Air ambulance services offer many advantages in rural and remote regions when compared to conventional ground ambulance services, such as: the increased speed at which the patient can be transported; access to regions which are inaccessible via conventional vehicles; and highly trained medical staff, sometimes including specialist doctors. Countries such as Australia, Canada, America and Norway consequently rely heavily on air transport in their rural and remote regions.

A Discussion Regarding the Use of Air Ambulance Services in Rural and Remote Regions

Australia was one of the first known countries to implement what is now known as an air ambulance program, mainly owing to the wide distances which exist between sparsely situated settlements, and the consequent inaccessibility of medical facilities. The earliest air ambulance program in Australia involved transporting doctors to patients in cases of emergency, this later changed to the well known contemporary patient transport system.

Currently air ambulance services in Australian rural areas are primarily utilized for patient transfers. Many rural and remote areas throughout Australia include medical facilities of some shape or form however; these installations are often not equipped to deal with emergency situations. This therefore often requires the timely transfer of patients to larger medical institutions, which may be thousands of kilometers away.

Air ambulance services in rural regions of Canada have also been utilized for some time due to the unforgiving terrain, wild weather and long transfer distances. It is a well known fact that over 75 percent of the Canadian populations reside in rural areas, and like Australia, the small medical installations located in Canada’s rural areas are unable to deal with severe emergencies such as trauma cases. Many of the smaller primary care facilities employ only nurses, which must quickly transfer emergency cases via air ambulance to larger urban centers.

Areas such as Alaska in the United States and the Arctic regions in Norway, in comparison to Australia and Canada, are comprised of small islands which makes transportation via ship or air ambulance the only option for many communities. These regions face numerous issues with their air ambulance transport however, the primary of which is the weather. Air ambulance pilots in these areas are however, highly trained, meaning that transport via air ambulance services is usually available. This is highly preferable to transfer via ship, owing mainly to the speed at which these air ambulances can travel.

In conclusion, air ambulances can be seen to be a vital component of medical care in many small rural and remote communities. Without this form of transport, severely injured people in these areas would have little chance of receiving the medical care that they need, consequently resulting in numerous unnecessary fatalities, and a drop in the general standard of rural healthcare.

According to Safaei (2011) the main obstructions inhibiting rural populations from accessing medical care are: the lack of medical institutions in the direct vicinity; the shortage, and/or sporadic distribution of qualified medical personnel; and the difficulty involved with securing any kind of reliable ongoing non-emergency medical transport.

The findings reported by Safaei (2011) are however, not new to governments, the medical community, or the general public in most countries, with first world nations such as Australia and America already attempting to solve the majority of the above mentioned issues via the implementation of various non emergency medical transportation services.

Issues Regarding the Provision of Rural Non Emergency Transportation Services

The implementation of non emergency transportation services in many first world rural and regional areas has met with a number of different obstacles, the most significant of which, is the cost of providing, and generally maintaining, such a service.

In many rural areas throughout Australia for example, the distances which have to be traveled in order to reach required medical care are enormous. This means that medically related trips become unaffordable for patients, as well as for governmental institutions that attempt to aid with covering the costs. As a consequence numerous small towns around Australia have little or no access to non-emergency medical transport, relying instead, upon emergency vehicles in non-emergency situations. This can leave the region with a dangerous shortage of emergency medical transportation in the event of an emergency.

Medicaid and Non Emergency Transportation Services

In America the issues faced by rural areas are much the same; however, the healthcare program Medicaid currently operates a state funded non-emergency medical transport scheme. This program is aimed at increasing rural dwellers access to medical care via the utilization of public and private non emergency transportation services. This scheme is unique, in that medical transportation brokers are employed by Medicaid to locate and organize the cheapest possible right-sized form of transport for patients. This may include options such as public transport or rideshares.

Even though America has a more established program in place than Australia, the United States is still facing a major healthcare crisis in rural areas, with over 50 percent of the rural population in America having little or no access to any form of non-emergency transportation. This is due to a number of different reasons, including the fact that a large number of Americans do not qualify for Medicaid membership, and consequently may not participate in the scheme.

