Research Opportunities

Where are the greatest opportunities for research?

Research papers often end with ideas for future studies. We collected those ideas from published air medical research and grouped them by topic. The result is a set of research questions, each linked to the papers that support it. Questions sent in by the air medical community are posted here too, after review. Use the filters below to explore, and open any question to see where it came from.

Past research agendas in air medical transport came from expert panels. This page is built from the published research itself. To our knowledge, it is the first online, interactive resource of its kind.

40questions from the literature

15topics

63papers with stated directions

177research directions recorded

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Where the literature points

Each bar counts the papers that state a research direction on that topic. Select a topic to filter the questions below.

40 questions

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Accidents and accident data
24 papers state a direction on this topic. 4 proposed questions.
The most repeated need is a denominator. Without flight hours, mission counts, and conditions for all flights, studies can describe accidents but cannot calculate rates or compare aircraft, operators, or flight phases. Papers also ask whether the safety measures adopted over the past two decades explain the decline in fatal accidents, and they call for sources beyond accident investigations, such as near-miss and aborted-flight records.
7papers
From the literatureAccidents and accident dataOperational safety
What are air medical accident and fatal accident rates per 100,000 flight hours, by aircraft category and phase of flight, when complete exposure data are available?
Published 2009 to 2024
What the 7 papers ask for on this topic
1. Analysis of Helicopter Air Ambulance Accidents in the United States From 2010 to 2021
  Sanchez 2024, Air Medical Journal In the Evidence Library
  Calls for Study in depth the root causes and contributing factors behind the higher share of accidents among pilots with less HAA experience, including HAA flight hours and certificate type. Discussion, p. 7; Conclusions, p. 8
  Calls for Determine whether regulatory, training, and technology changes actually caused the drop in the share of fatal HAA accidents, since other explanations remain possible. Discussion, p. 7
  Calls for Develop methods to estimate the total number of HAA flights, patients carried, or flight hours so accident rates can be calculated against operations rather than against total accidents. Discussion, p. 7; Conclusions, p. 8
  “Further indepth research is needed to understand the root cause and contributing factors”
  In the authors’ words, p. 7
2. Fatal Air Medical Accidents in the United States (2000-2020)
  Shekhar 2023, Prehospital and Disaster Medicine In the Evidence Library
  Calls for Calculate true accident rates for the whole industry and for aircraft categories and models, which first requires better reporting of annual hours flown by air ambulances. Limitations, p. 4
  Calls for Continue to examine the causes and circumstances of air medical accidents, supported by exposure data on total hours flown. Conclusions, p. 5
  “further studies should continue to interrogate causes and circumstances surrounding air medical accidents”
  In the authors’ words, p. 5
3. A Bayesian Approach on Investigating Helicopter Emergency Medical Fatal Accidents
  Simonson 2021, Aerospace Medicine and Human Performance In the Evidence Library
  Calls for Build a research framework for data-driven analysis of HEMS accident risk and of the added risk that air transport places on patients. Discussion, p. 6
  Calls for Study how much additional risk HEMS flights carry for patients, passengers, and medical providers compared with the benefit of transport. Discussion, p. 6
  Calls for Collect exposure data on all HEMS flights, including yearly flight totals and environmental conditions, and compare accident flights with nonaccident flights to learn whether accident conditions are distinctive. Discussion (limitations), p. 6
  “Future research should explore the increased risk HEMS flights”
  In the authors’ words, p. 6
4. Statistical learning for turboshaft helicopter accidents using logistic regression
  Subagia 2020, PLOS ONE In the Evidence Library
  Calls for Extend the analysis from accidents to incidents, the lower-damage events excluded here, as a source of further safety learning. Data and methods, p. 3
  Calls for Examine helicopters with reciprocating engines in later work, since sparse data prevented modeling them alongside turboshaft aircraft. Data and methods, p. 4
  Calls for Collect exposure data such as flight hours and mission type, stratified by helicopter configuration, so accident rates can be calculated and confounding by usage addressed. Limitations, p. 18
5. Helicopter Type and Accident Severity in Helicopter Emergency Medical Services Missions
  Hinkelbein 2011, Aviation, Space, and Environmental Medicine In the Evidence Library
  Calls for Gather denominator data, such as flight hours or missions by helicopter model, so that accident and injury risk can be compared across aircraft types. Discussion, p. 5
  Calls for Record HEMS accidents in a dedicated detailed database that captures confounders such as weather, pilot factors, urban or rural setting, and maintenance data, to support valid future analyses. Discussion and Conclusion, p. 5
  “More data on potential confounding factors is required for detailed HEMS accident analysis”
  In the authors’ words, p. 5
6. Aviation Safety: Potential Strategies to Address Air Ambulance Safety Concerns
  Dillingham 2009, U.S. Government Accountability Office In the Evidence Library
  Calls for Obtain complete and reliable flight activity data, including flight hours, from all air ambulance operators so an accurate accident rate can be calculated and safety efforts evaluated. Limitations Preclude Complete Understanding of Safety Record, p. 10; Potential Strategies, pp. 15-16
  “we recommended in 2007 that FAA collect data on flight activity, including flight hours”
  In the authors’ words, p. 10
7. An Analysis of Helicopter Emergency Medical Services and Human Error Contributors to Accidents
  Lawton 2024, Doctoral dissertation, Embry-Riddle Aeronautical University In the Evidence Library
  Calls for Investigate why accident rates and error types are similar across en route, transport, and repositioning legs, including whether route familiarity and complacency matter, possibly through simulation studies. Discussion, pp. 127 and 131
  Calls for Use sources beyond NTSB reports, such as pilot surveys and records of aborted flights and near misses, to capture supervisory and organizational failures that accident reports rarely describe. Limitations, p. 134
Build on this questionAMSN-L-001
4papers
From the literatureAccidents and accident dataOperational safety
To what extent is the decline in fatal accidents over the past two decades attributable to regulatory, technology, and safety management changes, rather than to changes in flight volume or mission mix?
Published 2012 to 2024
What the 4 papers ask for on this topic
1. Analysis of Helicopter Air Ambulance Accidents in the United States From 2010 to 2021
  Sanchez 2024, Air Medical Journal In the Evidence Library
  Calls for Study in depth the root causes and contributing factors behind the higher share of accidents among pilots with less HAA experience, including HAA flight hours and certificate type. Discussion, p. 7; Conclusions, p. 8
  Calls for Determine whether regulatory, training, and technology changes actually caused the drop in the share of fatal HAA accidents, since other explanations remain possible. Discussion, p. 7
  Calls for Develop methods to estimate the total number of HAA flights, patients carried, or flight hours so accident rates can be calculated against operations rather than against total accidents. Discussion, p. 7; Conclusions, p. 8
  “Further indepth research is needed to understand the root cause and contributing factors”
  In the authors’ words, p. 7
2. Human Error Analysis of Helicopter Emergency Medical Services (HEMS) Accidents Using the Human Factors Analysis and Classification System (HFACS)
  Cline 2018, Journal of Aviation/Aerospace Education & Research In the Evidence Library
  Calls for Trend HFACS-coded HEMS accident data over time to judge whether the many safety measures the industry has adopted are producing the intended effect. Conclusion, pp. 16-17
  “further research, specifically trending the data in an attempt to determine if the numerous”
  In the authors’ words, p. 17
3. The Effects of SMS Implementation on Safety Culture within Helicopter Emergency Medical Services
  Gardner 2017, Master's thesis, University of North Dakota In the Evidence Library
  Calls for Repeat the study with a much larger and regionally balanced sample to test whether SMS adoption among operators relates to the recent decline in accidents. Future Research, p. 70
  Calls for Compare fatal crashes and safety measures in military and civilian medical helicopter transport to identify what civilian operators could adopt. Future Research, p. 71
  “For that research it would need a much bigger sample size”
  In the authors’ words, p. 70
4. Strategies to Reduce US HEMS Accidents
  Winn 2012, Air Medical Journal In the Evidence Library
  Calls for Evaluate whether three strategies, the OSI-HEMS root cause project, the NEMSPA pressure initiative, and the national EMS safety culture effort, lower accident numbers, and follow adoption with cost and value analysis. Identifying and Quantifying HEMS Risks, p. 2; Conclusions, p. 6
Build on this questionAMSN-L-002
5papers
From the literatureAccidents and accident dataOperational safety
Which flight, environmental, and pilot factors distinguish accident flights from comparable nonaccident flights, and fatal from nonfatal accidents?
Published 2011 to 2021
What the 5 papers ask for on this topic
1. A Bayesian Approach on Investigating Helicopter Emergency Medical Fatal Accidents
  Simonson 2021, Aerospace Medicine and Human Performance In the Evidence Library
  Calls for Build a research framework for data-driven analysis of HEMS accident risk and of the added risk that air transport places on patients. Discussion, p. 6
  Calls for Study how much additional risk HEMS flights carry for patients, passengers, and medical providers compared with the benefit of transport. Discussion, p. 6
  Calls for Collect exposure data on all HEMS flights, including yearly flight totals and environmental conditions, and compare accident flights with nonaccident flights to learn whether accident conditions are distinctive. Discussion (limitations), p. 6
  “Future research should explore the increased risk HEMS flights”
  In the authors’ words, p. 6
2. Medical Helicopter Accident Review: Causes and Contributing Factors
  Greenhaw 2021 In the Evidence Library
  Calls for Explore why fatal accidents make up a much larger share of EMS helicopter accidents than of non-EMS helicopter accidents. Executive Summary, p. 7; Discussion, p. 28
  Calls for Analyze in depth the factors that separate fatal from non-fatal EMS accidents, such as visibility and darkness, pilot judgment, pilot medical certificate class, and absence of a second pilot. Discussion, p. 28
  “Exploring the reasons for the much higher proportion of fatal EMS vs. non-EMS accidents”
  In the authors’ words, p. 7
3. Trends of Non-Fatal HEMS Accident-Related Injuries
  Simonson 2021, Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care In the Evidence Library
  Calls for Determine whether the lack of predictors of non-fatal injury reflects a true absence of relationships or missing data, including factors investigators may have dropped because they did not bear on fatalities. Abstract, p. 1; Discussion, p. 4
  Calls for Investigate two observed patterns, the rise in non-fatal injuries in 2008 and the concentration of non-fatal injuries in September, which available variables could not explain. Discussion, p. 4
  “Future research should identify if these null results are due to a true lack”
  In the authors’ words, p. 1
4. Pilot Decision Making in Weather-Related Night Fatal Helicopter Emergency Medical Service Accidents
  Aherne 2018, Aerospace Medicine and Human Performance In the Evidence Library
  Calls for Identify additional risk factors and preventive interventions for fatal night loss-of-control and controlled flight into terrain accidents involving pilots with limited HEMS experience. Discussion, p. 7
  “More research is required to identify further risk factors and preventative interventions”
  In the authors’ words, p. 7
5. Fixed-Wing Medical Transport Crashes: Characteristics Associated with Fatal Outcomes
  Handel 2011, Air Medical Journal In the Evidence Library
  Calls for Carry out longitudinal analysis with more cases to gain power to separate fatal from nonfatal fixed-wing medical crashes, including whether fire or the crash mechanism drives fatality. Conclusions, pp. 3-4
  Calls for Determine whether mission urgency or other factors explain the higher share of fatal outcomes, fires, and ground collisions in medical flights relative to other flights. Discussion, p. 3
  “is needed to increase the power of the study and its ability to detect differences”
  In the authors’ words, p. 4
Build on this questionAMSN-L-003
3papers
From the literatureAccidents and accident dataOperational safety
What do near-miss reports, aborted flights, and other events without harm show about organizational and supervisory contributors that accident investigations rarely capture?
Published 2012 to 2024
What the 3 papers ask for on this topic
1. An Analysis of Helicopter Emergency Medical Services and Human Error Contributors to Accidents
  Lawton 2024, Doctoral dissertation, Embry-Riddle Aeronautical University In the Evidence Library
  Calls for Investigate why accident rates and error types are similar across en route, transport, and repositioning legs, including whether route familiarity and complacency matter, possibly through simulation studies. Discussion, pp. 127 and 131
