Program Management

A Shared Approach to Program Expansion by David D. Smith

On June 16, 1986 the Center For Emergency Medicine of Western Pennsylvania (CEM) expanded its STAT (Specialized Treatment and Transport) System by placing a second twin-engine helicopter in Greensburg, Pennsylvania, 50 miles east of its primary helicopter base in Pittsburgh. This expansion was accomplished through an agreement with Air Rescue East (ARE), a consortium representing hospitals, EMS pre-hospital providers, business leaders, and local government from the five-county region immediately to the east of Pittsburgh.

This event marked the first time that an aeromedical program sponsored by a consortium of competing hospitals had expanded through a satellite basing arrangement with a second consortium. However, the unique organizational model presented here is simply a logical outgrowth of the principles and the history of the STAT System and CEM, The purpose of this paper is to describe those principles and that history, to present the characteristics and benefits of this expansion, and to offer insight to hospitals contemplating similar cooperative efforts.

Center for E m e r g e n c y Medic ine CEM was founded in 1978 as an

educational and research institute within the University of Pittsburgh School of Medicine. It was separately incorporated in April, 1983 under the Non-Profit Corporation Law of the Commonwealth of Pennsylvania. CEM is operated exclusively to perform or to carry out the following charitable, educational, and scientific goals:

1. To provide a coordinated system of emergency medical care to improve the quality of care and outcome; to reduce the social and economic costs of accidents and other medical and surgical emergencies incurred; to provide

accessibility to emergency medical facilities through a coordinated and comprehensive system that includes communication, transportation, and treatment.

2. To provide education and training for residents, medical students, fellows, faculty members, practicing physicians, paramedical personnel and others, and to conduct and encourage basic and clinical research in emergency medical care and related fields that will enhance knowledge and improve emergency medical care and its delivery.

3. To do such other work as may be necessary to carry out the stated goals including the right to purchase or lease equipment or property, real or personal, to render consultative advice, education and training, and to provide medical and technical assistance to hospitals and physicians and to health-related organizations in Western Pennsylvania, Eastern Ohio, Northwestern Maryland, and Northern West Virginia.

As such, CEM is not a health care facility nor is it located within a health care facility. Rather, the services of the Center are offered to many health care facilities as well as other organizations within the region. Members of the Center include Children's Hospital of Pittsburgh, Eye and Ear Hospital of Pittsburgh, Jefferson Health Services, Magee-Womens Hospital, the Mercy Hospital of Pittsburgh, The Montifeore Hospital Association of Western Pennsylvania, Presbyterian-University Hospital, Shadyside Hospital, The South Side Hospital, St. Francis Medical Center, University Health Center of Pittsburgh, and Western Pennsylvania Hospital.

These hospitals which have chosen to be members of CEM have recognized the benefit of being part of an organization whose goals are enumerated in the Center's Articles of Incorporation, and have appreciated the economies of scale

realized by doing so. In addition, membership in the Center assists each hospital in fulfilling its mission of education and research in the field of emergency medicine and pre-hospital care. CEM is governed by a Board of Directors composed of the Chief Executive Officer of each of its member institutions.

Within the Center, services are provided through one of five functional areas, which include:

1. Office of Education Programs: are offered to medical students, house staff, nurses, paramedical personnel, and physicians.

2. Office of Research: Clinical and basic research is conducted in all aspects of emergency medicine and pre-hospital care.

3. Office of Life Support: Programs are offered in basic and advanced life support at both the provider and the instructor level.

4. Office of Transport: The STAT (Specialized Treatment and Transport) Program provides coordinated air and land critical-care transport throughout the region. Medical direction is provided for the Department of Public Safety of the City of Pittsburgh.

5. Office of Information Services: Responsible for the marketing and development efforts of the Center and its offices, as well as provision of information to member hospitals, media, health care providers, and the general public regarding activities and programs of CEM.

