Transcript Document

Chapter 1
EMS Systems
National EMS Education
Standard Competencies
Preparatory
Integrates comprehensive knowledge of the
EMS system, safety/well-being of the
paramedic, and medical/legal and ethical
issues, which is intended to improve the
health of EMS personnel, patients, and the
community.
National EMS Education
Standard Competencies
Emergency Medical Services (EMS)
Systems
– EMS systems
– History of EMS
– Roles/responsibilities/professionalism of EMS
personnel
– Quality improvement
– Patient safety
National EMS Education
Standard Competencies
Research
– Impact of research on emergency medical
responder (EMR) care
– Data collection
– Evidence-based decision making
– Research principles to interpret literature and
advocate evidence-based practice
Introduction
• The EMS system
is constantly
evolving.
– Originally, the
primary role was
transportation.
• As a paramedic,
you will encounter
many different
situations.
© Mark C. Ide
Introduction
• The public’s perception of you is based on:
– TV and articles
– Your treatment of their loved ones
• Continued education is a must.
• Treat everyone with respect and dignity.
The History of EMS
• 1485
– First use of an
ambulance
– Transport only
• 1800s
– First use of
ambulance/
attendant to care
for injuries on site
• 1926
– Service started
similar to present
day
• 1940s
– EMS turned over to
fire and police
departments
– No standards set
© National Library of Medicine
The 20th Century and Modern
Technology
• EMS made major
strides after WWII.
– Bringing hospital to
field gave patients
a better chance for
survival
– Korean War
• First use of a
helicopter
• M*A*S*H units
The 20th Century and Modern
Technology
• 1956
– Mouth-to-mouth resuscitation developed
• Late 1950s/early 1960s
– Focus shifted to bringing hospital to patients
– MICUs developed
The 20th Century and Modern
Technology
• 1965: “The White Paper” released
– Findings included:
• Lack of uniform laws and standards
• Poor-quality equipment
• Lack of communication
• Lack of training
The 20th Century and Modern
Technology
• “The White Paper” findings outlined 10
critical points for EMS system
– Led to National Highway Safety Act
– Created US Department of Transportation
• 1968
– Training standards implemented
– 9-1-1 created
The 20th Century and Modern
Technology
• 1969
– First true
paramedic
program
– Standards for
ambulance design
and equipment
• 1970s
– NREMT began
Courtesy of Eugene L. Nagel and the Miami Fire Department
The 20th Century and Modern
Technology
• 1970s (cont’d)
– 1971: Emergency Care and Transportation of
the Sick and Injured published by the AAOS
– 1973: Emergency Medical Services System Act
– 1977: First National Standard Curriculum for
Paramedics developed by US DOT
The 20th Century and Modern
Technology
• 1980s/1990s
– Number of trained personnel grew
– NHTSA developed 10 system elements to help
sustain EMS system
– Responsibility for EMS transferred to the states
– Major legislative initiatives
Licensure, Certification, and
Registration
• Certification examination:
– Ensures all health care providers have the
same basic level of knowledge and skill
– Once you pass certification you can apply for
state licensure.
Licensure, Certification, and
Registration
• Licensure:
– How states control
who practices
– Also known as
certification or
credentialing
– Unlawful to
practice without
licensure
• Holding a license
shows you:
– Completed initial
education
– Met the
requirements to
achieve the license
• Paramedics are
required to receive
medical direction.
Licensure, Certification, and
Registration
• You may be required to be registered and
licensed.
– Board of registration holds your:
• Education records
• State or local licensure
• Recertification
Licensure, Certification, and
Registration
• Reciprocity
– Certification granted from another state/agency
– Requirements:
• Hold a current state certification.
• Be in good standing.
• National Registry certification.
The EMS System
• A complex network of coordinated services
that provides care to the community
• The public needs to be taught how to:
• Recognize emergencies.
• Activate the EMS system.
• Provide basic care.
The EMS System
• Patient outcomes determined by:
– Bystander care
– Transportation
– Dispatch
– Response
– Emergency
department care
– Prehospital care
– Definitive care
– Rehabilitation
The EMS System
• Dispatchers
– Usually the public’s first contact
– Training level varies by state
• Scene may differ from what dispatcher
relays
The EMS System
• As a paramedic, you must:
– Develop care plan
– Decide on transport method
– Determine receiving facility
– Be active in your community.
