz Ri, Jacobs LM, Juda Ri, (1990) A Comparison of Ground Paramedics andAeromedical Treatment of Severe Blunt Trauma Patients, Connecticut Medicine, Vol 54,No. 12, pp 660-662

21. Schwartz RJ, Jacobs, LM, Yaezel, D, (1989) Impact of Pre-trauma Centre Care on Length ofStay and Hospital Charges, The lournal of Trauma, Vol 29, No. 12, pp 1611-1615

22. Spencer-Jones R, Varley GW, Thomas P, Stevens DB, (1993) Helicopter transfer of traumapatients: the isle of Man experience, International Journal of Care of the Iniured, Vol 24, No.7, pp 447-450

23. Stone CK, Thomas SH, (1993) Inter-hospital Transfer of Cardiac Patients by Air, Americanjournal of Emergency Medicine, Vol 11, No. 6, pp 651-652.

24. Thomas F, Clemmer TP, Larsen KG, Menlove RL, Orme iF, Christison EA, (1988) TheEconomic Impact of DRG Payment Policies on Air-evacuated Trauma Patients, The Journalof Trauma, Vol 28, No. 4, pp 446-452.

Page 99


Reports:

1. ACC: Annual Reports

2. Accident Rehabilitation and Compensation Insurance Corporation: 1994-1997 StrategicDirections

3. Perry L (1988)A Com parison of Air and Road Ambulance Costs in the Waikato HospitalBoard Region

4. Aeromedical Transport Services, November 1995.

5. Agreement Pilot Re gional Trauma S ystem, between the ACC and The Life Fli ght Trust,undated.

6. Auckland Regional Rescue Helicopter Trust (1993), Review of Airborne Emergency MedicalServices in New Zealand

7. CAA (1995) Concepts in Safe Administration of Air Ambulance O perations, Introduction ofthe AlA Standards Document

8. Southern Regional Health Authority (1995) Draft Re g ional Trauma Service Plan, Stage One,Pre-Hospital Emergency Care, Primary Responses in Medical Emer gencies (The PrimeSystem)

9. Emergency Ambulance Services, A back ground for the consensus conference, March 1993.

10. Report of the Working Party to Midland Health, (1994) Emergency Trauma & Seriously IllServices in Midland

11. Midland Health Service Req uirement Definition (1995) for the Re gional Co-ordination ofSeriously Iniured and Critical Care for 1995/96.

12. Midland, Order of St John Regional Ambulance Service, Air Ambulance Protocol, 1988.

13. Policy Guidelines for Re gional Health Authorities, 1996/97.

14. Royal Australasian College of Surgeons (1992) Policy on Trauma

15. Report of the Working Part y on Trauma S ystems, National Road Trauma Advisory Council,Australia, July 1993.

16. ACC (1994) Strategic Directions, Staff Summary, A Year of Achievements 1994-1995.

Page 100

IA NATIONAL AIR AMBULANCE NETWORK

y7/

I $_-'-•e--

the At and CcimbiDECEMBER 1996


Page

2

281122

24

28

Appendix 1 Introduction References

1.1Terms of Reference

1.2Key Personnel and Organisations Consulted

1.3List of Operators and Questionnaire

1.4Data Assumptions and Validity and Reliability

1.5List of Interested Parties to Whom "DisclosureDraft" Circulated

Appendix 2 Aircraft Data and Standards

2.1Types of Missions, Numbers of Patients, andAssociated Hours

2.2Aircraft Types by RHA Region

2.3AlA Standards

2.4Information on Air Ambulance Prices

Appendix 3 Implementation Issues

3.1Air Ambulance Quarterly Report

28303349

50

50

Page 1


Introduction

The Accident Rehabilitation and Compensation InsuranceCorporate (ACC) wants to facilitate the establishment of a

cost effective national emergency air ambulance network whichmeets the needs of patients. To be effective that network needsto be integrated with, and complement, the road basedambulance service.

Emergency air ambulance services are also used by serious illnesspatients and for inter-hospital transfers. There is merit, therefore,in the Corporation and the RHAs reaching agreement on aircraftlocations and standards, staffing, and medical equipmentstandards, callout protocols, the effective co-ordination of inter-hospital patient transfers and the contractual arrangementsneeded to establish a cost effective emergency air ambulancenetwork that will meet the needs of both trauma and medicalpatients.

BackgroundConsistent with overseas practice, and in accord with the RoyalAustralasian College of Surgeons RACS Trauma Care Guidelines,ACC recognises that an effective trauma system which integratespre-hospital management, hospital treatment, and rehabilitationservices will optimise patient outcomes.

The pre-hospital component of a trauma system needs to providea rapid retrieval/primary emergency response ambulance service.That service is provided primarily by road ambulance andemergency medical helicopters. Fixed wing aircraft andemergency helicopters are also used for inter-hospital transfers.Emergency air ambulance services, therefore, need to be wellintegrated with the other pre-hospital emergency medical servicesand the hospital-based components of the trauma managementsystem to obtain optimum patient outcomes.

The RACS Trauma Care Guidelines provide a solid foundation forthe development of a trauma management system in NewZealand, including the emergency medical service component ofthat system. It was agreed that a project team undertake the workrequired to give operational effect to the guidelines as they affectthe provision of emergency air ambulance services, including theinterface with the road-based emergency service providers andthe role of the service in undertaking inter-hospital patienttransfers.

Page 2

A"

Issues

Air Am

The establishment of emergency air ambulance services withinNew Zealand does not always appear to have been informed byan assessment of patient need or the impact on the overall costeffectiveness of the broader emergency medical services.

In recent years there has been a growth in the number of airrescue craft and air ambulances operating in New Zealand.

Given the high fixed costs associated with the operation of airambulances, the increasing number of operators could drive upcosts as individual helicopter utilisation rates decline. Conversely,other parts of the country - such as the West Coast of the Southisland - appear to be poorly serviced.

The emergency callout arrangements for air ambulances throughthe 111 system ensure the effective co-ordination of air and roadambulance resources. Guidelines for the emergency callout of airambulances do, however, vary from region to region. Moreoverthere may be an opportunity to improve the co-ordination ofinter-hospital transfers between crown health enterprises.Consideration also needs to be given to the demand placed onthe emergency air ambulance providers by other users such asthe police and the New Zealand Fire Service.

While the aviation industry has taken steps to establishemergency air ambulance standards, the aircraft standards,equipment and level of services provided by operators variesacross the country. The RHA contracts for emergency medicalservices determine the level of service available to ACCclaimants. The contracting arrangements and standards set inplace by the RHAs for those services, however, vary from regionto region.

There is a need to establish nationally consistent contractualarrangements to:

Ensure appropriate service standards are met by air ambulanceoperators;Ensure both air and road ambulances are utilised in a cost-effective manner that achieves optimum patient outcome;Ensure inter-hospital transfers are co-ordinated in a mannerthat provides for the cost-effective use of available road and airambulance resources.

Page 3


Terms of Reference

Goal

The agreed Terms of Reference include the following goal,objectives and tasks.

The project team will provide recommendations to ACC and theRHAs on the establishment and funding of a cost effectiveemergency air ambulance network as part of the emergencymedical system that meets the needs of both trauma and medicalpatients.

ObjectivesThe working group will:

•Confirm the preferred location of a network of first andsecond tier emergency air ambulances;

• Confirm the aircraft, staffing and medical standards that airambulance providers will be required to meet;

• Establish the service objectives, standards and protocols thatshould be common to air ambulance service purchasearrangements;

• Estimate the marginal cost benefit of establishing the network;

• Recommend contracting arrangements for the operation ofthe air ambulance network that will meet the needs of boththe Regional Health Authorities and ACC; and,

• Establish an implementation plan for introducing the airambulance network that is accepted by the RHAs and ACC.

TasksConfirm the preferred location of a network of first and secondtier emergency air ambulances.

The RACS Trauma Care guidelines provide the starting point forconfirming the location of first and second tier emergency airambulances.

Page 4

In testing the feasibility of the proposed network, however, thestudy should assess:

• The current air and road emergency service response timesby location;

• The likely number of emergency medical callouts by location;

• Air ambulance flight times from the preferred air ambulancebase locations; and,

• The location of proposed hospital based district andadvanced trauma services.

The location of primary response air ambulances should bebased on patient need, and considerations of optimalcoverage and access to hospital based services. Indeveloping its proposals, however, the project team shouldtake account of:

• The location of current air services;

• Existing sponsorship arrangements; and,

•Existing, contractual relationships.

