EU UPDATE
FEATURED article!
by Christopher T. Boyer, M.P.A. M.A. NR-P, FP-C
by Alan M. Batt & Jennifer C. Berry
SPRING ‘16
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IN THIS ISSUE National Association of EMS Educators 250 Mount Lebanon Boulevard Suite 209 Pittsburgh, PA 15234 Phone: 412-343-4775 Fax: 412-343-4770 www.naemse.org
2015-2016 Board of Directors John Todaro, BA, NRP, RN, TNS, NCEE President Richard Beebe, MS, RN, NRP Vice President John Creech, MEd, LP Treasurer
WHAT’S INSIDE
Rebecca Valentine, BS, NRP, NCEE, I/C Secretary
PAGE 3 NAEMSE NEWS PAGE 4 Membership Spotlight
Linda Abrahamson, MA, ECRN, EMT-P, NCEE James Dinsch, MS, NRP, CCEMTP Lindi Holt, PhD, NRP, NCEE
by NAEMSE Staff
Connie Mattera, MS, RN, EMT-P
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NAEMSE Press Releases
Michael Nemeth, AEMCA(f), EMT-P, ICP, MA
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NAEMSE Committee Corner
Dr. Nerina Stepanovsky, PhD, MSN, CTRN, PM
Mickey Moore, A.A.S., EMT-P Christopher Nollette, EdD, NRP, LP Dr. Walt Alan Stoy, PhD, EMT-P
by NAEMSE Staff
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National Office Staff
Disaster Response & EMS Training Simulator
Joann Freel, BS, CMP Executive Director, Editor
by Joann Freel, NAEMSE Executive Director
Stephen Perdziola, BS Business Manager
So We Bought a Simulator, Now What?
Brandon Ciampaglia, AS Communications Coordinator
by Christopher T. Boyer, M.P.A. M.A. NR-P, FP-C
Nora Davidson, BA Membership Coordinator Laurie Davin, AS Education Coordinator
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Larissa Kocelko, BA Administrative Assistant William Raynovich, MPH, NREMT-P, Ed.D Editor, Domain3
A Review of the FISDAP Research Summit by Alan M. Batt and Jennifer C. Berry
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Reprinting Information
Interested in reprinting one of the articles you find in this publication? If so, please contact Brandon Ciampaglia via e-mail at brandon.ciampaglia@naemse.org or by phone at (412)343-4775 ext. 29
Siren’s Off by Linda Keslar (Proto Magazine)
Submission Guidelines
Unsolicited submissions are welcomed. Members of the NAEMSE Publications Committee review Domain3 manuscripts. Acceptance of a manuscript for publication is contingent upon completion of the editing process.
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Manuscripts should be e-mailed to brandon.ciampaglia@ naemse.org. Submit a cover letter with each manuscript indicating: Author name, credentials, title, and affiliation. A title letter should also be included disclosing any commercial associations that could post a conflict of interest. If you have an idea brewing that you’d like to submit, please contact us. We would be happy to discuss it. New authors are welcome and encouraged.
NAEMSE NEWS
NAEMSE NEWS
NAEMSE Board of Director Completes Master’s Program NAEMSE would like to congratulate one of its Board of Directors, Linda Abrhamson, on achieving her Master’s of Arts in Communication and Training from Governors State University, University Park, IL. Along with serving on the NAEMSE Board, Linda will soon become its next Vice President. Congratulations, Linda!!
Saint Lucia EMT Students Receive International Accredited Certification
INSTRUCTOR COURSE DATES NAEMSE continues to bring its heralded EMS instructor course to all corners of the country. If you have never attended, you can reserve your spot online. If you’re an instructor, spread the good news to your colleagues in the EMS community. The following is a complete listing of some of our upcoming Spring ‘16 courses:
INSTRUCTOR COURSE I O’Fallon, IL: April 22-24, 2016 Louisville, KY: December 12-14, 2014 Held in partnership with Memorial Health & Held in partnership with Louisville Education Center Metro EMS Richmond, KY: April 29-May 1, 2016 Held in partnership with Eastern Kentucky University (EKU) Cherry Hill, NJ: May 13-15, 2016 Held in partnership with Cherry Hill Fire Dept. Irvine, CA: May 20-22, 2016 Held in partnership with Orange County Fire Authority
INSTRUCTOR COURSE II Charlotte, NC: May 13-14, 2016 Held in partnership with Central Piedmont Community College Lake Placid, NY: May 19-20, 2016 Held in partnership with Conference Center at Lake Placid
The Joint Governance and Program Management Committee wishes to inform the public that Emergency Medical Technician students who were recipients of the International Accredited Certification of Course Attendance and Completion from the Pasco Hernando State College in affiliation with the Center for EMS Education received their Certificates on Saturday January 16, 2016 at a special certificate presentation ceremony by representatives of the Pasco Hernando State College which is accredited by the Commission on Accreditation of Allied Health Education Programs. The certification presentation was held at the Tapion Hospital Conference Center and presided over and presented to Students by Professor Dr. David Sullivan Head of the EMS Department and Assistant Mr. Scott Scurlock Director for EMS Programs of Pasco Hernando State College. The recipients of the certification had been awaiting the certification for the past year and a half as a result of the PascoHernando State Colleges transition from a Community College to a State College and the pending completion of outstanding on complete course work by some of the certification recipients.
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NREMT REGIONAL SCENARIO DEVELOPMENT WORKSHOPS Roseville, CA: April 26-27, 2016 Held in partnership with NCTI Columbus, OH: May 12-13, 2016 Held in partnership with Columbus Div. of Fire Fairfax, VA: May 18-19, 2016 Held in partnership Fairfax County Fire & Rescue Academy
For more information, please visit
NAEMSE.ORG
NAEMSE MEMBER SPOTLIGHT
NAEMSE MEMBER
SPOTLIGHT
Hardest Job Aspect? The hardest part of the job is keeping up with all of the changes that happen in EMS while still teaching several on-campus and online courses. Like many others in my position, I am short-handed when it comes to faculty. Also, since my employer has a contract with SAFD, we tend to teach year-round so finding a time to take a break is sometimes a challenge. Most Rewarding Job Aspect? By far the most rewarding aspect of the job is to hear from a former student who got a ‘save’. Since my specialty is Cardiology, I like to think I had a small part in these successes. Since I started teaching EMS full time in 1990, I have had more than a few of these reports and it always make me feel proud and happy for these students. Why Did You Join NAEMSE? I joined NAEMSE in 2006 after I started working at UTHSCSA. My colleague, Dr. Billy James, was giving a presentation at the Symposium in Pittsburgh and asked me if I would assist him. After attending that first Symposium, I was hooked. Every year since (with one exception) I have been to the Symposium. I get so much inspiration and learn so much from the sessions every year. That, by itself, makes the membership worthwhile. I also enjoy serving on committees and contributing to the organization in whatever ways I can. What Activites Do You Enjoy Participating In? Away from work, I like to spend time with my children and grandchildren. I also enjoy reading, watching movies and working on old cars.
Bruce Butterfras, M.S. Ed., L.P. Hometown Bruce was born in Houston, Texas and grew up on the east side of Houston in La Porte, Texas. He also married and lived in Deer Park, Texas until about 10 years ago when he then moved to the San Antonio area to go to work for his current employer. Current Employer/s Mr. Butterfras currently works for the University of Texas Health Science Center at San Antonio. It is there that he teaches EMT and Paramedic courses for the San Antonio Fire Department, as well as others. UTHSC also has an online EMS Bachelor’s Degree program that is open to all certified paramedics. Bruce has had the privilege of overseeing that program for several years now.