The Center conducts all University of Pittsburgh School of Medicine programs in emergency medicine education and research. The Office of Research provides logistical support for all such grants and projects. Educational programs regarding emergency medicine are also offered by the Center to first, third, and fourth year medical students of the University. Post-graduate medical education programs are offered through the Division of Continuing Education of the Medical School as well. CEM contracts with the City of Pittsburgh

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Program Management to provide all medical direction for its Department of Public Safety. This includes on-scene and remote direction for patient care and treatment, medical quality assurance, training--both initial and continuing education, and disaster planning. This direction is provided by the faculty of the Center and sixteen of the twenty-four Emergency Medicine Residents of the University of Pittsburgh Affiliated Residency in Emergency Medicine. The Center works closely with the Affiliated Residency in Emergency Medicine, providing educational, research, and clinical experience to residents in all areas of the Center. The Center derives its revenue from tuition for educational and life support programs, research grants, STAT System services, services rendered to the City of Pittsburgh and other agencies, and support from member hospitals.

The STAT System The STAT (Specialized

Treatment and Transport) System is a coordinated air and land critical-care patient transportation program utilizing physician/nurse/ paramedic specialty teams and integrating research, education, and evaluation mechanisms through a community-based system. The STAT System was initiated on February 1, 1984 through the cooperative efforts of Corporate Jets, Inc., the air component contractor and a local ambulance service as the land component contractor. Corporate Jets remains as the air component contractor while the land component is offered through the cooperative efforts of two local ambulance services.

Six of the twelve member hospitals of CEM participate in the STAT System. Their participation indicates that this System provides improvements in patient-care service in a more cost-effective manner leading to the achievement of an optimal model of patient transportation. In addition, each is committed to the STAT System's design that assures matching the patient's medical condition with the hospital possessing the clinical capability needed to deal effectively with that condition. Finally, their

participation demonstrates this System's compatibility and consistency with their respective missions to provide care for patients throughout the region with trauma, burns, spinal cord injuries, medical and neonatal emergencies, etc. as well as their respective missions and goals in research and education.

The STAT System was granted a Certificate of Need by the Department of Health of the Commonwealth of Pennsylvania following review and unanimous recommendation by the Health Systems Agency of Southwestern Pennsylvania.

Medical direction for the STAT System is provided by its Medical Director. The Director of Operations is responsible for all day-to-day activities of the STAT System. The Administrator of the Center is responsible for the overall administrative direction of the STAT System. The STAT Team members are supervised by the Coordinator of the STAT Team.

The Team members consist of a physician drawn from a cadre of sixteen second and third year residents of the Affiliated Residency in Emergency Medicine and either a registered nurse or a paramedic at the P-II level drawn from a cadre of four full-time personnel and five on-call individuals. These STAT Teams cover the helicopter and the critical care modular ambulances when the land component is used in support of an air transport. Otherwise the STAT Teams for land transport are provided by the participating receiving hospital.

The aeromedical component of the STAT System began operation with a BO-105 as the helicopter provided by Corporate Jets. In January, 1986 the primary helicopter was changed to a BK-117. The secondary helicopter had been an A-Star since the initiation of the System. The Board of Directors of the Center voted to replace the single-engine A-Star with a twin-engine BO-105 during the spring of 1986. During the STAT Systems first two years (Feb '84 to Jan '86) a total of 1,505 helicopter flights were requested. Of those requests 1,142 flights were completed. Of the 363 flights that

were either missed or aborted, the reasons are categorized as follows:

Weather 152 In-Service 112 Change in patient condition 29 Maintenance 25 Other 45

During the STAT System's third year, requests for service showed an increase of 66% over the previous year. Similarly, completed flights showed an increase of 36% and missed flights due to in-service or maintenance showed an increase of 320% during the same time periods. This dramatic growth confirmed the need of staffing STAT's second helicopter.

Air Rescue East Air Rescue East was incorporated

in July, 1985 under the Non-Profit Corporation Law of the Commonwealth of Pennsylvania. According to its Articles of Incorporation, the purpose for which Air Rescue East was formed is:

To function as an integral component of the health care delivery system by providing high quality air treatment and transportation in an efficient and effective manner to the communities it serves.