Confirm the aircraft, staffing and medical standards that airambulance providers will be required to meet.

The project team will establish core standards in the followingareas that should be incorporated into any contractualarrangements entered into by the ACC and the RHAs:

• Aircraft capacity and capability;

• Operational crew requirements;

• Minimum medical personnel requirements;

• Minimum medical equipment; and,

• Operational standards (including availability and activationtime).

The standards should conform with Civil Aviation Authorityregulations and guidelines. They should also take into accountRACS Trauma Care Committee Guidelines and the AviationIndustry Association's Guidelines.

Establish the service objectives, standards and protocols thatshould be common to air ambulance service purchasearrangements.

Page 5


The following objectives, standards and protocols should beestablished by the project team:

• Service objectives which underpin the delivery of integratedemergency medical services by air and road ambulanceproviders and other emergency service providers;

• Standard activation times, and target response and retrievaltimes for emergency medical services;

• Model callout protocols between Ambulance Control andthe ambulance operators to ensure optimum patientoutcomes through the best use of road and air ambulanceresources;

• Protocols ensuring regular reporting of activation, responseand retrieval times and medical interventions for inclusionwithin a broader trauma management and injury surveillancesystem; and,

• Protocols for clinical outcome and peer review auditingthrough Regional Trauma Management Co-ordinatingCommittees.

Estimate the marginal cost-benefit of establishing the network.

• The project group should determine whether the introduction ofthe network will result in any change in the cost of emergencymedical services and whether that will be off set by quantifiablebenefits in terms of patient outcomes.

The project team should consider undertaking selectedretrospective patient outcome reviews as a basis for helping todetermine the number of cases where earlier retrieval was, orcould have been, instrumental in achieving enhanced patientoutcomes.

Recommend contracting arrangements for the operation of airambulance network that meets the needs of both the RegionalHealth Authorities ancIACC.

In establishing the most appropriate contracting arrangements forthe rationalisation and maintenance of the network the projectteam should:

• Assess the suitability of the existing contractual arrangements;

• Take into account both ACC and RHA requirements andstatutory obligations;

Aim to minimise transaction costs while reinforcing nationalstandards.

Page 6


Establish an implementation plan for introducing the airambulance network that is accepted by the RHAs anc/ACC.

The implementation plan should achieve the earliest possibleimplementation of the network, taking into account existingcontractual arrangements.

LiaisonIn undertaking the study it is expected the project team will needto liaise with:

• Ministry of Health• Regional Health Authorities• Crown Health Enterprises Association• Civil Aviation Authority• Aviation Industry Association of New Zealand• New Zealand Society of Air Rescue Trusts• New Zealand Ambulance Board• New Zealand Police• New Zealand Fire Service• St John Ambulance Service• Wellington Free Ambulance• RACS NZ Trauma Care Committee• Air Ambulance sponsors, and• ACC

Project ManagementA Steering Group comprising representatives from the RHAs,representatives nominated by the Crown Health EnterprisesAssociation and ACC will oversee the project. The project leaderwill submit a project plan identifying milestones, additionalsupport that may be required to complete the project, and aproposed project budget. The project leader will report to theSteering Group on mutually agreed milestone dates.

FundingSubject their approval of a final project budget, the ACC and theRHAs agree in principle to fund the project. ACC will meet 50%of the costs of the project with the remaining 50% being sharedby the RHAs.

Page 7

Midland Order of St John RegionalAmbulance Service

Gary Salmon, CEOMidland Order of St John RegionalAmbulance ServiceP0 Box 1346Hamilton

Eddie JacksonRegional Chief Ambulance OfficerMidland Order of St John RegionalAmbulance ServiceP0 Box 1346Hamilton

Auckland St John Ambulance Service

Robin Williams, CEOSteve Hutchison, Regional ChiefAmbulance OfficerSt John Ambulance Service -Auckland RegionPrivate Bag 13902Auckland

John Bain, Deputy ChairmanOrder of St John Auckland RegionalAmbulance Board

Ian Lauder, Superintendent, Operations

Christchurch St John Ambulance Service

Bernie ChattertonRegional Chief Ambulance OfficerSt John Ambulance Service - CanterburyRegion

Dunedin St John's Ambulance Service

Craig WombwellRegional Chief Ambulance OfficerSt John Ambulance Service - OtagoRegion

The New Zealand Ambulance Board Inc

Robin WakelinExecutive DirectorThe New Zealand Ambulance Board IncP0 Box 714Wellington

Civil Aviation Authority

Dr Peter DodwellPrincipal Medical OfficerCivil Aviation Authority of NZP0 Box 31441Lower Hutt

Graham MarshManager - Rules & StandardsCivil Aviation Authority of NZP0 Box 31441Lower Hutt

Michael HuntController Flight Operations StandardsCivil Aviation Authority of NZP0 Box 31441Lower Hutt

Ted HawkerSpecialist Flight Operations (Helicopter)Rules and Standards GroupCivil Aviation Authority of NZP0 Box 31441Lower Hutt

Jim MacleanCAA/SAR

Page 8

Trauma Directors

Russell WorthDirector - Trauma ServicesWellington HospitalPrivate Bag 7902Wellington South

Ian CivilDirector - Trauma ServicesAuckland HospitalPrivate Bag 92024Auckland

Regional Health Authorities

Neil WoodhamsGeneral Manager, Hospital & SpecialistServicesMidland HealthP0 Box 1031Hamilton

Floss Caughey/Michael QuinlivanCentral RHAP0 box 10-097Wellington

Tony McKewenHealth Needs & Policy Manager -Medical/Surgical/Rural HealthSouthern Regional Health AuthorityP 0 Box 5849Dunedin

Air Ambulance Operators

John FunnellPhilips Search & Rescue TrustP0 Box 158Taupo

David WickhamPhilips Search & Rescue TrustPG Box 158Taupo

John Bain, ChairmanNorthland Emergency Services TrustP 0 Box 8011Whangarei

Scotty WatsonGeneral ManagerAuckland Rescue Helicopter TrustP 0 Box 2252Auckland

Simon BartonDirector of OperationsPacific Air AmbulanceP 0 Box 2252Auckland

Peter MairsDirectorThe Life Flight TrustP0 Box 14-448KilbirnieWellington

Graham GaleHelicopters OtagoP 0 Box 88Mosgiel

John CurrieManaging DirectorGarden City HelicoptersP0 Box 14147Christchurch

Ivan CampbellAdministration ManagerGarden City HelicoptersP0 Box 14147Christchurch

Nick FletcherMarketing ManagerAuckland Rescue Helicopter TrustP 0 Box 2252Auckland

SPONSORS

Westpac Bank CorporationPG Box 691, Wellington(Bill Day, Manager Corporate Affairs)

Tranz Rail

Grey City Council

Page 9

Aviation Industry AssociationAll members attending meeting January17, 1996:• John Funnell, Chairman• Stuart W Quayle, Aviation Consultant• Tom Riddell, Executive Director

RNZAF Air CommandPrivate BagWhenuapai

Auckland 1250Squadron Leader Steve BoneFlight Lieutenant Peter Annyes

Hugh JonesAirworks NZ LtdAirfield RoadArdmore

New Zealand PoliceInspector Tony McLeodNational HeadquartersP 0 Box 3017WELLINGTON

Page 10


List of OperatorsNationally

AUCKLAND • Air New Zealand• Ansett New Zealand• Christian Aviation• Auckland rescue Helicopter Trust• Great Barrier Airlines• Ski Care Limited• RNZAF, Whenuapai

BALCLUTHA • Kitto Helicopters

BLENHEIM • Straits Air Charter• Safe Air Limited

CARTERTON • Amalgamated Helicopters

CHRISTCHURCH • Bellview Flight Centre• Garden City Helicopters• Southflight Aviation Limited• Canterbury Aero Club• RNZAF

ELTHAM • Beck Helicopters

GISBORNE • Air Gisborne Limited• Ashworth Helicopters limited• Faram Helicopters

GORE • Peter Garden Helicopters• Southern Region Lions Air Ambulance

HAMILTON • Eagle Air• Philips Search and Rescue Trust

HASTINGS • Hawkes Bay and East Coast Aero Club• Hawkes Bay Helicopter Rescue Trust