Personal Hobbies? My ‘hobby’ for much of my adult life has been firefighting. I was a volunteer firefighter for about 18 years and I still miss (for some bizarre reason) waking up to an alarm for a structure fire, rushing to the station and climbing on the engine to respond. The thrill of fighting fire is something that many people don’t get, but those of us who love it find it hard to live without. Who Would Play You In a Movie? I think it would have to be Tom Hanks. I am a huge fan of his, so that probably has something to do with it, but we are also about the same age and he seems to be able to play any part. I think he could pull off playing an aging EMS educator although it would probably be a boring movie. What is Your Refrigerator Never Without? My refrigerator is never, ever, ever without Diet Coke. I very rarely drink it, but my wife is somewhat more fond of it. We go through at least 2 cases a week but as she reminds me - that is her only vice, so I guess I can live with it.
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NAEMSE ANNOUNCES BOARD OF DIRECTORS OFFICER RESULTS FOR 2016-2017
NAEMSE - Press Release March 2016
National Association of EMS Educators (NAEMSE) Announces Board of Directors Officer Results for 2016-2017 The National Association of EMS Educators (NAEMSE) announces the newly elected Officers of the Board of Directors for the 2016-2017 term. The Officers’ election was held during the month of March at the Board of Directors Mid-Year meeting in Ft. Worth, Texas. The officers of the Board of Directors are President – Chris Nollette, Ed D, Vice President - Linda Abrahamson, MA, Treasurer – James Dinsch, MS, and Secretary – Rebecca Valentine, BS. Dr. Chris Nollette, is recognized as the only Board of Director to serve a second term as the Board President. Ms. Linda Abrahamson, is recognized as a former Board of Director and Past President of NAEMSE. Ms. Rebecca Valentine, is serving a second term as the Secretary of NAEMSE and Mr. James Dinsch, is a current Board of Director serving a first year Officer position. Mr. John Todaro will remain as the current President until the NAEMSE general membership meeting August 11, 2016. These individuals empower the profession of EMS Education through collaboration, education and innovation. The Board’s primary objective is to serve the NAEMSE membership and shape the future of EMS Education. As such, the NAEMSE Board of Directors requires candidates who are recognized as excellent leaders with significant knowledge and an ability to think strategically. “Year after year I’m astounded at the level of experience and dedication we’re able to access with our board,” said Joann Freel, Executive Director of NAEMSE. “We have a very strong leadership foundation in place and we couldn’t be more pleased with the newly elected officials. Each of these individual’s passionate commitment to the EMS community will bring more insightful perspectives to our Board. “ The newly elected Officers of Board of Directors will take office at the general membership meeting August 11, 2016 in Ft. Worth, TX.
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NAEMSE ANNOUNCES THE IDENTIFICATION OF ASSOCIATION CORE VALUES
NAEMSE Press Release March 2016
National Association of EMS Educators (NAEMSE) Announces the Identification of the Association Core Values The National Association of EMS Educators’ Board of Directors are happy to announce the establishment of the following Core Values created at its Mid-Year meeting in Ft. Worth, Texas. As a member focused association built on loyalty, trust, respect and evidence based practice, we embrace the following core values:
Integrity Innovative Leadership Collaborative Inclusive Trust
The NAEMSE Board of Directors have recognized the following attributes as criteria for these Core Values: 1. Values are the foundation on which we perform work and conduct ourselves. 2. In an ever-changing world, core values are constant. 3. Core values are not descriptions of the work we do or the strategies we employ to accomplish our mission. 4. The values underlie our work, how we interact with each other, and which strategies we employ to fulfill our mission. NAEMSE empowers the profession of EMS Medical Education through collaboration, education and innovation. The Board’s primary objective is to serve the NAEMSE membership and shape the future of EMS Medical Education.
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NAEMSE COMMITTEE CORNER NAEMSE Executive Director, Joann Freel, led the discussion (via a PowerPoint presentation) that hit upon all of the association’s exciting ventures, including the new and highly successful NREMT Regional Scenario Development Workshop. This led into Ms. Mattera’s SWOT analysis report of Illinois-based educators who assisted in addressing the strengths and weaknesses of NAEMSE’s educational courses. The conversation wrapped following a show of participation in the Trading Post Review process. A number of committee members offered up their services in helping NAEMSE to clean up and better organize one of the association’s most valuable membership assets.
engaging updates. Welcome to Committee Corner! This section of Educator Update will be an ongoing series of updates that will strive to accurately represent that which has been discussed during the most recent round of committee meetings. Here you will be caught up on the constant going’s on of the association and it’s affiliated groups. And who knows! Perhaps you may want to join one of the committees below as a result of their updates. We always welcome and encourage you to become a more active voice for the association! If interested, please visit: http://naemse.org/members/group_select.asp? type=18354
RECOGNITION COMMITTEE Meeting Date: November 2015 Next Meeting: TBD
The Recognition Committee, chaired by Dr. Chris Nollette, is responsible for acknowledging the hard work of EMS Educators across the country. The committee is now accepting applications for the 2016 Heroes Awards. These include the Legends that Walk Among Us, Unsung Hero, and Fallen Hero Awards as well as the James O. Page Scholarship. Please visit http://naemse. org/?page=heroawards to find the application process for each award. Nominations and submissions are due by May 31, 2016, so that travel arrangements can be made for the selected recipients.
EDUCATION COMMITTEE
Meeting Date: Tuesday, March 22, 2016 Next Meeting: TBD A very active 1-hr long meeting produced many great topics that showcased how engaged this committee is in furthering NAEMSE’s mission and goals. Chaired by Connie Mattera, the conversation got started through a discussion that addressed the overeaching success and history of NAEMSE’s vast roster of educational programs.
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PROGRAM COMMITTEE
Meeting Date: Wednesday, October 14, 2015 Next Meeting: TBD The Program Committee met in October to discuss the 2015 Symposium reviews in order to make any changes or revisions for Symposium 2016. Voting for the 2016 Call for Presentations commenced before the holidays, and the Program Co-Chairs met in Pittsburgh in January to review the rated presentations and put together the 2016 program. CoChairs Jim Dinsch and John Todaro are very excited about the 2016 Symposium’s educational offerings and hope that you will consider attending this year in Ft. Worth, TX, August 1-6, 2016.
COMMUNUCATIONS COMMITTEE Meeting Date: Monday, January 25, 2016 Next Meeting: TBD
Meeting earlier this year, the Communications Committee led by NAEMSE Board of Director, Richard Beebe discussed the various ways in which NAEMSE can be more of a presence on social media and how to engage both our members and non-members in the most universal way/s possible. The group also addressed its plans to present a writer’s workshop at this year’s Symposium in Ft. Worth, TX. After some background on this workshop and its importance at Symposium, provided by Bill Raynovich, it was determined that this would be a very valuable addition to the event’s roster and aid in acquiring both interest in and new writers for NAEMSE’s Educator Update/Domain3.
EDUCATION TECHNOLOGY COMMITTEE
Meeting Date: Thursday, March 24, 2016 Next Meeting: Thursday, April 28, 2016 A very interesting discussion was held on Virtual Worlds in Education. Committee leader, Doug Gadomski, shared a handful of videos and examples (including SECOND LIFE) to emphasize how this new type of virtual education can really aid in a student’s learning process. Showcasing customization and even diving into an already pre-fashioned virtual world, education is now becoming an experience that is propelling both the teacher and the student into new landscapes... literally.