  Calls for Use sources beyond NTSB reports, such as pilot surveys and records of aborted flights and near misses, to capture supervisory and organizational failures that accident reports rarely describe. Limitations, p. 134
2. A Review of Risk Analysis and Helicopter Air Ambulance Accidents
  Nix 2014, Air Medical Journal In the Evidence Library
  Calls for Review self-reported events with good outcomes, such as those in the Concern Network database, alongside accident vulnerabilities, to inform the design of risk analysis programs. Conclusion, pp. 3-4
  “Reviewing these successful outcomes in addition to the vulnerabilities that were evidenced in this study”
  In the authors’ words, p. 4
3. A systemic analysis of patterns of organizational breakdowns in accidents: A case from Helicopter Emergency Medical Service (HEMS) operations
  Kontogiannis 2012, Reliability Engineering & System Safety In the Evidence Library
  Calls for Make systemic analysis methods more proactive, for example by running the organizational analysis during audits, so they can guide formal investigations and reveal latent conditions before an investigation ends. Conclusions, pp. 15-16
Build on this questionAMSN-L-004
Safety culture and organizations
21 papers state a direction on this topic. 4 proposed questions.
Papers ask for evidence on whether organizational programs work. Safety management systems and voluntary guidance have been widely adopted, with little outcome evaluation. Several papers call for safety culture measures built for dispersed, multidisciplinary transport teams, and for study of performance pressure.
5papers
From the literatureSafety culture and organizationsOperational safetyClinical and patient safety
Is the extent of safety management system implementation among air medical operators associated with accident, incident, or near-miss rates?
Published 2009 to 2020
What the 5 papers ask for on this topic
1. Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019
  NTSB 2020, National Transportation Safety Board In the Evidence Library
  Calls for Determine how widely Part 135 operators have adopted the FAA voluntary safety management system program, and measure how well SMS mitigations address identified safety risks. Analysis, Safety Management Systems, p. 55 to 56
  “it is necessary to measure how effective a mitigation is in addressing a safety risk”
  In the authors’ words, p. 55
2. The Effects of SMS Implementation on Safety Culture within Helicopter Emergency Medical Services
  Gardner 2017, Master's thesis, University of North Dakota In the Evidence Library
  Calls for Repeat the study with a much larger and regionally balanced sample to test whether SMS adoption among operators relates to the recent decline in accidents. Future Research, p. 70
  Calls for Refine and narrow the survey instrument to one or two research questions and prevent multiple answers on single-choice items. Limitations, p. 70
  Calls for Examine each survey section as its own study, such as perceived safety culture compared across demographic groups. Future Research, p. 71
  Calls for Compare fatal crashes and safety measures in military and civilian medical helicopter transport to identify what civilian operators could adopt. Future Research, p. 71
  “For that research it would need a much bigger sample size”
  In the authors’ words, p. 70
3. A blueprint for critical care transport research
  Jaynes 2013, Air Medical Journal In the Evidence Library
  Calls for Safety research priorities include evaluating safety programs and SMS, line reporting, safe operational designs, pilot characteristics, practices from other industries, data sharing among competitors, and human performance in past accidents. Discussion, Table 2, p. 4
  Calls for Human factors priorities include identifying elements of crew fatigue and rest during and outside duty, and how far the industry addresses human performance. Discussion, Table 2, p. 4
  “Evaluate safety programs, safety management systems”
  In the authors’ words, p. 4
4. Aviation Safety: Potential Strategies to Address Air Ambulance Safety Concerns
  Dillingham 2009, U.S. Government Accountability Office In the Evidence Library
  Calls for Collect information on operator adoption of voluntary FAA guidance and evaluate whether that guidance is effective. FAA Has Taken a Number of Actions to Address Safety Concerns, p. 15
5. Strategies to Reduce US HEMS Accidents
  Winn 2012, Air Medical Journal In the Evidence Library
  Calls for Evaluate whether three strategies, the OSI-HEMS root cause project, the NEMSPA pressure initiative, and the national EMS safety culture effort, lower accident numbers, and follow adoption with cost and value analysis. Identifying and Quantifying HEMS Risks, p. 2; Conclusions, p. 6
Build on this questionAMSN-L-006
3papers
From the literatureSafety culture and organizationsOperational safety
How prevalent are operational and economic performance pressures, such as pressure to shorten lift-off times or to accept flights, and do they differ by phase of flight?
Published 2024 to 2026
What the 3 papers ask for on this topic
1. Human Factors Analysis of Helicopter Air Ambulance Accidents, Incidents, and Events (2013-2023)
  Baumgartner 2024 In the Evidence Library
  Calls for Identify factors that undermine adherence to procedures, such as workload, task prioritization, and time pressure, with attention to pre-flight duties and risk assessments. Finding 3 Research Opportunity, p. 20
  Calls for Assess safety culture in helicopter air ambulance operations, including how common performance pressures are, such as economic pressure and pressure to shorten lift-off times. Finding 6 Research Opportunity, p. 23
  Calls for Examine challenges operators face in developing, coordinating, distributing, and implementing policies and procedures, particularly as safety management systems are adopted under Part 135. Finding 7 Research Opportunity, p. 24
2. An Analysis of Helicopter Emergency Medical Services and Human Error Contributors to Accidents
  Lawton 2024, Doctoral dissertation, Embry-Riddle Aeronautical University In the Evidence Library
  Calls for Use sources beyond NTSB reports, such as pilot surveys and records of aborted flights and near misses, to capture supervisory and organizational failures that accident reports rarely describe. Limitations, p. 134
3. Pressure to Fly and Phase of Flight Analysis in Helicopter Air Ambulance Accidents
  Griffin 2026, Air Medical Journal In the Evidence Library
  Calls for Measure pressure to fly directly in every operational phase, testing whether organizational, interpersonal, identity, fatigue, and environmental sources differ by phase and whether pressure is one construct or several related ones. Discussion, p. 5
  Calls for Evaluate prospectively whether applying structured risk assessment to return-to-base and repositioning flights, not only patient acceptance, improves safety outcomes. Discussion, p. 5
  “Future research should examine whether organizational expectations, interpersonal influences, professional identity”
  In the authors’ words, p. 5
Build on this questionAMSN-L-008
3papers
From the literatureSafety culture and organizationsOperational safetyClinical and patient safety
Can a safety culture instrument validated for dispersed, multidisciplinary transport teams support benchmarking across programs and over time?
Published 2012 to 2017
What the 3 papers ask for on this topic
1. Perceived patient safety culture in a critical care transport program
  Erler 2013, Air Medical Journal In the Evidence Library
  Calls for Test the survey's teamwork items in more critical care transport settings, and develop items that fit the dispersed, multidisciplinary transport team. Discussion, p. 6
  Calls for Investigate communication openness further in the transport context, including willingness to question decisions made by people in authority. Discussion, p. 6
  Calls for Examine the causes of low error reporting frequency, including how staff view near misses versus harmful errors and how well the reporting process works. Discussion, p. 6
  Calls for Work with AHRQ to develop and psychometrically test survey items suited to transport, and identify key safety culture elements to build a shared benchmarking database across programs. Strengths and Limitations, p. 7; Conclusion, p. 7
  “Further HSOPSC use may warrant working with the AHRQ for the development and psychometric analysis”
  In the authors’ words, p. 7
2. Safety culture in the air ambulance services
  Abrahamsen 2012, Tidsskrift for Den norske legeforening In the Evidence Library
  Calls for Measure patient safety climate among operational air ambulance staff nationwide to identify strengths and weaknesses, guide improvements, and track change over time. Measuring patient safety climate (Målinger av pasientsikkerhetsklima), p. 1; Conclusion (Konklusjon), p. 1
3. The Effects of SMS Implementation on Safety Culture within Helicopter Emergency Medical Services
  Gardner 2017, Master's thesis, University of North Dakota In the Evidence Library
  Calls for Repeat the study with a much larger and regionally balanced sample to test whether SMS adoption among operators relates to the recent decline in accidents. Future Research, p. 70
  Calls for Refine and narrow the survey instrument to one or two research questions and prevent multiple answers on single-choice items. Limitations, p. 70
  Calls for Examine each survey section as its own study, such as perceived safety culture compared across demographic groups. Future Research, p. 71
  Calls for Compare fatal crashes and safety measures in military and civilian medical helicopter transport to identify what civilian operators could adopt. Future Research, p. 71
  “For that research it would need a much bigger sample size”
  In the authors’ words, p. 70
Build on this questionAMSN-L-009
2papers
From the literatureSafety culture and organizationsOperational safetyClinical and patient safety
What factors are associated with low reporting of errors and near misses in transport programs, and which changes to reporting systems increase reporting?
Published 2013
What the 2 papers ask for on this topic
1. Perceived patient safety culture in a critical care transport program
  Erler 2013, Air Medical Journal In the Evidence Library
  Calls for Test the survey's teamwork items in more critical care transport settings, and develop items that fit the dispersed, multidisciplinary transport team. Discussion, p. 6
  Calls for Investigate communication openness further in the transport context, including willingness to question decisions made by people in authority. Discussion, p. 6
  Calls for Examine the causes of low error reporting frequency, including how staff view near misses versus harmful errors and how well the reporting process works. Discussion, p. 6
  Calls for Work with AHRQ to develop and psychometrically test survey items suited to transport, and identify key safety culture elements to build a shared benchmarking database across programs. Strengths and Limitations, p. 7; Conclusion, p. 7
  “Further HSOPSC use may warrant working with the AHRQ for the development and psychometric analysis”
  In the authors’ words, p. 7
2. Analyzing Communication Errors in an Air Medical Transport Service
  Dalto 2013, Air Medical Journal In the Evidence Library
  Calls for Develop, put in place, and measure strategies for better detection of communication errors in quality reporting, such as a standard ontology, an improved user interface, and staff education. Discussion, p. 7
  “studies are now required to develop, implement, and measure strategies to better identify communication errors”
  In the authors’ words, p. 7
Build on this questionAMSN-L-010
Utilization and triage
18 papers state a direction on this topic. 4 proposed questions.
Papers agree that patient selection remains unresolved. They ask which patients benefit from helicopter transport and at what distance, what overtriage rate is acceptable, whether some interfacility patients can move by ground with equivalent outcomes, and what helicopter transport costs. Two papers call for reliable national volume data.
6papers
From the literatureUtilization and triageOperational safetyClinical and patient safety
Which field triage criteria identify injured patients who gain survival or functional benefit from helicopter transport, and how does that benefit vary with distance or time to definitive care?
Published 2014 to 2022
What the 6 papers ask for on this topic
1. Helicopter Transport of Trauma Patients Improves Survival Irrespective of Transport Time
  Schneider 2021, The American Surgeon In the Evidence Library
  Calls for Define which injured patient groups, and at what distances from a trauma center, gain the most survival benefit from helicopter transport. Conclusion, p. 4
  Calls for Develop tools that let EMS crews quickly recognize patients likely to benefit from helicopter transport, to reduce overtriage and unneeded transport cost. Conclusion, p. 4
  “Further study is needed to delineate the specific patient populations and their distance”
  In the authors’ words, p. 4
2. Overutilization of Helicopter Emergency Medical Services in Central Gulf Coast Region Results in Unnecessary Expenditure
  Miles 2022, Journal of Surgical Research In the Evidence Library
  Calls for Research should determine what overtriage rate is acceptable for HEMS, possibly using stricter criteria tied to the critical care and remote transport capabilities HEMS offers. Discussion, p. 5
  Calls for Further study should identify which trauma patients benefit from HEMS, through scene triage criteria that predict better outcomes after helicopter transport. Discussion, p. 6
  Calls for Larger multicenter studies with transparent cost data should define additional variables linked to warranted HEMS transport and give better estimates of excess spending. Discussion, p. 6
  “further investigation is needed to elucidate what patients with trauma will benefit from HEMS transport”
  In the authors’ words, p. 6
3. Predictors of Inappropriate Helicopter Transport
  Brown 2021, The American Surgeon In the Evidence Library