ARE is governed by a twenty-two member Board of Directors consisting of the following:

-Contributing members Ex-Officio -Hospitals in service area One

Director each -EMS Councils in service area

One Director each -Mutual Aid Ambulance, Inc. One

Director Seven hospitals providing service

in the five-county service area have elected to fully support this effort by appointing representatives to the Board of Directors and providing direct financial support. The seven hospitals are: Forbes Regional Health Center, H.C. Frick Community Hospital, Highland Hospital and Health Center, Jeanette District Memorial Hospital, Monsour Medical Center, Uniontown Hospital, and Westmoreland Hospital Association.

Four other hospitals, while not participating on the Board of Directors and providing direct

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Program Management financial support, have indicated their support of this program by indicating a willingness to act as receiving hospitals for patients appropriate to each hospital's level of medical care provided and to pay for the costs for such transports.

A third group of hospitals, which are not in a position to receive patients from the helicopter, nevertheless have indicated a willingness to encourage the use of this program by members of their hospital's medical staffs when patients require aeromedical transfer to other health care facilities.

ARE announced its intentions in September, 1985 to initiate a medical evacuation program to serve the five-county region east of Pittsburgh. In discussing the feasibility of this new and independent aeromedical program with hospital administrators and business and community leaders within the region, the leadership of ARE was encouraged to contact CEM to explore the feasibility of a cooperative effort with the existing STAT System rather than initiate a new ( and third) aeromedical program in Southwestern Pennsylvania. In November, 1985 CEM was contacted by representatives of ARE for that purpose. The events of June 16, 1986 mark the successful culmination of seven months of planning, negotiating, and developing of the model presented below.

The Model Major dissimilarities existed

between CEM and ARE constituents. CEM consisted mainly of urban teaching hospitals providing referral services with tertiary care capabilities, a major commitment to research, and all contained within the geographic confines of one county. ARE consisted mainly of non-urban community hospitals with primary and secondary care capabilities accustomed to referring patients, along with the pre-hospital providers from a relatively large five-county region. Therefore the establishment of a solid base of common ground was essential.

Therefore, at an early state in the discussions, a set of eight guiding principles was drafted. During the negotiations that followed, these principles were modified and eventually formed the model that received unanimous approval by the Boards of Directors of these two consortia. They are listed below followed by parenthetical comments that apply to the approval and implementation of each.

ARE/CEM guiding principles 1. Governance and policy making

of Air Rescue East will be open to all hospitals and pre-hospital providers within the five-county region desiring to be involved. (This openness to all appropriate organizations within the service area is consistent with one of the basic principles underlying the STAT System and CEM That the advantages of the involvement of competing hospitals with differing objectives and priorities in the governance of such a system

outweigh the disadvantages and result in a superior final product. In addition, ARE and CEM are represented on the other consortium's Board of Directors by one ex-officio member.)

2. The STAT System's secondary helicopter will be based in the five-county region through the modification of CEM's contract with Corporate Jets. This modification will include provision of pilots, maintenance, and all other contractual elements. ARE will have a role in recommending pilots, maintenance, and all other contractual elements. ARE will have a role in recommending pilots for Corporate Jets' consideration. (This contractual modification with Corporate Jets, Inc. resulted in the replacement of the A-Star with a BO-105.)

3. This helicopter will initially have a flight nurse and a paramedic as the flight crew. These personnel will be drawn from a small cadre of paramedics from pre-hospital

HOSPITAL AVIATION, AUGUST 1987 9

Program Management providers in the region and registered nurses from hospitals in the region. They will be selected by CEM utilizing existing standards and will be oriented and exposed to continuing education similar to other STAT Team members. These personnel will be paid by their employers or by ARE (A total of eight registered nurses from three hospitals within the region and six paramedics from four pre-hospital providers within the region were selected, oriented, and now form the cadre described above. The demonstrated advantages of the presence of a flight physician has led to a common goal: the provision of a physician on every flight by this expansion's first anniversary. This will bring the expansion into line with the staffing model of the primary helicopter, a priority of the highest order among STAT's participating hospitals. In fact, less than a year after the start-up of the expansion, partial physician staffing on flights is a reality.)

