History of the Starflight, Inc. Regional Medevac Program

The evolution of the Starflight Regional Medevac Program has been one like no other in the country. With the early history and funding being as unique as it was, many key players put huge efforts to ensure our rural communities would benefit from a much needed program. Today, the program has made over 7,600 successful flights for the most critically ill and injured patients. Without this program, our area hospitals would need to find a less effective and slower means of transport for these patients in desperate need of urgent care. This story will show how evolution of the Starflight program has come to be what it is today.

Credits to the early conception of the Starflight program can be given to 3 key people after a much recognized need for medevac transportation. John Bentley, then Chautauqua County Sheriff, WCA Hospital Administrator, Mr. Murray Marsh and Philanthropist Betty Sheldon began to collaborate together in 1985 to form our local medevac program. Being that the partnership involved the Chautauqua County Sheriff's Department and WCA Hospital, it was evident that backing and program structure would need to start there. The Sheriff's Department would provide the pilots, co-pilots, maintenance and fuel. The medical equipment, dispatch and staff would be provided by W.C.A. Services Corporation. The very first aircraft, hangar and landing field for the Starflight program was donated by Betty Sheldon through the Ralph C. Sheldon Foundation.

The first aircraft was a Bell UH-1L military surplus helicopter. For a while, supplies for the helicopter were inexpensive and easy to come by. Starflight billed minimally to the patient as a community-based program fo rhte medical care provided and not fo the transportation costs. However, this was not enough to keep the program alive. Most of the funding came from the Sheldon Foundation, WCA Foundation and Chautauqua County through tax dollars. During the first 10 years of operation, Starflight was completing about 190 flights per year until health care began to change and an increase in need for urgent care transportation began to rise.

Up until 1996, the population and demographics of our local communities were well suited for the Starflight program as it was operating in its earlier years. However, the health care environment continued to change and there began to be an increased need for medevac transports. An increase in air medevac transport demand began for patients requiring a higher level of specialty care not available in our local communities. Many critical cardiac, trauma, neuro, pediatric and obstetric patients needed to be transported out of Chautauqua County for care as specialty centers of excellence continued to emerge. Unfortunately at this time, as the helicopter was aging out, it became harder to find supplies for the Bell UH-1L. Funding through tax dollars provided by the Chautauqua County Sheriff's Department and WCA Foundation was reallocated in 2009 and through billing initiatives, W.C.A. Services Corporation became the primary financial source.

After upgrading to more feasible helicopters a couple more times, exciting news came in 2009 when Starflight, Inc. replaced the old helicopters with 2 newer MD-900 Explorer helicopters. These helicopters were top of the line and much easier to find parts for. The current Starflight hangar could fit only one helicopter so a hangar expansion soon began. This expansion would allow both helicopters to be mission ready and mechanics would have a place to work on the aircraft.

Being a community-based and a not-for-profit program, the Starflight program is able to maintain lower patient and operating costs. Unlike hospital-based programs, this program model would not allow Starflight to roll the cost of the patient's medevac transportation bill to the patient's hospital bill since 100% of transports were made to care centers not located in Chautauqua County. For-profit flight programs bill at a much higher set rate since they operate as a free standing organization. Public service models are funded from tax dollars previously removed from the Starflight program.

In 2011 after several months of transitioning, Starflight became a Part 135 service which would allow the program to bill all insurance companies previously unable to bill. Prior to becoming a Part 135 service, Starflight would bill non-governmental insurance companies for medical transportation. After receiving the Part 135 certificate, each medevac transport made is billed for lift off and a set rate for each patient loaded mile. Along with being able to bill all insurance companies, this new certification came with many rules and regulations to comply with. Several pilots were hired with need for additional training. Additional mechanics were hired and hangar updates were made. As this was a great step forward for the program, medical reimbursements would never cover the actual cost of operating the program. The program to this day, still operates at a loss.

Today, the Starflight, Inc. program has endured many hardships and continues to be your local not-for-profit medevac service. Flights are being made to help critical patients from the communities of Chautauqua, Cattaraugus, Warren, Allegany and McKean Counties. Technology is constantly changing and the two MD-900 helicopters are always being upgraded with the latest technological advances to ensure the safest transport. Keeping with the FAA Expected level of compliance; our helicopters are being upgraded to include a night-vision compatible cockpit, a state of the art GPS system and refurbished crashworthy seats among a few others. In 2014, Starflight, Ic. completed 444 flights which proves that the program is a crucial element in our rural communities. Funding is being explored through support of the public in hopes that the program will be viable for the next generation.