HAWKES BAY • Shaw Helicopters Limited

Page 11


HOKITIKA • Anderson Helicopters Limited

INVERCARGILL • Southern Air Limited

MOSGIEL • Helicopter Otago Limited

NELSON • Nelson Marlborough Rescue Helicopter• Helicopters (NZ) Limited• Air Nelson Limited• Flight Corporation Limited• Nelson Helicopters

NEW PLYMOUTH • New Plymouth Aero Club

OAMARU • Helimac Helicopters Limited

PALMERSTON NORTH • Helipro• Philips Search and Rescue Trust

PAPAKURA • Corporate Flight Services• Flightline Aviation Limited

QUEENSTOWN • Lakes District Air Rescue Trust Inc

RAKAIA • Mt Hutt Air Limited

ROTORUA • Forestry Corp BOP Rescue Trust

RUATORIA • Helicopter Rescue Trust East Cape

TAUMARUNUI • Commercial Helicopters

Page 12


TAUPO • Helicopter services BOP Limited• Philips Search and Rescue Trust

THAMES • Miller Helicopter Services Limited

TIMARU • The Helicopter Line

WAIKARI NORTH CANTERBURY • Amuri Helicopters Limited

WAIMANA • Waimana Helicopters

WAKA11PU • Southern Lakes Helicopters (Qtn) Limited

WANGANUI • Air Wanganui

WELLINGTON • The Life Flight Trust• Airwork NZ Limited

WHAKATANE • Bell Air• Heliwing Limited

WHANGAREI • Northland Emergency Services Trust

Page 13

tional Emerencv Air Ambulance Network

National Air Ambulance' NetworkOperators' Survey

Page 14

National Emereencv Air Am

National Air Ambulance Network Operators' SurveyThis questionnaire has been compiled to facilitate the co/led/on ofgross data for a review of the NationalAfr Ambulance Network

Name of Organisation: Location:

Please state distance from nearest Road Ambulance Station:

Aircraft Details:What type(s) of Aircraft do you operate?

IFRVFRWinch REG. NoCapacityWhich of the AlAPlease list anyNo ofNo of categories do theseadditional specialist

PatientsCrewaircraft fulfil ?equipment for each aircraftabove the AlA Categoriesand requirements

1.

2.

3.

Page 15

National Emer gency Air

-Back Up Arrangements: -What back up arrangements do you have? What types of aircraft are used as back up?

1.With whom do you have these arrangements ? Is this relationshipformal or informal? 2

3.Do the back up aircraft conform to the national AlA standards?

Call Out Protocols (Operational Standards/Protocols/Accreditation Standards)What Call Out Protocols do you have? What are your activation times?

Day:

Please comment ( if you have any written mater/a/availableNight:could you attach a copy to your reply)

Do you have any standards relating to operations underWhat is your availability? Do you have a 24 hour operation orRegulation 35 / If so, please could you attach to your reply?limited hours? Please state hours of availability:

age


Types of MissionPlease could you complete the following table as to the types of missions flown for each of the following financial years:

1992'93 1993'94 1994'95No ofNo ofNo ofNo ofNo ofNo ofNo ofNo ofNo ofNo ofNo ofNo ofCommentsMissionsAbortedPatientsHoursMissionsAbortedPatientsHoursMissionsAbortedPatientsHours

Missions Missions Missions

ACC related(Ambulance)Transportation FlightsMedical related(Ambulance)Transportation FlightsInter HospitalTransfersTraining flightsSearch and RescuePoliceFire Service

1992/93 1993/94 1994/95Please could you state the number of available flight hours for:

Page 17

National Emereencv Air Ambulance Network

CrewingPlease list the personnel who make up your crew for the following types of mission:

ACC Related Transportation Flights Who is the employer?

(for ambulance service)Medical Related Transportation Flights(for ambulance service)Inter Hospital TransfersTraining FlightsOther ( Aborted Missions, Search and Rescue, etc.)

Is your Paramedic and/or Ambulance Person on Site?

Yes 1J

No

-age -

National Emergency Air

Page 19


BudgetaryissuesPlease could you supply the following information:

Total Expenditure Budget 1990/91 1991/92 1992/93 1993/941994/95

% Sponsorship ofExpenditure BudgetTotal Aircraft lease feesTotal Pilot CostsTotal Crew CostsTotal Equipment CostsTotal Administration CostsAverage Cost per hourcharged to ACCAverage Cost per hourcharged to HospitalsAverage Cost per hourcharged to otherorganisationsPlease state the names /types of other organisations you charge:

,age

Emergency Air Ambulance Network

Benefits and Outcomes

Do you have any information on the cost benefits of using air ambulances?Do you have any information on patient outcomesassociated with air ambulance retrieval?

Comment:Comment

Other. CommentsI.. .. .Any additional comments, please:

Thank you for taking the time to complete this questionnaire.. .

Page 21

IntroductionThe following assumptions have been made in the developmentof this document and any associated data sets.

Confidentiality and All data is presented in an aggregate form to ensure respondentsAnonymityanonymity and confidentiality

The Questionnaires53 Questionnaires were sent to all Air Ambulance operators thatcould be identified by the Aviation Industry Association and the NewZealand Association of Search and Rescue Trusts.

The questionnaire was responded to by 35 operators, 8 respondentscombined their questionnaires with other operators as severalservices provide collaborative operations. This resulted in an overall27 responses. The responses have been collated into the tables andgraphs found throughout this document.

Validity / ReliabilityThe data is not definitive - it is questionnaire based; responses havenot been cross checked nor are they a total sample.

5 Operators responded but did not supply any of the informationrequested in the questionnaire.

The following numbers of operators per region returned thequestionnaire but did not supply any mission or budget details.

RHA 1 Central RHASouthern R21 2 1

The following numbers of operators per region returnedquestionnaires and supplied information for the years 1992/931993/94 and 1994/95.

Missions Budget

92/93 93/94 94/95 92/93 93,/9494/95Northern444333Midland666467Central787787Southern234233

Page 22

Responses from the Southern RHA region were particularlydisappointing and data estimated or manipulated from this region isparticularly suspect. Data for years other than the most recent isnotably incomplete.

Best Data AvailableThe working group believes that it has obtained the best dataavailable at this time. It must also be stated that the validity andreliability of this data is questionable however it is valuable for theinformation it provides about trends.

Page 23

Mr John Allan Mr John Ayling Mrs Glenys BaldickPlanning Manager Chief Executive Officer Chief Executive OfficerCoast Health Care Healthcare Otago Nelson Marlborough HealthPO Box 387 Private Bag l92l PO Box l32GREYMOUTH DUNEDIN NELSON

Mr Tony BarracloughChristchurch Women's HospitalP0 Box 731CHRISTCHURCH

Mr Forbes BennettClinical Director of TraumaServicesHealthcare Hawkes BayPrivate Bag 9014HASTINGS

Flight Lt. Peter AmyesRNZAF Air CommandPrivate BagWHENUAPAI

Mr Mark FlowersChief Executive OfficerHealthcare Hawkes BayPrivate Bag 6023NAPIER

Mr Dave ChristensenSponsorship ManagerDominion BreweriesP0 Box 1659AUCKLAND

Mr Craig ClimoSupport Services ManagerHealthcare Hawkes BayPrivate Bag 6023NAPIER

Ms Patricia Bayley"Waihiriwa"RD 7ArohenaTE AWAMUTU

Mr Rod BirdCorporate Aviation NetworkNew ZealandP 0 Box 8885CHRISTCHURCH

Mr Odile BonifaceSponsorship ManagerNew Zealand PostPrivate Bag 39-990WELLINGTON

Mr Scott HollingsheadAmbulance ManagerTaranaki HealthcarePrivate Bag 2016NEW PLYMOUTH

Mr Ian CivilDirector, Trauma ServicesAuckland HospitalPrivate Bag 92024AUCKLAND

Ms Anthea GreenChief Executive OfficerSouthern HealthP 0 Box 828I NVERCARGILL

Mr Malcolm BeattieChairNZ Society of Air Rescue TrustsP 0 Box 2252AUCKLAND

Mr Tony BlacklerManager, Technical/SterileServicesCanterbury HealthPrivate Bag 4710CHRISTCHURCH

Mr John BoristonGeneral ManagerTrustbank WaikatoVictoria StreetHAMILTON

Ms Sheryl SmailChief Executive OfficerTairawhiti HealthcarePrivate Bag 7001GISBORNE

