NAEMSE Educator Update - Spring/Summer 2013

EDUCATOR

EU

SPRING/SUMMER

UPDATE

by William J. Leggio, Jr., EdD(abd), MS NDR, BS EMS, NREMTP

Also in this issue:

E

IS THE BAR FOR ENTRY INTO THE PRACTICE OF EMS TOO LOW? DUCATOR an

dT ow h rade S

INITIATING A COLLEGE WIDE INTERDISCIPLINARY SCENARIO TRAINING by Sally A. Cantwell, PhD(c), RN, and Jeffrey R. Grunow, MSN, NREMT-P 3

y Sherry Clark

INSIDE

EMS EDUCATION and HEALTHCARE REFORM by Sherry Clark, MS, RN, LP

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IN THIS ISSUE

SPRING/SUMMER

National Association of EMS Educators 250 Mount Lebanon Boulevard Suite 209 Pittsburgh, PA 15234 Phone: 412-343-4775 Fax: 412-343-4770

2013

2012-2013 Board of Directors Donna Tidwell, MS, RN, EMT-P President Scott Bourn, PhD, RN, NREMT-P President-Elect Chris Nollette, EdD, NREMT-P, LP Past President Joe Grafft, MS, NREMT Treasurer Richard Beebe, MS, RN, REMT-P

WHAT’S INSIDE

John Creech, MEd, LP

Page 3

Connie Mattera, MS, RN, EMT-P

Page 5

Member Spotlight

Page 11

Press Release

Page 14

No Crime in Asking

by Doug Lederman

Page 15

Michael Miller, BS, MS, EMS, RN, NREMT-P Michael Nemeth, AEMCS(f), EMT-P, ICP, MA(c) John Todaro, REMT-P, RN, TNS, NCEE Bill Young, M.S., NREMT-P

National Office Staff Joann Freel, BS, CMP Executive Director, Editor Stephen Perdziola, BS Business Manager Nora Davidson Membership Coordinator

Curing the Common Cold of Leadership

by Daniel Goleman

Page 17

Domain

Page 38

Curriculum: Does Sequencing Matter?

by Patricia L. Tritt, RN, MA

Page 40

Kim McKenna, M.Ed, RN, CEN, EMT-P

NAEMSE NEWS REVIEW: Resuscitation Outcomes Consortium (ROC Epistry) – Cardiac Arrest

by Paul L. Rosenberger, MPA, NREMT-P

Page 8

Theresa Devito, Ed, D, RN, EMT-P, EMSI

Brandon Ciampaglia, AS Communications Coordinator Laurie Davin Education Coordinator Larissa Kocelko, BA Administrative Assistant

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William Raynovich, MPH, NREMT-P, Ed.D Editor, Domain3

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.

Concussion Confusion

by Allie Grasgreen

www.naemse.org | Educator Update |

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Manuscripts should be e-mailed to submissions@ 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.

MEMBER SPOTLIGHT

MEMBER SPOTLIGHT Name: John Alex Gelinas Hometown: Red Deer, Alberta (Born in St Jerome, Quebec, raised in Saskatchewan and have lived in Alberta past 30 + years) Organization: Alberta Health Services Emergency Medical Services

Job Title: Manager, Learning & Development, Alberta Health Services Emergency Medical Services

Job Scope: Responsible for EMS Learning and Development activities in Central Alberta Zone and hold several provincial portfolios. Current roles include Manager of provincial Patient Simulation program, Project Manager for provincial 2013 Medical Control Protocol (MCP) development and implementation and Acting Chair of AHS EMS Research Committee.

INSTRUCTOR COURSE DATES NAEMSE continues to bring its heralded EMS instructor course to all corners of the country. If you have never attended, reserve your spot online. If you’re an instructor, spread the good news to your colleagues in the EMS community. The following are upcoming Fall courses: INSTRUCTOR COURSE I

Rock Island, IL: June 21-23, 2013 Held in partnership with Trinity Medical Center West Chester, PA: June 28-30, 2013 Held in partnership with the Good Fellowship Ambulance and EMS Training Institute

Hardest/Most Rewarding Job Aspect: I thought I would merge these two categories as I find that the hardest job is often the most rewarding. The most challenging and satisfying aspect with my current duties is to ensure all of my projects and portfolios receive the time and attention they require. I’m fortunate to have a great group of talented manager colleagues and Clinical Educators in AHS EMS who work as a team to achieve our goals and deliver quality training and education to our EMR’s, EMT’s and Paramedics.

Reason/s Why I Joined NAEMSE: Excellent resources and networking opportunities. It’s important to keep up with what is happening in our ever rapidly changing industry and NAEMSE is a vital link to keep current.

INSTRUCTOR COURSE II

Activities/Hobbies: I’m an avid sea kayaker and diver and have had the opportunity and privilege to kayak in the Pacific Rim National Park off the coast of beautiful Vancouver island, the ecological wonder and World Heritage site of Ha Long Bay located in the Gulf of Tonkin off the coast of Vietnam, and have kayaked and dived in the tropical waters of the Andaman Sea off the cost of Thailand and Belize in Central America.

Being an educator, my hobbies include learning, so to that end I’m currently enrolled in graduate studies at the University of Edinburgh (distance education). Being a proud father, my favorite past time is texting with my son who is in school at Berklee College of Music in Boston.

Washington, D.C.: August 5-6, 201 Held in partnership with NAEMSE Educator Symposium

Who Would Play Me in a Movie: John Cleese. He looks and talks nothing like me, but I’m a huge fan.

For more information, please visit us online at:

One Thing My Fridge is Never Without: Cat Food. Our 2 ¾ cats - or my wife - would never forgive me (one cat has three legs).

Fairmont, WV: July 12-14, 2013 Held in partnership with Pierpont Community & Tech. Inst.

Oroville, CA: July 19-21, 2013 Held in partnership with Oroville Hospital Education Department Washington, D.C.: August 5-7 2013 Held in partnership with NAEMSE Educator Symposium

NAEMSE.ORG

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Career Path: I have been involved in Emergency Medical Services in Alberta for the past 30 years. I have spent most of my EMS career in Fire based EMS services as a Firefighter/Paramedic with Fort McMurray Fire Department and Red Deer Emergency Services. In 2009, when the Alberta provincial government assumed ambulance service responsibility, I moved to Alberta Health Services Emergency Medical Services (AHS EMS) where I am Manager, Learning and Development.

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NAEMSE NEWS

NAEMSE NEWS NAEMSE to Collaborate with NREMT on Paramedic Instructor Workload Project

Former NAEMSE President Represents the Association at the 2013 Stars of Life Ceremony in Washington, D.C.

The American Ambulance Association (AAA) held its annual STARS OF LIFE Awards ceremony this past March in Washington, D.C. and a former NAEMSE President was there to spread the mission of our organization: Dr. Bruce J. Walz, PhD, NREMT-P

NAEMSE Research Committee Members (left to right - Greg Cliburn, Elliot Carhart, Art Hsieh and Kim McKenna) met with NREMT Board of Director Heather Davis, NREMT Lead Researcher Melissa Bentley, and Research fellow Jennifer Purcell on March 14th at the NREMT headquarters in Columbus, OH. The group, led by Melissa Bentley, worked to develop a survey that will explore paramedic instructor workload. The project is fully developed and has IRB approval. A sample of paramedic educators will receive the survey instrument within the next few weeks. This will be a great opportunity for educators to help us define our profession. The group, led by Melissa Bentley, worked to develop a survey that will explore paramedic instructor workload. The project is fully developed and has IRB approval. A sample of paramedic educators will receive the survey instrument within the next few weeks. This will be a great opportunity for educators to help us define our profession.

