History of EMS Past, Present, Future Jeff Dostalek EMS Instructor, NREMT-P

Introduction EMS System Development History of EMS Role of the Paramedic today versus the “ambulance driver” of yesterday Paramedic professional responsibilities to enhance their ability to provide quality service Licensure, Certification, Credentialing So when did this role change for EMS? Role is much different than that of the “Ambulance Driver” of yesterday. Today's medics are provided better training, better equipment and are involved in the industry.

Objectives Describe benefits of continuing education Medical Direction List the benefits of professional association membership

Introduction The public perception of you is based on TV and articles Your treatment of their loved ones Continuing education is a must Treat everyone with respect and dignity

How far have we come

EMS System Development 1485 First use of an ambulance. Transport only 1800s First use of and ambulance/attendant to care for injured on site 1926 Service started similar to present day 1940 EMS turned over to fire and police department No set standard of care

The 20th Century and Modern Technology EMS Made major strides after WWII Bringing hospital to filed gave patients a better chance for survival Korean War First use of helicopter M*A*S*H* Units

The 20th Century and Modern Technology 1956 Mouth-to-Mouth resuscitation developed Late 1950s/early 1960s Focused shifted to bring hospitals to patients MICU developed

The 20th Century and Modern Technology 1965: “The White Paper” released Finding 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: finding outlined 10 critical points for EMS Systems 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 1970 NREMT began First paramedic trained in Miami NREMT organized to standardize education, examinations and certifications

The 20th Century and Modern Technology 1970s (cont’d) 1971: Emergency Care and Transportation of the Sick and Injured published by AAOS 1973: Emergency Medical Services 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 NHTA developed 10 system elements to help sustain EMS System Responsibility for EMS transferred to the stated Major legislative initiatives Human Resources Training Communications Transportation Medical record keeping EMS Physicians and State EMS Director Focused on public health and safety Research Medical Direction Communications legislation Education Clinical Care finance Public education Information systems HR Prevention State preventative health service block grants. Paid to State Health Dept. Monies spent on other projects. EMS funding was eliminated. The Emergency Medical Treatment and Active Labor Act is a statute which governs when and how a patient must be (1) examined and offered treatment or (2) transferred from one hospital to another when he is in an unstable medical condition.

Licensure, Certification, and Registration Certification examination Ensure 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 How states control who practice Also known as certification or credentialing Unlawful to practice without license Holding a license shows you: Completed initial education Met the requirement to achieve the license

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 Network of coordinated services that provide 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 are determined by: Bystander care Dispatch Response Pre-hospital care Transportation ER Care Definitive care and Rehabilitation Use Dad as an example:

The EMS System Dispatcher Scene may differ from what dispatcher relays Usually the publics first contact Training level varies from State to State Scene may differ from what dispatcher relays

The EMS System As a paramedic, you must: Develop care plan Decide on transportation mode Determine receiving facility Be active in your community

Levels of Education EMS System function 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 guideline designed to create more consistent delivery of EMS nationally. 2009: national EMS Education Standard NREMT provides a national standard for testing and certification There are 20,410 licensed EMS personnel; 4,021 certified First Responders, 9,275 EMT-Basics, 3,027 Intermediate Technicians, 222 Intermediates, 3,865 Paramedics. For the year 2011, there were 598,416 calls for EMS in Wisconsin, which is almost 15% higher than the EMS calls in 2010.  

The Dispatcher Plays a critical role Receives and enters information Interprets it relays it to appropriate service Pre-arrival instructions

Emergency Medical Responder (EMR) Formerly “First responder” Requirements vary by state Should be able to: Recognize seriousness of condition Provide basic first aid Relay information Might be a police officer First in Fire Company Staff at school

EMT Formerly EMT Basic Primary provider level in many systems Most populous level in the system

Advance EMT (AEMT) Formerly EMT-I Trained in: More advanced Pathophysiology Some advanced procedures Initially developed in 1985 Major revision in 1999

Paramedic Highest Level to be nationally certified 1999: Major revision to curriculum to increase level of training and skills Even if independently licensed, you must: Function under the guidance of physician Be affiliated with a paramedic level service

Paramedic Education Initial education Most states based on National EMS Education Standards States require varying hours of educations national Average: 1,000-1,500 hours While it is a common belief that the local fire department also provides ambulance services, in Wisconsin, 40% of 911 responding ambulance services come from the fire department 60% are separate and apart from the fire department. Fire department ambulance vehicles transport approximately 45% of patients each year while 55% are transported by non-fire-based ambulance providers. When taking into account all ambulance services including interfaculty, special event and intercept services, 68% are non-fire-based and 32% are provided by the fire department Volunteer EMS providers are responsible for staffing nearly 75% of Wisconsin’s ambulance services. However, they are responsible for responding to only 25% of Wisconsin’s EMS calls. The majority of ambulance transports are provided by full-time, paid ambulance services and fire departments.