Mr Alan ClarkAlA Working PartyBurwood HospitalPrivate Bag 4708CHRISTCHURCH

Mr Greg CosterThe Royal NZ College of GPsP 0 BOx 10-440WELLINGTON 6036

Mr Bill Day Dr Peter Dodwell Ms Fiona LindopManager, Corporate AffairsPrincipal Medical OfficerGeneral Manager, MajorWestpac Banking CorporationCivil Aviation Authority of NZProvidersPO Box 69l P0 Box 31441 North HealthWELLINGTON LOWER HUll Private Bag 92-522

AUCKLAND

Page 24

Mr Robin Wakelin Mr Alan Flaws Mrs Glenda FosterExecutive Director Team Leader, Lottery GeneralCentral Regional HealthThe NZ Ambulance BoardDepartment of Internal AffairsAuthorityP0 Box 714 P0 Box 805 PO Box lO-097WELLINGTON WELLINGTON WELLINGTON

Mr Ian FrameChief Executive OfficerCanterbury HealthP0 Box 1600CHRISTCHURCH

Mr Mackay GeorgeChief PilotAir Wanganui Commuter LtdP 0 Box 42WA N GA N U

Mr Robert GilchristChief Executive OfficerHealth South Canterbury LtdPrivate Bag 911TIMARU

Mr Ray WatsonChief Executive OfficerLakeland HealthPrivate Bag 3023ROTORUA

Mr Wayne HarrisonAir New PlymouthNew Plymouth AirportRD NEW PLYMOUTH

Mr Peter KiddHawkes Bay Air AmbulanceServiceP0 Box 2199HASTINGS

Mr John FunnellPresident, AlA AirAmbulance/Air Rescue DivisionPhilips Search and Rescue TrustP0 Box 214TA U P0

Mr Alex GibbMaritime Safety Authority ofNZP 0 Box 27-006WELLINGTON

Mr Tony GillMarketing ManagerTrust Bank WaikatoP 0 Box 230HAMILTON

Mr Chris HarringtonManager, Personal HealthServicesMinistry of HealthP0 Box 5013WELLINGTON

Ms Paula DayeChief Executive OfficerCoast Health CareP 0 Box 387GREYMOUTH

Mr Brent LaytonCHE AssociationC/- Canterbury Health LtdP 0 Box 1600CANTERBURY

Mr Owen Genty-NottSecretaryLakes District Air Rescue TrustP0 Box 123QUEENSTOWN

Mr Peter GibsonChairmanSouthern Region Lions AirAmbulance TrustP0 Box 6116INVERCARG ILL

Dr Bruce GollopChief Executive OfficerNorthland HealthP 0 Box 742WHANGAREI

Mr Jack JenkinsExecutive ChairmanCapital Coast HealthPrivate Bag 7902WELLINGTON SOUTH

Mr Peter GoldupChief Executive OfficerGood Health WanganuiPrivate BagWA NGA N U I

Dr Lester LevyChief Executive OfficerSouth Auckland HealthPrivate Bag 93311, OtahuhuAUCKLAND

Mr Jim Maclean Mrs Margot Mains Mr Peter MairsCivil Aviation Authority/SARChief Executive Officer The Life Flight TrustP0 Box 31-441 Midcentral Health P0 Box 14448, KilbirnieLOWER HUU P 0 Box 2056 WELLINGTON

PALMERSTON NORTH

Page 25

Ms Jeanette BlackHospital & Specialist ServicesMidland HealthP0 Box 1031HAMILTON

Mr John McGeeCommittee SecretaryGreymouth District CouncilP 0 Box 382GREYMOUTH

Mr Robin MilneChief Executive OfficerWestern Bay HealthPrivate Bag 12-024TAURANGA

Mr Joel GeorgeChief Executive OfficerWairarapa HealthP 0 Box 96MASTE RIO N

Mr Mahanga MaruWellington International AirportCorporate OfficeP0 Box 14175WELLINGTON

Mr Tony McKewenSouthern Regional HealthAuthorityP 0 Box 5849DUNEDIN

Ms Jane GreenTranz RailPrivate BagWELLINGTON

Mr Graeme EdmondChief Executive OfficerAuckland HealthcareGreen Lane West, EpsomAUCKLAND 1003

Sergeant L N Matheson QSMSergeant in ChargePolice StationTE ANAL)

Mr Tom MillikenWakatipu Medical CentreMcBride StreetQUEENSTOWN

Ms Jane HoldenChief Executive OfficerHutt Valley HealthPrivate Bag 31-907LOWER HUll

Dr Karen PoutasiDirector GeneralMinistry of HealthP0 Box 1031WELLINGTON

Mr Tom RiddellExecutive DirectorAviation Industry AssociationP 0 Box 2096WELLINGTON

Mr Cameron RodgersFlight CorporationP0 Box 2196, StokeNELSON

Mr Duncan ScottGroup Manager, ClinicalSupportMidcentral HealthP 0 Box 2056PALMERSTON NORTH

Ms Karen SmithManager, Clinical ServicesEastbay HealthP 0 Box 241WHAKATANE

Mr Max RobinsChief Executive OfficerTaranaki HealthcarePrivate Bag 2016NEW PLYMOUTH

Mrs Judith HobanActing Chief Executive OfficerOrder of St JohnP0 Box 1443CHRISTCHURCH

Ms Elizabeth SegedinDirector, Paediatric IntensiveCare UnitStarship Children's HealthPrivate Bag 92024AUCKLAND

Mr Garry SmithChief Executive OfficerHealth Waikato LtdP 0 Box 934HAMILTON

Dr Peter RobinsonChairRegional Trauma ManagementCo-ordinating CommitteeC/- P 0 Box 242WELLINGTON

Mr Steve RuruHospital & Specialist ServicesMidland HealthP0 Box 1031HAMILTON

Mr Ron DunhamChief Executive OfficerEastbay HealthP 0 Box 241WHAKATANE

Mr Denis SnelgarChief Executive OfficerWaitemata HealthPrivate Bag 93-503, TakapunaAUCKLAND

Page 26

Mr Mike ToogoodChief Executive OfficerLowe Walker NZ Ltd304 Fitzroy AvenueHASTINGS

Dr Marjory van der PylEmergency DepartmentHealth Waikato LtdP 0 Box 934HAMILTON

Dr Charles AllisterDirector, Trauma ServicesWellington HospitalPrivate Bag 7902WELLINGTON SOUTH

Commissioner Peter DooneCommissioner of PoliceNew Zealand Police NationalHeadquartersP 0 Box 3017WELLINGTON

Mr Neil LowsleySales ManagerSpeights Breweries Ltd200 Rattray StreetDUNEDIN

Mr John CurrieManaging DirectorGarden City HelicoptersP0 Box 14147CHRISTCHURCH

Mr Steve NicksonChief Executive OfficerWellington Free AmbulanceServiceP 0 Box 601WELLINGTON

Mr John OrsbornGeneral ManagerHawkes Bay St JohnAmbulance ServiceP0 Box 5118NAPIER

Mr Paul WylieChief Executive OfficerHealthlink SouthP 0 Box 800CHRISTCHURCH

Ms Tina DouglasForestry CorporationP 0 Box 7246, Wellesley StreetAUCKLAND

Mr Ian RaeChief Executive OfficerSt John Ambulance ServiceSouthern RegionP 0 Box 5055DUNEDIN

Mr Graham GaleHelicopters OtagoP 0 Box 88MOSGIEL

Mr Ian UffindellSafe Air LtdP 0 Box 244BLENHEIM

Mr Phil WestonPaediatric DepartmentHealth Waikato LtdP 0 Box 934HAMILTON

Mr Maurie CommingsChief Executive OfficerNew Zealand Fire ServiceNational OfficeP0 Box 2133WELLINGTON.