DISASTER RESPONSE AND EMS TRAINING SIMULATOR
Disaster Response and EMS Training Simulator: A NOTE FROM THE NAEMSE EXECUTIVE DIRECTOR By: Joann Freel, NAEMSE Executive Director
• To provide increased outreach educational opportunities for emergency care personnel in rural communities • To enhance competence and confidence among rural emergency care personnel through life-like realistic continuing education • Provide relief and community stabilization, reduce disability, and speeding the recovery for victims of disasters TRUE-TO-LIFE EXPERIENCE
While attending the NREMT/NAEMSE Regional Scenario Development Workshop in Lafayette, LA, I had the pleasure of speaking with Ms. Gina Riggs, EMS Director of the Kiamichi Technology Center in Oklahoma, and discuss her program. Gina is a charter member of NAEMSE, and is very involved in the EMS profession on a national basis. As we were talking about her program, Gina told me about the development of the Disaster Response & EMS Training Simulator and how two organizations joined forces to create this valuable resource. The final result of the Oklahoma Department of Career and Technical Education (ODCTE) and the Kiamichi Technology Center (KTC) EMS Program partnership became the DR ETS: A Disaster Response and EMS Training Simulator. This 48-foot mobile trailer brings unique training directly to community healthcare providers. Hospitals, EMS agencies, fire departments, educational facilities and other emergency medical organizations can request the use of the simulator across the state of Oklahoma. The DR ETS can also be used during manmade or natural emergency disasters as a triage and supply center. The vision of the Disaster Response & EMS Training Simulator is to: To ensure quality health care of all Oklahomans. The goals are as follows:
At the heart of the Disaster Response and EMS Training Simulator (DR ETS) unit is the life-size mannequins capable of breathing, talking, crying, seizing and reacting to healthcare provider interventions. The adult mannequin (SimMan) has been installed in an accurately spec-out ambulance simulator for EMS students to train in a realistic environment. The Pediatric mannequin (SimBaby) is located in a classroom style set-up and can be adapted to almost any type of healthcare profession training situation. Through this program and mobile simulation unit we are able to bring realistic life-like emergency training to all areas of the state, especially rural locations. We bring the lab to you! Along with the high fidelity mannequin training opportunities DR ETS provides, there are other special features and/or benefits such as: • Video cameras and speakers are located throughout the unit. This allows for high quality, digital recording complete with timelines for accurate appraisals and debriefings. These training recordings will provide immediate feedback to the students and instructors. • Simultaneous broadcasts of training and instruction to or from across the state by satellite. Equipment provides a totally interactive communication system from one site to another, saving travel time and expense for rural healthcare providers. • Equipment is provided to simulate actual environmental emergency situations which may occur in real life. Emergency training and triage can be simulated in homes, buildings, roadways, pastures, etc. www.naemse.org | Educator Update |
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DISASTER RESPONSE AND EMS TRAINING SIMULATOR DR ETS SET-UP SPECS Parking Location A level area consisting of firm or hard materialsurface is required. The trailer is 48-foot and the truck is 20 feet in length. Sufficient room will be needed to turn and back the unit. Security The DR ETS must be in a secured, lighted location and locked when not in use.
Housekeeping Items After using the mobile unit it should be in the same condition (clean and organized) when received. No smoking is allowed in the DR ETS or within 50 feet, due to oxygen equipment. Food or open containers of drinks are not allowed inside the unit. For further set-up information contact: JR Polzien, Health Specialists Oklahoma Department of CareerTech 1-405-334-1300; jpolz@okcareertech.org Gina Riggs, EMS Director Kiamichi Technology Center 1-918-647-2108; griggs@ktc.edu *Email contact is preferred* I would love to hear from other NAEMSE members on the uniqueness of their programs. If you are participating in or creating an exciting EMS program, please contact me at the following address: joann.freel@naemse.org.
Benefits of DR ETS include: Liability Any agency, company, school or other facility using the DR ETS is totally responsible for any damages that may occur to trailer, truck or the accompanying equipment during its use.
• Accessible, hands-on training for pre-hospital personnel provided in their own communities,
Power Requirements The mobile unit is equipped with a generator, battery and electrical (shore power) hookups. Shore power plug-in is the preferred method of operations. Minimum electrical requirements are 60 amps plug-in. If the generator is used, the diesel tank must be refueled to the original level when received.
• Access to state-of-the-art equipment including life-like patient simulator mannequins,
Lab Equipment and Supplies All lab equipment and supplies will be inventoried prior to and after use. Any supplies used should be replaced with appropriate replacement items or user agrees to reimburse KTC for such items. Any equipment damaged or not working properly should be reported so it can be repaired or replaced.
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• Enhanced team performance in critical care crisis management, • A non-threatening learning environment where the mannequins simulate complex medical and trauma patients,
• An opportunity for emergency medical personnel to test and practice their critical thinking reactions and skills, leading to higher degree of performance and confidence, • Focused feedback and low-stress learning environments,
• Serve as a disaster response unit for triage, command, supplies, satellite communications, etc.
SO WE BOUGHT A SIMULATOR, NOW WHAT?
So We Bought a Simulator, Now What? Simple steps to begin to integrate high-fidelity simulation into EMS Education
By: Christopher T. Boyer, M.P.A. M.A. NR-P, FP-C When I began working for my current employer, I happened upon a barely-used high fidelity simulator that was taking up valuable space on a stretcher in our lab. Like many other paramedic programs, our program purchased the simulator through a grant but failed to completely lay out how the new technology would be used. This lack of a plan led to an underutilization of the resource. Over a series of three years, through a lot of work and careful planning, we managed to integrate the concept of high-fidelity simulation throughout our paramedic program. If you are facing the same quagmire of not knowing where to start with simulation, here are some simple steps you can take to get you started: 1. You do not need to re-write your entire program! Simulation should be used to enhance your current program. 2. Identify gaps in your current program. You cannot integrate Sim unless you know how it is going to help. Identify your current approach and what your ideal approach is. The difference between the two will identify how you will go about implementing simulation. 3. Identify the key stakeholders, especially those who will be playing a role in your enhanced simulation program. Identify their strengths and weaknesses and plan accordingly. Do your colleagues know how to utilize the simulator, and if not have you budgeted for training? 4. Identify your target audience, including their learning styles and the level of training they have prior to coming to your program. This is a CRITICAL step! You need to identify the needs specific to your audience as well as the needs and values of your institution. 5. Identify barriers to implementation and work to address those. Do the instructors in your program buy in to the concept of high-fidelity simulation, and will they take the time to learn how to utilize this new tool? 6. Set long-term and short-term goals, being sure to celebrate those short-term wins. Remember: this is a marathon! If every student in every class, every year, gets the EXACT SAME experience then you are not improving your program! How, then, should the simulation program be structured?
The answer to this question may vary from one program to another. The simulator, however, cannot be used to replace your low-fidelity skills trainer (I actually added a new simulator to our program in the same year that I added new intubation skills trainers). Here is how our simulation program is currently structured: • Skills are taught using low-fidelity simulators with skill sheets and LOTS of practice (20 adult intubations, 20 IV starts, 20 IV med pushes, etc.). • We begin assessment practice with student roleplay and single state simulations. • We then move into increasingly complex cases with instructors present. o Early on I will stop and re-start the same simulation 6+ times to correct a student error before they actually complete an accurate primary assessment. o I also routinely utilize simulations as guided discussions to walk through an ACLS algorithm or complicated process, entering the treatment as we go so the students can watch the effects occur in real time. •After the students become comfortable with the concept and the expectations, the instructor is removed from the room. This forces the students to critically think and solve problems as a group. o As I explain to the students, this is as close to sending them on a call by themselves that I can get without actually assigning them to a unit.
• After the students develop a practice with critical thinking and multitasking at acceptable levels, we move around the campus (outside, bathrooms, other rooms, etc.). • I am never satisfied with the status quo or the bare minimum. While you can complete ACLS and PALS with a static mannequin, why not utilize those card courses as an opportunity to actually encounter the dynamic patients that are presented in the courses via high-fidelity simulation? o This is a great place to start with simulation if you are unsure how to integrate the tool into your program since the cases and standards are provided.