NAEMSE Member Recognized by JEMS as One of the Top 10 EMS Innovators of 2012 The NAEMSE Board of Directors would like to congratulate NAEMSE member David Page (MS, NREMT-P) on being recognized as one of the EMS 10: Innovators in EMS 2012 (a special award given to those EMS professionals who drove the EMS practice forward in 2012). This special recognition is presented by/held in partnership with JEMS and Physio-Control.

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On behalf of the NAEMSE Board of Directors, we would like to extend our appreciation and thanks to Dr. Walz for representing NAEMSE at this very important meeting.

--------------------------------More Information on AAA’s STARS of LIFE AWARDS: The American Ambulance Association’s Stars of Life Celebration is the most rewarding and exciting national event in the industry. This one of a kind event honors the dedication of ambulance services professionals — those remarkable individuals that stand out and represent excellence in every area of the industry. Your simple act of Nominating creates a “Star”.

www.naemse.org | Educator Update |

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NAEMSE NEWS

NAEMSE NEWS Health Care Innovation Award Receives Second Round of Funding

Dear EMS friends and colleagues, I am pleased to let you know that the Center for Medicare and Medicaid Innovation (http://innovations.cms.gov) has recently announced the second round of funding for the Health Care Innovation Award. This is another tremendous opportunity for funding of creative EMS and emergency care ideas!

Like the first round, this Health Care Innovation Award will award up $1 billion in grants to test ways to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid and CHIP (see Fact Sheet - http://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/faqround-2.html). CMS is specifically seeking new payment and service delivery models in four categories: * models that will rapidly reduce costs for Medicare, Medicaid, and CHIP in outpatient settings; * models that improve care for populations with specialized needs; * financial and clinical models for specific types of providers and suppliers; and * models that link clinical care delivery to preventative and population health.

The focus of this round is highly favorable to EMS proposals.

My Division, in collaboration with Federal partners at DOT and HRSA, have spent considerable time working with CMMI staff and leadership about EMS issues and they are well aware of some of the ways that EMS can address individual and population health care needs at lower costs.

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We are optimistic that these funding categories create excellent opportunity to test creative EMS models and I would like to personally encourage you to think about applying for one of these grants. Please help me get the word out and forward this e-mail to anyone in EMS that you think may be interested.

For more detailed information about the healthcare innovation awards, please see the Funding Opportunity Announcement on the CMMI website.

Of course, this is a competitive process and there are no guarantees. That having been said, a billion dollars is a lot of money!

This grant will fund many projects and I hope that some of them involve EMS and emergency care. For that to happen, the Center for Innovation must receive numerous, high-quality proposals from the emergency care community. Get creative, put on your thinking caps, build partnerships and alliances, and get writing!

A letter of intent is due June 28, 2013, with applications due August 15, 2013.

Respectfully, Gregg S. Margolis, Ph.D., NREMT-P Director, Division of Health System Policy U.S. Department of Health and Human Services (http://www.hhs.gov/)

OUT-OF-HOSPITAL PRACTICES

REVIEW: Resuscitation Outcomes Consortium (ROC Epistry) – Cardiac Arrest

The researchers found that the initiation of resuscitation and transport of OOHCA and the reporting of ROSC before transport vary from one ROC site to the next.

By: Paul L. Rosenberger, MPA, NREMT-P

The identified variation may help to explain the differences in survival rates among the sites and may provide a target for identifying best practices that can enhance patient survival.

Title, authors, journal, volume, number, and page: Variation in Out-of-Hospital Cardiac Arrest and Transport Practices in the Resuscitation Outcomes Consortium: ROC Epistry – Cardiac Arrest Dive, D., Koprowicz, K., Schmidt, T., Stiell, I., Sears, G., Van Ottingham, L., Idris, A., Stephens, S., & Daya, M. Resuscitation 82 (2011), 277-284.

Summary The authors of the article are the Resuscitation Outcomes Consortium (ROC) investigators. The objective of the research study was to identify variation in patient event, and scene characteristics of out-of-hospital cardiac arrest (OOHCA) victims and examine variations in transport practices in relation to ROSC within eight regional clinical centers that participate in the consortium.

Brief Review The researchers used multivariate logistic regression models, descriptive statistics, and chi-square tests to examine patients that were treated and transported in relation to ROSC, and survival to hospital discharge. The variables included the typical Utstein covariates. The aggregate reported findings are that 58% of the non-traumatic cardiac arrest victims received EMS treatment (CPR and/or defibrillation). Of the patients that were treated by EMS, 59% were transported (many were field terminated). Many of the transported patients were loaded without a documented ROSC. A small amount of these patients achieved ROSC before ED arrival. An even smaller amount survived to hospital discharge (4%). Patients who were transported after a documented on scene ROSC had a survival rate of 28%. The authors discuss the risks associated with transporting non-viable OOHCA victims.

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OUT-OF-HOSPITAL PRACTICES The authors discuss the risks associated with transporting non-viable OOHCA victims. The statistics from one ROC site to the next varied greatly. It was identified that that patients with the initial rhythm of ventricular fibrillation, pulseless ventricular tachycardia, or an AED shock were the largest group transported after ROSC. A limitation that was identified is that intermittent ROSC and sustained ROSC cannot be distinguished by the ROC epistry.

Additionally, if the time of ROSC was not documented the data was excluded from analysis and when hospital outcome data was not known, it was excluded as well.

Finally, the authors report that OOHCA protocols are not standardized, nor were they reviewed. All of these factors are identified as limitations.

Relevant to EMS and Integrated into Education This article is relevant because it identifies marked site variations in the initiation of resuscitation, and patient survival following transportation with and without ROSC. The proportion and type of patients transported with or without ROSC varies greatly. These factors could affect the overall survival rates within a community.

Further research is called for and the establishment of best practices would be beneficial for patients of OOHCA. This is important for EMS education because identifies that on-scene ROSC (if achievable) should be a goal, rather than expeditious transport. The transport of non-viable patients has risks associated with the decision.

Take Home Message The choice to resuscitate on the scene or enroute matters. More patients survive hospital discharge when they are resuscitated before transport. If possible attempt the resuscitation on the scene. The variation in resuscitation success that was identified in the ROC data analysis requires further investigation. The resuscitation rates varied greatly from ROC site to another site. Further research may identify EMS best practices.

doi: 10.1016/j.resuscitation.2010.10.022

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PRESS RELEASE Loudoun County, Virginia Department of Fire, Rescue, and Emergency Management 801 Sycolin Road SE, Suite 200 Leesburg, VA 20175 Phone 703-777-0333 Fax 703-771-5359

For Additional Information: Mary L. Maguire, Public Affairs Officer or Firefighter Laura Rinehart, Public Information Officer Fire and Rescue Services May 1, 2013 For Immediate Release: Ten from Loudoun Graduate a Nationally Acclaimed EMS Educator Course The Loudoun County Department of Fire, Rescue and Emergency Management (FREM) proudly commends the 37 graduates of the recent National Association of Emergency Medical Services Educators (NAEMSE) acclaimed EMS Educator Course Part 1.