  Calls for Future studies could test prehospital interventions, total prehospital time, and distance as factors in patient morbidity, to inform a protocol that identifies patients best served by helicopter transport. Discussion, p. 4
  “Future studies could examine other HT factors such as prehospital interventions, total prehospital time”
  In the authors’ words, p. 4
4. Probable cause in helicopter emergency medical services crashes
  Habib 2014, Journal of Trauma and Acute Care Surgery In the Evidence Library
  Calls for Identify more accurately which patients benefit most from HEMS transport, to reduce overtriage and limit crew exposure to flight risk. Discussion, p. 5
  Calls for Build a database of all trauma HEMS missions that can be reviewed for compliance with standards and for deviations, similar to trauma center registries. Discussion, p. 5
  “more accurately identifying patients who would benefit most from HEMS transport, minimizing overtriage”
  In the authors’ words, p. 5
5. Stop Flying the Patients! Evaluation of the Overutilization of Helicopter Transport of Trauma Patients
  Horwood 2020, Journal of Surgical Research In the Evidence Library
  Calls for Study and put in place standard triage criteria for helicopter transport of trauma patients, possibly regional ones that account for weather, geography, and traffic, to reduce overuse. Discussion, p. 4
  “Further study and implementation of standard triage criteria is required”
  In the authors’ words, p. 4
6. Appropriate Air Medical Services Utilization and Recommendations for Integration of Air Medical Services Resources into the EMS System of Care: A Joint Position Statement and Resource Document of NAEMSP, ACEP, and AMPA
  Lyng 2021, Prehospital Emergency Care In the Evidence Library
  Calls for Develop and adopt more objective decision support tools for air medical utilization, since decisions often rest on subjective perceptions of worst-case scenarios. Section 1 (Clinical, Temporal, and Geographic Considerations), p. 5
  Calls for Identify which suspected stroke subtypes benefit from air transport and how air medical services should fit into regional stroke destination protocols, pending reliable prehospital detection of large vessel occlusion. Medical Emergencies (stroke), p. 8
  Calls for Research patient selection for air transport of high-risk obstetric and neonatal patients and the effect of air transport on maternal and neonatal outcomes. Obstetric and Neonatal Emergencies, p. 8
  Calls for Study the use of air medical services for other high-acuity or time-sensitive medical and surgical conditions, such as threatened airways or emergent surgery, which remain poorly studied. Other Medical or Surgical Emergencies, p. 8
  “there is clearly a need for development and adoption of other objective decision support tools”
  In the authors’ words, p. 5
Build on this questionAMSN-L-011
3papers
From the literatureUtilization and triageOperational safetyClinical and patient safety
What overtriage rate is acceptable for helicopter transport of trauma patients, and how should overtriage be defined and measured?
Published 2014 to 2022
What the 3 papers ask for on this topic
1. Overutilization of Helicopter Emergency Medical Services in Central Gulf Coast Region Results in Unnecessary Expenditure
  Miles 2022, Journal of Surgical Research In the Evidence Library
  Calls for Research should determine what overtriage rate is acceptable for HEMS, possibly using stricter criteria tied to the critical care and remote transport capabilities HEMS offers. Discussion, p. 5
  Calls for Further study should identify which trauma patients benefit from HEMS, through scene triage criteria that predict better outcomes after helicopter transport. Discussion, p. 6
  Calls for Larger multicenter studies with transparent cost data should define additional variables linked to warranted HEMS transport and give better estimates of excess spending. Discussion, p. 6
  “further investigation is needed to elucidate what patients with trauma will benefit from HEMS transport”
  In the authors’ words, p. 6
2. Probable cause in helicopter emergency medical services crashes
  Habib 2014, Journal of Trauma and Acute Care Surgery In the Evidence Library
  Calls for Identify more accurately which patients benefit most from HEMS transport, to reduce overtriage and limit crew exposure to flight risk. Discussion, p. 5
  Calls for Build a database of all trauma HEMS missions that can be reviewed for compliance with standards and for deviations, similar to trauma center registries. Discussion, p. 5
  “more accurately identifying patients who would benefit most from HEMS transport, minimizing overtriage”
  In the authors’ words, p. 5
3. Helicopter Transport of Trauma Patients Improves Survival Irrespective of Transport Time
  Schneider 2021, The American Surgeon In the Evidence Library
  Calls for Define which injured patient groups, and at what distances from a trauma center, gain the most survival benefit from helicopter transport. Conclusion, p. 4
  Calls for Develop tools that let EMS crews quickly recognize patients likely to benefit from helicopter transport, to reduce overtriage and unneeded transport cost. Conclusion, p. 4
  “Further study is needed to delineate the specific patient populations and their distance”
  In the authors’ words, p. 4
Build on this questionAMSN-L-012
3papers
From the literatureUtilization and triageClinical and patient safety
Can validated criteria identify interfacility trauma and burn patients for whom ground transport yields equivalent outcomes, and what is the effect on cost?
Published 2015 to 2022
What the 3 papers ask for on this topic
1. Overuse of helicopter transport in the minimally injured: A health care system problem that should be corrected
  Vercruysse 2015, Journal of Trauma and Acute Care Surgery In the Evidence Library
  Calls for Further define the group of minimally injured interfacility transfer patients who gain no apparent benefit from helicopter transport. Discussion, p. 4
  Calls for Conduct an adequately powered prospective trial of whether excluding minimally injured patients from helicopter transfer to a tertiary center is cost-effective. Limitations, p. 5
  Calls for Validate and reach agreement on firm criteria for choosing ground or helicopter transport. Limitations, p. 5
  “Future studies should further explore and delineate such a patient population.”
  In the authors’ words, p. 4
2. Overutilization of Helicopter Transport in the Minimally Burned-A Healthcare System Problem That Should Be Corrected
  Roman 2020, Journal of Burn Care & Research In the Evidence Library
  Calls for Conduct a prospective study of how triage changes, burn center consultation, and teleconsultation are used, how well they work, and whether they are safe. Discussion (limitations paragraph), p. 7
  Calls for Repeat the analysis with data from other hospitals in different regions to see whether the single-center results for minimally burned patients still apply. Discussion (limitations paragraph), p. 7
  Calls for Validate firm criteria for which burn patients can be moved safely by ground instead of helicopter. Discussion (limitations paragraph), p. 7; Discussion, p. 5
  “a prospective investigation is necessary to assess the usage, efficacy, and safety”
  In the authors’ words, p. 7
3. Helicopter versus ground ambulance transport for interfacility transfer of critically ill children
  Joseph 2022, The American Journal of Emergency Medicine In the Evidence Library
  Calls for Assess the value of helicopter versus ground transport with granular cost data and decision-analytic models that identify break-even points, ideally designed prospectively for local systems. Limitations and Conclusion, p. 6
  “Further research, such as decision-analytic models that incorporate a range of potential costs”
  In the authors’ words, p. 6
Build on this questionAMSN-L-013
2papers
From the literatureUtilization and triageOperational safety
How reliably do national prehospital data systems capture annual air medical transport volumes when checked against counts reported by programs?
Published 2019 to 2024
What the 2 papers ask for on this topic
1. Using NEMSIS to report annual air medical transport statistics
  Reimer 2024, Air Medical Journal In the Evidence Library
  Calls for Analyze several years of NEMSIS data to see whether national air medical transport counts are stable over time. Conclusion, p. 3
  Calls for Survey transport programs directly and compare their reported volumes with NEMSIS figures to establish long-term reliability of NEMSIS as a national tracking source. Conclusion, p. 3
  “Future work will include longitudinal analysis of NEMSIS datasets and direct survey of transport programs”
  In the authors’ words, p. 3
2. Establishing Transport Statistics: Results From the Medevac Transport Statistics Survey
  Reimer 2019, Air Medical Journal In the Evidence Library
  Calls for Increase transport program participation in anonymous national data collection so that precise annual transport statistics can support research and policy. Conclusion, p. 4; Abstract, p. 1
  Calls for Establish consistent definitions and broad program reporting for critical care ground transport so its national volume can be measured. Discussion, p. 4
  “Future participation is encouraged to enable more accurate data reporting”
  In the authors’ words, p. 1
Build on this questionAMSN-L-015
Regulation and policy
18 papers state a direction on this topic. 3 proposed questions.
These directions concern what regulators would need to measure. They ask how widely voluntary programs are used, what activity data services report, and whether risk assessment tools meet the elements that guidance specifies.
3papers
From the literatureRegulation and policyOperational safety
How widely have air medical operators adopted voluntary safety programs such as flight data monitoring, and what challenges do they report in implementing them?
Published 2009 to 2024
What the 3 papers ask for on this topic
1. Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019
  NTSB 2020, National Transportation Safety Board In the Evidence Library
  Calls for Determine how widely Part 135 operators have adopted the FAA voluntary safety management system program, and measure how well SMS mitigations address identified safety risks. Analysis, Safety Management Systems, p. 55 to 56
  Calls for Measure the level of voluntary participation in flight data monitoring programs among Part 135 operators, since installed recorders are not paired with required data analysis. Analysis, Flight Data Monitoring, p. 59
  Calls for Review flight risk assessments of all helicopter air ambulance operators for compliance with the risk analysis regulation and advisory circular guidance, including en route weather and prior flight refusals. Recommendations (A-20-14), p. 71
  “it is necessary to measure how effective a mitigation is in addressing a safety risk”
  In the authors’ words, p. 55
2. Aviation Safety: Potential Strategies to Address Air Ambulance Safety Concerns
  Dillingham 2009, U.S. Government Accountability Office In the Evidence Library
  Calls for Obtain complete and reliable flight activity data, including flight hours, from all air ambulance operators so an accurate accident rate can be calculated and safety efforts evaluated. Limitations Preclude Complete Understanding of Safety Record, p. 10; Potential Strategies, pp. 15-16
  Calls for Collect information on operator adoption of voluntary FAA guidance and evaluate whether that guidance is effective. FAA Has Taken a Number of Actions to Address Safety Concerns, p. 15
  “we recommended in 2007 that FAA collect data on flight activity, including flight hours”
  In the authors’ words, p. 10
3. Human Factors Analysis of Helicopter Air Ambulance Accidents, Incidents, and Events (2013-2023)
  Baumgartner 2024 In the Evidence Library
  Calls for Examine challenges operators face in developing, coordinating, distributing, and implementing policies and procedures, particularly as safety management systems are adopted under Part 135. Finding 7 Research Opportunity, p. 24
Build on this questionAMSN-L-016
5papers
From the literatureRegulation and policyOperational safety
What activity data, such as flight hours, missions, and transport volumes, do air and ground medical transport services report, and is that reporting complete enough to calculate accident rates?
Published 2009 to 2023
What the 5 papers ask for on this topic
1. Aviation Safety: Potential Strategies to Address Air Ambulance Safety Concerns
  Dillingham 2009, U.S. Government Accountability Office In the Evidence Library
  Calls for Obtain complete and reliable flight activity data, including flight hours, from all air ambulance operators so an accurate accident rate can be calculated and safety efforts evaluated. Limitations Preclude Complete Understanding of Safety Record, p. 10; Potential Strategies, pp. 15-16
  Calls for Collect information on operator adoption of voluntary FAA guidance and evaluate whether that guidance is effective. FAA Has Taken a Number of Actions to Address Safety Concerns, p. 15
  “we recommended in 2007 that FAA collect data on flight activity, including flight hours”
  In the authors’ words, p. 10
2. Fatal Air Medical Accidents in the United States (2000-2020)
  Shekhar 2023, Prehospital and Disaster Medicine In the Evidence Library
  Calls for Calculate true accident rates for the whole industry and for aircraft categories and models, which first requires better reporting of annual hours flown by air ambulances. Limitations, p. 4
3. Statistical learning for turboshaft helicopter accidents using logistic regression
  Subagia 2020, PLOS ONE In the Evidence Library
  Calls for Collect exposure data such as flight hours and mission type, stratified by helicopter configuration, so accident rates can be calculated and confounding by usage addressed. Limitations, p. 18
4. Establishing Transport Statistics: Results From the Medevac Transport Statistics Survey
  Reimer 2019, Air Medical Journal In the Evidence Library
  Calls for Increase transport program participation in anonymous national data collection so that precise annual transport statistics can support research and policy. Conclusion, p. 4; Abstract, p. 1