As you integrate simulation into your program, your students will immediately understand the value of the tool as long as it is done well. As long as you are entering into the semester fully planning on changing course midsemester when you realize your initial plan isn’t working, you will soon find yourself running a well-structured simulation program with verifiable results. For more information on the use of simulation in EMS education, please click this link to read NAEMSE’s Vision Paper on the subject.
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DOMAIN SPRING/SUMMER ‘15
Providing a Voice for EMS Educators
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Discipline Dilemmas: Dealing with Student Clinical Document Fraud
by: Gene Iannuzzi, RN, MPA, CEN, EMT-P
Assistan Professor and EMS Program Director - Borough of Manhattan Community College Paramedic Services
Editorial Review Board William Raynovich Les R.Becker Bruce Butterfras Todd Cage Deb Cason
Lynne Dees Kim McKenna Beth Ann McNeill Mike G. Miller Kelly Wanzek
MISSION STATEMENT: To inspire and promote excellence in EMS education and lifelong learning within the global community.
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DOMAIN3
To inspire and promote excellence in EMS education and lifelong learning within the global community
Discipline Dilemmas: Dealing With Student Clinical Document Fraud
EMS educators typically believe that only low performing students or students who lack integrity would cheat or falsify a document but, via a writing in a 2013 article, the Boston Globe, James M Lang notes:
By: Gene Iannuzzi, RN, MPA, CEN, EMT-P Assistant Professor and EMS Program Director - Borough of Manhattan Community College Paramedic Services
“...recent research into cheating and dishonesty suggests a different conclusion: Most of us are willing to engage in acts of dishonesty under the right circumstances. As behavioral economist Dan Ariely demonstrated in a fascinating series of experiments and reported in his book “The (Honest) Truth about Dishonesty,” the extent to which people are willing to engage in acts of cheating and dishonesty “depends on the structure of their daily environment.” The structure of that environment proves more influential than an individual’s ethical profile or some general cultural milieu.” 1
“Honor dies where interest lies.”
-Master Po
EMS educators and practitioners are well aware of the phrase, “If it isn’t documented, it didn’t happen” or one of its many variants. Proper documentation is rightly given a high priority in all levels of EMS education as a means of ensuring accurate communication, as well as a means of QA/QI, risk management and defense against potential legal actions. Unfortunately, educators must also be prepared to deal with occasions when documents say that things happened when they never really did. Such fraudulent documentation endangers the integrity of the individual student and of the program as a whole, and while it may not be possible to verify every document submitted in a way that removes all possible doubt, all programs must have a plan to assess and deal with such violations of procedural and ethical standards. Why Students Cheat Make no mistake: falsifying or altering a document, be it a patient care report, a rotation completion form, or a preceptor evaluation is a form of cheating, with the same ethical/integrity issues attached. Program directors and instructors assume that most EMS students are essentially honest individuals, but why would someone risk the consequences of cheating by submitting a falsified or fraudulent form? The answer is often simple: because they think they can. Other factors educators may encounter (and that have been encountered at BMCC) include: • They are overwhelmed with course requirements. • They have conflicts with work, home, and the demands of paramedic school. • They feel “everyone does it”. • They think no one will notice. • Their ethical system is at odds with the ethical system required of EMS providers. • They don’t fear consequences.
The clinical environment, with rapidly changing conditions, rotations based on an honor system, with varying levels of preceptor oversight, may provide those so inclined with the ideal environment to cut corners, free of the prying eyes of course faculty and preceptors with multiple responsibilities or additional students. Isolated Incidents or Widespread Problem? No studies from the EMS environment that we are aware of address the issue of clinical cheating, limited research exists from other clinical disciplines. However, a study by Theresa Hegmann, writing in a 2008 edition of The Journal of Physician Assistant Education, noted the following, which should give paramedic educators pause: “Medical educators commonly rely on patient encounter logs to evaluate the adequacy of students’ clinical encounters. Anecdotally, most training programs that utilize logging systems encounter problems with student falsification of entries. However, despite a large body of work on medical student cheating, falsification of log entries during clinical rotations has not been researched. ….an anonymous paper survey was distributed to a random sample of 1,800 recent PA graduates... the response rate was 31%. The majority ofrespondents reported completing encounter logs during clinical rotations (94%), and of those who completed logs, 63% reported that patient encounter logs were tied to grades or some other measure of student progress. More than half (57%) self-reported some degree of cheating behavior themselves, and 90% of respondents reported cheating behavior in their classmates. …Cheating on patient logs during clinical training of PA students is a significant problem, but one that schools may not be aware of, since 46% of graduates reported that their program did not check theaccuracy of logs. PA educators need to take proactive measures to address this issue.” 2
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DOMAIN3
To inspire and promote excellence in EMS education and lifelong learning within the global community
Changing the Environment to Make Cheating Harder Paramedic program staff can’t be everywhere at all times and cannot expect preceptors to see and hear everything, but there are things that can be done to prevent cheating during clinical rotations. Close contact with clinical preceptors, making program expectations clear, is an important first step. Routine personal, phone, or e mail contact with clinical sites builds relationships and fosters dialogue (regarding students) that goes beyond mere check-off boxes on a document and emphasizes that preceptors, whether directly compensated or not, are truly partners in the education of paramedics. Other program activities that BMCC found effective in changing the environment: • Clear program policies that address document fraud or falsification, either as part of the clinical policy or the affective domain • Policies that specify consequences for such infractions, be it three strikes, one strike, or any variation thereof, and that involve senior program faculty, administrators, and the medical director in the disciplinary process • On site spot checks by program faculty. Nothing sends a message like program staff showing up unannounced at random intervals. This is a particular deterrent to students who may cut corners by showing up late or leaving early by offering an excuse to a sympathetic hospital or ambulance preceptor • On site sign in sheets • Requiring students to punch an electronic timeclock • Requiring students to call from site specific phones at specified times • Requiring forms to be submitted to preceptors for validation, and having the preceptor place the forms in a sealed and signed envelope before returning to the student • Routine auditing and comparison of rotation documents to FISDAPTM or other tracking reports When Fraud is Detected Sadly, despite a program’s best efforts there are still some students who will find a way to defeat any controls that have been established. How program leaders respond has implications far beyond the individual student. When class members learn of others cutting corners without detection or consequence, it promotes the belief that such behavior is tolerated.
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In the “small world” of EMS, word tends to spread and such tales, repeated often, impact program credibility and the credibility of the larger institution. Lack of sound procedures and responses to such issues may also affect the attainment or renewal of local and national accreditations. Perhaps a more direct connection can be made by saying that if a student is willing to cheat in a clinical rotation, they may be just as likely to cut corners or falsify information when practicing independently. Sharron Graves, writing in The Journal of Diversity Management, notes the following in relation to future workplace performance: “The high correlation between cheating and workplace deviance has tremendous implications for both employers and academicians. Students who cultivate a cheating mentality in the academic arena will more than likely demonstrate the same behavior in the workplace. Educators at all academic levels must take the responsibility for encouraging ethical behavior among students. They need to openly state that cheating is unacceptable and that violators will be punished. Since students’ values and their conceptsof what constitutes cheating may differ, it is helpful for academic institution have a written policy that outlines acceptable behavior and the consequences for unacceptable behavior.” 3
Quick and decisive action is thus necessary: • Once the facts are established, don’t hesitate. Take action immediately. Delaying action sends a message to other students that such activity will be tolerated. • Follow program policy to the letter, regardless of who the student is or how well they are doing. Offenses of this nature will usually require at least a clinical suspension. Inconsistencies invite challenges from other students. If you do not do so at present, make sure your students sign acknowledgements of the receipt and review of all policies and an agreement to comply at the beginning of your program. That way, when such incidents occur, the student cannot say “nobody told me” regarding the seriousness of the offense or the specified consequences. • Assemble as much documentation as possible and correlate violations to specific sections of program policy. • Advise the student of all findings. If in the program policy, convene the appropriate body and advise the student of their opportunity to present a rebuttal. • Do not make such proceedings personal and do not lump in other issues (attendance, grades, attitude, etc.) that are not germane and dilute the issue at hand.