The course was held April 19th through April 21st in Leesburg. Course attendees were representative of many agencies, some traveling from as far as New Mexico and Canada to participate. Ten of the 39 graduates were from Loudoun County, seven career personnel and part-time instructors and three volunteer members. Deputy Chief of EMS and Training, Jose Salazar was among the attendees and responsible for bringing the program to Loudoun County. “NAEMSE’s research based and informational approach resonates with everyone, regardless of their teaching style,” said Chief Salazar. “Dr. Nollette and his staff provided fresh ideas and new approaches to complement our current practices.”

Veteran instructor, Lieutenant and EMT-Intermediate Nicole Artisst was one of seven career personnel in attendance. “This course definitely got my attention and has truly re-awakened my passion for teaching. They showed us better ways to reach students based on their individual learning styles and demonstrated how to play a more active role in shaping our future providers. If we expect to send capable, compassionate and confident students into the field, we have to create that culture as instructors and lead by example,” said Lieutenant Artisst.

Chris Nollette, PhD, NREMTP,LP was the lead instructor for the intensive three day course. Dr. Nollette has almost thirty years of experience as a flight, tactical and field paramedic and now serves as the Director of the Riverside Community College District EMS Program in Riverside, CA. “Our goal is to help these EMS providers understand the true power and responsibility that comes along with teaching. They have the ability to immeasurably affect the experience of their students and what they take away from these courses”, says Dr. Nollette. “Many of them are seasoned instructors, and we want to take what they already do well and make it even better.” Bringing yet more experience to the group was instructor Mickey E. Moore. Mr. Moore has been an instructor in the State of Georgia for over 20 years and currently serves as the Deputy Director of EMS and Trauma for the Georgia Department of Public Health. He has also been a chartered member with NAEMSE and the Treasurer for the association for 10 plus years.

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-More-

PRESS RELEASE News Release Page 2

NAEMSE is a professional membership organization that is made up of over 3,000 EMS educators, whose mission is to inspire and promote excellence in EMS education and lifelong learning within the global community. The objective of the EMS Educator curriculum is to provide EMS instructors with tools and

resources that will allow them to teach to the best of their ability, to further build their leadership skills and better evaluate current programs, students, and faculty. Currently, this course is accepted in 40 states as the Credentialing course for EMS Educators.

For information on training opportunities within the Loudoun County Fire-Rescue system please visit www.loudoun.gov/training.

Photo Courtesy of NAEMSE:

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www.naemse.org | |Educator EducatorUpdate Update | |A 12 www.naemse.org

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September 8–12, 2013 • Las Vegas Convention Center SePt. 9, 2013 Discover the latest trends in trauma care from internationally recognized experts. Details at WorldTraumaSymposium.com

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Educator Update |

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Group rates also available.

View the full conference lineup & register at EMSWorldExpo.com. www.naemse.org

NEW THIS YEAR

NO CRIME IN ASKING

No Crime in Asking By: Doug Lederman

Roughly two-thirds of colleges elicit information about the criminal pasts of prospective students, either through questions on their application forms or, increasingly, through the use of background checks. But the inquiries do little to keep their campuses safer, a new study suggests.

Students who had a history of pre-college criminal behavior were likelier than other students to engage in college misconduct, the researchers found. “In other words, precollege misconduct is a risk factor for college misconduct,” they write.

But it does not follow, they say, that the methods that colleges now use to screen for those behaviors (questionnaires and, in some cases, criminal background checks) are effective at identifying, let alone preventing, misbehavior in college.

The study, published in Injury Prevention and conducted by researchers at the Colorado School of Public Health, seeks to gauge whether information that colleges collect about students’ pre-college behavior reduces violence or other misbehavior on campuses.

Only 3.3 percent of the seniors who engaged in misconduct while in college actually reported pre-college criminal histories during the admissions process. And 8.5 percent of applicants with a criminal history in high school engaged in misconduct while in college, the study found.

The short answer: No. But the researchers note that the data aren’t widespread enough to inform policy, and that the findings don’t necessarily mean that there aren’t still reasons to ask students about their behavioral backgrounds – a point that some admissions officials reinforce.

“The ability to screen at the time of application and weed out the bad apples just doesn’t exist,” Runyan said in an interview. The study suggests that colleges should be careful about using their existing tools to screen people out of higher education, especially given inequity in how the criminal justice system functions.

Carol Runyan, an epidemiologist at the Colorado School of Public Health and professor of pediatrics at the University of Colorado School of Medicine, analyzed the misconduct before and during college of students at an unnamed university in the South. (The study was conducted when Runyan and the other three authors worked at the University of North Carolina Injury Prevention Research Center, in Chapel Hill.)

Admissions officials whose institutions collect information on students’ criminal backgrounds said they found the new study helpful in making it clear that there were risks in overdependence on such screening tools. “It certainly raises questions about the utility of these questions in keeping campuses safe,” said Pam Horne, associate vice provost for enrollment management and dean of admissions at Purdue University.

The students’ pre-college behavior was gauged by reviewing their answers to questions on the students’ college applications about their criminal histories. Students were directed to report whether they had been convicted of crimes, taken responsibility for a crime, or had criminal charges pending at the time of their application, excluding minor traffic offenses.

But Horne said that colleges have other reasons for asking applicants about their pre-college misbehavior -- most notably to send them signals about how institutions wanted them to behave once on their campuses.

The researchers had two methods of discerning on-campus misconduct. First, they examined disciplinary records in the dean’s office, and counted all nonacademic honor code violations, which included sexual and physical assaults, thefts, etc.; alcohol-related violations that involved disruptive, disorderly or dangerous conduct; and charges that were dismissed by the honor court but successfully prosecuted in local courts. Second, they surveyed a random sample of the 6,972 graduating seniors in 2010 and 2011 about misconduct before and during college, and got some of those seniors to submit to criminal background checks. One hundred twenty students emerged from the review of disciplinary records, and 151 through the second method.

“The application for admission is really valuable real estate, and it gives you a chance to express what some of your values are,” she said. “When you put those kinds of questions in the first formal contact you’re having, you’re stating something about your institution and how you expect members of your academic community to treat each other.”

Reprinted from INSIDE HIGHER ED April 18, 2013 with the permission of Inside Higher Ed, copyright 2013.

Inside Higher Ed is the free daily news Web site for people who work in higher education. Breaking news, lively commentary and thousands of job postings bring more than 800,000 people to the site each month.

Read more: http://www.insidehighered.com

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CURING THE COMMON COLD OF LEADERSHIP: POOR LISTENING

Curing the Common Cold of Leadership: Poor Listening By: Daniel Goleman

This leads to the common cold of the workplace: Tuning out of what that person is saying before we fully understand – and telling them what we think too soon. Real listening means hearing the person out and then responding, in a mutual dialogue.

So there you have a bad habit to replace – poor listening – and a positive alternative to practice instead.

People are notoriously poor at changing habits.

Neuroscience findings make clear why: habits operate from the basal ganglia, in the unconscious part of the mind. They are automatic and most often invisible, even as they drive what we do.

Leaders today are beset by overwhelming demands – scheduled every 15 minutes through the day, with an incoming barrage of messages via phone, email, texts, and knocks on the door. Who has time to pay full attention to the person you’re with?

