1. CALS Comprehensive Advanced Life Support Program A Team Approach to Rural Emergency Care

2. CALS Delivery of Rural Emergency Care Emergency/Critical Care in Urban settings – subspecialty trained personnel with latest equipment. Life or Death in rural communities depends on a small team of providers. Customary medical training does not prepare providers for the demands of rural practice. Advanced life support courses – fall short Medical-legal expectations Rural - lack of state-of-the-art equipment Rural - lack backup staff

3. CALS Agenda for the Future - Rural Public Access “The further one is from a large emergency medical facility – the more one needs a high level of local emergency capacity and the less likely it is that the emergency capability will be available”.

4. CALS Rural Emergency Paradox On a clinical bases, a rural emergency medical paradox results because Advanced Life Support (ALS) Services are difficult to establish and maintain in systems that experience insufficient volume to enable advanced providers to be paid and to retain their skills.

5. CALS Rural Emergency Care Suffers due to: Lack of ongoing education in advanced emergency care. Limited availability of appropriate RURAL ALS training. Lack of sufficient volume for providers to retain emergency knowledge and skills.

6. CALS Rural Emergency Care Suffers due to (cont): The high cost of ALS training – multiple ALS Courses. Inadequate patient volume to pay for emergency training based on a fee-for- service revenue system. Lack of appropriate equipment.

7. CALS Results in Rural Communities Disparity between rural and urban – especially evident in trauma care Difficulty of recruiting medical personnel to rural communities Increased provider burnout Mounting medical-legal risks

8. CALS The Need Provide better patient care Solve the feelings of being inadequate Address medical-legal concerns Help with professional burn-out

9. CALS What is CALS? Educational program or educational experience in ALS including trauma, OB, cardiac, airway management, pediatrics, etc. Developed for the whole emergency TEAM including nurses, midlevel providers, physicians and other paramedical personnel.

10. CALS Primary Focus of CALS Train medical personnel in a team approach. Training targeted for health care professionals who provide emergency and critical care. Specifically designed for rural providers who must treat a broad range of medical/traumatic emergencies.

11. CALS CALS Mission Statement “The primary mission of CALS is to improve patient care by enhancing the provider’s established scope of practice through advanced education”.

12. CALS CALS Vision We envision that the quality of emergency and critical care provided in rural communities by primary care provider teams can be enhanced by the use of the resuscitation triangle consisting of: * A systematic approach * Mastery of skills and knowledge * Utilization of essential equipment.

13. CALS CALS Value Statements We demonstrate our commitment to improving rural medical care by providing quality education especially designed to meet the needs of Rural Health Care Providers. We strive to provide information that is State-of-the-art and Evidence Based.

14. CALS CALS Values Statements (cont) We believe each member of the health care team provides a value regardless of professional status and thus we emphasize the Team Approach to patient care.

15. CALS Educational Components of the CALS Program Home study – CALS Manual and study-focusing question guide. Two-day CALS Provider Course – consisting of airway, cardiac, trauma, pediatric, obstetrical, neonatal, environmental, and medical advanced life support training. One-day CALS Benchmark Lab – covering about 50 skills useful for stabilization of critically ill or injured patients.

16. CALS CALS Educational Materials CALS Provider Manual 2-day CALS Scenario-based Classroom Course Benchmark Lab Manual 1-day Benchmark Skills Lab Training Course CALS Instructor Manual CALS Instructor Course CALS Emergency Procedures CD CALS RSI Card CALS Rescue Airway Card CALS Equipment List

17. CALS CALS Provider Manual

18. CALS CALS Provider Manual 3 volume - loose leaf manual *Vol 1 – “The First 30 Minutes” *Vol 2 – “Emergency Skills” *Vol 3 – “Diagnostic and Treatment Portals” Study guide – 100 questions to help focus pre- course studying Pre-course questionnaire – help focus training to the needs of the providers Pre-test - CME

19. CALS CALS 2–Day Interactive Provider Course Brought to the rural communities. Taught to teams of rural providers. 20 to 30 providers per course. Interactive scenario based. Conducted in the rural settings in the local hospital.

20. CALS Components of the CALS Provider Course Didactic group sessions (interactive -- Not Lectures!) Small group demonstrations and hands-on practice of skills Case-based learning Emphasis on a team approach Practice a Universal Approach to Emergency Care Opportunity for dialogue between different disciplines and practice settings Emphasize transfer of learning

21. CALS Airway Management: Rapid Sequence Intubation

22. CALS The CALS Benchmark Lab Intense hands-on instruction in 50 critical &/or life saving emergency procedures. Full eight hour day of skills training. Taught in teams consisting of 4 providers.