DOMAIN3
To inspire and promote excellence in EMS education and lifelong learning within the global community
• Advise the student of when a decision will be rendered and if there is an appeal process. With collegiate programs, there may be appeals available outside the program or department which the student may be entitled to. • Keep minutes of all proceedings. Advise the student of the decision in writing and place all documents in the student’s file. In program reports to the student, document clearly the specific policy points violated. Quote liberally from your policies. Have students and faculty sign the document as an acknowledgement that it was presented and received. • Know your state EMS office requirements. Some offenses, particularly falsification of patient care records, may require reporting. The student should also be made aware of any such requirements. • Be aware that this is a litigious age, and students may choose to take legal action on dismissals or other disciplinary actions that impact them financially or threaten their careers. Good documentation that adheres to policy and is reviewed by program/school administration in addition to the program coordinator will usually stand the test of time and law. Examples of Documentation The program at Borough of Manhattan Community College was faced with a student who falsified the “time in-time out” of a rotation on both written and electronic documents. The student was slated for and 0800 to 1600 shift, but actually left at 12 noon. The issue was discovered by an unannounced random site visit by one of the program staff. Subsequent to the discovery, the student was given a suspension and informed that the program academic committee would convene within 5 days to make a determination regarding the student’s continuing status in the program. Excerpts of the written findings and determination may serve as an example for documenting such situations in your program. The excerpts are edited to comply with academic privacy regulations: All students receive and sign an acknowledgement of policies, procedures, and guidelines for the academic and clinical portions of the paramedic program on the first night of class… On page 6 of the Program Academic Manual, the following is stated (the salient portion is indicated in bold and underlined):
“Clinical Attendance: The clinical requirements of the Program are covered in greater detail in the Clinical Policy, which will be provided prior to the start of your clinical rotations. Students must give prior notification to the Clinical Coordinator, or if unable to reach the Clinical Coordinator, the Course Coordinator if they are going to be either absent or late for a scheduled clinical rotation. Actual arrival and departure times must be indicated on the student’s clinical rotation sheet.” Page 13 of the Program Academic Manual also states: “INTERPERSONAL/JUDGEMENT SKILLS As EMS professionals, paramedic students are expected to conduct themselves in a responsible manner at all times. Students will be evaluated to ensure they exhibit the appropriate interpersonal skills desired of a paramedic.” And also states: “INTEGRITY In order to ensure that graduating members of the Paramedic Program provide quality patient care, all students must adhere to the academic and professional integrity and standards of the Program. Any student suspected of cheating or of assisting another student to cheat will be required to attend a meeting with the Program’s Academic Committee. The issue will be presented to the student, who will have the opportunity to rebut. A decision will be rendered upon completion of the meeting. If cheating has been determined, the student will receive an immediate failure of the Program.” The Clinical Policy Manual, on page 3, states the following: “The Paramedic Program and the clinical rotation sites may employ a variety of methods to ensure that students have completed the required hours. These methods may include paper or electronic means of verifying attendance or spot check by Paramedic Program staff. In the event that student is unable to complete a rotation; he/ she is required to notify the Clinical Coordinator prior to the start of the rotation, no later than two hours in advance. Students may not attend a rotation without prior permission from the Clinical Coordinator or the Paramedic Program Coordinator. Any student who is found to have falsified attendance at a clinical rotation will be dismissed from the program.”
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DOMAIN3
To inspire and promote excellence in EMS education and lifelong learning within the global community
Student Acknowledgement of Policies and Procedures (The student) signed acknowledgement forms for both Academic and Clinical Policy Manuals on August 28th and September 30th of 2014 respectively. Findings of the Program Academic Committee The committee finds that the student is in direct violation of the Academic and Clinical Policies of the program in that the student: • Willfully documented attendance from 0800-1600 when in fact the student left at 1200. • Displayed poor judgement and ethics in submitting a falsified document, casting doubt on the validity of any of his rotation documents throughout the program. • Falsified attendance in an effort to gain credit for hours not performed.
It is also the determination of the Program Academic Committee that falsification of a document is sufficient to warrant immediate termination from the program. The student is hereby dismissed, effective immediately. Summary Falsification of a document is a form of cheating. Despite the best efforts made by educators, some students will cheat, mainly because they think they can and this behavior is not necessarily limited to “bad” students or students who are otherwise unethical. Any falsification of documents is a serious matter that casts doubt on the veracity of all other documents submitted by the student. There are a variety of methods that programs can use to limit the opportunities to falsify documents on rotations.
The committee was unmoved by the student’s explanation that:
All programs should have clear written policies regarding document fraud as well as other forms of cheating.
• The preceptor said he could leave • He did not know he was supposed to notify the Clinical Coordinator • He left so that he could get to the college to enter data into FISDAPTM (the clinical reporting program) • He was “planning” to inform the staff of the change in hours
When document fraud is detected, swift action is essential. Program policies must be followed to the letter with no deviation. Students should be informed of all policies at the outset of the program and should be required to sign acknowledgement of same. Policies should include clearly defined sanctions, who will be addressing the violation, the timeframe involved, and the method the student will be notified. College based programs may have additional levels of appeal beyond the program or department.
The committee was also concerned that the student had no clear understanding of the ethical problems with falsifying a document or the implications for clinical practice as a paramedic. The committee asserted that 10 months into the paramedic program, the student was well aware of the policies governing clinical attendance and notification, was aware that FISDAP data is supposed to be entered outside of class or clinical time, and had multiple opportunities to correct the time listed on the rotation but failed to do so, and would not have done so unless confronted with the facts presented at the meeting. Determination of Disciplinary Action It is the determination of the Program Academic Committee that the violations of policy described above are of a serious nature and demonstrate conduct inconsistent with that expected of a paramedic.
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Programs should anticipate possible legal actions from any student dismissed for fraud or cheating. Complete and accurate documentation reduces the possibility of the program’s decisions being challenged or reversed. Collegiate programs may face several layers of appeal beyond the program. Incorporating the steps of college level appeals into program manuals aids in clearly defining the process. Including college administration (such as Deans) on the program’s academic review or advisory committee is a useful way of fostering communication as well as keeping the process consistent and transparent. State certifying bodies may need to be notified, and all programs should be aware of their individual state’s requirements.
DOMAIN3
To inspire and promote excellence in EMS education and lifelong learning within the global community
Final Thoughts
References
Discipline and possible dismissal of a student is never a pleasant matter. Such decisions may impact a student financially, educationally, and socially.
1. Lang, James M., “How College Classes Encourage Cheating”, https://www.bostonglobe.com/ideas/2013/08/03/how-college-classes-encourage-cheating/3Q34x5ysYcplWNA3yO2eLK/story.html, retrieved 2/3/2016 2. Hegmann, Theresa, “Cheating By Physician Assistant Students on Patient Encounter Logs”, J Physician Assist Educ 2008;19(2):4-9 3. Graves, Sharron M, “Student Cheating Habits: A Predictor of Workplace Deviance”, Journal of Diversity Management, First Quarter 2008, Volume 3, Number 13
Often, student’s emotional appeals may cause us to waver but EMS educators must be steadfast in protecting the integrity of programs. One thing to always keep in mind is that students will soon be providers and providers are expected to be persons of integrity and honesty. Anytime a provider deviates from those standards, it is no longer a test or grade that is at stake but rather the health and well-being of a patient.