And yet it is in the moments of total attention that interpersonal chemistry occurs. This is when what we say has the most impact, when we can come up with the most fruitful ideas and collaborations, when negotiations and brainstorms are most productive.

And it all starts with listening, turning our attention fully to the person we are with. It’s not just leaders, of course. We’re all besieged by distractions, falling behind on our to-do lists, multi-tasking.

A classic study of doctors and patients asked people in the physician’s waiting room how many questions they had for their doctor. The average was around four. The number of questions they actually asked during that visit with their doctor turned out to be about one-and-a-half. The reason? Once the patient started talking, an average of 16 seconds or so the doctor would cut them off and take over the conversation.

That’s a good analog for what happens in offices everywhere. We’re too busy (we think) to take the time to listen fully.

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This arrangement works well, for the most part.

The basal ganglia’s repertoire of unconscious habits includes everything from how to operate your smartphone (once you’ve mastered the details) to how to brush your teeth. We don’t want to have to think about these routines – and our brain doesn’t want to waste on them the mental energy that would take.

But when it comes to our unhelpful habits, that arrangement creates a barrier to changing them for the better. We don’t notice them, and so have no control. We need to become consciously aware of the habit, which transfers control to the brain’s executive centers in the prefrontal area. This offers us a choice we did not have before.

The key is being mindful of those moments in your day when you have a naturally occurring opportunity to practice good listening. Most often those moments go by unnoticed and we launch into our old, bad habits.

Once you notice the moment is here, there’s another task for mindfulness: to remind you of the better habit. In this case, you would intentionally put aside what you’re doing, ignore your phone and email, stop your own train of thought – and pay full attention to the person in front of you.

Mindfulness is the secret ingredient in successful habit change. There are several resources to help you mindfully shift patterns:

CURING THE COMMON COLD OF LEADERSHIP: POOR LISTENING - Mirabai Bush, a key contributor to Google’s Search Inside Yourself course, developed a new CD called Working with Mindfulness. It includes a guided exercise on how to be a more mindful listener.

- Tara Bennett-Goleman’s new book, Mind Whispering: A New Map to Freedom from Self-Defeating Emotional Habit, combines principles and practices from mindfulness and Buddhist psychology, the neuroscience of habit change, and cognitive therapy to offer a new lens on repatterning our emotional habits.

- Clear communication – and good listening skills – is key for managing virtual teams and connecting with long-distance clients. The CD Socially Intelligent Computing by professor and Internet theorist, Clay Shirky, offers ways to apply social intelligence for group interactions online. *Originally published May 02, 2013 on LinkedIn.

ABOUTthe AUTHOR Emotional Intelligence

author, Daniel Goleman lectures frequently to business audiences, professional groups and on college campuses. A psychologist who for many years reported on the brain and behavioral sciences for The New York Times, Dr. Goleman previously was a visiting faculty member at Harvard.

Be sure to check out Dr. Goleman’s Leadership: A Master Class video series. This 8-part video collection examines the best practices of top-performing executives, and offers practical guidance for developing emotional intelligence competencies. http://www.morethansound.net/store/

SAFER CITIES THRIVING COMMUNITIES Resources diminish and become harder to connect. Technology advances and overwhelms.

Threats increase, but we’re not in an arms race.

We’re in a communications race.

Within the information flowing between citizens, responders and agencies is the intelligence that builds a safer city. Motorola Solutions can help you collect more of it, make it actionable and securely distribute it across mission critical devices and easy-to-manage networks. It’s the technology and expertise that turns noise into information, information into intelligence, and intelligence into safety. And it’s how to do the absolute most with less – build safer cities, counties, states and provinces… and communities that thrive.

motorolasolutions.com/safercities

MOTOROLA, MOTO, MOTOROLA SOLUTIONS and the Stylized M Logo are trademarks or registered trademarks of Motorola Trademark Holdings, LLC and are used under license. All other trademarks are the property of their respective owners. © 2013 Motorola Solutions, Inc. All rights reserved.

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DOMAIN SPRING/SUMMER 2013

3

Providing a Voice for EMS Educators

Official Publication of the National Association of EMS Educators

pg

18 Is the Bar for Entry

into the Practice of EMS Too Low? A Reflection from the Inside and Outside

by William J. Leggio, Jr., EdD(abd), MS NDR, BS EMS, NREMT-P

pg

26 Initiating a College

Wide Interdisciplinary Scenario Training: Working Together, Tying it Together

by Sally A. Cantwell, PhD(c), RN and Jeffrey R. Grunow, MSN, Colonel, NREMT-P pg

33 EMS Education and Healthcare Reform

by Sherry Clark, MS, RN, LP

Editorial Review Board William Raynovich Les R.Becker Bruce Butterfras Todd Cage Lynne Dees Attila Heterlendy Kim McKenna Mike G. Miller

Maddie O’Donnell Michael D. Pante Lance Villers Richard A. Walker David Blevins Greg LeMay Beth Ann McNeill Fred W. Wurster

NAEMSE MISSION: To inspire and promote excellence in

within the global community.

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EMS education and lifelong learning

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DOMAIN3 Is the Bar for Entry into the Practice of EMS Too Low? A Reflection from the Inside and Outside By: William J. Leggio, Jr., EdD(abd), MS, NDR, BS EMS, NREMT-P Introduction

Completing an emergency medical technician (EMT) training program and having a current CPR card is all that is needed to obtain a state license and practice as an Emergency Medical Technician (EMT) in many states. Add a few hundred hours of training and the EMT is eligible to practice as a Paramedic, ready to respond to emergency calls and stand face to face with death, provide invasive interventions, or deliver a new life into the world. The role of being an EMT or Paramedic and all of the associated responsibilities ought not to be taken lightly. The question addressed here is if the American bar for entry into the field of Emergency Medical Services (EMS) is too low.

This article was written in Riyadh, Kingdom of Saudi Arabia, where the author holds a Faculty appointment at Prince Sultan bin Abdul Aziz College for Emergency Medical Services, a college of King Saud University.

This academic appointment as a Saudi EMS educator began through the traditional EMS training route of most EMTs and paramedics, with a background as a practicing paramedic in rural communities along with having worked in emergency departments, one of which was an Academic Level 1 Trauma Center.

Reflecting on the published minimum educational requirements for EMS training leaves one asking if these standards truly prepare future EMS responders for the roles that they will have to fill and if the preparation they are receiving adequately protects the public. After reflecting on personal and professional educational and practice experiences from both the United States and international, this author suggests that the educational bar continues to be set too low and it is time to begin an earnest reflection and further dialogue on the level and standards of EMS education.