  Calls for Establish consistent definitions and broad program reporting for critical care ground transport so its national volume can be measured. Discussion, p. 4
  “Future participation is encouraged to enable more accurate data reporting”
  In the authors’ words, p. 1
5. Ground Versus Air: Which Mode of Emergency Medical Service Transportation Is More Likely to Crash?
  Hartmann 2023, Air Medical Journal In the Evidence Library
  Calls for Obtain national data on ground ambulance transport activity so that crash risk for ground and helicopter transport can be compared more fully. Abstract (Conclusion), p. 1
  “National GEMS transportation data could be useful in studying this topic further.”
  In the authors’ words, p. 1
Build on this questionAMSN-L-017
2papers
From the literatureRegulation and policyOperational safety
Do the flight risk assessment tools in use address the elements that regulations and guidance specify, such as en route weather and prior declines of the same flight?
Published 2012 to 2020
What the 2 papers ask for on this topic
1. Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019
  NTSB 2020, National Transportation Safety Board In the Evidence Library
  Calls for Determine how widely Part 135 operators have adopted the FAA voluntary safety management system program, and measure how well SMS mitigations address identified safety risks. Analysis, Safety Management Systems, p. 55 to 56
  Calls for Measure the level of voluntary participation in flight data monitoring programs among Part 135 operators, since installed recorders are not paired with required data analysis. Analysis, Flight Data Monitoring, p. 59
  Calls for Review flight risk assessments of all helicopter air ambulance operators for compliance with the risk analysis regulation and advisory circular guidance, including en route weather and prior flight refusals. Recommendations (A-20-14), p. 71
  “it is necessary to measure how effective a mitigation is in addressing a safety risk”
  In the authors’ words, p. 55
2. Strategies to Reduce US HEMS Accidents
  Winn 2012, Air Medical Journal In the Evidence Library
  Calls for Evaluate whether three strategies, the OSI-HEMS root cause project, the NEMSPA pressure initiative, and the national EMS safety culture effort, lower accident numbers, and follow adoption with cost and value analysis. Identifying and Quantifying HEMS Risks, p. 2; Conclusions, p. 6
Build on this questionAMSN-L-018
Decision-making and risk
17 papers state a direction on this topic. 4 proposed questions.
Papers ask what leads to continued flight into deteriorating weather, whether risk assessment works when applied to every phase of flight, how pilots and medical crew differ in go and no-go judgments, how experience relates to risk, and how programs decide whether to respond to an accident involving their own aircraft.
4papers
From the literatureDecision-making and riskOperational safety
What factors are associated with decisions to continue flight into deteriorating or below-minimum weather, compared with flights that are delayed, diverted, or aborted?
Published 2012 to 2024
What the 4 papers ask for on this topic
1. An Analysis of Helicopter EMS Accidents using HFACS: 2000-2012
  Bryan 2014, Master's thesis, Embry-Riddle Aeronautical University In the Evidence Library
  Calls for Investigate why many HEMS pilots knowingly violate weather minima, contrasting pilot motivation when minima are violated with cases where they are not. Discussion, p. 31; Future directions, p. 35
  Calls for Investigate which strategies best reduce obstacle collisions and degraded visibility accidents when landing at semi-prepared or improvised scene sites. Future directions, p. 35; Conclusion, p. 36
  “further investigation is indicated. Investigation into pilot motivation when intentionally violating weather minima”
  In the authors’ words, p. 35
2. Strategies to Reduce US HEMS Accidents
  Winn 2012, Air Medical Journal In the Evidence Library
  Calls for Before asking how controlled flight into terrain accidents could be prevented, find out why experienced, qualified pilots kept flying into marginal or below-minimum weather. No Pressure Initiative, p. 3
  Calls for Improve preflight risk assessment, since scoring and included factors are not standardized and the one published evaluation found the score did not reliably predict transport outcome. Preflight Risk Assessment, p. 5
  “must be preceded by the question of why qualified pilots were continuing to fly into”
  In the authors’ words, p. 3
3. An Analysis of Helicopter Emergency Medical Services and Human Error Contributors to Accidents
  Lawton 2024, Doctoral dissertation, Embry-Riddle Aeronautical University In the Evidence Library
  Calls for Investigate why accident rates and error types are similar across en route, transport, and repositioning legs, including whether route familiarity and complacency matter, possibly through simulation studies. Discussion, pp. 127 and 131
  Calls for Study the medical necessity of interfacility flights and the circumstances that lead pilots to fly these missions in degraded visual conditions, since such accidents were more often fatal. Discussion, pp. 129-130
  Calls for Evaluate simulation training, including low-cost simulators with realistic stressors and immersive virtual reality, for reducing skill-based errors and poor decisions such as continued VFR flight into IMC. Future Research, pp. 135-137
  “should include further investigation of the use of virtual reality simulation to address”
  In the authors’ words, p. 137
4. American Helicopter Emergency Medical Service Pilots Report to Work Despite High Rates of Sleepiness
  Kamine 2022, Air Medical Journal In the Evidence Library
  Calls for Survey a larger sample of HEMS pilots, possibly through Part 135 operators rather than a listserv, to measure fatigue burden and the barriers that keep pilots from declining flights. Discussion, p. 3; Conclusions, p. 3
  Calls for Determine whether pilots who felt they should have declined a flight were single pilots or on day or night shifts, whether adverse outcomes followed, and when in the flight they reached that judgment. Discussion, p. 3
  “More research is necessary to quantify the burden of fatigue among HEMS pilots.”
  In the authors’ words, p. 1
Build on this questionAMSN-L-020
4papers
From the literatureDecision-making and riskOperational safetyClinical and patient safety
Does structured risk assessment applied to every phase of flight, including return-to-base and repositioning, change risk decisions and safety outcomes compared with assessment at patient acceptance only?
Published 2012 to 2026
What the 4 papers ask for on this topic
1. Pressure to Fly and Phase of Flight Analysis in Helicopter Air Ambulance Accidents
  Griffin 2026, Air Medical Journal In the Evidence Library
  Calls for Measure pressure to fly directly in every operational phase, testing whether organizational, interpersonal, identity, fatigue, and environmental sources differ by phase and whether pressure is one construct or several related ones. Discussion, p. 5
  Calls for Study the human factors of the period after patient handoff, including shifts in workload, vigilance, situational awareness, fatigue, and priorities, using qualitative work with pilots and medical crew. Discussion, p. 5
  Calls for Evaluate prospectively whether applying structured risk assessment to return-to-base and repositioning flights, not only patient acceptance, improves safety outcomes. Discussion, p. 5
  “Future research should examine whether organizational expectations, interpersonal influences, professional identity”
  In the authors’ words, p. 5
2. Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019
  NTSB 2020, National Transportation Safety Board In the Evidence Library
  Calls for Review flight risk assessments of all helicopter air ambulance operators for compliance with the risk analysis regulation and advisory circular guidance, including en route weather and prior flight refusals. Recommendations (A-20-14), p. 71
3. Strategies to Reduce US HEMS Accidents
  Winn 2012, Air Medical Journal In the Evidence Library
  Calls for Before asking how controlled flight into terrain accidents could be prevented, find out why experienced, qualified pilots kept flying into marginal or below-minimum weather. No Pressure Initiative, p. 3
  Calls for Improve preflight risk assessment, since scoring and included factors are not standardized and the one published evaluation found the score did not reliably predict transport outcome. Preflight Risk Assessment, p. 5
  “must be preceded by the question of why qualified pilots were continuing to fly into”
  In the authors’ words, p. 3
4. Operational Impact of a Critical Care Transport Duty Time Tool Implementation: A Quality Improvement Project to Enhance Crew and Patient Safety
  Sorensen 2018, Air Medical Journal In the Evidence Library
  Calls for Refine the duty time risk assessment tool so it accounts for patient acuity in relation to scene times. Conclusion, p. 5
  “refining the tool further to take acuity into account related to scene times”
  In the authors’ words, p. 5
Build on this questionAMSN-L-021
2papers
From the literatureDecision-making and riskOperational safety
Do pilots and medical crew differ in go and no-go judgments for the same scenarios, and what explains any differences?
Published 2009 to 2012
What the 2 papers ask for on this topic
1. Aeronautical Decision Making in Helicopter Emergency Medical Systems (HEMS): The Effect of Mission Orientation and Local Base Finances on the Go/No Go Decision
  Cline 2012, Master's thesis, University of North Dakota In the Evidence Library
  Calls for Examine how large the pilot versus medical crew differences in go/no-go attitudes are and whether they stem from personality or education, differ from non-flying peers, or vary by gender. Further Research, p. 91
  Calls for Use situational judgment tests as a lower-cost way to assess pilot and medical crew attitudes toward factors in the go/no-go decision. Further Research, p. 91
  Calls for Run confidential scenario-based simulations in which a full crew decides to accept, decline, or abort a flight, designed to limit observation effects. Further Research, pp. 92-93
  Calls for Recruit broader samples from other operators, national and international, because responses came mainly from one company. Limitations, p. 89
  “The preliminary findings indicating a difference may exist along occupational lines beg further investigation”
  In the authors’ words, p. 91
2. Transport Nurse Safety Practices, Perceptions, and Experiences: The Air and Surface Transport Nurses Association Survey
  Frakes 2009, Air Medical Journal In the Evidence Library
  Calls for Identify factors associated with nurses declining or ending transports for safety reasons, to find screening steps that could lower risk exposure earlier. Discussion, p. 4
Build on this questionAMSN-L-022
3papers
From the literatureDecision-making and riskOperational safety
How do total flight experience and air medical experience relate to pilot risk acceptance and accident involvement?
Published 2016 to 2024
What the 3 papers ask for on this topic
1. Pilot Decision Making in Weather-Related Night Fatal Helicopter Emergency Medical Service Accidents
  Aherne 2018, Aerospace Medicine and Human Performance In the Evidence Library
  Calls for Examine how accumulated flying hours and HEMS experience relate to pilot risk taking, since this and earlier work point in different directions. Discussion, p. 6
2. Analysis of Helicopter Air Ambulance Accidents in the United States From 2010 to 2021
  Sanchez 2024, Air Medical Journal In the Evidence Library
  Calls for Study in depth the root causes and contributing factors behind the higher share of accidents among pilots with less HAA experience, including HAA flight hours and certificate type. Discussion, p. 7; Conclusions, p. 8
  “Further indepth research is needed to understand the root cause and contributing factors”
  In the authors’ words, p. 7
3. Pilot Domain Task Experience in Night Fatal Helicopter Emergency Medical Service Accidents
  Aherne 2016, Aerospace Medicine and Human Performance In the Evidence Library
  Calls for Separate night and instrument flight hours by fixed wing and rotary wing time when analyzing pilot experience, because the source data did not allow this distinction. Discussion (methodological limitations), p. 6
Build on this questionAMSN-L-023
Clinical care and patient outcomes
15 papers state a direction on this topic. 3 proposed questions.
Papers ask why air transport is linked to better survival in some studies, which conditions beyond trauma benefit, how on-scene time can be shortened, whether outcomes hold after hospital discharge, and whether service coverage relates to population crash mortality.
2papers
From the literatureClinical care and patient outcomesClinical and patient safety
What accounts for survival differences between air and ground transport of injured patients, such as onboard blood products, crew training, and transport time?
Published 2013 to 2021
What the 2 papers ask for on this topic
1. Helicopter Transport of Trauma Patients Improves Survival Irrespective of Transport Time
  Schneider 2021, The American Surgeon In the Evidence Library
  Calls for Identify why air transport was linked to better survival than ground transport, including the possible roles of onboard blood products and advanced flight crew training. Discussion, p. 4
  Calls for Define which injured patient groups, and at what distances from a trauma center, gain the most survival benefit from helicopter transport. Conclusion, p. 4
  “Further study is needed to delineate the specific patient populations and their distance”
  In the authors’ words, p. 4
2. A blueprint for critical care transport research
  Jaynes 2013, Air Medical Journal In the Evidence Library
  Calls for Outcome priorities include whether helicopter transport benefits patients, which conditions are time dependent, air versus ground mortality after crashes, outcomes on no-fly weather days, and the value of local stabilization. Discussion, Table 2, p. 4