In conclusion, it is obvious that the provision of non-emergency medical transportation services is currently a pressing issue in many first world countries, with no real comprehensive solution in sight. It seems that the American model of non-emergency transport which involves privatization of the industry, coupled with government backing for low income earners may however be a step in the right direction.

Rising costs have therefore resulted in the gradual alteration of numerous hospital based air ambulance services within the United States, via the implementation of aircraft lease agreements with private aviation companies. This has in turn, allowed for the current 250 million dollar private air ambulance business, which is believed to be responsible for the annual emergency helicopter transport of over 100,000 critical patients.

Many experts are however, beginning to question the validity of such high ‘emergency’ helicopter utilization, with modern medical researchers loudly criticizing the ‘overuse’ of these aircraft in urban situations.

Issue Regarding the High Utilization of Helicopter Air Ambulance Services

The majority of contemporary literature exploring the concept of helicopters as air ambulances, reiterate that helicopters were originally intended to be used primarily for the emergency evacuation of patients located in regions inaccessible by conventional ambulances. Currently however, helicopters are employed in urban ‘time dependent emergencies’, and are believed to result in better health outcomes, due to the timely provision of medical care.

Numerous contemporary studies are however, calling these assumptions into question, with research such as that undertaken by Chappell et al. (2002) finding that over distances of less than 66km, depending on road conditions, traditional ambulances are actually faster. Other studies such as Arfken et al (1998) have additionally shown no significant difference in the medical outcome of patients, coupled with a higher incidence of adverse events in patients transported via helicopter.

These counterintuitive findings in addition to the fact that transfer of a patient via helicopter costs magnitudes more than transfer via traditional ground ambulances, seems to show that the air ambulance industry is not well enough controlled or regulated. Another trend which seems to confirm this hypothesis is the high contemporary incidence of crashes involving medical transport helicopters.

Researchers such as Bledsoe et al (2004) have found a marked increase in medical helicopter accidents over the last 10 years, with a fatality rate of 0.86 people per accident reported between 2000 and 2003. According to Sandal et al. (2010), the fatality rate of traditional ambulances during the period 2007 to 2009 was only 0.21 people per accident, although there were a significantly higher number of annual incidents involving ground vehicles. These time periods may not be directly comparable however; these figures still provide food for thought when one is arguing against the constant utilization of medi-vac helicopters in urban regions.

In conclusion, it may be noted that helicopters are contemporarily being utilized as a form of medical transportation in situations which may not require such extreme action. It is believed that this is not a sustainable course of action, unless it can be proved that helicopters can provide patients with better health outcomes.

One of the things that many critics have overlooked, however, is the amount of pressure that ambulance programs in many regions are operating under. Emergency vehicles in most communities are expected to carry out a number of different roles, including acting as: first responder vehicles; non-emergency patient transfer vehicles; and general non-emergency transportation measures. This is especially problematic in many rural and remote areas owing to the overall shortage of general transportation options.

The Role of Non-Emergency Transportation Services in Assisting Emergency Services

It is obvious that ambulance services in most of these regions are unable to satisfactorily fulfill their various enforced rolls. This has caused a marked drop in the standard of care, with some areas throughout the United States in particular, referring to the current state of the healthcare system as a ‘healthcare crisis’. In order to change the current condition of these services, governmental organizations have begun looking into non-emergency medical transportation.

The idea behind the introduction or furtherance of non-emergency transportation services is that providing alternative means of transportation frees-up emergency ambulance service resources, as well as allowing patients better access to primary medical care. The issue in many countries however, is the extent to which these non- emergency transportation programs are implemented.

In the United States a comprehensive non-emergency transportation services program is said to be in operation. This service involves state and private transportation companies, transportation brokers and the government subsidization of non-emergency medical transport. The program is however, operated by Medicaid, and as such, is only available to Medicaid members, which include low income individuals or families, and individuals with certain disabilities.