Comparison

FIGURE 1. Quick Facts: EMTs and Paramedics (in the US, 2010) 2010 Median Pay ................... $30,360 per year / $14.60 per hour Entry-Level Education ............. Postsecondary non-degree award Work Experience in a Related Occupation ............................ None On-the-job Training ............................................................... None Number of Jobs, 2010 ....................................................... 226,500 Job Outlook, 2010-20 ................. 33% (Much faster than average) Employment Change, 2010-20 ........................................... 75,400

FIGURE 2. Quick Facts: Registered Nurses (in the US, 2010) 2010 Median Pay .................... $64,690 per year / $31.10 per hour Entry-Level Education ....................................... Associate’s degree Work Experience in a Related Occupation ............................. None On-the-job Training ................................................................ None Number of Jobs, 2010 ..................................................... 2,737,400 Job Outlook, 2010-20 ........................... 26% (Faster than average) Employment Change, 2010-20 ........................................... 711,900

FIGURE 3 . Quick Facts: Respiratory Therapists (in the US, 2010) 2010 Median Pay ................... $54,280 per year / $26.10 per hour Entry-Level Education ....................................... Associate’s degree Work Experience in a Related Occupation ............................. None On-the-job Training ................................................................ None Number of Jobs, 2010 ......................................................... 112,700 Job Outlook, 2010-20 ........................... 28% (Faster than average) Employment Change, 2010-20 ............................................ 31,200

For perspective these results are compared to two similar healthcare occupations: Registered Nurses (Figure 2.) and Respiratory Therapists (Figure 3.).

There are three important differences to point out between these summaries. The 2010 median pay of $30,360 for EMTs and Paramedics is $34,330 less then that of a Registered Nurse. This difference is more than the actual EMT and Paramedic median pay. The 2010 median pay for EMTs and Paramedics is $23, 920 less then that of a Respiratory Therapist.

Second to note is the 2010 to 2020 job outlook. All three professions are predicted at faster then average increases.

In increasing order Registered Nurses are projected at 26% growth rate, Respiratory Therapists at 28% growth rate and EMTs and Paramedics growth rate is 33%. This indicates a 7% higher growth rate for EMTs and Paramedics compared to those of Registered Nurses, and positive 5% difference compared to Respiratory Therapists.

To start, a comparison of current and future EMS salaries is informative. The US Department of Labor’s Bureau of Labor and Statistics (2010) published these quick facts summary on EMTs and Paramedics (Figure 1.). Figure 1. shows that the entry-level of education for EMTs and Paramedics requires only a postsecondary non-degree certificate and that the median pay is only $30,360, with a 10-year job outlook of 33% growth, which is much faster than the projected average for all

US job markets.

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The final important difference between the three is the entry-level education. Both Registered Nurses and Respiratory Therapists have an Associate’s degree for entry-level education, compared to that of a postsecondary non-degree award entry-level education for EMTs and Paramedics. One cannot simply conclude just from these figures that a college degree in EMS will automatically result in an immediate salary increase. However, from this you can summarize these points into one; EMTs and Paramedics have a higher 2010 to 2020 job outlook for the next ten years, have at-least a negative median pay difference of $23,920 and require less entry level education when compared to Respiratory Therapists and Registered Nurses.

Figure 4 is general in nature and does show the added financial award over a lifetime that comes from a higher degree of education. Figure 4 indicates the added value from having a degree and Alexander, Weiss, Braude, Ernst, Fullerton-Gleason (2008) state that one of the important investments made by EMS personnel, particularly, by paramedics is education (p. 831). At this time this specific statement of education in EMS does not have strong data to support it, but the added value from different levels of degrees in nursing is documented.

Carnevale, Rose and Cheah (2011) released data on the Lifetime Earnings in 2009 dollars for each level of degree.

In the following levels the lifetime earnings in 2009 dollars for nursing and home health aids are presented in Figure Undergraduate Education 5. Figure 6 graphs the lifelong earnings in 2009 dollars for nurses in addition to the difference one degree to the next It is difficult to answer the age-old question in EMS of higher degree. Figure 7 illustrates the percentage of change why should I get a degree if I’m not going to make more in salary from one degree to the next highest based on the money? This question is difficult because there is little lifetime earnings in 2009 dollars (Carnevale, Rose and to no historical data to answer the specific added finanCheah, 2011). cial value from having a degree in EMS. However, there is general data on the added value from having a college FIGURE 5. Lifetime Earnings in 2009 Dollars degree. Carnevale and Rose (2011) released a report Based on Education For Nurses in the U.S. through Georgetown University Public and Policy Institute titled The Undereducated American in which they High School Diploma argue that the United States has been under producing Nursing and Home Health Aids ........................... $966,000 college-going workers since 1980 and this has failed to Some College / No Degree keep with growing demand. This failure has resulted in Nursing and Home Health Aids ......................... $1,030,000 income inequality and they warn if we do not change Associate’s Degree this then the gap between the earnings of Americans of Registered Nurses .............................................. $2,267,000 different educational attainment will continue to grow Bachelor’s Degree even wider (Carnevale & Rose, 2011). The gap between Registered Nurses .............................................. $2,527,000 the earnings of paramedics compared to nursing and Master’s Degree respiratory therapists is an example of the arguments Registered Nurses .............................................. $3,044,000 made by Carnevale and Rose (2011).

Professional Degree Registered Nurses ............................................... $2,722,000 If the profession does not advocate for a higher entry level of education, then on what new grounds do we *Source: Carnevale, Rose & Cheah, 2011 (SEE PAGE 25) really stand on to justify the need for a higher salary?

If the motivation is simply to increase salaries then at minThere is no guarantee, but there is evidence that clearly imum an associate’s degree ought to be required to practice indicates higher degrees of education do result in more as a Paramedic. For nursing the difference of salary in a money over a lifetime. Figure 4 summarizes Carnevlifetime based on 2009 dollars from some college / no deale, Rose and Cheah (2011) results on median lifetime earnings in 2009 dollars for “Some College/No Degree” gree to an associates is an increase of $1,237,000 or 120% (Carnevale, Rose and Cheah, 2011). It is also important to at $1,547,000; “Associate’s Degree” at $1,727,000 and note that the difference between some college / no degree “Bachelor’s Degree” at $2,268,000. and an associates resulted in the largest increase in salary Figure 4. The Median Lifetime Earnings in 2009 Dollars then any other increase in education. The only increase in education that nurse’s actually loose money, along with eleMEDIAN DIFFERENCE FROM DIFFERENCE FROM DEGREE ASSOCIATE’S LIFETIME SOME COLLEGE/NO mentary and secondary teachers, accountants and auditors, DEGREE LEVEL DEGREE EARNINGS was from a Master’s Degree to a Professional Degree (CarBachelor’s $2,268,000 $721,000 $541,000 nevale, Rose and Cheah, 2011). Carnevale, Rose and Cheah Degree (2011) do not report any other decrease in salary, other Associate’s $1,727,000 $180,000 Degree then this, in their findings. Carnevale, Rose and Cheah, Some College/ $1,547,000 2011 conclude their report by stating, “No matter how you No Degree cut it, more education pays… there is a sizeable economic Source: Carnevale, Rose & Cheah, 2011 return to going to college and earning at least a two- or four-year degree.” (p. 20) 19 | Educator Update | www.naemse.org

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As a profession we need to re-evaluate how we are asking the questions surrounding education and salary in addition to the required entry level of education into the EMS profession. Advocating for an associate’s degree is a step in the right direction because it would at-least be placing paramedics at the same entry level of education as registered nurses and respiratory therapists.

This even ground for entry into our profession would give paramedics, in general, new ground to start negotiating for comparable salaries to associate level nurses, respiratory therapists and one that calculates out to the median lifetime earnings for an associate’s degree.

The author holds true that the profession should truly be advocating for a Bachelor’s degree to practice as a Paramedic. This would continue to positively answer financially driven questions of why to obtain a degree.

