1. Chapter 1
EMS Systems

2. 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.

3. 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

4. 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

5. 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

6. 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.

7. The History of EMS 1485 1800s 1926 1940s 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

8. 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
© National Library of Medicine

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. Licensure, Certification, and Registration
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.

17. 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

18. Licensure, Certification, and Registration
Reciprocity
Certification granted from another state/agency
Requirements:
Hold a current state certification.
Be in good standing.
National Registry certification.

19. 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.

20. The EMS System Patient outcomes determined by: Bystander care
Transportation
Dispatch
Emergency department care
Response
Definitive care
Prehospital care
Rehabilitation

21. The EMS System Dispatchers
Usually the public’s first contact
Training level varies by state
Scene may differ from what dispatcher relays

22. The EMS System As a paramedic, you must: Develop care plan
Decide on transport method
Determine receiving facility
Be active in your community.

23. 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

24. 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

25. © Peter Casolino/Alamy Images
The Dispatcher
Plays a critical role
Receives and enters information
Interprets it
Relays it to appropriate service
Some locations train EMDs
Give prearrival instructions
© Peter Casolino/Alamy Images

26. 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

27. EMT Formerly EMT-B Primary provider level in many EMS systems
EMT certification precedes paramedic education
Most populous level in the system
© Amanda Herron, The Jackson Sun/AP Photos

28. Advanced EMT (AEMT) Formerly EMT-I Initially developed in 1985
Major revision in 1999
Trained in:
More advanced pathophysiology
Some advanced procedures

29. 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.

30. 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

31. 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.

32. 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.

33. 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.

34. 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

35. 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.

36. National EMS Group Involvement
Many national and state organizations exist and invite paramedic membership.
Impact EMS future
Provide access to resources
Promote uniformity

37. Professionalism
You have responsibilities as a health care professional.
You will be measured by:
Standards, competencies, and education requirements
Performance parameters
Code of ethics

38. Professionalism You are in a highly visible role in your community.
You must:
Instill confidence.
Establish and maintain credibility.
Show concern for your patients.

39. 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.

40. Professionalism Attributes of professionalism: Integrity
Communications
Empathy
Express and exchange ideas, thoughts, findings
Self-motivation
Have an internal drive for excellence
Listen well.
Documentation is important.
Confidence
Strive to be the best paramedic you can.

41. Professionalism Attributes of professionalism (cont’d):
Teamwork and respect
Careful delivery of service
Work together
Deliver the highest-quality care
Patient advocacy
Time management
Act in the patient’s best interest
Prioritize your patient’s needs
Injury prevention
Administration

42. Professionalism
More health care locations are using paramedic services, including:
Administering vaccinations
Serving as home health nurses
Performing special transports

43. Roles and Responsibilities
© Dan Myers

44. Roles 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

45. 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

46. 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”

47. Medical Direction
Medical directors also provide online and off-line medical control.
Online
Allows for the development of:
Provides immediate and specific patient care resources
Protocols or guidelines
Standing orders
Allows for continuous quality improvement
Procedures
Training
Can render on-scene assistance
Offline

48. 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

49. 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

50. Improving 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

51. 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

52. 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.

53. EMS 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.

54. 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.

55. The Research Process Determine the research domain.
Area of research
Domains: clinical, systems, or education
Research may be performed within a research consortium.

56. 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.

57. Types of Research Qualitative Quantitative
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

58. 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

59. Types of Research Other types of research: Prospective Cohort
Case study
Cross-sectional design
Longitudinal design
Literature review

60. 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.

61. Research Methods Studies can be: Research statistics 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

62. 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.

63. 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.

64. 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.

65. 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.

66. 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.

67. 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

68. 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

69. Evidence-Based Practice
Level IV
Lowest level
Reviews of:
Descriptive studies
Expert opinion
Uncontrolled studies

70. 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.

71. 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.

72. 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.

73. 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.

74. 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.

75. 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.

76. 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.

77. 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.

78. 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.

79. 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. ,