Ms Justine PedersonChief Executive OfficerRoyal Australian College ofSurgeonsP0 Box 7451WELLINGTON

Ms Gloria AntonioGeneral Manager, SecondaryCare & Public Health ServicesNelson-Marlborough HealthP 0 Box 46BLENHEIM

Mr Hugh JonesAirworks NZ LtdAirfield RoadARDMORE

Ms Marie LongManager, Ambulance ServicesWairarapa HealthP0 Box 96MASTERTON

Mr Peter ThompsonChief Executive OfficerCentral Region Trust BoardP 0 Box 682PALMERSTON NORTH

Page 27

1 1 1994/95Missions Patients Hours MissionsHours Missions Patients Hours

Casevac MissionsNorthern RHA 321323241368373287423432350Midland RHA 202204272227231283344358443Central RHA 223234210493494404426444335Southern RHA 444 443231231223Totals 750765727109211029771,4241,4651,351

Medevac MissionsNorthern RHA 329333212244252192227230182Midland RHA 124124205118118187172172274Central RHA 109115159236257296222235340Southern RHA 4418101021525273Totals 566576594608637696673689869

Interhospital TransfersNorthern RHA 223227328372379526521535757Midland RHA 4305047444575037656407051016Central RHA 4135238357948581367110512761806Southern RHA 2291616387474124Totals 106812561916163917562696234025903703

SAR/OtherNorthern RHA 190 40080 18781 194Midland RHA 37 5869 10983 113Central RHA 69 79137 155140 169Southern RHA 4 416 2413 33Totals 300 540302 476317 509

Page 28

National Emergency Air Ambulance Ne

MISSIONS PA TIENTS HOURS19921931993194199419519921931993/94199419519921931993/941994/95

Casevac MissionsNorthern RHA 321 368 423 323 373 432 241 287 350Midland RHA 202 227 344 204 231 358 272 283 443Central RHA 223 493 426 234 494 444 210 404 335Southern RHA 4 4 231 4 4 231 4 3 223TOTALS 7501092142476511021465 7279771351Medevac MissionsNorthern RHA 329 244 227 333 252 230 212 192 182Midland RHA 124 118 172 124 118 172 205 187 274Central RHA 109 236 222 115 257 235 159 296 340Southern RHA 4 10 52 4 10 52 18 21 73TOTALS 566608673576637689594696869Interbospital TransfersNorthern RHA 223 372 521 227 379 535 328 526 757Midland RHA 430 457 640 504 503 705 744 765 1016Central RHA 413 7941105 523 858 1276 835 13671806Southern RHA 2 16 74 2 16 74 9 38 124TOTALS 106816392340125617562590191626963703SAR/Other MissionsNorthern RHA 190 80 81 400 187Midland RHA 37 69 83 58 109 113Central RHA 69 137 140 79 155 169Southern RHA 4 16 13 4 24TOTALS 300302317 540476509

GRAND TOTAL 268436414754259734954744377748456432

Page 29

National Emer gency Air Ambulance Network

Air Ambulance Specifications

01-Feb-96

AircraftAircraft TypeIFR/VFRAlA Category# Patients# CrewClass AirRegionAmbulance

Twin OtterFixed Wing IFR 9 2Emergency OnlyNorthern RHAIslander Fixed Wing IFR 9 1Emergency OnlyNorthern RHAChieftan Fixed Wing IFR 9 1Emergency OnlyNorthern RHAPartenaviaFixed Wing IFR 51EmergencyOnlyNorthernRHASenecaFixedWingIFR1 4Emergency OnlyNorthern RHANavajo Fixed Wing IFR 1 5Emergency OnlyNorthern RHAChieftan Fixed Wing IFR 1 6Emergency OnlyNorthern RHANavajo Fixed Wing IFR 2 4Emergency OnlyNorthern RHACheyenneFixed Wing IFR 1 6Emergency OnlyNorthern RHABK 117 Helo IFR A 2 324 Hour Northern RHAAS355F '-lelo VFR A 1 324 Hour Northern RHAAS350B Helo VFR A 1 324 Hour Northern RHABK1 17 Helo IFR A 2 324 Hour Northern RHABK1 17 Helo VFR A, B 2 3Emergency OnlyMidland RHAAS350BAHelo VFR B 1 2Emergency OnlyMidland RHACessna Fixed Wing IFR 1 4Emergency OnlyMidland RHACessna Fixed Wing IFR 1 3Emergency OnlyMidland RHACessna Fixed Wing IFR 1 2Emergency OnlyMidland RHABell 222 Helo IFR A 2 224 Hour Midland RHAChieftan Helo IFR A 2 4Emergency OnlyMidland RHAPA34 Helo IFR C 3 3Emergency OnlyMidland RHAPA34 Helo IFR C 3 3Emergency OnlyMidland RHAC172 Helo VFR D 2 2Emergency OnlyMidland RHAAA5 Helo VFR E 2 2Emergency OnlyMidland RHAAA5 Helo VFR E 1 2Emergency OnlyMidland RHAAS350B Helo VFR A 1 4Emergency OnlyMidland RHAAS350B Helo VFR A 1 4Emergency OnlyMidland RHANavajo Fixed Wing IFR 1 1Emergency OnlyCentral RHASeneca Fixed Wing IFR C,D,E 1 2Emergency OnlyCentral RHAArrow Fixed Wing VFR D,E 2 1Emergency OnlyCentral RHANavajo Fixed Wing IFR A 1 4Emergency OnlyCentral RHA

Page 30


AircraftAircraft TypeIFR/VFRA/A CategoryClass AirRegionAmbulance

AS350B Helo VFR AEmergency OnlyCentral RHAOMD500DHelo VFR Emergency OnlyCentral RHABK1 17 Helo IFR A24 Hour Central RHACheyenneFixed Wing IFR A24 Hour Central RHAPA31 Fixed Wing IFR AEmergency OnlyCentral RHABell 212 Helo IFR AEmergency OnlyCentral RHAAS350B Helo VFR CEmergency OnlyCentral RHAAS350 BAHelo VFR AEmergency OnlyCentral RHAHughes 500Helo VFR BEmergency OnlyCentral RHABell 206BHelo VFR CEmergency OnlySouthern RHATwin OtterFixed Wing IFR A,FEmergency OnlySouthern RHATwin OtterFixed Wing IFR A,FEmergency OnlySouthern RHANomad Fixed Wing VFR B,FEmergency OnlySouthern RHANomad Fixed Wing VFR B,FEmergency OnlySouthern RHAIslander Fixed Wing VFR B,FEmergency OnlySouthern RHAIslander Fixed Wing VFR B,FEmergency OnlySouthern RHAIslander Fixed Wing VFR B,FEmergency OnlySouthern RHACessna Fixed Wing VFR B,FEmergency OnlySouthern RHACessna Fixed Wing VFR BFEmergency OnlySouthern RHACessna Fixed Wing VFR B,FEmergency OnlySouthern RHACessna Fixed Wing VFR B,FEmergency OnlySouthern RHACessna Fixed Wing VFR B,FEmergency OnlySouthern RHAAS350BAHelo VFR B,FEmergency OnlySouthern RHAAS350B Helo VFR B,FEmergency OnlySouthern RHAAS3 SOB Helo VFR B,FEmergency OnlySouthern RHAAS3 SOB Helo VFR B,FEmergency OnlySouthern RHAAS350B Helo VFR B,FEmergency OnlySouthern RHAAS350B Helo VFR B,FEmergency OnlySouthern RHABell 206 Helo VFR CEmergency OnlySouthern RHABell 206BHelo VFR DEmergency OnlySouthern RHAIslander Fixed Wing IFR AEmergency OnlySouthern RHAIslander Fixed Wing IFR AEmergency OnlySouthern RHAIslander Fixed Wing VFR Emergency OnlySouthern RHANavajo Fixed Wing IFR AEmergency OnlySouthern RHA

'age -.

National Emerencv Air

AircraftAircraft TypeIFR/VFRA/A CategoiyClass AirRegionAmbulance

Seneca Fixed Wing IFR AEmergency OnlySouthern RHASeneca Fixed Wing IFR AEmergency OnlySouthern RHASeneca Fixed Wing (FR AEmergency OnlySouthern RHA

Page 32

National Emer gency Air Ambulance Network

Air Ambulance StandardsFixed Wing Aircraft • Air Ambulance Operation Standards

OPERA TION AIRCRAFT EQUIPMENT MEDICAL EQUIPMENT A 7TENDANTS P/LOTSCATEGORY (NOTE 1) (No TE 2) (No TE55& 6)I FR Intensive Care AirStandard multi SP-/FR A TO/FR Kit including:Vital signs monitors: Doctor plus 1000 hours SP-IFR rated, orAmbulance (Note 3 &•2 x VOR •Electrocardiograph Paramedic/Nurse/Technician1000 hr and 500 hr Pilots:4) •1 x DME •Pulse oximeter Minimum of two attendantsThe PinC shall have:

•2 x ADR or ADF & GPS •Blood pressure (Automatic NIBP) •100 hrs IFR•1 x ILS •Temp recorder (electronic) •50 hrs multi•Auto Pilot or 2 Pilots •Capnograph •50 hrs IMC