  Calls for Clinical and training priorities include features that predict the value of air transport, evidence-based airway, breathing, and circulation management in transport, and the effect of crew training and certification on outcomes. Discussion, Table 2, p. 4
Build on this questionAMSN-L-025
2papers
From the literatureClinical care and patient outcomesClinical and patient safety
For which time-sensitive conditions beyond trauma, such as stroke subtypes, obstetric emergencies, and threatened airways, does air transport change patient outcomes?
Published 2013 to 2021
What the 2 papers ask for on this topic
1. Appropriate Air Medical Services Utilization and Recommendations for Integration of Air Medical Services Resources into the EMS System of Care: A Joint Position Statement and Resource Document of NAEMSP, ACEP, and AMPA
  Lyng 2021, Prehospital Emergency Care In the Evidence Library
  Calls for Identify which suspected stroke subtypes benefit from air transport and how air medical services should fit into regional stroke destination protocols, pending reliable prehospital detection of large vessel occlusion. Medical Emergencies (stroke), p. 8
  Calls for Research patient selection for air transport of high-risk obstetric and neonatal patients and the effect of air transport on maternal and neonatal outcomes. Obstetric and Neonatal Emergencies, p. 8
  Calls for Study the use of air medical services for other high-acuity or time-sensitive medical and surgical conditions, such as threatened airways or emergent surgery, which remain poorly studied. Other Medical or Surgical Emergencies, p. 8
2. A blueprint for critical care transport research
  Jaynes 2013, Air Medical Journal In the Evidence Library
  Calls for Outcome priorities include whether helicopter transport benefits patients, which conditions are time dependent, air versus ground mortality after crashes, outcomes on no-fly weather days, and the value of local stabilization. Discussion, Table 2, p. 4
  Calls for Clinical and training priorities include features that predict the value of air transport, evidence-based airway, breathing, and circulation management in transport, and the effect of crew training and certification on outcomes. Discussion, Table 2, p. 4
Build on this questionAMSN-L-026
2papers
From the literatureClinical care and patient outcomesOperational safetyClinical and patient safety
When prehospital, hospital, and long-term follow-up records are linked, do functional and patient-centered outcomes differ by transport mode?
Published 2022 to 2025
What the 2 papers ask for on this topic
1. Helicopter versus ground ambulance transport for interfacility transfer of critically ill children
  Joseph 2022, The American Journal of Emergency Medicine In the Evidence Library
  Calls for Use multicenter databases to build larger cohorts with enough power to detect small but clinically meaningful outcome differences by transport mode. Limitations, p. 6
  Calls for Link long-term patient cohorts to interhospital transport records to capture functional and other patient-centered outcomes that may depend on timely retrieval. Limitations, p. 6
2. High-altitude HEMS missions—a retrospective analysis of 3,564 air rescue missions conducted between 2011 and 2021
  Klocker 2025, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine In the Evidence Library
  Calls for Identify which contributors to on-scene time can be changed, given that longer scene times have been linked to higher trauma mortality, while accounting for confounding by injury severity. Discussion, pp. 8-9
  Calls for Determine which lengthy medical interventions could be moved from the scene into the flight to shorten on-scene time. Limitations, p. 9
  Calls for Link prehospital records to hospital and follow-up data to check whether field diagnoses are confirmed and whether field injury management predicts long-term outcomes. Limitations, p. 9
Build on this questionAMSN-L-028
Training and simulation
13 papers state a direction on this topic. 4 proposed questions.
The common gap is outcome evidence. Most training studies measure satisfaction or self-report. Papers ask whether simulation changes operational performance and patient outcomes, how often training must repeat, how far crew resource management training reaches medical crew and communication specialists, and where clinicians report gaps in readiness.
3papers
From the literatureTraining and simulationOperational safety
Does simulation-based training, technical and non-technical, improve measured operational performance and patient outcomes, beyond learner satisfaction and self-report?
Published 2019 to 2026
What the 3 papers ask for on this topic
1. Enhancing High-Fidelity Simulation Flight–Based Training for Critical Care Paramedics in EMS Aviation: A Systematic Review
  Hilditch 2026, Air Medical Journal In the Evidence Library
  Calls for Experimental studies should test whether high-fidelity flight-based simulation for critical care paramedics improves validated operational, safety, and patient-centered outcomes, instead of relying on learner satisfaction and self-report. Discussion, p. 5
  Calls for Longitudinal, multi-institution studies with standardized frameworks and objective measures of learning gain and team performance should examine whether short-term perceived gains carry over to operational performance and patient safety. Future Initiatives and Recommendations; Conclusion, p. 6
  Calls for International registries that connect simulation results with operational mission data could identify performance gaps and support shared research across programs. Future Initiatives and Recommendations, p. 6
  Calls for Simulation programs need cost-effectiveness analysis, along with evaluation of virtual and augmented reality tools and refresher modules meant to limit skill decay in rare, high-risk procedures. Future Initiatives and Recommendations, p. 6
  “must prioritize experimental studies that link HFS training to validated operational, safety, and patient-centered outcomes”
  In the authors’ words, p. 5
2. Training and assessment of non-technical skills in Norwegian helicopter emergency services: a cross-sectional and longitudinal study
  Rasmussen 2019, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine In the Evidence Library
  Calls for Further research is needed to establish what effect simulation-based non-technical skills training has on patient outcomes. Limitations, p. 8
  Calls for HEMS-specific behavioural marker tools such as AeroNOTS need full validation, and systematic assessment of non-technical skills, including fatigue management, should become a focus. Discussion, p. 8; Conclusion, p. 9
  “to fully understand the effect of simulation training on patient outcome, further research is needed”
  In the authors’ words, p. 8
3. An Analysis of Helicopter Emergency Medical Services and Human Error Contributors to Accidents
  Lawton 2024, Doctoral dissertation, Embry-Riddle Aeronautical University In the Evidence Library
  Calls for Evaluate simulation training, including low-cost simulators with realistic stressors and immersive virtual reality, for reducing skill-based errors and poor decisions such as continued VFR flight into IMC. Future Research, pp. 135-137
  “should include further investigation of the use of virtual reality simulation to address”
  In the authors’ words, p. 137
Build on this questionAMSN-L-030
3papers
From the literatureTraining and simulationOperational safety
Do low-cost or immersive simulators with realistic stressors improve pilot responses to inadvertent entry into instrument meteorological conditions?
Published 2012 to 2024
What the 3 papers ask for on this topic
1. An Analysis of Helicopter Emergency Medical Services and Human Error Contributors to Accidents
  Lawton 2024, Doctoral dissertation, Embry-Riddle Aeronautical University In the Evidence Library
  Calls for Evaluate simulation training, including low-cost simulators with realistic stressors and immersive virtual reality, for reducing skill-based errors and poor decisions such as continued VFR flight into IMC. Future Research, pp. 135-137
  “should include further investigation of the use of virtual reality simulation to address”
  In the authors’ words, p. 137
2. Human Factors Analysis of Helicopter Air Ambulance Accidents, Incidents, and Events (2013-2023)
  Baumgartner 2024 In the Evidence Library
  Calls for Establish a baseline of how helicopter air ambulance pilots currently scan visually, identifying effective techniques and weaknesses that affect situation awareness. Finding 1 Research Opportunities, p. 18
  Calls for Examine operator and pilot training on finding and using reliable, authoritative weather sources for go, no-go, and continue decisions, to locate weaknesses and mitigations. Finding 2 Research Opportunities, p. 19
  Calls for Examine whether leadership and command training improves pilot judgment and decision-making in helicopter air ambulance operations, where no HAA-specific guidance exists. Finding 2 Research Opportunities, p. 19
  Calls for Examine the current state of differences training for pilots who fly multiple helicopter types or cockpit configurations. Finding 4 Research Opportunities, p. 20
  Calls for Examine current training for non-normal conditions such as high-density operations, night flight, and low visibility. Finding 4 Research Opportunities, p. 21
  Calls for Examine the extent and effectiveness of crew resource management training for medical crew members and operational control center specialists. Finding 5 Research Opportunity, p. 22
  “a research opportunity to investigate current visual scanning techniques and behaviors within HAA pilots”
  In the authors’ words, p. 18
3. Aeronautical Decision Making in Helicopter Emergency Medical Systems (HEMS): The Effect of Mission Orientation and Local Base Finances on the Go/No Go Decision
  Cline 2012, Master's thesis, University of North Dakota In the Evidence Library
  Calls for Use situational judgment tests as a lower-cost way to assess pilot and medical crew attitudes toward factors in the go/no-go decision. Further Research, p. 91
  Calls for Run confidential scenario-based simulations in which a full crew decides to accept, decline, or abort a flight, designed to limit observation effects. Further Research, pp. 92-93
Build on this questionAMSN-L-031
2papers
From the literatureTraining and simulationOperational safety
How often must safety training repeat to maintain knowledge and skill for rare, high-risk events?
Published 2008 to 2026
What the 2 papers ask for on this topic
1. Formal testing and utilization of streaming media to improve flight crew safety knowledge
  Bellazzini 2008, Air Medical Journal In the Evidence Library
  Calls for Future studies should measure safety knowledge retention at intervals shorter than six months to find the best frequency for safety training. Discussion, p. 3
  “Future studies addressing knowledge retention at shorter intervals should be conducted”
  In the authors’ words, p. 3
2. Enhancing High-Fidelity Simulation Flight–Based Training for Critical Care Paramedics in EMS Aviation: A Systematic Review
  Hilditch 2026, Air Medical Journal In the Evidence Library
  Calls for Experimental studies should test whether high-fidelity flight-based simulation for critical care paramedics improves validated operational, safety, and patient-centered outcomes, instead of relying on learner satisfaction and self-report. Discussion, p. 5
  Calls for Longitudinal, multi-institution studies with standardized frameworks and objective measures of learning gain and team performance should examine whether short-term perceived gains carry over to operational performance and patient safety. Future Initiatives and Recommendations; Conclusion, p. 6
  Calls for International registries that connect simulation results with operational mission data could identify performance gaps and support shared research across programs. Future Initiatives and Recommendations, p. 6
  Calls for Simulation programs need cost-effectiveness analysis, along with evaluation of virtual and augmented reality tools and refresher modules meant to limit skill decay in rare, high-risk procedures. Future Initiatives and Recommendations, p. 6
  “must prioritize experimental studies that link HFS training to validated operational, safety, and patient-centered outcomes”
  In the authors’ words, p. 5
Build on this questionAMSN-L-032
3papers
From the literatureTraining and simulationOperational safety
Where do transport clinicians report gaps in safety readiness and competency, and how do those gaps relate to experience and training?
Published 2009 to 2022
What the 3 papers ask for on this topic
1. Safety Competency, Certification, and Practical Drift
  York 2022, Air Medical Journal In the Evidence Library
  Calls for Further examine how transport nurses are trained in safety and how their safety competency is assessed, given lower scores among more experienced nurses. Discussion, p. 2
  Calls for Determine how useful the adapted C3Q-safety scale is in transport nursing practice. Limitations and Strengths, p. 3
  Calls for Study safety competency trends in flight crew members who are not nurses. Limitations and Strengths, p. 3
  “further examination of nursing safety training and competency assessment is needed”
  In the authors’ words, p. 2
2. A Survey the Critical Care Transport Industry Should Listen To
  Miller 2021, Air Medical Journal In the Evidence Library
  Calls for Look more closely at the roughly one quarter of transport nurses who did not report feeling prepared and competent, to find where gaps in readiness could be closed. Results, p. 1
  “looking at those who did not report feelings of preparedness and competency”
  In the authors’ words, p. 1
3. Transport Nurse Safety Practices, Perceptions, and Experiences: The Air and Surface Transport Nurses Association Survey
  Frakes 2009, Air Medical Journal In the Evidence Library
  Calls for Identify which safety training needs of transport teams are going unmet. Discussion, p. 4
Build on this questionAMSN-L-034
Fatigue and scheduling
10 papers state a direction on this topic. 4 proposed questions.