23. CALS CALS Instructor Course Teach “transfer of learning” theory Review essential components of CALS training * Universal Approach to patient care * Team Work * Difficult Airway management Practice scenario-based interactive teaching

24. CALS CALS Benchmark Emergency Skills CD Reviews the life saving skills taught in the Lab Includes the many difficult airway techniques, chest tube insertion, newborn procedures, etc.

25. CALS CALS Airway Cart

26. CALS Essential Aspects Unique to CALS Team development CALS universal approach to ALS Approach to the difficult airway Rapid Sequence Intubation (RSI) Advanced airway skills Additional topics not covered in current ALS courses Instruction in the proper emergency equipment for rural hospitals

27. CALS Developmental Goals of CALS To be the most comprehensive ALS Course Cover all of the ALS needs of rural providers Cover the essentials of all of the other ALS courses Maximize the emergency skills of the rural providers (especially in airway management) Improve the quality of emergency care in rural communities Improve the outcomes of emergency care in rural areas Help rural hospitals be correctly equipped to handle emergencies

28. CALS Most Valuable Parts of the CALS Provider Course Based on evaluations provided by 377 CALS Provider Course participants (2002- 03) * RSI Training * Teamwork training * Scenario-based interactive learning * 12-lead ECG interpretation

29. CALS Most Valuable Parts of the CALS Benchmark Lab Based on evaluations provided by 137 CALS Skills Lab participants (2002) * Hands-on learning * The learning of advanced and surgical airway management skills * The learning of chest tube insertion skill

30. CALS CALS Courses through December 2005 First course – September of 1996 112 courses held throughout state of MN 2500+ participants (33% physicians, 53% nurses, 6% PA/NP, 3% allied health, 5% EMPT) Includes the Medical Personnel that work in the US Embassies throughout the world (US Department of State)

31. CALS CALS training for State Dept. Personnel Trained 258 providers who staff the US Embassies throughout the world. Many are in very remote areas with limited resources available. One week CALS course in Minnesota.

32. CALS Embassy Personnel Training (cont) “Thanks again for the wonderful course. It’s unanimous that this was among the best we have ever had.” Larry Brown MD, Medical Director – Department of State and Foreign Service. “CALS was the best CME I’ve ever attended (and I used to be an ACLS and ATLS instructor) and we are still raving about it.” Tom – Singapore “I can honestly say that I will not panic if there is a major problem at my Embassy. I could not say that a week ago.”

33. CALS Obtaining Acceptance of CALS in Minnesota Built the case for the need for CALS type of training among the Trauma Centers, University of MN Med School, NICU, Cardiac Care Centers, etc. Sought and received support from the leaders of the MN ACLS and ATLS Programs. The observed change in rural emergency/critical care after CALS Training - spoke for itself to the urban referral centers.

34. CALS Financial Support for CALS Development Initial development largely pro bono Early seed money from MAFP, MN ACEP, University of MN Dept of FP. Lab developed by Dr Ruiz, Emergency Physician at U of MN and HCMC Trauma Center. Support from EMS Regulatory Board, MN ORHPC, MAFP, MN ACEP, Trauma hospital leaders – led to state legislative funding to help off-set cost of conducting the courses and labs.

35. CALS Financial Support (cont) MN state legislative support – grant money administered through the EMS Regulatory Board: * Off-sets part of cost of the lab and provider course. * Assists in the development and editing of the CALS Provider Manual. * Helps with CALS Office expenses. * Helps with CALS Instructor training. * Helped develop the CALS Benchmark Lab CD.

36. CALS Financial Support (cont) Support from the MN ORHPC – flex grants: * Financed much of the development of the CALS Benchmark Lab CD. * Helped CAH providers attend CALS courses and labs. * Financed some emergency equipment for CAHs. * Conducted Site-Study on the value of CALS training in a CAH.

37. CALS Future Distribution of CALS The need for CALS type of training is universal in rural communities. Up until now CALS Training has only been in Minnesota. We believe that we have a responsibility to share the CALS Program with other states if there is interest in the CALS training.

38. CALS Conclusion about Rural Emergency Care Training It is possible to create a Rural Emergency Team. It is possible to prepare for the unknown. A Rural Health Care Team can stabilize most medical/trauma emergencies. Rural Health Care Teams can practice state-of-the- art emergency care with the use of basic emergency equipment, the mastery of needed skills and working in an organized fashion as a team.

39. CALS Conclusions about the CALS Program CALS training is helping to make some order out of the chaos and nightmares of rural emergency care CALS is positively impacting the rural emergency care in Minnesota CALS MD “Physicians in Minnesota consider CALS the gold standard for rural emergency medical care”

40. CALS To contact CALS www.calsprogram.org Kari Lappe, RN, CALS Program Manager kdlappe@umn.edu 612-624-5901