The medical considerations of caring for multiple patients are complex and extensive. From interior cabin design to physical space, equipment and staff, all factors must be considered. But above all else, the delivery of superior medical care has to be facilitated, with patient comfort and safety ensured. There are benefits to multiple patient transfers, including the enhanced speed of care, but there are also challenges, such as logistical obstacles. But with the right aircraft and medical crew, flying with more than one patient can be perfectly orchestrated.

Reflecting on key criteria an air ambulance company must determine before flying with more than one patient, Paul Tiba, Managing Director, Airlec Ambulance, highlighted that there cannot be any risk of cross-infection – and the patient’s condition always needs to be evaluated beforehand: “We would not transport patients with different infectious diseases, for example,” he told AirMed&Rescue. “A thorough evaluation of each patient’s condition takes place before accepting the mission, so we can rule out any ‘surprises’ during the flight.” Another factor is space available onboard to accommodate sufficient crew. “It is necessary to have enough medical staff to ensure that superior care can be given to each patient. So, we sometimes work with up to five staff on our bigger aircraft,” Tiba said.

There cannot be any risk of cross-infection – and the patient’s condition always needs to be evaluated beforehand

Dr Joseph Choi, Medical Director of Redstar Aviation, said the clinical severity of each patient dictates whether co-transport is possible, while ensuring there is sufficient physical space for comfort and suitable care. “The presence of a high-acuity patient may not allow the medical crew to delegate their time and attention to more than one patient simultaneously. Patients whose clinical conditions allow for co-transport would need to have the right physical dimensions and body weight, depending on the aircraft and stretcher systems onboard,” he stated. “There must be sufficient physical space in the cabin for the patients to be comfortable in their stretchers. There also needs to be room for medical equipment to serve the monitoring and therapeutic needs of all patients onboard, not to mention enough room for medical crew to care for all individuals without hindrance.”

In terms of medical equipment for multiple patient missions, Tiba said that dedicated gear is used for each stretcher, with backup resources also carried onboard. “This allows Airlec to handle all situations safely and with the patient’s wellbeing in mind. As we can operate long-range jets with extensive cabin space, this allows for medical staff to work in a suitable environment, with sufficient space for treatment and monitoring,” he stated. The equipment required depends on the clinical severity of the patients being co-transported. “Oxygen, medical devices, medications and consumables should be present to serve the needs of multiple patients, including backups for each item. Crew composition is usually extended to a third, or even fourth member, to simultaneously provide care.”

SAR aircraft serve a different operational purpose to air ambulances, confirmed by the Maritime and Coastguard Agency (MCA): “SAR aircraft are designed and equipped to enable the rescue of multiple casualties, which fulfils our core responsibilities for rescue missions. These SAR aircraft are required to be able to carry two stretchered casualties, which means on occasion more than one patient will be moved at one time. For this reason, there are infection control and safety measures in place, to prevent putting patients or crew members at risk. All SAR aircraft carry winch paramedics, who will determine the appropriateness for the carriage of any patient on behalf of the ambulance service.”

Examining the involvement of air medical providers in cabin design, Dr Choi said they provide feedback to aeromedical systems manufacturers to help with improvements. “Some providers have developed the capabilities in-house to custom design cabin solutions to serve individual needs, specific to their aircraft type. Naturally, effective and efficient usage of the cabin space is one of the major considerations. Multiple stretcher air ambulance cabins are quite prevalent in the industry today,” he said.

We want to make sure we can make the most out of each transport – whether that is for the patient, client or the environment

Tiba confirmed that this is something Airlec is heavily involved with: “All aircraft are suited to transport at least two patients and – depending on the size – can move up to five people. We at Airlec want to make sure we can make the most out of each transport – whether that is for the patient, client or the environment,” he said. “In our Merlin and Citation aircraft, we are able to transport one ICU patient and one stable patient at the same time. In our Hawkers, either three fully stable patients – with two medics onboard – or two ICU patients with three medics onboard. Our largest aircraft – Falcon 900EX – can even transport up to four ICU patients with five medics.”