Defibrillator •200 hrs PinC X/C1 x Mobile phone (hands free)lntercrew Communication1 x Stretcher and mattressPatient loading facility1 x Stretcher bridge1 x Equipment stowage unitPower Supply = 1 2v/24v as appropriateSuction power lead and adaptorBack-up power lead/supplyIncubator power lead/adaptorStowage for incubator, monitors & equipmentOverhead hooks2 x Attendant seatsTorch for each crew personClimate control & lighting in patient/attendantareas

Mountings for:•1 x Stretcher•All oxygen to be carried•1 x Vacuum mattress with mountings•1 x Neonate incubator

Suction pump •20 hrs night timeBag/mask resuscitator (NOTE 7) •IFIR recent experienceOxygen with delivery equipment (NOTE 8)Suitably equipped medical kit including at Pilot induction course toleast: include direct and indirect•IV Fluids & giving set supervision•IV Pressure bag•Laryngoscope blades & suitable El tubes 6 monthly checks tailored toPleural drainage equipment AA OpsCricothyroidotomy setMedication & delivery equipment appropriatefor the patient

AS REQUIRED:•Transport ventilator with disconnect and

high pressure alarm•Syringe pump(s) (available)•Medical anti-shock trousers (available)• Incubator and oxygen (NOTE 8)• Neonate drugs and equipment•Incubator monitoring equipment•Stretcher

Page 33


OPERA 1/ON AIRCRAFT EQUIPMENT MEDICAL EQUIPMENT A 17ENDAN7S P/LOTSCATEGORY (NOTE 1) (NOTE 2) (NOTES 5 & 6)

A Standard VFRATO KIT including. Vital signs monitors: Doctor plus 1 x 1000 hr Pilot with 500 hrsVFR Intensive Care Air •Electrocardiograph Paramedic/Nurse/TechnicianVFR X/CAmbulance (Note 3 &•Instrument panel equipped to night VFR•Pulse oximeter or4) standards •Blood pressure (Automatic NIBP)Minimum of two attendants1000 hr & 2nd pilot with CPL.

1 x ADF or GPS • Temp recorder (electronic) PinC to have 300 hours VFRCapnograph X/C

1 x mobile phone (hands free)lntercrew Communicationlx Stretcher & MattressPatient Loading Facility1 x Stretcher bridge1 x Equipment stowage unitPower Supply = 1 2v/24v as appropriateSuction power lead and adaptorBack-up power lead/supplyIncubator power lead/adaptorStowage for incubator, monitors & equipmentOverhead hooks2 x Attendant seatsTorch for each crew personClimate control & lighting in patient/attendantareas

Mountings for:•1 x Stretcher•All oxygen to be carried•1 x Vacuum mattress with mountings•1 x Neonate incubator

DefibrillatorSuction pump Pilot induction course toBag/mask resuscitator (NOTE 7) include direct and indirectOxygen with delivery equipment (NOTE 8) supervisionSuitably equipped medical kit including atleast: 6 monthly checks tailored to•IV Fluids & giving set AA Ops•IV Pressure bag•Laryngoscope blades & suitable ET tubesPleural drainage equipmentCricothyroidotomy setMedication & delivery equipment appropriatefor the patient

AS REQUIRED:•Transport ventilator with disconnect and

high pressure alarm•Syringe pump(s) (available)•Medical anti-shock trousers (available)• Incubator and oxygen (NOTE 8)• Neonate drugs and equipment•Incubator monitoring equipment•Stretcher

Page 34


OPERA 1/ON A /RCRA FT EQUIPMENT MEDICAL EQUIPMENT A 7TENDANTS P/LoTsCATEGORY (NOTE 1) (NOTE 2) (NOTES 5 & 6)

B IFR: Intermediate care ambulance kit appropriateDoctor or Paramedic and/orIntensive Care PilotRapid Response AirStandard multi ATO IFR Kit including: to callout situation Nurse/TechnicianAmbulance •2 x VOR Electrocardiograph or(Note 3 & 4) •1 x DME Pulse oximeter Minimum of one medical

•2 x ADF or ADF & GPS End tidal CO. detector (disposable) (Note 9)attendant Stretcher Care Pilot•1 x ILS Defibrillator

Suction pump lAW emergency and patientVFR: Blood pressure measuring equipment conditionStandard VFR ATO and night VFR kit plus:Bag/mask resuscitator (Note 7)•1 x ADF or GPS IV pressure bag Pilot induction course to

Oxygen with delivery equipment (Note 8) include direct and indirectIFR/VFR: Medical kit set up as a Paramedic supervision1 x Mobile Phone (Hands free) Ambulance Officer's Kit suitable for commonlntercrew communication out of hospital medical and trauma 6 monthly checks tailored toPower Supply 1 2v/24v as appropriateemergencies AA Ops1 x stretcher bridge1 x stretcher or incubator As Required:Climate control and lighting in patient and•Medical anti-shock trousersattendant areasTorch for each crew person

Mountings for:•1 stretcher and/or• 1 vacuum mattress

Page 35

National Emerencv Air

OPERA 1/ON A IRCRA FT EQUIPMENT MEDICAL EQUIPMENT ATTENDANTS P/LoTsCATEGORY (NOTE 1) (Noff 2) (NOTES 5 & 6)

C JFR:Stretcher Care AirStandard multi ATO IFR Kit including:Ambulance (Note 3)• 2 x VOR

• 1xDME• 2xADForADF&GPS•1xILS

As Required:• IV syringe pump•Stretcher• Neonate incubator and oxygen (Note 8)

IFR/VFR: • Neonate drugs and equipment1 x Mobile Phone (Hands free) orlntercrew communicationlx Stretcher bridge 1 x 1000 hr VFR Pilot withlx Equipment stowage unit 400 hrs VFR X/CPower Supply 1 2v/24v as appropriate1 x stretcher bridge Pilot induction course to1 x Equipment stowage unit include direct and indirectPower supply 12v or 24v as appropriate supervisionSuction power lead and adaptorBackup power lead 6 monthly checks tailored toIncubator power lead and adaptor AA OpsIncubator, monitors and equipment stowageOverhead hooks1 x Attendant seat (2 seats with babies - motherand nurse)Torch for each crewpersonClimate control and lighting in patient andattendant areasMountings for:•1 x Stretcher•1 x Neonate incubator. All oxygen to be carried

VFR:Standard VFR ATO and night VFR kit plus

1xADForGPS

Oxygen and delivery equipment (Note 8)Drugs and delivery equipmentSuction pumpBlood pressure monitor, Non invasiveSuitable medical kitAir sickness facilities

Nurse/Technician or AmbulanceIntensive Care PilotOfficer or Doctor

or(minimum of one attendant)

1000 hr & 2nd Pilot with CPL:PinC to have:•lOOhrslFR•50 hrs multi• 50 hrs IMC• 200 hrs PinC X/C•IFR recent experience

Page 36


OPERA 1/ON CA IfGORY A FR CRAFT EQUIPMENT MEDICAL EQUIPMENT A 7TENDANTS PILOTS(NOTE!) (NOTE 2) (NOTES 5& 6)

D lEg Oxygen and delivery equipment (Note 8)Nurse/Technician or Ambulance1 x 750 hr IFIR pilot with 200Seated Patient AirStandard multi ATO IFIR kit including: Drugs and delivery equipment Officer hrs X/C and 100 hrs IFRAmbulance •2 x VORs Air sickness facilities IFR recent experience

1xDMENB: Includes child in•2 x ADF or ADF & GPS 1 x 750 hr VFR pilot with 200car seat •1 x ILS hrs X/C

Eøli

VFRStandard VFR ATO and night VFR kit plus1 x ADF or GPS

1 x mobile phone (hands free)lntercrew communication1 x Equipment stowage unit1 x Attendant seatTorch for each crewpersonClimate control and lighting in patient andattendant areas

Mounting for:•All oxygen to be carried

Pilot induction course toinclude direct and indirectsupervision

6 monthly checks tailored toAA Ops

Page 37


OPERATION CATEGORY A JR CRAFT EQ U/PMENT MEDICAL EQUIPMENT A TTENDANTS PILOTS(NOTE 1) (NOTE 2) (NOTES 5 & 6)

E IFR Air sickness facilities Companion 1 x 500 hr IFR pilot with 75Independent PatientStandard multi ATO IFR kit including: hrs IFRAir Transport •2 x VORs Current hR for IFR Ops

• 1xDME• 2 x ADF or ADF & GPS or•1xILS

1 x 600 hr VFR pilot with 100or hrsX/C

VFR Pilot preflight briefStandard VFR ATO & night VFR kit plus•1 x ADF or GPS 6 monthly checks tailored to

