In 1915, the American College of Surgeons (ACS), recognizing the need to standardize patient care in hospitals, allocated $500.00 to establish standards to promote quality patient care. ⁵ Hospitals in 1915 were not necessarily places patients went to be cured but places patients went to die. Medical knowledge was minuscule compared with today’s world. Penicillin had not yet been discovered, and although aseptic technique was used in surgery, no effective medications were available to manage postoperative infections. ⁷

By 1917, the ACS developed a one-page list of requirements they called Minimum Standards for Hospitals.

An on-site inspection was developed by the ACS in 1918 to determine whether hospitals with more than 100 beds could meet compliance with the Minimum Standards for Hospitals. More than 700 hospitals throughout the United States were evaluated in the first year, and only 89 (13%) met the requirements of the Minimum Standards. Although these results were dismal, the inspection raised the awareness of the medical community, who were ready to accept the need for standardization and a verification process to improve quality.

More than 3000 hospitals were voluntarily surveyed by 1951. With the growth and overwhelming success of voluntary accreditation for hospitals, the ACS organization became overwhelmed and invited other organizations to participate. The Joint Commission on Accreditation of Hospitals (JCAH) was chartered in 1951 with the ACS and the following participating organizations: the American College of Physicians, the American Medical Association, the Canadian Medical Association, and the American Hospital Association.

Later in the 1950s, the Canadian Medical Association withdrew to form its own national organization, and JCAH expanded to include healthcare outside the hospital environment, such as home health, mental health, and ambulatory healthcare. This expansion eventually resulted in a name change to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), known as the Joint Commission today.

The Joint Commission was well established before standards even existed for medical transport. In fact, problems in transport were not even identified until 1966 when the White Paper entitled “Accidental Death and Disability: The Neglected Disease of Modern Society”² was published by the National Academy of Science. At that time, helicopter transport for the civilian population was unheard of, and standardization did not exist for ground transport vehicles or for the medical attendants who accompanied patients. Untrained personnel in the back of a mortician’s vehicle did 50% of ground transports. Fire, police, or volunteer groups did the other 50% of the transports.

The White Paper triggered legislation that specifically addressed emergency medical services (EMS) and even suggested the use of helicopters. ⁵

The Maryland State Police Aviation Division developed the earliest known public service helicopter system in 1969. A few hospital-based helicopter programs were seen by the mid 1970s, but the growth of these types of services did not really peak until the mid 1980s. At this time, hospitals were regionalizing, with specific hospitals recognized as centers of excellence in one or more specialty areas. Trauma center designation often included a helicopter program or access to a helicopter program, which was an added impetus to the growth in the number of helicopter services.

Also, the Vietnam experience proved a sharp decrease in mortality rates because of the rapid response of helicopters in transporting the injured from the field to definitive care. From a civilian perspective, the Golden Hour theory by Dr R. Adams Cowley of the Shock Trauma Unit of Baltimore proposed that a critically injured patient had a precious 60 minutes to obtain definitive surgical treatment after an injury to survive. ⁸ The Golden Hour theory and the Vietnam experience⁶ were frequently touted as reasons for a hospital, especially a trauma center, to start a helicopter service.

In 1980, a new organization, the Association of Hospital Based Emergency Air Medical Services (ASHBEAMS; the name was later changed to the Association of Air Medical Services [AAMS]) was formed. This organization started as a forum for administrators and personnel to get together and network with other hospital-based helicopter programs. No standards were available at this time, so those assigned to start up a hospital-based helicopter program usually had no air transport experience, no pattern to follow, and no awareness of the potential hazards and managers who understood the risks even less. The aviation component (aircraft, pilots, and maintenance) was contracted from an aviation vendor. Pilots were usually Vietnam survivors who were still operating under the oath they practiced in the military—complete the mission. Care providers were thrust into the unfamiliar aviation environment without standardized transport training and with the ingrained attitude that the patient, not safety, always comes first. Clearly all were well intentioned, but as more and more accidents began to occur, it was recognized that the profession needed standardization, not unlike the ACS recognized the need for standards in hospitals in the early 1900s.

In 1985, 16 air medical accidents with 12 fatalities occurred. ⁴ The Federal Aviation Administration (FAA) was concerned, and the press began to alert the public. At the time, ASHBEAMS had minimal guidelines addressing patient care issues, but when the press started to focus on the number of air medical accidents, ASHBEAMS began to meet with other national groups, such as the Helicopter Association International (HAI), the National Flight Nurses Association (NFNA), National Flight Paramedics Association (NFPA), and the National EMS Pilots Association (NEMSPA), to develop consensus standards on safety and operational practices.

In 1986, the ASHBEAMS Safety Committee started a peer review safety audit called Priority One, with use of the safety guidelines that had been developed through the consensus process of the organizations listed previously. Priority One was beta-tested at Duke University in Durham, NC, and at the Staff for Life Program in Columbia, Mo. As a result of these visits, the Safety Committee found that patient care standards specific to the transport environment were needed as were the safety guidelines to make the process complete. Therefore, a feasibility study was performed to determine the need and viability of an accreditation program specifically for air medial transport.

Part of the feasibility study involved dialogue with the Joint Commission and other accrediting bodies. Many organizational leaders felt that the Joint Commission should incorporate transport standards into its accreditation process and then layer in the air medical profession, which would negate the expense and effort needed to create another accrediting agency. However, the Joint Commission was not interested in responsibility for standards addressing the aviation environment, stating that it was completely out of their field of expertise. Also, in the late 1980s, helicopter services were starting to be outsourced or privately owned and no longer sponsored or based at hospitals. Typically, fixed-wing medical transport services were privately owned and operated by an aviation company with no connections to hospitals. Both types of services were completely outside the realm of the Joint Commission.

In 1989, with the feasibility study completed and presented, ASHBEAMS members voted to fund start-up costs for an air medical accreditation agency. Conceptually, this organization would be separate and independent of ASHBEAMS and would be made up of member organizations, so each member organization had equal representation on the Board of Directors.

The following seven organizations met on July 13, 1990, in Kansas City, Mo, to form the Commission on Accreditation of Air Medical Services (CAAMS): the American College of Emergency Physicians, the Association of Air Medical Services, the National Association of Air Medical Communication Specialists, the National Association of EMS Physicians, the National EMS Pilots Association, the National Flight Nurses Association (now called Air and Surface Transport Nurses Association [ASTNA]), and the National Flight Paramedics Association.

The Commission on Accreditation of Air Medical Services was formally incorporated in the state of Pennsylvania as a nonprofit organization. The mission of CAAMS was and is to improve the quality of patient care and safety of the transport environment. Along with the tools for the new organization’s foundation, such as the articles of incorporation, policies, and bylaws, the most important task for the new board was to develop the accreditation standards.

All accrediting organizations have a similar process of site visits, usually every 3 years, to verify compliance with standards. But the standards are what define the site survey process. Medical transport services that apply for accreditation are awarded or are withheld from accreditation based on compliance with the accreditation standards. Therefore, the standards must be attainable, measurable, and consistent with current practice.

To gain acceptance of the accreditation standards, CAAMS used guidelines and standards from many of the organizations mentioned previously (ASHBEAMS, HAI, NFNA, NEMSPA, and NFPA) to begin the process. In an attempt to create a document that would address both safety and patient care issues, the CAAMS board studied the National Transportation Safety Board’s (NTSB) accident reports to determine whether a standardized practice, policy, or procedure could have prevented an accident. The CAAMS board also worked with officials from the FAA who were specifically assigned to be a liaison with the air medical profession.