Paramedic Education Continuing Education Most states require proof of hours Attend conferences and seminars Read EMS journals Get involved in post run review

Continuing Education Maintenance of core knowledge and skills Expansion of knowledge and skills Awareness of advances in profession Forms of CEU are many Conferences Seminars Skills Labs Journal studies Case presentation

Working With Other Professionals Hospital Staff Become familiar with the hospital; The best patient care occurs when emergency care providers have a close rapport with staff ASK QUESTIONS

Health Care Professional Conform to professional standards Provide quality patient care Instill pride in the profession Strive for high standards Earn respect of others Societal expectations on & off duty Position of public trust Unprofessional conduct tarnishes the profession, the service, and you Image and Behavior Stories about firefighter and police offers arrested. Darlington Firefighter for embezzlement Milwaukee Firefighter for 3 offense OWI

Working With Other Professionals Public safety agents Some have EMS Training Can better perform certain functions than you Interagency cooperation benefits patients A lot of police officers have EMT or paramedic training so they understand you

Working With Other Professionals Continuity of care the community has expectation of EMS Focus on prevention You will interact with many professional groups Understand your role, as well as others

EMS Group Involvement National, state, regional, and local Development, education, implementation and setting standards for EMS NREMT: verifies competency and reciprocity Wisconsin: DHS EMS Advisory Board WEMSA STAC / RTAC PSOW WTCS WPS,Inc. Others ?

Primary Responsibilities Preparation Response to scene Scene assessment Patient assessment Recognition of injury or illness Management Appropriate disposition Patient transport and transfer of care Documentation Return to service

Professionalism Standards of conduct and performance established by the profession You will be measured by: Standard, competencies, and education requirments Performance parameters Adherence to a “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 Present a professional image and treat colleagues with respect. Arguing with colleagues is inappropriate Raising issues at the appropriate time and place

Professional Attributes of the Paramedic Integrity Empathy Self-motivation Appearance and Personal Hygiene Self confidence Excellent communications Time management Teamwork Diplomacy Respect Patient Advocacy Careful delivery of service Integrity Honest in all actions Empathy Caring and compassion Self Motivation CQI Constructive feedback Self confident- Strive to be the best Documentation Listening skills Injury prevention

Roles and Responsibilities Teach the community about injury prevention and illness Appropriate use of EMS CPR Training Influenza and pandemic issues Campaign for EMS system

Medical Direction paramedic carry out advanced skills Must take direction from medical directors Medical Director may perform many roles Educate and train Recommend new personnel or equipment Develop protocols, guidelines, and QA

Medical Direction Roles of the Medical Director (cont) Provide input for patient care Interface between EMS and other agencies Advocate for EMS

Medical Direction (Medical Control) Online Provides immediate and specific patient care resources Allows for continues quality improvement Can render on-scene care assistance Offline Allows for the development of: Protocols or guidelines Standing orders Procedures Training

Improving System Quality Goal: evaluating and improving patient care Continuous Quality Improvement Quality Assurance

Improving System Quality Continues quality improvement (CQI) Tools to continually evaluate care Quality Control Process of assessing current practice looking for ways to improve Dynamic Process

Improving System Quality Review ambulance runs when possible Focus of CQI is improving care CQI can be peer review: Be professional Should be a constructive process

Improving System Quality CQI programs helps prevent problems by: Evaluating day-to-day operations Identify possible stress points Look for ways to eliminate human error: Ensure adequate lighting Store medications properly

Improving System Quality Ways to eliminate human error Be careful when handing patients off Three 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 sheet Be conscientious of protocols

Patient Safety 1996 Institute of Medicine Launched efforts to improve patient safety and quality of care. At least 44,000 and may up to 98,000 people die in hospital each year as a result of medical errors

Highest Risk for EMS Ambulance Crashes Dropping Patients Hand-off Communication issues Medication issues Poor sterile technique Airway issues Spinal Immobilization

Preventing Medical Errors Look-alike, Sound-alike Medication Patient identification Communication on hand-off Perform correct procedures Medication accuracy Pulling tubes and line Using proper technique Proper Hand hygiene

Preventing Medical Error in EMS Environmental methods Clear-established protocols Sufficient lighting for procedures and assessment Performing patient care duties with minimal interruptions Organizing and packaging drugs Securing equipment in patient care compartments.

Preventing Medical Error in EMS (cont’d) Individual methods Reflection in actions Question assumptions Reflection bias Use decisions aids Ask for help Reflection Think during an event (Is this working, how can we do it better) Question assumptions Critical thinking to look for better ways to do things reflection bias Avoid the tendency to judge an event on a bad outcome. “See I knew that would happen” Review the events after the fact. Use decision Aid Pocket guide, protocol book Ask for help You have a partner, probably someone with more experience

Summary Ambulance corps were developed in WW II to transport and rapidly care for solders Helicopter implemented during the Korean War

Summary 1966 the National Academy of Sciences and the National Research Council released the “The White Paper” Paramedics must be licensed before performing any function

Summary Standards for pre-hospital care are regulated by state law and State EMS offices Four levels of training First Responder EMT Advance EMT Paramedic

Summary Paramedics should be familiar with: Roles of other health care providers Continuing education requirements Medical Control Code of ethics Professional attributes of a health care provider Quality Assurance Patient safety consideration

EMS Star of Life Detection Reporting Response On Scene Care Care in Transit Transfer to Definitive Care The six branches of the star are symbols of the six main tasks executed by rescuers all through the emergency chain: Detection: The first rescuers on the scene, usually untrained civilians or those involved in the incident, observe the scene, understand the problem, identify the dangers to themselves and the others, and take appropriate measures to ensure their safety on the scene (environmental, electricity, chemicals, radiation, etc.). Reporting: The call for professional help is made and dispatch is connected with the victims, providing emergency medical dispatch. Response: The first rescuers provide first aid and immediate care to the extent of their capabilities. On scene care: The EMS personnel arrive and provide immediate care to the extent of their capabilities on-scene. Care in Transit: The EMS personnel proceed to transfer the patient to a hospital via an ambulance or helicopter for specialized care. They provide medical care during the transportation. Transfer to Definitive care: Appropriate specialized care is provided at the hospital.