The MCA provided insight on requirements for SAR aircraft: “Our contracted service requirements state that SAR aircraft must be able to take two stretchered casualties onboard, and/or multiple rescued persons. Aircraft have been designed in a way to ensure this service can be delivered. Different to an air ambulance, SAR aircraft are bigger and equipped to provide a different role. Cabin design, capacity and crew skills are all tailored with a SAR focus, different from the medical provision priority of an air ambulance.”

Aircraft interior manufacturers offer another key perspective. Thomas Redder, VP International Sales, Spectrum Aeromed said: “We see a trend towards larger cabins for air ambulance usage,” he said. “This is quite often also linked to aircraft with a greater range. The two major advantages are better ergonomics for the medical crew and higher service quality for the patient. In order to offset the extra cost for operating those aircraft, a dual-patient configuration seems to make a lot of sense. We hear quite often, though, that the majority of flights will still be with a single patient, but at least operators have this option.”

Once an aircraft type is selected, Spectrum Aeromed analyze the available space, with the result of the final cabin design typically a balance between different factors. “Some of them are hard facts that need to be complied with (e.g. availability of emergency egress routes, compliance with European Norms that talk about space between and above patients, requirements to meet industry standards, amount of seats required for the medical crew),” Redder said. “This gives the basic design framework, then we typically have in-depth discussions with the medical crews to integrate their very specific needs. This is an iterative process that balances the operational requirements, certification requirements and cost.”

Looking at the benefits of multiple-patient flights, there are cost savings. But as the MCA highlights, there is one overriding factor: “We never put a cost on the price of saving a human life. We are called to various incidents and life-saving emergencies, and the priority to rescue overcomes any cost-saving schemes that could be implemented. We respond to incidents with the appropriate resources, equipment and skillsets.”

Tiba confirmed there are significant benefits – both financial and environmental – to transporting multiple patients on a flight: “Depending on the pick-up point and destination, cost savings can be as much as 50 per cent per flight. This is, of course, given that all patients are suitable to be transported. While sometimes logistically more challenging than a single-patient flight, we at Airlec strongly support combining patients on a mission. As we have done on many combined flights, we now not only have extensive experience, but can serve our clients as a platform for these kinds of flights. For example, by suggesting potential combinations with other patients. This has worked out well. In addition to the financial benefits, it also generates a favorable outcome in regards to the CO2 emissions, as we can greatly reduce the carbon footprint.”

Considering the implications for payers in terms of sharing costs with another insurer, Tiba said this can be summed up in two words: ‘informed consent’. “The basis of combining patients is that both client and patients are aware of the same and agree to it. It is of utmost importance that a thorough medical evaluation takes place beforehand in order to ensure that patients are stable enough to be combined and that sufficient medical staff and equipment is onboard. For ICU patients, it is a requirement at Airlec that we fly with additional medics to ensure that each patient can be cared for in the most suitable way. As always, our team at the operations centre is in constant communication with the clients, so we can inform them very early on in the planning about opportunities to combine patients – and the logistics and medical criteria that come along with that.”

Larger aircraft do provide more space, allowing more possibilities for multiple patient transportations

Dr Choi believes there are further opportunities to work together: “Larger aircraft do provide more space, allowing more possibilities for multiple patient transportations. However, for many air medical providers, it is the range advantage that is behind the drive in investing in larger aircraft. The general rule is: the larger an aircraft, the greater the cost-per-flight-hour to the payer as a result of maintaining and operating that aircraft. While co-transport of multiple patients that are policyholders from the same insurance company is common, it is not so common to see patients from different insurance companies flown together. It’s certainly an area that could be developed, as it will have considerable cost benefits to the insurers – with obvious positive environmental effects as well.”

It appears cost savings are a silver lining to the economical and environmental benefits associated with flying with more than one patient – and for air ambulance operators, SAR operators and manufacturers alike, the primary goal is saving lives. Given that multiple-patient transfer has the potential to do just that, it’s an opportunity that should be seized wherever possible.