Chapter 1Chapter 1

EMS Systems

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 CompetenciesNational 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 CompetenciesNational 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

National EMS Education Standard CompetenciesNational EMS Education Standard Competencies

IntroductionIntroduction

• The EMS system is constantly evolving.– Originally, the

primary role was transportation.

• As a paramedic, you will encounter many different situations.

© Mark C. Ide

IntroductionIntroduction

• 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 EMSThe 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

The 20th Century and Modern Technology

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

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The 20th Century and Modern Technology

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

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 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

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

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

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

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, 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

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

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 SystemThe 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 SystemThe EMS System

• Patient outcomes determined by:

The EMS SystemThe EMS System

• Dispatchers– Usually the public’s first contact

– Training level varies by state

• Scene may differ from what dispatcher relays

The EMS SystemThe EMS System

• As a paramedic, you must:– Develop care plan

– Decide on transport method

– Determine receiving facility

– Be active in your community.

Levels of EducationLevels 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 EducationLevels 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 DispatcherThe Dispatcher

• Plays a critical role– Receives and

enters information

– Interprets it

– Relays it to appropriate service

• Some locations train EMDs– Give prearrival

instructions

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Emergency Medical Responder (EMR)

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

EMTEMT

• Formerly EMT-B

• Primary provider level in many EMS systems

• EMT certification precedes paramedic education

• Most populous level in the system

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Advanced EMT (AEMT)Advanced EMT (AEMT)

• Formerly EMT-I

• Initially developed in 1985– Major revision in 1999

• Trained in:• More advanced pathophysiology

• Some advanced procedures

ParamedicParamedic

• 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 EducationParamedic 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 EducationParamedic 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 TransportsAdditional 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

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

Working With Other Professionals

• Public safety agents– Some have EMS

training

• Can better perform certain functions than you

– Interagency cooperation benefits patient

© Mark C. Ide

Working With Other Professionals

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

National EMS Group Involvement

• Many national and state organizations exist and invite paramedic membership.– Impact EMS future

– Provide access to resources

– Promote uniformity

ProfessionalismProfessionalism

• You have responsibilities as a health care professional.

• You will be measured by:– Standards, competencies, and education

requirements

– Performance parameters

– Code of ethics

ProfessionalismProfessionalism

• You are in a highly visible role in your community.

• You must:– Instill confidence.

– Establish and maintain credibility.

– Show concern for your patients.

ProfessionalismProfessionalism

• 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.

ProfessionalismProfessionalism

• Attributes of professionalism:

ProfessionalismProfessionalism

• Attributes of professionalism (cont’d):

ProfessionalismProfessionalism

• More health care locations are using paramedic services, including: – Administering vaccinations

– Serving as home health nurses

– Performing special transports

Roles and ResponsibilitiesRoles and Responsibilities

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Roles and ResponsibilitiesRoles and Responsibilities

• Teach the community about prevention of injury and illness.– Appropriate use of

EMS

– CPR training

– Influenza and pandemic issues

– Campaign for EMS system

Courtesy of Captain David Jackson, Saginaw Township Fire Department

Medical DirectionMedical 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 DirectionMedical 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 DirectionMedical Direction

• Medical directors also provide online and off-line medical control.

Improving System QualityImproving 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 QualityImproving 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 QualityImproving System Quality

• CQI programs help prevent problems by:– Evaluating day-to-

day operations

– Identifying possible stress points

• Look for ways to eliminate human error.– Ensure adequate

lighting

– Limit interruptions

– Store medications properly

Improving System QualityImproving 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 QualityImproving 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 ResearchEMS Research

• EMS has been drawn toward evidence-based 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 ProcessThe 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 ProcessThe Research Process

• Determine the research domain.– Area of research

– Domains: clinical, systems, or education

• Research may be performed within a research consortium.

FundingFunding

• 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 ResearchTypes 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 ResearchTypes 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 ResearchTypes of Research

• Other types of research:– Prospective

– Cohort

– Case study

– Cross-sectional design

– Longitudinal design

– Literature review

Research MethodsResearch 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 MethodsResearch 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 ConsiderationsEthical 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 ConsiderationsEthical 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 ResearchEvaluating 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 ResearchEvaluating 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 PracticeEvidence-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 PracticeEvidence-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 PracticeEvidence-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 PracticeEvidence-Based Practice

• Level IV– Lowest level

– Reviews of:• Descriptive studies

• Expert opinion

• Uncontrolled studies

Evidence-Based PracticeEvidence-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.

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

• 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.

SummarySummary

CreditsCredits

• 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.

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