4. The facilities for the helicopter basing and maintenance as well as flight crew quarters will be those under construction by ARE in Greensburg. (Facilities, including a landing area sufficient to support two helicopters, a hanger, flight crew quarters, and on-site refueling have been constructed or secured completely by ARE)

5. Dispatching will be conducted from Mutual Aid Ambulance Service in coordination with the STAT dispatch operation. Dispatchers will be trained by CEM as are STAT dispatchers. The helicopter will be available to be dispatched by the STAT dispatch operation to destinations outside of the five-county region. (This use of existing community resources rather than the creation of new ones is consistent with another of the basic principles underlying the STAT System.)

6. Triage protocols established between the Center and those hospitals wishing to participate in the five counties will guide the determination of the receiving hospital for undesignated pre-hospital patients. (The determination to remain within the five-county region or to transport

directly to Pittsburgh and the specific receiving hospital of choice is, of course, the prerogative of the patient or family member. As a backup, triage protocols have been designed with the purpose of matching the patient's condition with the hospital providing the clinical capability to treat that condition. By using protocols based upon quantifiable criteria, ie. trauma scores, and establishing a review mechanism, the fears among hospitals that patients would be inappropriately diverted to a hospital in Pittsburgh or to a competing hospital have been satisfactorily addressed.)

7. Billing will be done by CEM under STAT's current billing procedure. Contracts with hospitals in the five-county region which will be receivers of transported patients will be signed. (As stated earlier, eleven hospitals had indicated such a willingness.)

Operating losses (or gains) will be the responsibility of CEM with the exception of the responsibility to provide the medical flight crew which will be the responsibility of ARE (This negotiated compromise is designed to match financial responsibility with benefit.)

Benefits This negotiated arrangement was

developed with the goal of maximizing benefits for both ARE and CEM The unanimous approval by both Boards of Directors indicates that this goal was achieved. Among the perceived benefits are:

1. The provision of the life-saving advantages of an aeromedical system to seriously ill and injured patients throughout the five counties of Cambria, Fayette, Indiana, Sommerset, and Westmoreland by the integration with an established EMS system.

2. The provision of rapid access to emergency medical facilities through a coordinated and comprehensive system that includes treatment, transportation, and communications.

3. The reduction of the human and economic costs of accidents and other surgical and medical emergencies.

4. The participation in the

governance and policy making of this expansion to all hospitals and pre-hospital providers desiring such participation.

5. The extension of the research and education efforts in critical care transport of the STAT System.

6. The securing of the necessary level of appropriate patient transport activity to assure the financial viability of the expansion of the STAT System.

7. The substantial contribution to the achievement of the goals and objectives of the STAT System, the member hospitals of CEM and the hospitals served by ARE.

Summary The demand trend established

during the third year showed an increase of 66% over the second year. However, with a second staffed helicopter, the number of completed flights also increased by 66%, thereby providing early justification of the decisions indicated above. This occurred despite the efforts of a competing single hospital-sponsored program which placed helicopters within the very same five counties under an arrangement with another single hospital.

This paper has presented a unique model of cooperation among competing hospitals and pre-hospital providers covering a wide geographic area, which has made possible the early expansion of a successful critical-care patient transportation system. This model and the STAT System itself bear close examination as they appear to provide significant direction for other aeromedical programs throughout the country dealing with the effects of limited resources brought by restrictive reimbursement policies.

David D. Smith, MS, MPH, is President of Smith Associates, a health care management consulting firm based in Huntington, W~. He was formerly the Administrator of the Center for Emergency Medicine of Western Pennsylvania and a consultant to CEM and ARE in the development of the model described in this paper. The author gratefully acknowledges the assistance of Michael B. Heller, MD, Medical Director of the STAT System in the preparation of this article.

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