Papers call for fatigue evidence across the full range of shift systems and operating contexts in use, for a validated fatigue measure for transport crews, for tests of specific mitigations such as on-duty rest and napping, and for study of how fatigue relates to flight decisions.
5papers
From the literatureFatigue and schedulingOperational safety
Which shift lengths and scheduling practices are associated with lower fatigue and better alertness among pilots and medical crew, across the shift systems and operating contexts in use?
Published 2010 to 2023
What the 5 papers ask for on this topic
1. Causes and Management of Sleepiness Among Pilots in a Norwegian and an Austrian Air Ambulance Service—A Comparative Study
  Zakariassen 2019, Air Medical Journal In the Evidence Library
  Calls for Investigate how sleep loss and sleepiness vary among individual pilots across a duty week. Discussion (limitations), p. 4
  Calls for Isolate the effect of shift systems using duty-week data, sleep diaries, time-of-day sleepiness ratings, actigraphy, reaction time tests, and workload measures. Discussion, p. 4
  Calls for Repeat the study among air ambulance pilots working 8-hour and 12-hour shifts. Discussion, p. 4
  “Further research is needed to isolate the effect of shift systems”
  In the authors’ words, p. 4
2. Evaluation of a New Helicopter Crew Transport Fatigue Assessment
  Bushmaker 2019, Air Medical Journal In the Evidence Library
  Calls for Study fatigue in crews whose shifts run longer than 24 hours, since no participating program scheduled shifts beyond 24 hours. Discussion, p. 4
  Calls for Study fatigue in transport programs that routinely perform ground, fixed wing, long-duration, and international transports. Discussion, p. 4
  Calls for Test the transport fatigue assessment in other high-risk shift-work occupations such as firefighters, emergency medical technicians, and nurses. Discussion, p. 4
  “More research is needed that addresses shift duration in excess of 24 hours”
  In the authors’ words, p. 4
3. Pilot Fatigue Survey: Exploring Fatigue Factors in Air Medical Operations
  Gregory 2010, Air Medical Journal In the Evidence Library
  Calls for Study sleep inertia in air medical pilots who sleep on duty during night shifts and are then called to fly. Future Considerations, p. 7
  Calls for Evaluate scheduling policies and practices to learn which are most effective at managing fatigue and which need revision. Future Considerations, p. 7
  Calls for Follow this exploratory survey with smaller, focused field studies, because self-reports of sleep and alertness are subjective and often inaccurate. Caveats, p. 4
  “the sleep inertia issue should be further studied”
  In the authors’ words, p. 7
4. Human Factors in Helicopter Air Ambulance Operations Annotated Bibliography (2014 – 2022)
  Baumgartner 2023 In the Evidence Library
  Calls for Conduct more fatigue research within the operating models under study, because scheduling findings from services working under different rules and structures may not transfer directly. Findings (Flightcrew Fatigue), p. 13
5. American Helicopter Emergency Medical Service Pilots Report to Work Despite High Rates of Sleepiness
  Kamine 2022, Air Medical Journal In the Evidence Library
  Calls for Survey a larger sample of HEMS pilots, possibly through Part 135 operators rather than a listserv, to measure fatigue burden and the barriers that keep pilots from declining flights. Discussion, p. 3; Conclusions, p. 3
  Calls for Determine whether pilots who felt they should have declined a flight were single pilots or on day or night shifts, whether adverse outcomes followed, and when in the flight they reached that judgment. Discussion, p. 3
  Calls for Compare sleepiness and fatigue during instrument flight rules versus visual flight rules flights, since IFR flights tend to be longer and more demanding. Discussion, p. 3
  Calls for Study fatigue mitigation for HEMS pilots, such as better pre-flight and post-flight sleep facilities, strategic napping, and caffeine use, including differences in scheduling practice. Discussion, p. 3
  “More research is necessary to quantify the burden of fatigue among HEMS pilots.”
  In the authors’ words, p. 1
Build on this questionAMSN-L-035
3papers
From the literatureFatigue and schedulingOperational safetyClinical and patient safety
Does a validated fatigue measure for transport crews predict performance or safety events?
Published 2018 to 2019
What the 3 papers ask for on this topic
1. Training and assessment of non-technical skills in Norwegian helicopter emergency services: a cross-sectional and longitudinal study
  Rasmussen 2019, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine In the Evidence Library
  Calls for Fatigue survey instruments built and tested for emergency medical services are needed, given no agreed definition of fatigue and few validated tools for these workers. Discussion, p. 8
  Calls for HEMS-specific behavioural marker tools such as AeroNOTS need full validation, and systematic assessment of non-technical skills, including fatigue management, should become a focus. Discussion, p. 8; Conclusion, p. 9
2. Evaluation of a New Helicopter Crew Transport Fatigue Assessment
  Bushmaker 2019, Air Medical Journal In the Evidence Library
  Calls for Study fatigue in crews whose shifts run longer than 24 hours, since no participating program scheduled shifts beyond 24 hours. Discussion, p. 4
  Calls for Study fatigue in transport programs that routinely perform ground, fixed wing, long-duration, and international transports. Discussion, p. 4
  Calls for Test the transport fatigue assessment in other high-risk shift-work occupations such as firefighters, emergency medical technicians, and nurses. Discussion, p. 4
  “More research is needed that addresses shift duration in excess of 24 hours”
  In the authors’ words, p. 4
3. Operational Impact of a Critical Care Transport Duty Time Tool Implementation: A Quality Improvement Project to Enhance Crew and Patient Safety
  Sorensen 2018, Air Medical Journal In the Evidence Library
  Calls for Refine the duty time risk assessment tool so it accounts for patient acuity in relation to scene times. Conclusion, p. 5
  “refining the tool further to take acuity into account related to scene times”
  In the authors’ words, p. 5
Build on this questionAMSN-L-036
2papers
From the literatureFatigue and schedulingOperational safety
Which mitigations, such as on-duty rest facilities, strategic napping, and caffeine, reduce sleep inertia and fatigue for crews called to fly from on-duty sleep?
Published 2010 to 2022
What the 2 papers ask for on this topic
1. Pilot Fatigue Survey: Exploring Fatigue Factors in Air Medical Operations
  Gregory 2010, Air Medical Journal In the Evidence Library
  Calls for Study sleep inertia in air medical pilots who sleep on duty during night shifts and are then called to fly. Future Considerations, p. 7
  Calls for Evaluate scheduling policies and practices to learn which are most effective at managing fatigue and which need revision. Future Considerations, p. 7
  Calls for Follow this exploratory survey with smaller, focused field studies, because self-reports of sleep and alertness are subjective and often inaccurate. Caveats, p. 4
  “the sleep inertia issue should be further studied”
  In the authors’ words, p. 7
2. American Helicopter Emergency Medical Service Pilots Report to Work Despite High Rates of Sleepiness
  Kamine 2022, Air Medical Journal In the Evidence Library
  Calls for Survey a larger sample of HEMS pilots, possibly through Part 135 operators rather than a listserv, to measure fatigue burden and the barriers that keep pilots from declining flights. Discussion, p. 3; Conclusions, p. 3
  Calls for Determine whether pilots who felt they should have declined a flight were single pilots or on day or night shifts, whether adverse outcomes followed, and when in the flight they reached that judgment. Discussion, p. 3
  Calls for Compare sleepiness and fatigue during instrument flight rules versus visual flight rules flights, since IFR flights tend to be longer and more demanding. Discussion, p. 3
  Calls for Study fatigue mitigation for HEMS pilots, such as better pre-flight and post-flight sleep facilities, strategic napping, and caffeine use, including differences in scheduling practice. Discussion, p. 3
  “More research is necessary to quantify the burden of fatigue among HEMS pilots.”
  In the authors’ words, p. 1
Build on this questionAMSN-L-037
2papers
From the literatureFatigue and schedulingOperational safety
How is crew fatigue related to decisions to decline, delay, or abort flights?
Published 2022 to 2026
What the 2 papers ask for on this topic
1. American Helicopter Emergency Medical Service Pilots Report to Work Despite High Rates of Sleepiness
  Kamine 2022, Air Medical Journal In the Evidence Library
  Calls for Survey a larger sample of HEMS pilots, possibly through Part 135 operators rather than a listserv, to measure fatigue burden and the barriers that keep pilots from declining flights. Discussion, p. 3; Conclusions, p. 3
  Calls for Determine whether pilots who felt they should have declined a flight were single pilots or on day or night shifts, whether adverse outcomes followed, and when in the flight they reached that judgment. Discussion, p. 3
  Calls for Compare sleepiness and fatigue during instrument flight rules versus visual flight rules flights, since IFR flights tend to be longer and more demanding. Discussion, p. 3
  Calls for Study fatigue mitigation for HEMS pilots, such as better pre-flight and post-flight sleep facilities, strategic napping, and caffeine use, including differences in scheduling practice. Discussion, p. 3
  “More research is necessary to quantify the burden of fatigue among HEMS pilots.”
  In the authors’ words, p. 1
2. Pressure to Fly and Phase of Flight Analysis in Helicopter Air Ambulance Accidents
  Griffin 2026, Air Medical Journal In the Evidence Library
  Calls for Measure pressure to fly directly in every operational phase, testing whether organizational, interpersonal, identity, fatigue, and environmental sources differ by phase and whether pressure is one construct or several related ones. Discussion, p. 5
  Calls for Study the human factors of the period after patient handoff, including shifts in workload, vigilance, situational awareness, fatigue, and priorities, using qualitative work with pilots and medical crew. Discussion, p. 5
  “Future research should examine whether organizational expectations, interpersonal influences, professional identity”
  In the authors’ words, p. 5
Build on this questionAMSN-L-038
Weather and flight conditions
10 papers state a direction on this topic. 1 proposed question.
Papers ask how crews obtain and use weather information for go, no-go, and continue decisions, and how altitude and other environmental stressors combine to affect performance. Accident analyses by weather and lighting appear under Accidents and accident data.
3papers
From the literatureWeather and flight conditionsOperational safety
How do pilots and operators obtain, interpret, and apply weather information in go, no-go, and continue decisions, and where do gaps occur?
Published 2014 to 2024
What the 3 papers ask for on this topic
1. Human Factors Analysis of Helicopter Air Ambulance Accidents, Incidents, and Events (2013-2023)
  Baumgartner 2024 In the Evidence Library
  Calls for Examine operator and pilot training on finding and using reliable, authoritative weather sources for go, no-go, and continue decisions, to locate weaknesses and mitigations. Finding 2 Research Opportunities, p. 19
  Calls for Examine current training for non-normal conditions such as high-density operations, night flight, and low visibility. Finding 4 Research Opportunities, p. 21
2. An Analysis of Helicopter EMS Accidents using HFACS: 2000-2012
  Bryan 2014, Master's thesis, Embry-Riddle Aeronautical University In the Evidence Library
  Calls for Investigate why many HEMS pilots knowingly violate weather minima, contrasting pilot motivation when minima are violated with cases where they are not. Discussion, p. 31; Future directions, p. 35
  “further investigation is indicated. Investigation into pilot motivation when intentionally violating weather minima”
  In the authors’ words, p. 35
3. Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019
  NTSB 2020, National Transportation Safety Board In the Evidence Library
  Calls for Review flight risk assessments of all helicopter air ambulance operators for compliance with the risk analysis regulation and advisory circular guidance, including en route weather and prior flight refusals. Recommendations (A-20-14), p. 71
Build on this questionAMSN-L-039
Crew communication and speaking up
9 papers state a direction on this topic. 3 proposed questions.
Papers ask how often concerns are raised and heard during normal operations, what is associated with transport clinicians raising concerns or questioning authority, and how non-technical skills and communication errors can be measured.
3papers
From the literatureCrew communication and speaking upOperational safetyClinical and patient safety
How often are safety concerns voiced during routine flights, and how are they received and acted on?
Published 2009 to 2025
What the 3 papers ask for on this topic
1. Safety Listening in High-Risk Situations: A Qualitative Analysis of Responses to Safety Voice in Aviation
  Pandolfo 2025, Risk Analysis In the Evidence Library
  Calls for Adapt the safety listening behavior framework to other high-risk industries such as healthcare, to direct in situ observation, and to training language models that flag listening behaviors in large datasets. Discussion (Theoretical and Practical Considerations), p. 20
  Calls for Test whether listeners engage more readily with safety concerns that fit their existing understanding than with concerns that surprise them. Discussion (Implications for the Literatures), p. 20
  Calls for Study whether a voiced concern was actually heard and understood as a step between speaking up and listening, and build hearing failures into theoretical models. Discussion (Implications for the Literatures), p. 20
