Interview Tina Giangrasso
Tina Giangrasso, Senior Vice-President of Clinical Services at Air Methods, spoke to AirMed&Rescue about advances in medical care in the air, medevac safety, and her most memorable patient mission
For how long have you worked with Air Methods, and what has changed in the company since you first started working there?
I started as a flight nurse with a hospital-based programme in 1990 and flew on hundreds of missions until 2004. I was then promoted to positions overseeing patient care quality, process improvement and patient safety. The biggest change in my nearly three decades in the industry is how much we’ve grown across the country. We now serve 48 states from more than 300 bases and flew more than 70,000 missions with more than 400 aircraft in 2017. It’s very fulfilling for me that we’re now able to deliver life-saving care to so many people who don’t live near Level I trauma hospitals or facilities with advanced, highly-specialised services.
Another recent change that I am very pleased with as a clinician is the number of commercial health plans that are adding Air Methods as an in-network benefit. In August 2018, Anthem, one of the largest health insurers in the country, added Air Methods as an in-network benefit in Indiana, Kentucky, Missouri, Ohio and Wisconsin. Just in November, BlueCross BlueShield of Tennessee added Air Methods to their network. We’re working on several more major agreements right now. Here again, it’s gratifying that these partnerships are helping the patients we care for to focus on their recovery instead of billing concerns.
In your newest role with Air Methods Corporation, what are your primary responsibilities?
As the Senior Vice-President of Clinical Services, I lead and direct all clinical functions for Air Methods. I work with various teams on quality of care standards and strategic initiatives and ensure proper monitoring, training and quality improvement processes are in place to reduce the incidence of adverse events and enhance patient safety. That also includes developing unified practice guidelines, operational policies, training, education, and quality management processes that are consistent with our mission and in accordance with the Commission on Accreditation of Medical Transport Systems (CAMTS) standards.
Air Methods has worked with United Rotorcraft for over 30 years on the installation of airframe accessories for the fleet of air medical aircraft – both rotary and fixed wing – do Air Methods clinicians work closely with United Rotorcraft developers to improve medical interiors?
Absolutely. I and the other clinical leaders, such as our director of education, work closely with Mike Slattery at United Rotorcraft on everything from entire aircraft interior redesigns to single modifications to ensure our crews can continue to deliver the highest quality and safest care possible. Mike has always been proactive in reaching out to us when his teams are considering any modifications, even something as small as an adjustment to a stretcher position or moving a monitoring device. It’s a very collaborative relationship that has always been productive and resulted in helping our crews deliver care more effectively or efficiently, or both, while protecting the patient’s health and safety.
Air Methods recently started carrying blood and plasma for in-flight use. What was the motivation behind this move?
We’re continually exploring opportunities to support our mission of delivering life-saving care. Carrying blood and plasma had been on our priority list for many years because it is often needed for our patients with traumatic injuries. In the rural areas we serve, however, it wasn’t always a feasible option to carry blood or plasma given that those resources are often limited, and understandably so considering the smaller populations and fewer blood banks. Thankfully, we recently partnered with the American Red Cross to supply the remainder of our aircraft with blood and plasma, so soon all our aircraft will have this capability.
Air Methods clinicians have a first-attempt tracheal intubation rate for airway management of 90 per cent or higher, which rivals the success rate of emergency department physicians. How has the company achieved this impressive rate?
Evidence-based practice. It started when our Clinical Education Manager Dave Olvera realised that human error increases when people are fatigued or stressed and wanted to put some safeguards in place to protect our patients. Working with Dr Dan Davis, our Medical Director and Scientific Advisor, Dave searched our internal procedure database to conduct university-style research and designed a rapid sequence intubation (RSI) prediction checklist tool to help our teams avoid overlooking a step when they’re hurrying to save lives. Dave’s research and prediction tool for RSI was approved by our Institutional Review Board, and a study, co-authored with Dr Davis, was published in Air Medical Journal. Dave’s work has also received international attention from the medical community and this checklist has been adopted by large physician groups, branches of the US military and will be published in a pre-hospital care textbook to train other clinicians. It’s been a tremendously rewarding experience for all of the clinicians here to not only be a part of implementing a new evidence-based best practice, but to also create new practice guidelines that are helping save more lives.
What are the training methods you find to be most effective for flight clinicians?
Practice and continued hands-on training methods are most effective because, as I’ve found, experience is the most meaningful and lasting form of education. That’s why all our aircraft are staffed with an RN and paramedic-level trained clinicians who have practised at least three years in an emergency care or intensive care setting. That’s also why we devote more time and resources to training than any other air medical provider. For example, when clinicians are hired, they spend 10 days in our training headquarters in Denver, which includes performing emergency-care scenarios on human patient simulators as well as cadavers. We also video-record the clinicians delivering care during these simulations and review them with the clinicians afterwards, which is a tactic shown in clinical studies to be a much more effective form of instruction.
Once they complete their training in Denver, the clinician then serves as a third member on missions until they have experienced sufficient patient encounters to function independently, which may take seven to eight weeks. The training, however, doesn’t stop after the clinician has completed orientation. They must also obtain 100 hours of continuing education every year to include following the CAMTS standards. In addition, we review every mission to, in part, identify training or education opportunities. Approximately 30 cases each month receive an in-depth quality review by our clinical quality, education, compliance and risk teams to ensure patient safety and best practices for continued success.
Air Methods’ high volume of missions and rigorous continuing education requirements usually means that our clinicians do not need to work in hospitals or ground ambulances to gain new experience or maintain their skills, but they are welcome to pursue that training modality if they wish and have the time.
Do you think it’s important that flight clinicians continue to work occasionally in a hospital setting to ensure a variety of skills and currency with other medical practices?
Again, it comes back to experience. If the clinician is not being exposed to emergency medical situations, either through patient encounters or hands-on training at their current place of employment, working at a hospital or ground ambulance can offer additional exposure to maintain their competencies. Air Methods’ high volume of missions and rigorous continuing education requirements usually means that our clinicians do not need to work in hospitals or ground ambulances to gain new experience or maintain their skills, but they are welcome to pursue that training modality if they wish and have the time.
What’s the most memorable mission you’ve ever taken part in, and why did this stand out?
When you’ve flown on hundreds of missions it’s hard to choose just one. But a mission that most stands out in my memory was not a chaotic, traumatic accident, but rather one where we helped an eight-hour-old newborn boy who needed specialised care so he could breathe on his own. The baby was born in a large academic hospital in Connecticut, but at the time in the early 1990s it lacked the extracorporeal membrane oxygenation (ECMO) equipment to adequately oxygenate, ventilate and perfuse his lungs and the closest facility with ECM0 capabilities at the time was Boston Children’s Hospital. I remember his blood-oxygen levels were very low and our team did everything we could on that mission to keep him stable before he was connected to ECMO. Thankfully, the treatment was successful. He suffered no neurological sequelae and is now a healthy adult. For many years, I received a Christmas card from his family updating me on his progress.