Reprinting Information
Interested in reprinting this article? If so, please contact Brandon Ciampaglia via e-mail at brandon.ciampaglia@ naemse.org or by phone at (412) 343-4775 ext. 29
It should never be forgotten that, as educators, protecting patients is our first responsibility.
2016/17 Call for Abstracts Now Accepting Research Abstracts for Presentation. Submit your abstract or learn more via online at: www.pcrf.mednet.ucla.edu Category: Deadline: Presented at:
Educational st March 31 , 2016 NAEMSE Conference 2016
Category:
Clinical, system, management, or personnel st October 31 , 2016 EMS Today Conference 2017
Deadline: Presented at:
For additional questions contact the Prehospital Care Research Forum at: Telephone: (310) 312-9315
Email: pcrf@mednet.ucIa.edu
www.naemse.org www.naemse.org || Educator Educator Update Update ||
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PLATINUM EDUCATIONAL GROUP, - PLATINUM PLANNER To inspire LLC and promote excellence in EMS education and lifelong learning within the global community
Platinum Educational Group Launches Skills Tracking App Available in the Apple Store and Google Play Store Platinum Educational Group, the Testing, Scheduling, and Skills Tracking Experts, has launched a fully functional skills tracking mobile app for students. This mobile app offers all the features of the full website from the student experience of PlatinumPlanner.com. PlatinumPlanner.com was released in 2012 and was created with the goal of bringing students, instructors, preceptors, school administrators, and clinical sites together for stress free scheduling, reporting, and skills tracking. PlatinumPlanner.com started with Emergency Medical Services (EMS) and has evolved to offer scheduling and skill tracking for the nursing and allied health fields. The Platinum Planner mobile app can be found by going to the Apple Store or Google Play Store on a device and searching for “Platinum Planner.” Students are able to input their information no matter where they are and have their information sync up when internet is available - perfect for hospital or lab settings where internet is sketchy or not available at all. Other features that the Platinum Planner mobile app offers students include: View, sign up, and create clinical or lab opportunities
View current classes along with details
Upload and attach images from mobile device cameras
View progress reports and overall skill status
View upcoming labs, document current labs, or review documentation from completed labs
Sign up for any additional classes available for a student’s course
Complete any and all forms necessary
And much more
For further information, go to www.platinumed.com.
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A REVIEW OF THE FISDAP RESEARCH SUMMIT To inspire and promote excellence in EMS education and lifelong learning within the global community
A Review of the FISDAP Research Summit AUTHORS: Alan M. Batt • Fanshawe College, Paramedic Programs, London, ON, Canada • Centre for Paramedic Education and Research, Hamilton Health Sciences, Hamilton, ON, Canada • Centre for Prehospital Research, University of Limerick, Ireland • National Ambulance LLC, Abu Dhabi, United Arab Emirates Jennifer C. Berry • EMS Reference • Fisdap, Saint Paul, MN, USA Corresponding Author: Alan M. Batt; c/o Paramedic Programs, Fanshawe College, 1001 Fanshawe College Blvd, London, ON N5Y5R6, Canada. Email: abatt@fanshawec.ca COMPETING INTERESTS AMB is a member of the NAEMSE Research Committee. JB is a product owner and employee at Fisdap. AUTHOR DECLARATIONS The authors declare that they are responsible and accountable for the accuracy and integrity of all aspects of this work. FUNDING & SUPPORT No funding or support has been received for the production of this manuscript from any manufacturer, pharmaceutical company, grant-awarding or commercial body. AMB was the recipient of funding from NAEMSE to attend the Summit. Fisdap contributed JB’s time.
What do you call a room full of research geeks? The Fisdap Research Summit! We’ve returned from the frozen tundra of Minnesota after an invigorating few days of research! Jennifer works for Fisdap and served as a liaison to Alan’s research group, and Alan was supported by the National Association of EMS Educators in attending the Fisdap Research Summit, hosted by HealthPartners in Minneapolis.
For the past 11 years, Fisdap has hosted the annual Research Summit, a workshop that attracts educators and clinicians from around the country. For two days, participants immerse themselves in focused research projects. The Research Summit has two primary goals: 1) to teach paramedics and paramedic educators how to conduct valid educational research, and 2) to facilitate research plans and apply real data to hypotheses so participants leave with a working, nearly finished research abstract. Since 2006, the Summit has produced 14 research awards winners, with 24 oral presentations and 32 poster presentations at the annual NAEMSE Symposium. To date, more than 160 people have graduated from the Summit program, producing hundreds of research projects over the years. “The Fisdap Research Summit is where our mission plays out in real time. Digging deep into our data to answer questions and create the evidence needed to determine best practice makes all the hard work worthwhile,” says Michael Johnson, Fisdap founder. Educators and non-educators alike with any level of research experience (i.e., from none to PhD), are highly encouraged to attend. Alan was one of three international attendees; he attended from Canada as faculty in the paramedic programs in Fanshawe College in Ontario along with Dr. Bill Lord from University of the Sunshine Coast, Australia, and Dr. Brett Williams, Monash University, Australia—both highly published and respected paramedic researchers. At the Summit, participants got to work on a great team with other paramedicine and education peers, editors, dedicated researchers, an amazing statistician, and a fantastic team of Fisdap computer developers who constructed queries to gather the data the groups required. The research projects undertaken this year included a mix of educational and clinical studies. Our group elected to undertake a study on the relationship between success in unit exams and success in the final comprehensive exam. The two active versions of the Fisdap comprehensive exam have been shown to have a more than 97% positive predictive value for first-time success in the National Registry cognitive exam. A number of programs across the U.S. terminate a student from the program if they fail one unit exam. Yet, we know as educators (and from previous research undertaken at the Summit by Lawler et al.) that the single biggest influence on student’s performance in comprehensive exams is exposure to patient contacts in the field (i.e., the more patients you see in the field, the better you perform on the comprehensive exam).