In addition, higher levels of education lead to an increase in career opportunities, and this could help address the known retention issues in EMS (Alexander et al., 2008). However, it is time to move away from the financial and career benefits of higher levels of education and focus on the true role of EMS professionals, to save lives.

Though focused on nursing these contentions most likely still hold true for EMTs and Paramedics. EMTs and Paramedics, just like nurses, play a major role in patient outcomes.

In addition to improved patient outcomes, BSN educated nurses have better communication skills (Aiken et al., 2003). Blau, Hochner and Portwood (2012) discussed three studies with a similar focus on patient satisfaction with EMS; one study was done in Helsinki, Finland (Kulsima, Maatta, Hakala, Nousila-Wiik, 2003) and the other two were in the United States (Doering, 1998; Curka, P., Pepe, P., Zachariah, B., Gary, G., & Matsumoto, C., 1995).

Blau et al. (2012) noted that in these three studies a common theme of disaffection from EMS patients resulted because of poor paramedic communication skills, including not introducing themselves, being rude or having unprofessional conduct, with either the patient or family.

Given the age of these studies, the author assumes the EMS providers that were complained against most likely did not have more then a certificate. Though not a guarantee to prevent such behavior, an associate and bachelor degree curriculum and educational program would be able to include courses on humanities, ethics and communication that most likely better a paramedics ability to communicate with patients and families.

Aiken, Clarke, Cheung, Sloane, Silber (2003) found nurses with their Bachelors of Science in Nursing (BSN) deliver more competent care than a nurse with an associates degree in nursing. BSN programs improve a nurse’s practice and therefore improve patient outcomes as well, thus supporting a relationship between nursing education and patient outcomes (Aiken et al., 2003).

Thus far, this discussion should resonate with all EMS professionals and begin to raise other questions. Questions such as, how can I be better at saving lives, grow in my profession, create job opportunities and make a higher salary and not why should I get an EMS degree if I’m not going to get paid more?

2014 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:

Clinical, system, management, or personnel st October 31 , 2013 EMS Today Conference 2014

Category: Deadline: Presented at:

Educational st March 31 , 2014 NAEMSE Conference 2014

For additional questions contact the Prehospital Care Research Forum at: Telephone: (310) 312-9315

Email: pcrf@mednet.ucIa.edu

DOMAIN3 Regardless of if you agree or disagree with the discussion, promoting the EMS profession and protecting our patients by matching the developing standards of undergraduate education should be a selfless priority. Alexander et al. (2008) make a similar call for action, … the importance of a more highly educated EMS workforce should be recognized, and efforts should be directed toward retention of highly educated paramedics (p. 835).

Currently similar discussions are occurring outside of the United States, For example, these questions are being answered in the Kingdom of Saudi Arabia where the author is an instructor and Director of Simulated Education for a pioneering Bachelor’s of Science Degree in Emergency Medical Services.

An International Perspective In February of 2012 Prince Sultan bin Abdul Aziz College for Emergency Medical Services hosted the First Saudi Forum on EMS Education. This forum hosted international and national speakers and visitors. At the end an online survey was conducted to help define what competencies and courses should be taught in a Bachelor’s of EMS, and if this level of education should be the minimum educational standard to practice as a paramedic in the Kingdom of Saudi Arabia; and the results strongly supported a Bachelors of Science in EMS as a minimum educational standard to practice as a paramedic in the Kingdom of Saudi Arabia (Prince Sultan bin Abdul Aziz College for Emergency Medical Services, 2012).

30.4% of those who completed the survey were faculty members or an EMS educator, 26.5% physicians, 23.5% EMS manager, 11.8% public, 8.8% hospital or clinical coordinators. The remaining respondents were civil service representatives, administrators, accreditation members and students or graduates. Out of these respondents 30.4% had a Bachelors Degree, 23.2% with a Masters, 11.6% with a Doctoral Degree (PhD or EdD) and 14.5% with a Professional Degree (MD, DDS, DO or JD). The remaining had high school or certificate in EMT as highest level of education.

We asked the participants to indicate the competencies that they considered desirable for graduates with a Bachelor of Science in Emergency Medical Services degree, including the specific EMS advanced life support skills traditionally taught in United States EMS NHTSA Educational Guidelines and Core Curriculum (Prince Sultan bin Abdul Aziz College for Emergency Medical Services, 2012). We also asked about other non-clinical care competencies, such as: 1. Display professionalism of medical profession (75% strongly agreed, 11.5% agree slightly)

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2. Possess an understanding of the medical and legal aspects of the profession (84.6% strongly agreed, 3.8% agree slightly) 3. Apply fundamentals of public health to prevent disease, prolong life and promote health (72.5% strongly agreed, 11.8% agree slightly) 4. Conduct research and review literature (59.6% strongly agreed, 23.1% agree slightly) 5. Be aware of current issues and trends in EMS (78.8% strongly agreed, 7.7% agree slightly) 6. Apply evidence-based practice to emergency care (76.9% strongly agreed, 13.5% agree slightly) 7. Participate in management and leadership of EMS systems (67.3% strongly agreed, 19.2% agree slightly) We also asked, as a community of interest from the program, “your needs or expectations from an ideal EMS specialist and Bachelor of Science Program.” These are a sample of five representative responses: 1. Provide best evidence-based management and maintain high degree of professionalism and collaboration with other health care worker.

2. I expect that an ideal EMS specialist should provide immediate care to his/her patients professionally, skillfully with consideration and respect of the patient’s individuality, culture and beliefs, regardless of race, color and financial status.

3. I need graduates [to] know what they are doing and [to] think critically in the cases that [they] may face in the field. I expect that graduates understand English very well and provide best emergency treatment and write down the recommended treatment in hospital in their records.

4. EMS personnel need to stand out [in their] skills need to be impeccable [in] [and] decision making is precise based on a protocol driven format.

5. EMS specialists should be able to mange any emergent situation independently, skillfully, and in a professional way, and have an organized way of thinking and be emotionally stable and be able to deal with different difficult emergency situations.

We asked the respondents to provide any other competencies apart of usual paramedic skills that they expected.

Five samples responses:

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DOMAIN3 1. Disaster planning and management 2. Communicate efficiently with public and scientific community.

3. Disaster management 4. Knowledge of quality management tools, accountability, honesty and ethics in EMS setup 5. Role of primary health care at major events, e.g., Hajj (annual Muslim pilgrimage to the Sacred Mosque in Mecca, Saudi Arabia)

There are also studies that indicate increased patient outcomes from BSN nurses compared to non-BSN nurses. Therefore, discussions on levels of education in EMS should not be just limited to an associate’s degree, but should include higher levels of education, educator requirements and developing EMS colleges. Decisions and outcomes from these discussions on how to advance the U.S. EMS profession could have an impact on international EMS systems.

These responses indicate that EMS is viewed to have a major role in public protection and mass casualty response. This is echoed in the author’s experiences and discussions with EMS students and professionals from around the world, including conversations with fellow American EMS responders working internationally in many other nations, as well. From these discussions one can conclude that there are strong needs perceived for well-developed EMS systems throughout the world and this includes a need for EMS leadership, research and professional development that goes beyond a certificate level, or even associate’s degree, education.

Worldwide, EMS is a vital component of civilization and a critical component of overall public safety. Nations of the world are not as fortunate as the United States to have been able to develop well structured and generally well-funded emergency medical response systems.