The History of Airmedical Care
BY Dr. Michael A. Shapiro

Physicians were among the earliest aviators. In 1783 the French physician Pilatre de Rozier became the first person to fly in a Montgolfer balloon.  The first American to fly was also a physician.  Dr. John Jefferies became a balloon enthusiast while living in London and in 1875 completed the first crossing of the English Channel.  Like his predecessor, Dr. Jefferies never explored the medical application of this new mode of transportation.

The first air transport of patients was reputed to have taken place in 1870 when hot air balloons reportedly transported 160 wounded French soldiers from Paris during the Prussian Siege. A review of the pilot flight reports reveals the evacuation of numerous carrier pigeons, several dogs (all uninjured), and 103 socially prominent civilians.  No mention of wounded soldiers appears in these reports.

Airplane ambulances were used on an experimental basis during World War I. The Curtis JN-4 was able to carry a single liter patient in the open rear cockpit.  During the Second World War, larger aircraft permitted over a million patient transports as well as allowing medical attendants to provide in-flight care.

Helicopters were first used for medical transport during the Korean War to evacuate the wounded directly from the battlefield.  As a result, the time form injury to definitive care was reduced from 6-12 hours during World War II to approximately 1 hour (average time for all wounded was 4-6 hours), with a drop in the mortality from 5.8% to 2.4%.  Twelve Bell-47 helicopters performed most of the 20,000 transports during the Korean War.  Patients were carried on external pods, covered to protect them against further injury from the rotor wash.  Later, the larger Sikorsky S-51 was modified to allow patients to be carried horizontally inside the aircraft where in-flight medical care was now possible.

In Vietnam, the terrain made ground evacuation extremely difficult, and the “DUSTOFF” helicopters (much larger Bell UH-1D “Huey” aircraft) transported over 800,000 patients.  “Dustoff “was the call sign of the first air ambulance units in Vietnam and was subsequently adopted by the entire air ambulance system.  ALS trained medical crews provided in-flight medical care.  Routine helicopter transport (with an average time to definitive care of 35 minutes) was one component of improved medical care that reduced mortality to 1.7% of patients transported, despite the increase in severity of wounds.  Towards the end of the Vietnam Was, it was realized that comparable helicopter ambulances could be of benefit back home, particularly for the rural population.

In the United States, a 1966 report by the National Academy of Science termed accidental injury the “neglected disease of modern society”.  While helicopters were being used by the military, civilian trauma victims were being transported by morticians’ assistants in poorly equipped ambulances.  The National Highway Safety Act of 1966 paved the way for eventual upgrading of pre-hospital care by the funding of EMAT and paramedic training programs and regionalized trauma care systems: “…Many of those injured in highway crashes die needlessly or are permanently disabled because they do not receive prompt and proper care…”  The helicopter is unsurpassed as a transportation tool in avoiding traffic congestion, speeding aid to the ill or injured in remote (70% if fatal accidents are in rural areas) or inaccessible locations, and rapidly transporting the injured to medical care centers.  Beginning in 1969, Army and Coast Guard MAST (Military Assistance to Safety and Transportation) helicopter units began to be used on an infrequent basis, usually for inter-hospital transports because of the 1 to 2 hours response time.

In 1967, planning began in Maryland for a system which became operational in 1969.  It represented a combined effort of the Maryland State Police and the University of Maryland Center for the Study of Trauma (CST) (which in 1973 became the Maryland Institute for Emergency Medical Services) to transport the critically ill/injured and  was supported by a Department of Transportation grant.  Dr. R. Adams Cowley recognized that the time to definitive care was critical, that for every thirty minutes, mortality increased three-fold, that the death/injury rate three times higher in rural areas and that 70% of all motor vehicle accidents occur in towns with populations less than 2500.  “It is a regrettable fact that hospital care of the acutely ill or injured is of an unacceptable standard in most areas of the United States.”  In 1969, four existing Maryland State Police Bell Jet Rangers 206A

Aircraft were modified to carry a stretcher, and medical equipment was installed. The helicopters were staffed by two officers that had already received standard first aid training and were entered into an 81 hour lecture course and a recurrent 2 week training program through the CST.  The four helicopters were based in four separate geographical areas, linked thorough the already existing State Police communications network to patrol cars, the Aviation Center and CST.  In the process of routine flights in their assigned areas, they would either directly observe an accident or be alerted by monitoring radio calls.  In either case, they were the first paramedical assistance to arrive.  IF they determined the victim didn’t require transport to CST, they would treat the patient until the ambulance arrived for transport to the nearest hospital.   In the first three years, over 1000 patients were transported with a 50% reduction in mortality.  At present the Maryland program has expanded to eight helicopters.  Also in 1969, the first hospital based fixed wing program (Samaritan AirEvac) began in Phoenix, Arizona.