Levels of Education
• EMS system functions from a federal to
local level
– Federal: National EMS Scope of Practice Model
– State: Licensure
– Local: Medical director decides day-to-day limits
Levels of Education
• The national guidelines designed to create
more consistent delivery of EMS nationally
– Medical director can only limit scope of practice
• 2009: National EMS Education Standards
– NREMT provides a national standard for testing
and certification
The Dispatcher
© Peter Casolino/Alamy Images
• Plays a critical role
– Receives and
enters information
– Interprets it
– Relays it to
appropriate service
• Some locations
train EMDs
– Give prearrival
instructions
Emergency Medical Responder
(EMR)
• Formerly “first
responder”
• Requirements vary
by state
• Should be able to:
– Recognize
seriousness of
condition.
– Provide basic care.
– Relay information.
© Matt Dunham/AP Photosages
EMT
© Amanda Herron, The Jackson Sun/AP Photos
• Formerly EMT-B
• Primary provider
level in many EMS
systems
• EMT certification
precedes paramedic
education
• Most populous level
in the system
Advanced EMT (AEMT)
• Formerly EMT-I
• Initially developed in 1985
– Major revision in 1999
• Trained in:
• More advanced pathophysiology
• Some advanced procedures
Paramedic
• Highest level to be nationally certified
– 1999: Major revisions to curriculum greatly
increased level of training and skills
• Even if independently licensed, you must:
– Function under guidance of physicians.
– Be affiliated with a paramedic-level service.
Paramedic Education
• Initial education
– Most states base education programs on the
National EMS Education Standards.
• Outline minimum knowledge needed for practice
– States require varying hours of education.
• National average: 1,000-1,500 hours
Paramedic Education
• Continuing
education
– Most states require
proof of hours.
– Attend conferences
and seminars.
– Read EMS journals.
– Get everyone
involved in postrun
critiques.
• The responsibility for
continuing education
rests with you.
Additional Types of Transports
• Specialty center
– Require in-house
staffs of specialists
– Transport time can
be slightly longer.
– Know:
• Location of centers
• Protocol for direct
transport
• Interfacility
– Use for:
• Nonambulatory
patients
• Patients who require
medical monitoring
– Other medical
professionals may
accompany patient.
Working With Other
Professionals
• Hospital staff
– Become familiar with the hospital.
– You may consult with staff by using the radio
through established procedures.
– The best patient care occurs when emergency
care providers have close rapport.
Working With Other
Professionals
• Public safety
agents
– Some have EMS
training
• Can better
perform certain
functions than you
© Mark C. Ide
– Interagency
cooperation
benefits patient
Working With Other
Professionals
• Continuity of care
– The community has expectations of EMS
– Focus on prevention
– You will interact with many professional groups
• Understand your role, as well as theirs.
National EMS Group
Involvement
• Many national and
state organizations
exist and invite
paramedic
membership.
– Impact EMS future
– Provide access to
resources
– Promote uniformity
Professionalism
• You have responsibilities as a health care
professional.
• You will be measured by:
– Standards, competencies, and education
requirements
– Performance parameters
– Code of ethics
Professionalism
• You are in a highly visible role in your
community.
• You must:
– Instill confidence.
– Establish and maintain credibility.
– Show concern for your patients.
Professionalism
• Your appearance is of utmost importance.
– Has more impact than you may think
• Present a professional image and treat
colleagues with respect.
– Arguing with colleagues is inappropriate.
– Raise issues at the appropriate time and place.
Professionalism
• Attributes of professionalism:
– Integrity
– Empathy
– Self-motivation
• Have an internal
drive for excellence
– Confidence
• Strive to be the best
paramedic you can.
– Communications
• Express and
exchange ideas,
thoughts, findings
• Listen well.
• Documentation is
important.
Professionalism
• Attributes of professionalism (cont’d):
– Teamwork and
respect
• Work together
– Patient advocacy
• Act in the patient’s
best interest
– Injury prevention
– Careful delivery of
service
• Deliver the highestquality care
– Time management
• Prioritize your
patient’s needs
– Administration
Professionalism
• More health care locations are using
paramedic services, including:
– Administering vaccinations
– Serving as home health nurses
– Performing special transports
© Dan Myers
Roles and Responsibilities
Roles and Responsibilities
• Teach the
community about
prevention of injury
and illness.