  Calls for Establish how often safety voice, safety listening, and misguided concerns occur during normal flights, for example by analyzing transcripts of instructional flights. Limitations, p. 20
  Calls for Measure naturalistic safety listening outside aviation, as a leading indicator through routine in situ monitoring, and in written channels such as email. Limitations, p. 21
  Calls for Analyze incidents where survivor interview transcripts are public, comparing recorded in situ conversation with recalled thoughts and behaviors and with official incident reports. Limitations, p. 21
  “Future research may adapt this framework for other high-risk industries”
  In the authors’ words, p. 20
2. Transport Nurse Safety Practices, Perceptions, and Experiences: The Air and Surface Transport Nurses Association Survey
  Frakes 2009, Air Medical Journal In the Evidence Library
  Calls for Replicate studies of nurses speaking up about poor teamwork or errors in the transport setting, and examine why about one in six transport nurses feel unable to raise safety concerns. Discussion, p. 4
3. Perceived patient safety culture in a critical care transport program
  Erler 2013, Air Medical Journal In the Evidence Library
  Calls for Investigate communication openness further in the transport context, including willingness to question decisions made by people in authority. Discussion, p. 6
Build on this questionAMSN-L-041
3papers
From the literatureCrew communication and speaking upOperational safetyClinical and patient safety
What factors are associated with transport clinicians' willingness to raise safety concerns and to question decisions made by people in authority, and which interventions change it?
Published 2009 to 2024
What the 3 papers ask for on this topic
1. Transport Nurse Safety Practices, Perceptions, and Experiences: The Air and Surface Transport Nurses Association Survey
  Frakes 2009, Air Medical Journal In the Evidence Library
  Calls for Replicate studies of nurses speaking up about poor teamwork or errors in the transport setting, and examine why about one in six transport nurses feel unable to raise safety concerns. Discussion, p. 4
2. Perceived patient safety culture in a critical care transport program
  Erler 2013, Air Medical Journal In the Evidence Library
  Calls for Investigate communication openness further in the transport context, including willingness to question decisions made by people in authority. Discussion, p. 6
3. The effects of psychological safety and employee voice behavior on flight attendants’ mindful safety practices adoption
  Hu 2024, Frontiers in Public Health In the Evidence Library
  Calls for Extend the model to other job roles, other high-risk industries, and other national cultures beyond Chinese flight attendants. Limitations and future research direction, p. 11
  Calls for Examine further mediating variables that may link psychological safety to the adoption of mindful safety practices, beyond voice behavior. Limitations and future research direction, p. 11
  “future research should target different job positions and cultures”
  In the authors’ words, p. 11
Build on this questionAMSN-L-042
2papers
From the literatureCrew communication and speaking upOperational safety
Can behavioral marker systems reliably measure non-technical skills in air medical crews?
Published 2012 to 2019
What the 2 papers ask for on this topic
1. Training and assessment of non-technical skills in Norwegian helicopter emergency services: a cross-sectional and longitudinal study
  Rasmussen 2019, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine In the Evidence Library
  Calls for HEMS-specific behavioural marker tools such as AeroNOTS need full validation, and systematic assessment of non-technical skills, including fatigue management, should become a focus. Discussion, p. 8; Conclusion, p. 9
2. Aeronautical Decision Making in Helicopter Emergency Medical Systems (HEMS): The Effect of Mission Orientation and Local Base Finances on the Go/No Go Decision
  Cline 2012, Master's thesis, University of North Dakota In the Evidence Library
  Calls for Examine how large the pilot versus medical crew differences in go/no-go attitudes are and whether they stem from personality or education, differ from non-flying peers, or vary by gender. Further Research, p. 91
  “The preliminary findings indicating a difference may exist along occupational lines beg further investigation”
  In the authors’ words, p. 91
Build on this questionAMSN-L-043
Patient safety and adverse events
8 papers state a direction on this topic. 1 proposed question.
Papers ask how often adverse events occur in transport, how patient factors, transport duration, and clinician experience interact, and whether crew configuration affects measured patient safety.
2papers
From the literaturePatient safety and adverse eventsOperational safety
How common are adverse events in air medical transport, and which human factors contribute to them?
Published 2012 to 2021
What the 2 papers ask for on this topic
1. Safety culture in the air ambulance services
  Abrahamsen 2012, Tidsskrift for Den norske legeforening In the Evidence Library
  Calls for Measure patient safety climate among operational air ambulance staff nationwide to identify strengths and weaknesses, guide improvements, and track change over time. Measuring patient safety climate (Målinger av pasientsikkerhetsklima), p. 1; Conclusion (Konklusjon), p. 1
  Calls for Study the human factors involved in adverse events in air ambulance care, whose frequency in this service is currently unknown. Adverse events (Uønskede hendelser), p. 1; Measuring patient safety climate, p. 1
2. A Bayesian Approach on Investigating Helicopter Emergency Medical Fatal Accidents
  Simonson 2021, Aerospace Medicine and Human Performance In the Evidence Library
  Calls for Build a research framework for data-driven analysis of HEMS accident risk and of the added risk that air transport places on patients. Discussion, p. 6
  Calls for Study how much additional risk HEMS flights carry for patients, passengers, and medical providers compared with the benefit of transport. Discussion, p. 6
  “Future research should explore the increased risk HEMS flights”
  In the authors’ words, p. 6
Build on this questionAMSN-L-046
Aircraft, technology, and maintenance
6 papers state a direction on this topic. 2 proposed questions.
Papers ask whether specific technologies help, how risk differs across aircraft models and configurations once exposure is known, and whether flight data monitoring is associated with fewer safety events.
3papers
From the literatureAircraft, technology, and maintenanceOperational safety
How do accident risk and severity differ across aircraft models and configurations when flight exposure is known?
Published 2011 to 2020
What the 3 papers ask for on this topic
1. Helicopter Type and Accident Severity in Helicopter Emergency Medical Services Missions
  Hinkelbein 2011, Aviation, Space, and Environmental Medicine In the Evidence Library
  Calls for Gather denominator data, such as flight hours or missions by helicopter model, so that accident and injury risk can be compared across aircraft types. Discussion, p. 5
2. Statistical learning for turboshaft helicopter accidents using logistic regression
  Subagia 2020, PLOS ONE In the Evidence Library
  Calls for Extend the analysis from accidents to incidents, the lower-damage events excluded here, as a source of further safety learning. Data and methods, p. 3
3. Fixed-Wing Medical Transport Crashes: Characteristics Associated with Fatal Outcomes
  Handel 2011, Air Medical Journal In the Evidence Library
  Calls for Carry out longitudinal analysis with more cases to gain power to separate fatal from nonfatal fixed-wing medical crashes, including whether fire or the crash mechanism drives fatality. Conclusions, pp. 3-4
  “is needed to increase the power of the study and its ability to detect differences”
  In the authors’ words, p. 4
Build on this questionAMSN-L-051
2papers
From the literatureAircraft, technology, and maintenanceOperational safety
Is the use of flight data monitoring associated with fewer safety events?
Published 2017 to 2020
What the 2 papers ask for on this topic
1. Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019
  NTSB 2020, National Transportation Safety Board In the Evidence Library
  Calls for Determine how widely Part 135 operators have adopted the FAA voluntary safety management system program, and measure how well SMS mitigations address identified safety risks. Analysis, Safety Management Systems, p. 55 to 56
  “it is necessary to measure how effective a mitigation is in addressing a safety risk”
  In the authors’ words, p. 55
2. The Effects of SMS Implementation on Safety Culture within Helicopter Emergency Medical Services
  Gardner 2017, Master's thesis, University of North Dakota In the Evidence Library
  Calls for Repeat the study with a much larger and regionally balanced sample to test whether SMS adoption among operators relates to the recent decline in accidents. Future Research, p. 70
  “For that research it would need a much bigger sample size”
  In the authors’ words, p. 70
Build on this questionAMSN-L-052
Night vision and night operations
4 papers state a direction on this topic. 1 proposed question.
Four papers point to night operations by pilots with limited air medical experience.
4papers
From the literatureNight vision and night operationsOperational safety
What risk factors and interventions are associated with fatal night loss-of-control and controlled flight into terrain accidents among pilots with limited air medical experience?
Published 2016 to 2024
What the 4 papers ask for on this topic
1. Pilot Decision Making in Weather-Related Night Fatal Helicopter Emergency Medical Service Accidents
  Aherne 2018, Aerospace Medicine and Human Performance In the Evidence Library
  Calls for Identify additional risk factors and preventive interventions for fatal night loss-of-control and controlled flight into terrain accidents involving pilots with limited HEMS experience. Discussion, p. 7
  “More research is required to identify further risk factors and preventative interventions”
  In the authors’ words, p. 7
2. Pilot Domain Task Experience in Night Fatal Helicopter Emergency Medical Service Accidents
  Aherne 2016, Aerospace Medicine and Human Performance In the Evidence Library
  Calls for Separate night and instrument flight hours by fixed wing and rotary wing time when analyzing pilot experience, because the source data did not allow this distinction. Discussion (methodological limitations), p. 6
3. Medical Helicopter Accident Review: Causes and Contributing Factors
  Greenhaw 2021 In the Evidence Library
  Calls for Analyze in depth the factors that separate fatal from non-fatal EMS accidents, such as visibility and darkness, pilot judgment, pilot medical certificate class, and absence of a second pilot. Discussion, p. 28
4. Human Factors Analysis of Helicopter Air Ambulance Accidents, Incidents, and Events (2013-2023)
  Baumgartner 2024 In the Evidence Library
  Calls for Examine current training for non-normal conditions such as high-density operations, night flight, and low visibility. Finding 4 Research Opportunities, p. 21
Build on this questionAMSN-L-053
Pediatric and specialty transport
2 papers state a direction on this topic. 1 proposed question.
Two papers raise directions here.
2papers
From the literaturePediatric and specialty transportClinical and patient safety
For which obstetric, neonatal, and pediatric patients does air transport change outcomes, and how should these patients be selected?
Published 2021 to 2022
What the 2 papers ask for on this topic
1. Appropriate Air Medical Services Utilization and Recommendations for Integration of Air Medical Services Resources into the EMS System of Care: A Joint Position Statement and Resource Document of NAEMSP, ACEP, and AMPA
  Lyng 2021, Prehospital Emergency Care In the Evidence Library
  Calls for Research patient selection for air transport of high-risk obstetric and neonatal patients and the effect of air transport on maternal and neonatal outcomes. Obstetric and Neonatal Emergencies, p. 8
2. Helicopter versus ground ambulance transport for interfacility transfer of critically ill children
  Joseph 2022, The American Journal of Emergency Medicine In the Evidence Library
  Calls for Use multicenter databases to build larger cohorts with enough power to detect small but clinically meaningful outcome differences by transport mode. Limitations, p. 6
  Calls for Link long-term patient cohorts to interhospital transport records to capture functional and other patient-centered outcomes that may depend on timely retrieval. Limitations, p. 6
  Calls for Assess the value of helicopter versus ground transport with granular cost data and decision-analytic models that identify break-even points, ideally designed prospectively for local systems. Limitations and Conclusion, p. 6
  “Further research, such as decision-analytic models that incorporate a range of potential costs”
  In the authors’ words, p. 6
Build on this questionAMSN-L-056
Resuscitation and airway management
2 papers state a direction on this topic. 1 proposed question.
Two papers raise directions here.
2papers
From the literatureResuscitation and airway managementClinical and patient safety
Which airway, breathing, and circulation practices in transport, including blood product administration, are associated with better outcomes?
Published 2013 to 2021
What the 2 papers ask for on this topic
1. Helicopter Transport of Trauma Patients Improves Survival Irrespective of Transport Time
  Schneider 2021, The American Surgeon In the Evidence Library
  Calls for Identify why air transport was linked to better survival than ground transport, including the possible roles of onboard blood products and advanced flight crew training. Discussion, p. 4
2. A blueprint for critical care transport research
  Jaynes 2013, Air Medical Journal In the Evidence Library
  Calls for Clinical and training priorities include features that predict the value of air transport, evidence-based airway, breathing, and circulation management in transport, and the effect of crew training and certification on outcomes. Discussion, Table 2, p. 4
Build on this questionAMSN-L-057