A national civilian helicopter program was introduced in 1970 in West Germany as part of a regional trauma system.  The “Rettingshubschrauber” now utilizes over 35 helicopter/stations dedicated to EMS, flying approximately 20,000 missions/year in an area twice the size, but with five times the population of the state of Pennsylvania.  Each station has a 50DM (31m) radius of operations.  Because of this effort (and because of the limited territory), today it is estimated that 905 of the West German population can be reached by a physician staffed helicopter within 20 minutes.  Eight are operated by ADAC, the West German auto club.  Others are operated by the federal emergency/disaster service and a branch of the military.  Much of the credit for starting the service belongs to an architect (Siegfried Stager) who founded a nonprofit organization after a fatal accident took the life of his son.  This organization, “German Air Rescue” operates five helicopters and two fixed wing ambulances.  Others programs have developed in Switzerland, Austria, and Australia.

In 1972, St. Anthony’s Hospital in Denver, Colorado began the first continuously operating US hospital based helicopter program not as a part of a regional trauma system, but in anticipation of the potential evacuation of injured from nearby mountain ski resorts.  The St. Anthony’s program began using a single engine Aorospatiale Alouette, had a strong medical leadership that was responsible for developing a well trained ALS crew of flight nurses and utilized a trauma center with comprehensive resources.  There was also a strong awareness of the importance of integration with the existing EMS systems including an educational program to train first responders and EMTs.  Radios were installed to allow communication between the helicopter and ground EMS units, public safety personnel, and hospitals. Over the next 10 years, 56 hospital based helicopter programs were initiated. Many of these early programs had similar characteristics: (1) single engine helicopters which became plentiful and relatively inexpensive with the decline of the domestic oil industry. (2) Military trained pilots who became available after the end of the war, (3) skilled ALS medical crews, (4) primary service to the owner hospital (which usually was seeking to fill excess bed capacity), (5) inappropriately low (subsidized) transport charges.  The costs of the flight program were subsidized by the hospital which was able to generate increased revenues through higher patient census.  The transportation charges were set below the actual cost of the service in order to encourage utilization and thereby expand the referral base of the hospital.

Following the success of the first generation programs, questions began to arise regarding which patients would actually benefit from the high cost service.  The early program’s hospitals saw a dramatic increase in bed occupancy with resulting positive fiscal results, resulting in an explosive increase in the number of new startup programs.  Characteristics of these “second generation” programs included (1) the requirement of a certificate of need process (CON), (2) quantitative research to predict the use of the service as part of the CON approval, and (3) multiple medical missions involving cardiac, critical medical patients and neonates as well as trauma patients.  Several studies were undertaken to determine which patients would benefit from helicopter transport.  With the introduction of centers developing expertise in specific areas as the treatment of cardiac, high risk OB/neonatal, and trauma, rapid transport of critically ill to these centers became essential for optimal care.  Thus the growth of inter-hospital transports occurred with the development of second generation programs.

Third generation programs developed as hospital and medical costs were rising.  Prospective payment reimbursements caused change in the perception that the operational costs would be offset by patient revenues generated from hospital fees.  In addition, the increasing burden of uncompensated care provided by many trauma centers has caused many of them to close their doors.   Inconsistent and state by state variation in third party reimbursement became an important issue.  In addition,  to a substantial focus on cost effectiveness of helicopter services, the most recent generation of programs is characterized by (1) the increasing use of twin engine aircraft, (2) safety strategies, in response to an alarming accident rate, including FAA regulations as well as recommendations from the EMS helicopter industry, (3) involvement of the state regulatory agencies and external oversight committees, (4) the forming of multiple hospital consortiums as sponsoring institutions, (5) quality assurance and auditing, and (6) debate over the optimal medical crew configuration (i.e.. is a physician necessary on board??)

The future of helicopter emergency medical systems continues to evolve.  The rate of new program initiation has declined with the total number of programs leveling at approximately 200. Some existing programs continue to expand however with the use of additional helicopters and/or fixed wing aircraft.

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