This is problematic, as the program excludes a significant majority of the over 65 population, who are generally Medicare, not Medicaid members. Medicare members are only entitled to non-emergency care in particular cases, and if they choose to utilize non-emergency transport and Medicare deems it unnecessary, the patient is required to pay the full transport costs. Many elderly people consequently don’t utilize any form of medical transportation until the situation becomes critical and requires emergency transportation.

The fact that the elderly population in countries such as America account for at least a third of emergency transportation cases, makes this situation even direr, as those that utilize the majority of the resources are not being correctly included in the non-emergency programs.

It is therefore proposed that although non-emergency transportation systems are being implemented in many regions, and are somewhat successful in reducing ambulance misuse, certain aspects of many of these programs need to be altered. In order to reduce the pressure currently placed on emergency services, programs need to be geared toward those that demand the majority of emergency resources, which in most areas are geriatrics.

A survey undertaken in Canada in 2003 found that over 4.1 percent of emergency workers had reported being involved in a collision whilst on board an ambulance, with 12000 accidents estimated to occur annually. This figure is believed to be similar in the United States, with 300 fatal crashes recorded between 1991 and 2000, which involved the deaths of 82 ambulance occupants and 275 others, such as pedestrians and motorists.

These figures have been deemed by medical experts and the media alike to be unacceptable, and as such, there is now a plethora of literature discussing various means of reducing collisions involving medical vehicles. Some of the preventative methods which have been approached are: minimizing the utilization of lights and sirens; regulating the speed at which ambulance drivers are allowed to travel; and reviewing the design of ambulances in rural areas.

Measures to Reduce the Occurrence of Accidents Involving Ambulance Services

The proposed move toward minimizing light and siren utilization by ambulance services has come about due to the fact that experts believe that drivers displaying lights and sirens generally drive faster, which inherently increases the chance of having an accident in urbanized areas. It is also put forward that, as the majority of collisions involving ambulances occur at intersections, where lights and sirens are generally unable to give motorists fair warning regarding the speed and trajectory of an ambulance, they are ineffective in preventing accidents.

The regulation of ambulance services speed is another factor which is generally discussed, both in relation to, and separate from light and siren use. Many experts propose that speeding doesn’t save enough time during transport to warrant the risk posed to both the emergency personnel and patients aboard. A study undertaken by Petzäll et al. (2011) found that speeding saved a mean time of 2.9 minutes during urban medical transportation and 8.9 minutes in rural areas. It was consequently argued, that in many cases saving this amount of time would most likely not effect health outcomes, and was therefore not worth the risk.

Speeding in rural areas has also been found to be an issue owing to the current design of emergency vehicles. Modern ambulances are large and do not have good road handling capabilities, which when coupled with poor road conditions in many rural areas can result in accidents. A recent study undertaken by Weiss et al. (2011) found that the severity of accidents in rural areas was significantly greater than those in urban areas, generally owing to the high speeds at which the vehicles were traveling, when the accident occurred.

It can consequently be proposed that speed in conjunction with other factors such as the ineffectiveness of lights and sirens in certain situations, and the bulky construction of many ambulance vehicles, are major factors influencing the number of accidents involving ambulance services. It is therefore proposed that more research is required in order to effect change within this industry.

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Traditionally, medical transportation management services in many regions throughout the United States have been provided by the state, however, since the 1990’s this has altered significantly, owing to the increasing prevalence of private medical transportation companies. It was reported in 1997 that 40 percent of American cities were employing private ambulance services, as of 2005 however; this figure is believed to be closer to 50 percent (David & Chiang, 2009).

Utilization of Private Medical Transportation Management Services

The utilization of private medical transportation management services opposed to state run operations, may seem disadvantageous, owing to the fact that private systems are generally considered to be more expensive than public undertakings. As many private companies are quite large and, unlike public installations, run operations spanning over numerous different locations, they can however, be the cheaper option for a city. This is generally owing to the fact that these companies are already established, and as such entail basically no capital, research or administration costs.