Though some EMS responders in the United States are not aware of it, United States EMS is viewed internationally as having a strong influence in setting practice standards and providing scholarly evidence of best practices. These roles should be highly valued and not be taken for granted because some nations, for example Saudi Arabia, are starting to move beyond U.S. EMS educational requirements.

Currently, and many responders and educators in the United States may not be fully aware of the critical role that EMS in the United States can play internationally, but from a perspective of around 10,000 miles “across the pond,” the world is looking to American EMS and EMS education for leadership and guiding principles.

The author is yet to find an EMS textbook used in Saudi Arabia that is not published in the United States.

National Registry of EMTs is an organization known worldwide and a recognizable standard for psychomotor skill evaluation, even though it is not international. The U.S. educational standards serve as an international template, but programs outside of the United States are placing educational requirements and developing curriculums that surpass those of many EMS programs in the United States.

Conclusion

The job growth for EMS professionals is expected to grow up to 2020 at a higher rate then both nurses and respiratory therapists. There is a documented difference in salary for EMS professionals compared to nursing and respiratory therapists. The economic studies discussed in this article indicate that this gap could continue to grow even wider. The author strongly suggests one way to address this gap is to require at-least an associate’s degree from the current certificate requirement to practice EMS. For nursing, the difference in lifetime salary between some college / no degree and an associates degree is significant.

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In order to advance the profession, the evolving EMS environment must be acknowledged and leaders of EMS at all levels must be prepared to meet the coming challenges. This includes those who educate EMS students.

Ruple, Frazer, Hsieh, Bake and Freel (2005) surveyed 15,000 EMS educators and found that most EMS educators were working only part-time and that only 35.5% of the respondents had “some college education” and only 24% had completed a bachelor degree (any bachelor’s degree), and 21% had completed only an associate’s degree. Those results also indicated that fewer than 5% of the EMS courses were being taught in four-year colleges or universities, compared to 45% taught in a fire and or EMS venues not associated with accredited post-secondary institutions. In order to advance the profession academically, higher educational standards are necessary for institutions and instructors.

Our EMS community of educators, providers and leaders and must support those who want to advance their careers through achieving undergraduate and graduate degrees. EMS providers, educators and friends need to push for continued educational reform at all levels and components of the system. These reforms ought to include transforming current EMS programs in to Colleges of Emergency Medical Services that are dedicated to promoting and advancing our community heroes and their abilities to save lives with skilled hands through higher levels of education, professional development and evidence based practices.

DOMAIN3 References Aiken, L., Clarke, S., Cheung, R., Sloane, D., Silber, J., (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290(12), 1617-1623.

Alexander, M., Weiss, S., Braude, D., Ernst, A. A., Fullerton-Gleason,L., (2008). The relationship between paramedics level of education and degree commitment.

American Journal of Emergency Medicine, 27, 830837.

Blau, G., Hochner, A., Portwood, J., (2012). Public Perceptions of EMS. Journal of Allied Health, 41(2), e39-e43.

Bureau of Labor Statistics, U.S. Department of Labor.

(2012, March). Occupational Outlook Handbook, 201213 Edition, EMTs and Paramedics. Retrieved January 24,2013, from http://www.bls.gov/ooh/healthcare/ emts-andparamedics.htm

Key, C. B., (2002). Operational issues in EMS. Emergency Medicine Clinics of North America, 20,913-927.

Kulisma, M., Maatta, T., Hakala, T., & Nousila-Wiif, M., (2003). Customer satisfaction measurement in emergency medical services. Academic Emergency Medicine, 10(7), 812-815.

Ruple, J. A., Frazer, G. H., Hsieh, A. B., Bake, W., & Freel, J., (2005, April / June). Prehospital Emergency Care, 9(2), 203 – 212.

Prince Sultan bin Abdul Aziz College for Emergency Medical Services. (2012, February). First Saudi Forum on EMS Education. Conducted at King Saud University, Riyadh, Kingdom of Saudi Arabia.

Bureau of Labor Statistics, U.S. Department of Labor.

(2012, March). Occupational Outlook Handbook, 201213 Edition, Registered Nurses. Retrieved January 24, 2013, from http://www.bls.gov/ooh/healthcare/registered-nurses.htm Bureau of Labor Statistics, U.S. Department of Labor.

(2012, April). Occupational Outlook Handbook, 2012-13 Edition, Respiratory Therapists. Retrieved January 24, 2013, from http://www.bls.gov/ooh/healthcare/respiratory-therapists.htm Carnevale, A. P., Rose, S. J. (2011, June). The Undereducated American. Washington DC: Georgetown University, Georgetown Public Policy Institute. Retrieved from: http://www9.georgetown.edu/grad/gppi/hpi/cew/pdfs/ undereducatedamerican.pdf Carnevale, A. P., Rose, S. J., & Cheah, B. (2011, August).

The College Payoff. Washington DC: Georgetown University, Georgetown Public Policy Institute. Retrieved from: http://www9.georgetown.edu/grad/gppi/hpi/ cew/pdfs/collegepayoffcomplete.pdf

ABOUT AUTHOR the

William J. Leggio, Jr., EdD(abd), MS NDR, BS EMS, NREMTP, is a member of the EMS faculty as Director of Simulated Education at Prince Sultan bin Abdul Aziz College for EMS at King Saud University, Riyadh, Saudi Arabia. He has served as a paramedic in a level one trauma center in Omaha, Nebraska and EMS services in southwest Iowa and southeast Nebraska.

He has taught with Creighton University since completing his paramedic training in 2006 and continues to serve Creighton EMS on two advisory boards. He plans on defending his doctoral dissertation education at Creighton University in October of this year.

Curka, P., Pepe, P., Zachariah, B., Gary, G., & Matsumoto, C. (1995). Incidence, source and nature of complaints received in a large, urban emergency medical services system. Academic Emergency Medicine, 2(6), 508-512.

Doering, G., (1998). Customer care: Patient satisfaction in the prehospital setting. Emergency Medical Services, 27(9), 71-74.

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DOMAIN3 Initiating a College Wide Interdisciplinary Scenario Training: Working Together, Tying it Together By: Sally A. Cantwell, PhD(c), RN and Jeffrey R. Grunow, MSN, Colonel, NREMT-P Abstract

W

ith the increasing challenge to have simulation technology a part of higher education; faculty members have been encouraged to utilize this type of technology to better prepare students in the health professions to enter the workplace. To take it one step further, faculty have given students the opportunity to be collaborators with the entire health team in emergency situations at Weber State University’s (WSU) Dr. Ezekiel R. Dumke College of Health Professions (DCHP). With pre-written templates and weeks of preparation from faculty and students, a step-by-step process is laid out for an Interdisciplinary Simulation (I-Sim), which took place with six departments in WSU’s DCHP. The collaboration with students and faculty within these departments was a valuable learning experience, and the goals for the event were reached: improve communication between college departments and give students a feel in a safe setting for collaborating with one another in emergency situations, allowing them to put their learning and skills to the test.

The room can support separate scenario locations running independently and simultaneously. Additionally, each bed space can be filmed and stored using digital technology.

Over the years, college faculty have lamented that while each of our programs are successful and excellent individually, our students rarely interact with each other.