Courtesy of Captain David Jackson, Saginaw
Township Fire Department
– Appropriate use of
EMS
– CPR training
– Influenza and
pandemic issues
– Campaign for EMS
system
Medical Direction
• Paramedics carry out advanced skills
– Must take direction from medical directors
• Medical directors may perform many roles:
– Educate and train
– Recommend new personnel or equipment
– Develop protocols, guidelines, and quality
improvement programs
Medical Direction
• Roles of the medical director (cont’d):
– Provide input for patient care
– Interface between EMS and other agencies
– Advocate for EMS
– Serve as “medical conscience”
Medical Direction
• Medical directors also provide online and
off-line medical control.
• Online
– Provides immediate
and specific patient
care resources
– Allows for continuous
quality improvement
– Can render on-scene
assistance
• Offline
– Allows for the
development of:
• Protocols or
guidelines
• Standing orders
• Procedures
• Training
Improving System Quality
• Continuous quality improvement (CQI)
– Tool to continually evaluate care
– Quality control
– Process of assessing current practices, looking
for ways to improve
– Dynamic process
Improving System Quality
• Review ambulance
runs when possible.
• Focus of CQI is
improving care
• CQI can be a peer
review.
– Be professional
– Should be a
constructive process
Improving System Quality
• CQI programs help
prevent problems
by:
• Look for ways to
eliminate human
error.
– Evaluating day-today operations
– Ensure adequate
lighting
– Identifying
possible stress
points
– Limit interruptions
– Store medications
properly
Improving System Quality
• Ways to eliminate human error (cont’d)
– Be careful when handing patients off.
– Three main sources of errors:
• Rules-based failure
• Knowledge-based failure
• Skills-based failure
Improving System Quality
• Ways to eliminate human error (cont’d)
– Agencies need clear protocols.
– Be aware of your environment.
– Ask yourself “Why am I doing this?”
– Use cheat sheets.
– Be conscientious of protocols.
EMS Research
• EMS has been drawn toward evidencebased practice.
– Protocols should be based on scientific findings.
• Research should be performed by properly
educated researchers.
– More education centers now offer an EMS
track.
The Research Process
• Identify problem, procedure, or question.
• Develop research agenda by specifying:
– Questions to be answered
– Methods to gather data
• Stick to the research agenda.
The Research Process
• Determine the research domain.
– Area of research
– Domains: clinical, systems, or education
• Research may be performed within a
research consortium.
Funding
• Researchers should use an IRB when a
project begins.
• All research requires funding.
– Any type of support is considered funding.
• Researchers must:
– Disclose sources of funding.
– Maintain transparency of research methods.
Types of Research
• Qualitative
– Focuses on
questions within
surrounding events
and concurrent
processes
– Often used when
quantitative
research does not
provide answers
– Majority of research
• Quantitative
– Based on numeric
data
– Three types:
• Experimental
– Scientific
approach
• Nonexperimental
– Descriptive
• Survey
Types of Research
• Retrospective
– Examines available data
– May be used to:
• Develop educational sessions for EMS personnel
• Plan public education and prevention strategies
– In large studies, data often collected from
widespread databases
• Techniques can be used at the local level
Types of Research
• Other types of research:
–
–
–
–
Prospective
Cohort
Case study
Cross-sectional design
– Longitudinal design
– Literature review
Research Methods
• Identify the group(s) necessary for research.
• Ways to select subjects for research:
– Systematic sampling
– Alternative time frame sampling
– Convenience sampling
• Parameters should be identified.
Research Methods
• Studies can be:
– Blinded
• Subjects not told
project specifics
• Single-, double-,
or triple-blinded
– Unblinded
• Participants
advised of all
aspects
• Research statistics
can be:
– Descriptive
• Observations
made
• No attempts made
to alter event
– Inferential
• Hypothesis used
to prove one
finding
Ethical Considerations
• The IRB monitors whether a study is
conducted ethically and ensures:
– Protection of participants
– Appropriate conduct
• Benefits must outweigh risks.