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A REVIEW OF THE FISDAP RESEARCH SUMMIT So… if we terminate students prior to them undertaking field placements at all, are we in fact failing potentially successful students? We won’t give away the exact details of what we discovered (we’ll leave that to the official abstract) but what we can tell you is that a student can fail several unit exams in a program and still be successful in the comprehensive exam—meaning you can fail your way to success! (Terms and conditions apply.) Other projects undertaken at this year’s Summit included an investigation into the link between neurotic behavioural traits exhibited by students in their personality test (again, using Fisdap testing products) and their likelihood to restrain (chemically or physically) a patient. Another group researched the differences in analgesia administration to older adults and ethnic minorities. Yet another group investigated the value of lab-based “patient contacts”—and surprisingly found that lab-based patient contacts actually decrease the student’s likelihood of passing the comprehensive exam. Some attendees, like Ron Lawler, are veterans of the Summit: “I continue to go to the Fisdap Research Summit for several reasons. It is a great group of people who come to Minnesota in February (think really cold) to further the profession and education of EMS. Everyone is excited about learning to do research or expanding the amount of EMS research out there. Being a group leader allows me to help guide the newcomers in research while building relationships with everyone. We are a small community, and it always helps to have someone to call for ideas.” Becky Valentine, a first time attendee at the Summit shared the following thoughts: “I am truly grateful for the opportunity to learn the research process in such a hands-on way. I am fairly well-read on EMS research, which is why I’ve always wanted to try it myself… but it all seemed so daunting. The assembled group at the Summit was inspiring. The Fisdap team was there to support us, and divided into groups, our teamwork resembled that of putting together a puzzle.” “Everyone came to the table with a different viewpoint and level of expertise to make it all work. My take home lesson is that no one person has to do all the work on a research project”, Valentine says. “Other people with different areas of expertise are there to help. It is not as arduous as I’ve always thought it to be, and with luck, I’ll return to attend more Fisdap Research Summits. The valuable experience exceeded my expectations by far.” Becky concludes, “In any case, with more EMS related research needed to better understand how our industry acts, reacts and can improve, I plan to work on further research projects. I urge others to do the same. Developing research is not as daunting as one might think”
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In addition to our group’s primary research project, Alan had previously identified an area of personal interest: whether our current curricula are fit for purpose in the context of care of older adults. A number of other attendees signalled their interest in this side project, and we are now in the process of having the data extracted from the database for this study. We are investigating the overall incidence of medical and trauma calls that occur in older adults, and then we will investigate the educational preparation paramedic students have for these presentations. Alan’s hypothesis is that the proportion of calls to older adults far outweighs the proportion of time dedicated in paramedic programs to learning how to care for these patients (in proportion to other areas of the curriculum). We’ll have to await the data analysis to see if he’s right! A number of attendees took the opportunity to chat with Faizan Arshad on the EMS Nation podcast, live from the Summit. We outlined several aspects of the projects as well as discussing social media and its potential effect on prehospital education. You can check out the podcast at http://apple.co/1HDDEgW. A pre-summit Resuscitation Symposium was also held in conjunction with Zoll. This symposium included a review of haemodynamic monitoring and lectures on resuscitation and shock therapies. Outside of the research agenda, there was a fantastic social program, including an informal meet-and-greet, a Fisdapsponsored group dinner, and the opportunity to go for dinner with those who were left after the Summit, as well as taking in some of the sights around Minneapolis. The opportunity to meet and network with like-minded peers made attending the Summit worthwhile on its own! We strongly encourage all involved in EMS, be they student, clinician or educator, with an interest in EMS to consider attending the Fisdap Research Summit in the future. Keep an eye on fisdap.net/research for opening dates and application requirements. We’ll leave the last word to Ron Lawler, who sums it up perfectly, “Being a research nerd, I always leave with many more ideas for future research than I came in with. You should try it!”
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SIRENS OFF
Sirens Off By: Linda Keslar
The house calls have helped Collins, who is a Protestant minister and foster parent to six children, manage a complicated set of medical problems that includes congestive heart failure and kidney disease. Since open heart surgery in 2015 he has been to the emergency room six times, but now, a month after his latest hospital stay, Collins says he’s feeling “100% better.” One time he was on the verge of going to the ER because he was short of breath and retaining fluids—possible signs of congestive heart failure. But Farris came to see him and correctly identified an upper respiratory infection, for which Collins was able to get treatment at a local urgent care center. “A lot of times I haven’t been able to reach my primary care physician, but when I called John, he came immediately, and I ended up not going to the hospital,” Collins says. Scheduled house calls may seem like a throwback to an earlier era, but they’re an essential part of an innovation known as mobile integrated health care and community paramedicine (MIH-CP), or simply community paramedicine. Farris works in a program launched by MedStar Mobile Healthcare, an emergency services agency that works with several local health care groups. As a paramedic, Farris had been trained to aid accident victims and perform emergency care, but MedStar gave him the training to deliver primary care as well. And while MedStar continues to provide traditional ambulance services in 15 Texas townships, it has also partnered with hospital chain JPS Health Network and two other local hospitals, an independent physicians group, two hospice providers and a home health care agency. Those providers pay MedStar and its specially trained paramedics to coordinate care for patients and to help keep them out of the hospital.
Some paramedics are focusing on keeping patients out of the emergency room, rather than taking them there. TWICE A WEEK John Farris pulls up to a two-story home in Fort Worth, Texas. Farris is a paramedic but he drives a Ford Fusion, not an ambulance, and instead of coming to take 42-year-old Christopher Collins to the emergency room, he’s there to make sure Collins stays out of it. During today’s visit, Farris checks his patient’s vital signs, but on other visits he might draw blood and take an electrocardiogram. He records the data on his tablet computer, which gives him access to Collins’s medical records, and he sends information to Collins’s doctors. Farris reviews the list of medications Collins is taking, checks his home for hazards that could lead to falls or other problems, and works with him on meal plans to reduce the amount of salt and sugar he consumes.
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Paramedics and emergency services are speedy, mobile and around the clock—which is why medical systems, facing gaps in care, especially in patients’ homes, have started turning to them for answers. “Community paramedicine programs have grown exponentially in recent years, with pilot programs focusing on a wide variety of issues,” says Karen Pearson, a policy analyst at the Maine Rural Health Research Center at the University of Southern Maine in Portland. She’s studying a dozen three-year pilots in Maine, most of which are rural. But there are also trial programs in New York City, Chicago, Boston and the San Francisco Bay Area, which all grapple with overcrowded emergency rooms and lots of unnecessary ambulance trips. According to a 2015 survey by the National Association of Emergency Medical Technicians (NAEMT), more than 100 emergency medical services agencies in 33 states and the District of Columbia have launched MIH-CP programs, and another study found that virtually every state is at least looking into this approach. During home visits, EMS providers deliver health education and help patients navigate the health system and manage chronic diseases.
SIRENS OFF A primary goal has been to follow up after patients have been discharged from the hospital and help avoid readmission. They also transport patients to doctors’ offices, urgent care facilities, and mental health or substance abuse treatment centers—and while using trained paramedics to act as taxi drivers may seem lavish, it’s still much less costly than an ER visit. The Affordable Care Act and its mandate to boost access to care, improve quality and control costs is a big impetus for this approach. “Community paramedicine could result in a huge shift in the way we provide care,” says Alasdair Conn, a physician and chief emeritus of emergency services at Massachusetts General Hospital. But like many other hospitals, MGH is taking a wait-and-see approach, given the scarcity of published data confirming the safety, cost-effectiveness and feasibility of MIH-CP programs. The new models also face regulatory and reimbursement hurdles. The Centers for Medicare and Medicaid Services and private health insurers pay for emergency medical services only if patients are transported to the hospital. Pilot programs, meanwhile, are funded by foundations, federal agencies and other groups that have a stake in seeing whether MIH-CP can work as well as its proponents believe it can. But at some point insurers will have to change their policies if this model is to have a major impact. MODERN PARAMEDICINE began in the 1960s, largely as a response to carnage on the nation’s highways. Rescue squad personnel, police, firefighters and ambulance attendants began to get standardized emergency training, and most of the nation’s 20,000 EMS agencies still focus on their original mandate, responding quickly to accidents and emergencies, stabilizing patients and rushing them to emergency rooms. “You call, we haul—that’s the traditional role of the paramedic,” says Matt Zavadsky, public affairs director for MedStar. And although a report from the U.S. Department of Transportation in the mid-1990s called for integrating EMS into the community and providing preventive care, community health interventions and management of chronic illnesses, that didn’t happen. Now, however, demographic factors and other forces may converge to expand the role of EMS. Studies suggest that at least one-fifth of the estimated 240 million annual calls to 911 don’t qualify as medical emergencies but instead involve patients with chronic diseases or with mental health or social issues who need help managing their condition rather than a trip to the emergency room. A 2006 Institute of Medicine report, “Emergency Medical Services at the Crossroads,” notes that local EMS systems often “are not well integrated” with other groups providing health care.