AA Ops1 Mobile phone (hands free)Intercrew communication1 x companion seatTorch for each crewpersonClimate control and lighting in patient area

Page 38


Fixed Wing Search and Rescue

OPERATION CATEGORY AIRCRAFT EQUIPMENT MEDICAL EQUIPMENT A TIENDANTS P11015(NOTE 7)* (NOTE2)* (NOTES 5 & 6)

F IFR Aircraft First Aid Kit 2 observers (minimum) 1000 hrs with 200 hrs PinCSearch & RescueStandard multi ATO IFR kit including: x/CAircraft 2 x VORs

1 x DME Current hR for IFR OpsCategory A 2 x ADF or ADF & GPS

1 x ILS Trained knowledge ofVFR or IFR electronic and visual search

or techniquesRecorded on theNRCC databaseVFR 6 monthly checks to include

Standard VFR ATO & night VFR kit plus SAR Ops1 x ADF or GPS or

1 x mobile phone (hands free)Intercrew communicationVHF Direction Finder2 x observer seatsLife rafts & jackets over waterRadio for communication with Police andNRCCOperation area police radioMarker flares and dyes

*Where an intention to rescue is inherent in the tasking instruction the MedicalEquipment and Attendant Requirements shall be as prescribed for a RapidResponse Air Ambulance

Page 39

Category B1 Mobile phone (hands free)

VFR only lntercrew communication

VHF Aeronautical radio Prebriefed and trainedknowledge of visual searchtechniques


OPERA TION CATEGORY AIRcRAFTEQUIRAMNT MEDICAL EQUIPMENT ATTENDANTS PILOTS(NOTE 1) (NOTE 2 & 6) (NOTES 5 & 6)

F Standard day & night VFR kit Aircraft First Aid Kit 1 x observer (minimum) 300 hrsSearch Aircraft

Recorded on the1 x observer seat6 monthly checks to includeSAR Ops

NRCC databaseLife jackets over water

Page 40

National Emeraencv Air

Helicopter Air Ambulance Operation Standards

OPERA 1/ON CATEGORY AIRCRAFT EQUIPMENT MEDICAL EQUIPMENT A TTENDANTS PILOTS(NOTE 6) (NOTE 1 & 8) (NOTE 2) (NOTES 5 & 6)

A Standard ATO IFR or VFR kit to include theVital sign monitors: Doctor and Paramedic or1 x 2000 hr pilotIntensive Care Airfollowing for IFIR Ops: •Electrocardiograph Nurse/TechnicianAmbulance IFR or VFR •1 x VOR • Pulse oximeter or(Note 3 & 4) •1 x DME •Blood pressure (Automatic NIBP)Minimum of two attendants

•2 x ADF or ADF/GPS • Temp recorder (electronic) 1 x 1000 hr plus,•1 x ILS •Capnograph 1 x 500 hr pilot•2 x Artificial horizons Defibrillator•1 x Rad Alt Suction pump all with•1 x HSI Bag/mask resuscitator (Note 7)For VFR night Ops: Oxygen with delivery equipment (Note 8) 15 hrs X/C night VFR with•2 x AH Suitably equipped medical kit including at appropriate VFR night X/C•1 x HSI least: rating•1 x ADF or GPS •IV Fluids & giving set1 x mobile phone (hands free) •IV Pressure bag Min for IFR Ops:lntercrew Communication •Laryngoscope blades & suitable ET tubes 50 hrs IFR1 x stretcher and mattress Pleural drainage equipment 20 hrs multiPatient loading facility Cricothyroidotomy set 30 hrs IMC1 x Stretcher bridge Medication & delivery equipment appropriate 200 hrs PinC X/C1 x Equipment stowage unit for the patient Meet IFR recent experiencePower Supply = 1 2v/24v as appropriate requirementsSuction power lead and adaptor As Required:Backup power lead/supply •Transport ventilator with disconnect and 50% of a pilot's fixed wingIncubator power lead/adaptor high pressure alarm flight time may be creditedStowage for incubator, monitors & equipment•Syringe pump(s) (available) towards the above totals to aOverhead hooks • Medical anti-shock trousers (available) maximum of 50% of the2 x Attendant seats •Incubator and oxygen (Note 8) helicopter requirementsTorch for each crew person • Neonate drugs and equipmentClimate control & lighting in patient/attendant• Incubator monitoring equipment 6 monthly checks tailored toareas • Stretcher AA OpsMountings for:•1 x Stretcher•All oxygen to be carried•1 x Vacuum mattress with mountings•1 x Neonate incubator

Page 41


OPERA 1/ON 4/RCRAFTEQU/PMENT MEDICAL EQUIPMENT A JTENDANTS PilOTSCATEGORY (NOTE 6) (NOTE 1) (NOTE 2) (NOTES 5 & 6)

B Standard IFR or VFR kit for ATO to include theIntermediate care ambulance kit appropriateDoctor or Paramedic and/or1 x 2000 hr pilotRapid Response Airfollowing for IFIR Ops: to callout situation Nurse/TechnicianAmbulance IFR or VFR •1 x VOR Electrocardiograph or(Note 3 & 4) •1 x DME Pulse Oximeter Minimum of one medical

•2 x ADF or ADF/GPS End tidal CO. detector (disposable) (Note 9)attendant 1 x 1000 hr plus•1 x ILS Defibrillator 1 x 500 hr pilot•2 x Artificial horizons Suction pump•1 x Rad Alt Blood pressure measuring equipment all with•1 x HSI Bag/mask resuscitator (Note 7)For VFR night Ops: IV pressure bag 15 hrs X/C night VFR with•2 x Artificial Horizons Oxygen with delivery equipment (Note 8) appropriate VFR night X/C•1 x HSI or Dl Medical kit set up as a Paramedic Ambulance rating•1 x ADF or GPS Officer's Kit suitable for common out of 20 hrs mountain flying

hospital medical and trauma emergencies experience if operatin g inIFR/VFR:1 x mobile phone (hands free)lntercrew CommunicationPower supply 1 2v/24v as appropriate1 x Stretcher Bridge1 x Stretcher or IncubatorClimate control and lighting in patient andattendant areasTorch for each crew personMountings for:•1 x Stretcher and or•1 x Vacuum mattress

6 monthly checks tailored toAA Ops

mountainous terrainAs required:•Medical anti-shock trousers Min for IFR Ops:

50 hrs IFR20 hrs multi30 hrs IMC200 hrs PinC X/CMeet IFR recent experiencerequirements

50% of a pilot's fixed wingflight time may be creditedtowards the above totals to amaximum of 50% of thehelicopter requirements

Page 42


OPERATION CATEGORY AIRCRA FT EQ U/PMTNT MEDICAL EQUIPMENT A ITENDANTS PiiorS(NOTE 6) (NOTE 1) (NOTE 2) (NOTES 5 & 6)

C Standard IFR or VFR kit for ATO to include theOxygen and delivery equipment (Note 8)Nurse/Technician or Ambulance1 x 1500 hr pilotStretcher Care Airfollowing for IFR Ops: Drugs and delivery equipment Officer or Doctor (minimum ofAmbulance: •1 x VOR Suction pump one attendant) orIFR or VFR (Note 3)•1 x DME Blood pressure monitor (Non Invasive)

•2 x ADF or ADF/GPS Suitable medical kit 1 x 1000 hr plus•1 x ILS Air sickness facilities 1 x 500 hr pilot•2 x Artificial horizons•1 x Rad Alt As Required: all with•1 x HSI IV syringe pumpFor VFR night Ops: Stretcher 15 hrs X/C night VFR with•2 x Artificial Horizons Neonate incubator and oxygen (Note 8) appropriate VFR night X/C•1 x HSI or Dl Neonate drugs and equipment rating•1 x ADF or GPS 20 hrs mountain flying

experience if operating inIFR/VFR: mountainous terrain1 x mobile phone (hands free)Intercrew Communication Min for IFR Ops:1 x Stretcher Bridge 50 hrs IFR1 x Equipment towage unit 20 hrs multiPower supply 1 2v/24v as appropriate 30 hrs IMCSuction power lead and adaptor 200 hrs PinC X/CBackup power lead Meet IFR recent experienceIncubator power lead and adaptor requirementsIncubator, monitors and equipment stowageOverhead hooks 50% of a pilots fixed wing1 x Attendant seat (2 seats with babies - mother flight time may be creditedand nurse) towards the above totals to aTorch for each crewperson maximum of 50% of theClimate control and lighting in patient and helicopter requirementsattendant areasMountings for: 6 monthly checks tailored to•1 x Stretcher AA Ops•1 x Neonate incubatorAll oxygen to be carried