• Conflicts of interest must be identified.
Ethical Considerations
• All subjects must:
– Give consent.
– Know their rights
will be protected.
– Participate
voluntarily.
– Be informed of all
potential risks.
– Be free to
withdraw at any
time.
Evaluating Medical Research
• When evaluating research, look for certain
criteria to determine the research quality.
– Know what questions to answer.
• Read every part of the research.
• Consider the type of journal.
Evaluating Medical Research
• Peer review helps ensure quality.
– Subject-matter experts review material prior to
publication
• Internet sites can be valid tools.
• Studies must follow a structured process.
• There will always be limitations.
Evidence-Based Practice
• Care should focus on procedures that have
proven useful in improving patient
outcomes.
– Evidence-based practice will have a growing
role in EMS.
• Stay up to date on health care advances.
– Make sure you understand new research
results.
Evidence-Based Practice
• Level I
– Highest-quality
evidence
– Multiple studies
– Large sample size
– Randomization
– Uses multiple
techniques
– Significant positive
effect outcome
• Level II
– Single, randomly
controlled trial, or
– Multiple trials with
small sample sizes,
or
– Large, randomly
controlled studies
– Moderate effect on
patient outcome
Evidence-Based Practice
• Level III
– Level IIIA: Well-designed trial without
randomization
– Level IIIB: Evidence from causal comparison and
case or cohort studies
– Level IIIC: Evidence gathered from single
experiments
Evidence-Based Practice
• Level IV
– Lowest level
– Reviews of:
• Descriptive studies
• Expert opinion
• Uncontrolled studies
Evidence-Based Practice
• Research determines the effectiveness of
treatment.
– Can help identify which procedures,
medications, and treatments do and do not work
• When following a new study, measure the
results with your CQI program.
Summary
• Ambulance corps were developed during
World Wars I and II to transport and rapidly
care for soldiers.
• Helicopters were used to rapidly remove
soldiers from the battlefield during the
Korean and Vietnam Wars.
Summary
• In 1966 the National Academy of Science
and the National Research Council
released “The White Paper” outlining 10
points.
– The National Highway Safety Act and the US
Department of Transportation were created as a
result.
• Paramedics must be licensed (also known
as certification or credentialing) before
performing any functions.
Summary
• Standards for prehospital emergency care,
and the people who provide it, are regulated
under state law by a state office of EMS.
• There are four levels of training: emergency
medical responder, emergency medical
technician, advanced emergency medical
technician, and paramedic.
• Paramedics may be involved in interfacility
transports and transports to specialty
centers.
Summary
• Paramedics should be familiar with the roles
and responsibilities of other health care
providers and public safety agencies.
• Continuing education programs expose
paramedics to new research findings and
refresh their skills and knowledge.
• A physician medical director authorizes
EMS providers to provide care in the field
through off-line or online medical direction.
Summary
• There are expected standards and a code
of ethics for all paramedics.
• There are many professional attributes that
a paramedic is expected to have, including
but not limited to integrity, empathy,
teamwork, patient advocacy, and time
management skills.
Summary
• Some of the primary paramedic
responsibilities include preparation,
response, scene management, patient
assessment and care, management and
disposition, patient transfer and report,
documentation, and return to service.
• Paramedics evaluate their care through
quality control and continuous quality
improvement.
Summary
• Research establishes a consensus of what
EMS personnel should or should not do.
Research may be quantitative or qualitative.
• There are many ethical considerations
when conducting research. Researchers
must always obtain consent from subjects,
inform them of the research parameters,
and protect their rights and welfare.
Summary
• Paramedics should know how to evaluate
the quality of research, including how to
recognize peer-reviewed literature and how
to find quality research on the Internet.
• Review medical literature as it becomes
available, and stay up to date on changing
guidelines.
Credits
• Chapter opener: © Mark C. Ide
• Backgrounds: Purple – Courtesy of Rhonda
Beck; Green – Jones & Bartlett Learning; Blue –
Courtesy of Rhonda Beck; Lime – © Photodisc
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones &
Bartlett Learning, courtesy of Maryland Institute
for Emergency Medical Services Systems, or
have been provided by the American Academy of
Orthopaedic Surgeons.
• ,