Community paramedicine was pioneered in rural areas lacking adequate numbers of primary care doctors. A pilot program in New Mexico, launched in the mid-1990s, failed within five years, but many others showed considerable promise and served as models. Eagle County Paramedic Services—which serves patients across 1,600 square miles of Colorado, an area with a full-time population of 55,000 that triples in winter months when skiers arrive—studied a Nova Scotia program that had been operating since 2000. Using $500,000 in grant money, they began their own five-year community paramedicine program in 2010. Today the Eagle County paramedics visit patients to draw blood, provide wound care, follow up on hospital discharges and look for possible overlaps in the medications patients have been prescribed—a robust combination of services that has led to Eagle County’s program being dubbed “community paramedicine on steroids,” says Christopher Montera, the group’s chief of clinical services and assistant CEO. Meanwhile, urban and suburban communities have also begun to experiment with MIH-CP programs. In Fort Worth in July 2009, MedStar paramedics began to make house calls to regular emergency room visitors after an internal audit revealed that 21 patients had been transported to local ERs 800 times during a 12-month period at a cost of nearly $1 million—largely unreimbursed because most of the patients had no health insurance. MedStar has since launched six ongoing programs, including one that enrolls into their EMS loyalty program those it calls “frequent fliers,” patients who have called 911 at least 15 times in a three-month period. Specially trained paramedics educate these patients and connect them to available resources in the community. MedStar also has a program that diverts 911 callers with less severe issues to a nurse who helps the patients find alternatives to the ER. These services have become the fastest-growing part of their business, and in 2013, after 27 years as MedStar Emergency Medical Services, the company renamed itself MedStar Mobile Healthcare. MEDSTAR’S PARTNERSHIP WITH a local home health agency, Klarus Home Care, marks one of the first alliances between such groups. Klarus pays MedStar to provide care coordination services for Klarus patients who call 911 in MedStar’s service area. On the scene, MedStar paramedics work with clinicians by phone to administer home care to patients and determine whether they need to go to the ER. Home health agencies, whose visiting nurses provide medical care in patients’ homes, have good reason to get involved—like hospitals, it is possible that they could begin to be penalized if Medicare patients are readmitted to the hospital. But some home care providers are worried that an expanded role for paramedics bumps into their own.
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SIRENS OFF In Colorado, Eagle County’s community paramedicine pilot had to take a seven-month hiatus after it was seen to be encroaching on home health professionals’ turf by performing scheduled home visits. The state’s department of public health ruled that the EMS group would have to be licensed as a home health provider and its paramedics would need additional education and training. Similarly, the National Association for Home Care & Hospice and the Minnesota Nurses Association tried to block the expansion of community paramedicine programs in that state. The laws and regulations governing EMS licensing and the scope of practice vary from state to state. Most training for paramedics who take on the expanded duties is provided through specialized online instruction, the pilot programs or courses at local community colleges. “Community paramedicine, which involves chronic disease management, health teaching and counseling, is distinctly different from traditional EMS, and that presents challenges,” says Janet Haebler, senior associate director of state government affairs for the American Nurses Association, which is pushing for standardized training, education and credentialing for those involved in MIH-CP. Some states, meanwhile, are working to overcome regulatory barriers. In 2012, Maine passed an exception to existing law, authorizing the dozen community pilot projects now under way. And although California law normally requires that paramedics take 911 callers only to emergency rooms, that state, too, found a way to authorize the launch last year of a dozen paramedicine programs. Massachusetts, meanwhile, passed legislation in August that enlarged the scope of practice of community paramedics while also calling for more training and education. AS PILOT PROGRAMS AROUND the country work out snafus and collect data, those who are launching new efforts turn to existing experiments for help. Last spring, for example, Beth Israel Deaconess Medical Center in Boston began a trial program with Cataldo Ambulance Service, using funding from the Leon Lowenstein Foundation to supplement a federal grant supporting the hospital’s program to reduce readmissions for high-risk Medicare patients. In getting the Beth Israel Deaconess experiment up and running, physician Julius Yang sought out EMS providers in the Maine pilot groups for advice and insights. And MedStar has hosted 160 EMS programs from 42 states with the same purpose. So far, though, there’s not a lot of hard data to validate the performance of MIH-CP programs.
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“There are plenty of national reports encouraging the use of community paramedicine, but the peer-reviewed literature is sparse regarding evaluations and outcomes,” says Pearson at the University of Southern Maine, whose 2014 study identified some of the challenges of integrating community paramedics into health care delivery systems. In her ongoing analysis of the Maine programs, she has found that those making the most progress are affiliated with a hospital system that can serve as a source for referrals. Other pilots have struggled with low patient volumes because participating physicians weren’t consistently utilizing their services. “This is a change in the primary care practice model. Physicians aren’t used to being linked to EMS,” she says. A recent independent account of MedStar by the U.S. Health and Human Services Agency for Healthcare Research and Quality reported that its programs have significantly reduced 911 calls, leading to declines in EMS and hospital emergency room expenditures and reducing ER logjams. Based on two years of data, there was an almost 70% reduction in 911 calls and ER visits for “frequent flier” patients, and admissions to the hospital fell 45%. Overall, at an annual cost of about $560,000, the MedStar programs have saved more than $10.8 million in health care payments and reduced 911 calls by enrolled patients 86%, according to MedStar. Similarly, during a three-year period, the Eagle County community paramedicine program calculates that it has saved $412,000 by eliminating at least 800 unnecessary visits to physicians’ offices, emergency rooms or nursing facilities, according to the program. An MIH-CP program in Reno, operated by the Regional Emergency Medical Services Authority, has also achieved solid results, with an evaluation by the University of Nevada showing savings of $5.5 million in 2013 and 2014. The program helped avoid 3,483 emergency department visits, 674 ambulance trips and 59 hospital readmissions, according to the preliminary data, says Trudy Larson, director of the university’s School of Community Health Sciences. And North Shore-LIJ Health System on Long Island has spent $400,000 on a community paramedicine pilot that it started in late 2013 for about 1,300 high-utilizer Medicare and Medicaid patients. In its first 19 months, the pilot saved more than $4 million in Medicare payments, based on avoided emergency room transports. Yet despite promising results, the programs are unlikely to expand broadly without a change in federal reimbursement policies. Medicare, Medicaid and most private insurance plans still will pay EMS providers only to transport patients. Among the states, only Minnesota has passed legislation to reimburse paramedics for nontraditional services through its Medicaid program. And while MedStar and a few other programs have found partners to help them become financially self-supporting, most pilots continue to rely on federal, state and nonprofit funding.
SIRENS OFF The Centers for Medicare & Medicaid Innovation have delivered $30 million to MIH-CP pilot programs in Connecticut, New York and Arizona. But Bryan Choi, a physician and assistant professor of emergency medicine at Brown University’s Alpert Medical School in Providence, notes that implementing even a small pilot program can be a major effort and a significant risk because of the lack of normal reimbursement. Choi has been working with a dozen groups in Providence, including community officials, EMS providers, home health agencies and social services for more than two years to prepare a MIH-CP trial program to be launched this year. Providers in Providence need a new response to the rising cost of hospitalizations, new guidelines about readmissions, and the need to manage care in the home. Like administrators of community paramedicine programs around the country, Choi is optimistic about the work but realistic about the hurdles ahead. “Like any new initiative in medicine, you have to go about this very slowly,” he says.
Dossier “The Evidence for Community Paramedicine in Rural Areas: State and Local Findings and the Role of the State Flex Program,” by Karen Pearson et al., (Flex Monitoring Team, 2014). One of the first in-depth studies that defines and evaluates the role and challenges of community paramedicine. It also describes 12 pilot programs under way in Maine. “Mobile Integrated Health Care and Community Paramedicine: An Emerging Emergency Medical Services Concept,” by Bryan Y. Choi et al., Annals of Emergency Medicine, July 2015. This critical analysis by physician-scholars looks at existing programs and concludes that more study is needed to support both the clinical and economic benefits of community paramedicine services. *Originally published on February 12, 2016 through Proto Magazine. http://protomag.com/articles/sirens-off
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