Page 43


OPERATION AIRCRAFT EQUIPMENT MEDICAL EQUIPMENT A TTENDANTS PILOTS

CATEGORY (NOTE 1) (NOTE 2) (NOTES 5 & 6)D Standard ATO VFR kit Oxygen and delivery equipment (Note 8)Nurse/Technician or Ambulance1 x 750 hr pilot with 200 hrsSeated Patient Air officer X/CAmbulance 1 x Mobile phone (hands free) Drugs and delivery equipment

•lntercrew communicationNB Includes child in1 x Equipment stowage unit Air sickness facilitiescar seat Climate control and lighting in patient and

attendant areasVFR Patient and attendant areas

Mounting for all oxygen to be carried6 monthly checks tailored toAAOps

50% of a pilots fixed wingflight time may be creditedtowards the above totals to amaximum of 50% of thehelicopter requirements

Page 44


OPERA TION CATEGORY AIRCRAFT EQUIPMENT MEDICAL EQUIPMENT* ATTENDANTS* PILoTs(NOTE 6) (NOTE 1, 7&8) (NOTE 2) (NOTES 5& 6)

F Standard IFR or VFR kit for ATO to include theStandard first aid kit (minimum equipment)Winch crewman and trained1 x 2000 hr pilotSearch & Rescue IFRfollowing for IFR Ops: observers as appropriateorVFR • 1xVOR or

• 1xDMECategory A • 2 x ADF or ADF/GP5 1 x 1000 hr plus

•1 x ILS 1 x 500 hr pilot•2 x Artificial horizons•1 x Rad Alt all with•1xHSIFor VFR night Ops: 15 hrs X/C night VFR with•1 x Artificial horizon appropriate rating•1 x HSI or Dl 20 hrs mountain flying•1 x ADF or GPS experience if operating inFor VFR & IFR Ops: mountainous terrainVHF DF 20 hrs underslung load and1 x Mobile phone (hands free) long line experienceWinch, or static line as required in CASO 20Winch belts, strops, bo'sun, chair, harnesses Min for IFR Ops:Stretcher suitable for external recovery 50 hrs IFRScoop net, scoop stretcher 20 hrs multiNite Sun or other approved direction controllable 30 hours IMCexternal light 200 hrs PinC X/CRadio suitable for communications with police Meet IFR recent experienceand RCC requirementsAmbulance radioGround/air portable radios including waterproof 50% of a pilots fixed wingradios flight time may be creditedProtective equipment for crews as appropriate, towards the above totals to athermal survival suits, life raft maximum of 50% of theAerial drop bag - medical equipment, food, water, helicopter requirementsthermal blanketsMarker flares and dyes * Where an intention to rescue is inherent in 6 monthly checks tailored toLife jackets and harnesses the tasking instruction, the medical SAR OpsDiving equipment where appropriate equipment and attendant requirements shallAerial drop life rafts & crew raft be as prescribed for a Rapid Response Air

Ambulance.

Page 45

National Emereencv Air Ambulance Network

OPERA HON CATEGORY AIRCRAFT EQUIPMENT MEDICAL EQUIPMENT A ITENDANTS Pizors(NOTE 6) (NOTE!, 7& 8) (NOTE 2) (NorEs5& 6)

F Standard VFR kit for ATO Standard first aid kit (minimum equipment)1 x Observer or crewman1 x 500 hr pilotSearch & Rescue VFR

For VFR night Ops:Category 8 1 x Artificial horizon

1 HSI or Dl1 x ADF or GPS

1 x Mobile phone (hands free)

Life raft and jackets for all on board if over water

Crewman to be trained in staticline and winch ops as applicable

15 hrs X/C night VFR withappropriate rating20 hrs mountain flyingexperience if operating inmountainous terrain20 hrs underslung load andlong line experience

Pre-briefed or trained in visualsearch techniques

50% of a pilots fixed wingflight time may be creditedtowards the above totals to amaximum of 50% of thehelicopter requirements

6 monthly checks tailored toSAR Ops.

Page 46

Air

PROPOSED NATIONAL AIR AMBULANCE MODELNOTES: AirAmbulanceOperations

All air ambulance/air rescue operators wishing to be registered byAlA shall submit a Procedures Manual detailing their airambulance/air rescue operations. It is an objective of AlA to have allair ambulance flights conducted under IFR whenever practicable.

NOTES:

1. Medical equipment suitable for transports (light weight, compactwith dry' batteries) supplied by the Crown Health Enterprise or theoperator as agreed.

2. (a) Attendants must have been pre-trained or pre-briefed on airambulance patient care, including aviation medicine, inflightcommunications, air 'ambulance procedures, aircraft safety,rescue and survival.

(b) Attendants not to be subject to motion sickness or excessiveobesity

(c) Attendants should attend a suitable air transport refreshercourse every three (3) years

Part of the registration details for each aircraft should include themaximum safe number of patients to be carried in each ofCategories A, B, C and D. A factor in determining this number is thatfor reasons of safety the allocated attendants should be able to keeptheir safety harness fastened while having immediate and easy accessto their patient's head and upper body. No patient in any of thesecategories should ever be located such that head and upper bodyare accessible only to the pilot. In Category A air ambulanceoperations both allocated attendants should have access to the samepatient.

4. In Category A and B air ambulance operations it must be possible togain access from behind the patient's head, for intubation and airwaymanagement, without compromising CAA requirements for restraintof the stretcher. It is recognised that in certain aircraft in this unusualevent, the attendant may have to decide to be unrestrained (if thecircumstances permit this with safety) in order to gain suitableaccess.

1 YUASA Super Sealed motorcycle batteries is suitable for use in aircraft. (CAA 6313/1 CL dated 26 May 1995)

Page 47

Air Am

5. All pilots shall undergo an air ambulance induction course andinitially operate under direct supervision, then indirect supervisionand finally unrestricted with six (6) monthly checks, in accordancewith the approval induction course procedures.

6. When an operator wishes to make a variation to these standards(except under an emergency situation) the variation in the form of anamendment to the Operators Procedures Manual shall be submittedto AlA Air Rescue/Air Ambulance Division for assessment against therelevant standard.

7. Bag/Mask Resuscitator: Self-inflating, hand ventilating assembly withPEEP valve available.

8. When oxygen supplied, there must be a pressure gauge and flowmeter visible to the attendant, and sufficient oxygen for the flight plusa suitable margin for delays. As a contingency against failures theremust be suitable duplication of delivery systems.

9. NOT capnography.

10. The term "climate control" in these standards means that asatisfactory ambient temperature can be maintained

11. The Pilot in Command, or the senior attendant, may deviate fromthese Air Rescue/Air Ambulance Standards when an emergencysituations requires immediate action to save life or otherwise removean accident victim from further danger.

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Estimated Mean Cost Of Air Ambulance ServicesFor 1992/93 - 1994/95 taken from respondents survey prices.

Casevac Missions192/93 1993/94 1994/95$'OOOs $'OOOs $'OOOs

Helicopter 795 1109 1485Fixed Wing 111 126 201TOTAL 906 1235 1 1686

Medevac Missions .. . .1992/93 1993/94 1994/95$'Ooos $'OOOs $'OOos

Helicopter 509 499 631Fixed Wing 169 551 310TOTAL 1 678 1 750 1 941

Interhospital Transfers1992/93 1993/94 1994/95$'OOOs $'OOOs $'OOOs

Helicopter 762 1202 1 733Fixed Wing 1032 1379 1849TOTAL 1 1794 2581 1 3582

SAR/Others1992/93 1993/94 1994/95$'000s $'Ooos $'OOOs

Helicopter 714 603 625Fixed Wing 14. 26 39TOTAL 728 629 664

Total Cost of Services1992/93 1993/94 1994/95$'Ooos $'OOos $'000s

Helicopter 2780 3413 4474Fixed Wing 1326 1782 2399TOTAL 41061 5195 1 6873

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3.1 AIR AMBULANCE QUARTERLY REPORTInter Hospital / Inter CHE Operations Only

Quarterly Report for the period .....................................................................

Patient Information

TransfersReferred from (Hospital) Referred to (Hospital) Number

Note: Total A = Total B = Total C = Total D = Total E

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