How these questions were drawn. For this first edition, AMSN read the full text of 75 research papers from the Evidence Library. 63 of them state at least one direction for future research, and 12 do not. We recorded 177 directions, grouped them under the library's topics, and wrote 40 questions that restate what two or more papers ask for. 53 papers support at least one question.

The wording of each question, and each "Calls for" line, is ours. Text in quotation marks is the authors' own, with the page where it appears. The number of papers behind a question shows how many authors have asked for it. It is not a measure of importance.

Papers we could not obtain in full text are not yet included, so some topics rest on only one or two papers. These questions are proposals for discussion, not findings. Listing a paper does not mean AMSN endorses its methods or conclusions. Two of the papers are by the AMSN founder, Griffin 2026 and Benton and Griffin 2026. Their directions were recorded and grouped the same way as the others. To refine a question, use "Build on this question." First edition, October 31, 2026.

Where are the greatest opportunities for research?

Where the literature points

Questions

Accidents and accident data

What are air medical accident and fatal accident rates per 100,000 flight hours, by aircraft category and phase of flight, when complete exposure data are available?

To what extent is the decline in fatal accidents over the past two decades attributable to regulatory, technology, and safety management changes, rather than to changes in flight volume or mission mix?

Which flight, environmental, and pilot factors distinguish accident flights from comparable nonaccident flights, and fatal from nonfatal accidents?

What do near-miss reports, aborted flights, and other events without harm show about organizational and supervisory contributors that accident investigations rarely capture?

Safety culture and organizations

Is the extent of safety management system implementation among air medical operators associated with accident, incident, or near-miss rates?

How prevalent are operational and economic performance pressures, such as pressure to shorten lift-off times or to accept flights, and do they differ by phase of flight?

Can a safety culture instrument validated for dispersed, multidisciplinary transport teams support benchmarking across programs and over time?

What factors are associated with low reporting of errors and near misses in transport programs, and which changes to reporting systems increase reporting?

Utilization and triage

Which field triage criteria identify injured patients who gain survival or functional benefit from helicopter transport, and how does that benefit vary with distance or time to definitive care?

What overtriage rate is acceptable for helicopter transport of trauma patients, and how should overtriage be defined and measured?

Can validated criteria identify interfacility trauma and burn patients for whom ground transport yields equivalent outcomes, and what is the effect on cost?

How reliably do national prehospital data systems capture annual air medical transport volumes when checked against counts reported by programs?

Regulation and policy

How widely have air medical operators adopted voluntary safety programs such as flight data monitoring, and what challenges do they report in implementing them?

What activity data, such as flight hours, missions, and transport volumes, do air and ground medical transport services report, and is that reporting complete enough to calculate accident rates?

Do the flight risk assessment tools in use address the elements that regulations and guidance specify, such as en route weather and prior declines of the same flight?

Decision-making and risk

What factors are associated with decisions to continue flight into deteriorating or below-minimum weather, compared with flights that are delayed, diverted, or aborted?

Does structured risk assessment applied to every phase of flight, including return-to-base and repositioning, change risk decisions and safety outcomes compared with assessment at patient acceptance only?

Do pilots and medical crew differ in go and no-go judgments for the same scenarios, and what explains any differences?

How do total flight experience and air medical experience relate to pilot risk acceptance and accident involvement?

Clinical care and patient outcomes

What accounts for survival differences between air and ground transport of injured patients, such as onboard blood products, crew training, and transport time?

For which time-sensitive conditions beyond trauma, such as stroke subtypes, obstetric emergencies, and threatened airways, does air transport change patient outcomes?

When prehospital, hospital, and long-term follow-up records are linked, do functional and patient-centered outcomes differ by transport mode?

Training and simulation

Does simulation-based training, technical and non-technical, improve measured operational performance and patient outcomes, beyond learner satisfaction and self-report?

Do low-cost or immersive simulators with realistic stressors improve pilot responses to inadvertent entry into instrument meteorological conditions?

How often must safety training repeat to maintain knowledge and skill for rare, high-risk events?

Where do transport clinicians report gaps in safety readiness and competency, and how do those gaps relate to experience and training?

Fatigue and scheduling

Which shift lengths and scheduling practices are associated with lower fatigue and better alertness among pilots and medical crew, across the shift systems and operating contexts in use?

Does a validated fatigue measure for transport crews predict performance or safety events?

Which mitigations, such as on-duty rest facilities, strategic napping, and caffeine, reduce sleep inertia and fatigue for crews called to fly from on-duty sleep?

How is crew fatigue related to decisions to decline, delay, or abort flights?

Weather and flight conditions

How do pilots and operators obtain, interpret, and apply weather information in go, no-go, and continue decisions, and where do gaps occur?

Crew communication and speaking up

How often are safety concerns voiced during routine flights, and how are they received and acted on?

What factors are associated with transport clinicians' willingness to raise safety concerns and to question decisions made by people in authority, and which interventions change it?

Can behavioral marker systems reliably measure non-technical skills in air medical crews?

Patient safety and adverse events

How common are adverse events in air medical transport, and which human factors contribute to them?

Aircraft, technology, and maintenance

How do accident risk and severity differ across aircraft models and configurations when flight exposure is known?

Is the use of flight data monitoring associated with fewer safety events?

Night vision and night operations

What risk factors and interventions are associated with fatal night loss-of-control and controlled flight into terrain accidents among pilots with limited air medical experience?

Pediatric and specialty transport

For which obstetric, neonatal, and pediatric patients does air transport change outcomes, and how should these patients be selected?

Resuscitation and airway management

Which airway, breathing, and circulation practices in transport, including blood product administration, are associated with better outcomes?