In many regions throughout the United States private companies are consequently engaged in the provision of emergency and non-emergency transportation. In the majority of areas private firms provide non-emergency transportation, whilst the state provides emergency services. The presence of private transportation companies in these areas allows for the ‘freeing up’ of often over-utilized emergency service vehicles, consequently permitting more efficient emergency transportation operations.

It has been argued however, that private firms can actually provide better first responder care than state run operations, due to the technology which they possess, and the general scale of their operations. David & Chiang (2009) found that that in a lightly populated city, in close proximity to other cities, private firms are able to provide significantly better first responder care than state run systems. Private firms are also being employed as first responders when it comes to expensive air medical transportation programs.

Many state operated institutions such as hospitals currently choose to employ private air ambulance companies instead of, or in conjunction with state run services. This is mainly owing to the fact that hospitals cannot afford to run their own air medical transportation programs, with annual costs of such undertakings running in excess of 250 million dollars. Aircraft are therefore leased from private companies at a fraction of the cost. There have recently however, been problems with such arrangements in areas such as New Jersey, due to competition between existing state operations, and new private enterprises.

It is consequently obvious that there is an ever increasing movement within the United States toward the utilization of private medical transportation companies. The effect that this trend will have on the quality of medical care is however, highly unknown. It is believed that if this move is to continue, more regulation is needed, especially with regards to the budding private air ambulance industry.

In many nations such as the United States, state provided emergency transportation services have therefore been stretched to breaking point, owing to the absence of other sensible non- emergency transportation options. In most regions throughout America a certain level of state run non-emergent transport exists in an attempt to relieve emergency services however, in many areas it too, is unable to deal with growing demand. This has consequently resulted in the birth of the private non-emergent ambulance services industry.

Private Non-Emergent Ambulance Services

A quick internet search allows one to browse through numerous private non-emergency medical transportation providers, some of which even offer franchise opportunities to interested parties. The majority of these companies offer the use of specialized modified vehicles, some of which include: fully equipped ambulances; vans modified to permit for wheelchair access; and normal vehicles including a driver.

Non-emergent medical transport companies offering transport must therefore assess patients in order to choose and right-size the form of transportation provided. This may often result in more that one patient per vehicle. Right-sizing also influences the staff members, who are chosen to escort the patients, based upon their experience and medical knowledge.

The fact that the right-sizing process is so subjective however, and that almost any interested party can purchase such a non-emergent transportation business, has caused a large amount of controversy regarding this industry.

Safety Issues Regarding Private Non-Emergent Ambulance Services

One of the main criticisms regarding the non-emergent medical transportation industry is patient safety, especially in light of the lack of regulation this newly established sector has received. Authors such as Hains et al. (2010) have argued that although patient utilizing non-emergent transportation may not be ‘emergencies’, many of them are still seriously, and in many cases chronically ill.

Hains et al. (2010) consequently defined three factors which need to be considered and improved upon in order to assure the quality and safety of private non-emergent transportation, which include: appropriateness of transport; efficiency of transport; and communication.

The appropriateness of the transportation method chosen is critical due to the fact that patients traveling via non-emergent means may be, as previously stated, seriously ill, which means that a high level of care is required. Patients may also have specific transportation needs due to their age, or limited mobility.

Efficiency and communication are also important when it comes to non-emergency medical transportation as chronic patients, such as patients with renal issues, or cancers generally require continual, punctual, and consistent treatment, which can’t be acquired if companies aren’t dependable, efficient and able to be easily contacted.

In conclusion, it can be noted that private non-emergent ambulance services companies are here to stay, as the contemporary public system is unable to deal with the growing demand for all forms of medical transport. It is however, believed that stricter guidelines and regulation are needed to ensure the safety of this burgeoning sector.

A number of studies including research involving 5782 trauma patients in Los Angeles in 2000 have added fuel to the fire by reporting that patients transported to hospital via non-emergency vehicles (civilian transportation) actually displayed better health outcomes and lower mortality rates than those transported by emergency vehicles (Cornwell et al., 2000). The main reason put forward for this finding, was the fact that civilian transport often results in the patient arriving at medical facilities in a timelier manner.

A Brief Review of Studies Regarding the Benefits of Transportation via Ambulance Services

After sifting through available literature disputing health outcome differences between patients transported in emergency and non-emergency vehicles, it would seem as of there is no point in utilizing ambulance services. This is of course, not the case, with ambulances offering numerous advantages when compared to civilian transport methods.

One of the main advantages involved with ambulance services transport of the sick and injured is the fact that ambulance personnel in many countries are highly trained medical professionals. In nations such as Germany, emergency doctors are actually sent out in to accompany ambulances responding to serious emergencies. This allows for the commencement of onsite treatment, which in the case of conditions including serious spinal cord injuries has been proven to reduce preventable complications and significantly improve patients’ medical outcomes (Middleton et al., 2012).

The fact that patient transportation via civilian vehicles results in better health outcomes, owing to the fact that it often causes the patient to reach medical institutions in a timelier fashion is also debatable. Numerous recent studies, such as that undertaken by Pons et al. (2002), argue that response time does not significantly affect health outcomes in trauma cases. It may therefore be inferred that differing health outcomes resulting from transport are not always dependant on time to destination.

Some possible reasons for differing health outcomes arising from transportation methods are proposed to be: that trauma patients arriving at hospitals via civilian transport are perhaps not as severely injured as those transported by ambulance, hence the lower mortality rate; and, that some patient may be stressed by ambulance transport, with numerous patients displaying hypotension as natural stress response to transportation (Waddell et al., 1975). Hypertension is however, a well known and manageable issue regarding ambulance transportation.

In conclusion it can be noted that more research is required into medical transportation methods, with regards to patient outcomes. It is proposed however, that the majority of seriously ill or injured patients benefit from ambulance transportation.

There are many reasons put forward to explain why people have begun to misuse emergency transportation however, the most commonly recognized issue is the fact that some Americans have no other option. Due to these transportation difficulties medical transport management services have become increasingly important, especially in rural and remote areas. Medical management services are however, a little more complex than simply providing the patient with a means of transportation.

The Role of Software Regarding Medical Transportation Management Services

The role of medical transportation management services usually entails:

• Manning call centers
• Scheduling appropriate transportation
• Verifying clients’ details
• Arranging for drivers, nurses or doctors as required
• Arranging for billing and payment as required

These various tasks are generally not problematic regarding small firms however; some medical transportation firms in the United States now exist in thousands of locations and employ tens of thousands of people. Many companies have consequently turned to, and in some cases designed their own, medical transport management software.

There are many different software packages offered, most of which carry out similar functions such as:

• Planning and analysis of proposed trips
• Scheduling trips
• Controlling internal operations

Regarding planning and analysis, these software packages generally allow for the in depth examination of the intended trip including everything from regional information to complex GIS mapping data. This can help firms to cut cost by specifically choosing the best route for that particular period.

Scheduling is also simplified and made more cost effective; with medical transportation management services are able to access real-time broker information such as: driver utilization, available vehicles and possible ride shares. This in turn means that they can combine geographical data regarding the patient with available transport options and fit them quickly with the best alternative. Quick real-time changes in schedules can also be made as different options become available.

Finally, the operation of a firm can be closely monitored via such software with aspects such as employee utilization being extremely easy to control. This is due to the fact that a patients’ medical care needs during transportation can be quickly matched with an appropriately experienced, free staff member.

In conclusion, it is obvious that non-emergency transportation is a growing industry, especially within the United States. It is also an industry which requires precise and careful organization, due to the fact that patients may not be urgent, but many of them are still very ill. It is consequently proposed that software packages to aid with organization can only be beneficial.