Another observation was that each discipline trained their students in isolation and then released them to the clinical environment where the shock of interdisciplinary participation appears (Pecukonis, Doyle, & LeighBliss, 2008). In addition, discussion from local health care facilities have reported the lack of interdisciplinary communication between new graduates from all health profession backgrounds and a lack of desire to assume a leadership role in the clinical setting. Current research supports these findings, and adds that patient errors are mostly attributed to poor communication by the interdisciplinary team (Dillon, Noble, & Kaplan, 2009).

Planning for I-Sim An article from the Institute of Medicine (2001) reported that interdisciplinary practice improves health outcomes.

Introduction Simulation technology has been used for many years in Allied Health and Nursing education. From the early task trainers to the most sophisticated of computer driven manikins, simulation training continues to evolve (Nehring & Lashley, 2009). On November 6th, 2009, the Dr. Ezekiel R. Dumke College of Health Professions at Weber State University (WSU) in Ogden, Utah carried out a successful college-wide patient care scenario or interdisciplinary simulation (“I-Sim”) utilizing six of the eight health care departments. Weber State University supports 23,000 students, the majority non-traditional.

The College of Health Professions produces over 1,000 health care related degrees per year, half the of the University’s degree production.

The College of Health Professions received grant funding to build a 4-bed simulation lab using Laerdal’s Sim Man and Sim Baby. Space was donated by the Respiratory Therapy Department, walls were torn down and rearranged and a control room behind one-way construction was created.

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DOMAIN3 Also discussed is the support for programs to utilize increased collaboration and interdisciplinary practice within health profession programs, early on, in the classroom and in clinical settings.

This kind of casual talk led to the idea of scenario-based interdisciplinary training using the college departments as preparation for a clinical experience. Our purpose was two-fold: (1) to promote interdisciplinary communication and (2) to observe and provide students with an opportunity to exercise leadership. After two years of talk a formal meeting was held and the ball got rolling towards a college wide event.

An event of this magnitude requires significant pre-planning; it requires time, flexibility, and a sincere desire for change. In the remainder of this article we want to explain the planning and logistics needed to initiate a college wide scenario event.

Below are nine critical elements that need significant consideration and preplanning (ASHE Higher Education Report, 2009; Dillon, et al, 2009; Pecukonis, et al, 2008): 1.

2.

3.

4.

5.

6.

7.

8.

9.

Disciplines participating Appropriate faculty Level of the exercise Date, time location, and publicity Preplanning, initial choreography Preplanning, detailed choreography Setup Event management Debriefing

The first consideration was, which disciplines’ should or will participate. In the WSU College of Health Professions the eight entities included Medical Laboratory Science, Dental Hygiene, Emergency Care and Rescue, Health Administration Sciences, Health Sciences, School of Nursing, Respiratory Therapy and Radiologic Sciences. At the initial planning session all but Health and Radiologic Sciences participated. The School of Nursing, the largest program in the College represented both entry level associate degree nursing (ADN) and advanced level Bachelor of Science in nursing (BSN).

Key to the success of planning the I-Sim event was selection of the correct faculty to send to the planning committee. Faculty members on the planning committee must be knowledgeable in simulation education, be open minded to change, and be willing to step out of their comfort box. We were fortunate that each department chair selected the correct “technology and simulation enthused” faculty.

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The initial question was “how in-depth should the first I-Sim event be?” While the first thoughts were to involve entire classes of students, the committee quickly decided that the first event should be of prototypical nature and run on a limited scope. However, the college technical expert assured us that the scenario could be broadcast into classrooms with LCD projectors and plasma screens should non-participating students wish to participate or observe.

The next consideration was date, time and location. Location selection was the easiest to tackle and it was agreed to start the I-Sim event in a Dental Hygiene chair. Dental Hygiene would then be responsible to call the paramedics, who would then transport the simulated patient to the Sim Lab, which would require a trip through the Dean’s Lobby and a one-floor elevator ride. Selecting a date and time proved more difficult.

As previously stated the original idea was to involve full classes in the I-Sim. Anyone in Allied Health and Nursing education will recognize finding a common time around class and clinical schedules are nearly impossible. With an obvious stalemate looming, the discussion returned to the limited, prototypical size of the event. In the College of Health Professions, Friday afternoon has the lightest use of classrooms and lessened student traffic.

Additionally, in Dental Hygiene, no patients are seen at the Mid-Town Clinic that doubles as a skill lab. As indicated above, the decision about size and scope needs to be made prior to the date, time and location. It should be noted, as we reflect on possible future events, I-Sims might involve the athletic training department, the theater department, and our on campus police academy cadets. In this instance, the timing of the event must stay away from National Collegiate Athletic Association (NCAA) team training and events, theater productions, and any skill training that may be taking place at the police academy.

One additional item of discussion was “how much publicity should be considered”? There was significant agreement to announce the event to all classes and the University newspaper The Signpost; however, the jury was hung on inviting the regional paper. That decision was left in the hands of the original planners. We definitely did not want any live television coverage since this was the prototype event and we did not want “theatrical staging” that might interrupt play. A difficult part of initiating I-Sim was setting up a scenario template which would include all participating disciplines and provide the sought after outcomes of the interdisciplinary event (Galloway, 2009).

To expedite planning, the paramedic program director, (a USAF Reserve, Colonel) borrowed upon the military model of exercise planning.

DOMAIN3 Since choreography is critical, a master template was designed (Table 1). Using “D” as event start time the master template starts at “D minus 60 minutes and finishes at “D+3 hours.’ An advantage of using the generic “D” is the start time can be manipulated and changed as required.

With the master template completed, each department created a “shred out” that explicitly delineated objectives that needed accomplishment. Detailed choreography of each programs expectation prevents over saturation of skills and provides a basic script to prevent extemporaneous changes. Examples of the paramedic (Table 2) and nursing template (Table 3) can be found at the end of this paper.

As mentioned previously, preplanning and choreography are keys to success (ASHE Higher Education Report, 2009; Dillon, et al, 2009; Pecukonis, et al, 2008). Setup for the Sieving was just as critical. In our scenario Dental Hygiene needed to obtain either a practice automatic external defibrillator (AED) or additional electrodes. The paramedic program needed to deliver a VitalSim manikin to Dental Hygiene and make sure the training ambulance would start. Nursing considerations included staging the appropriate equipment for the ADN part (ED resuscitation) and the BSN part (ICU care).

Respiratory Therapy needed to have smaller ET tubes available for the SimMan manikin. Medical Laboratory Science needed to make sure appropriate reagents were available for a “rainbow draw.”

Executing I-Sim Days elapsed and soon the I-Sim day was upon us.

While there were limited classes in the college, none of the programs had difficulty obtaining student volunteers. There was an air of slight apprehension and great excitement.

Managing the event involved two pieces: observing and controlling. Borrowing from the military, we chose to utilize the “observer-controller” method to manage I-Sim. First let’s discuss the role of observer. An observer would be any discipline expert that could critique that disciplines’ performance. In a true observer role there is no interaction with the performing student.

The second role and possibly the most important is that of controller. Controllers in military exercises often nudge or guide the scenario if for some reason it stalls.

In the instance the scenario becomes unstable; the controller can call a “time-out.” When you combine the two roles of “observer-controller” you only need one faculty member at each I-Sim location.

Potential “controller” situations included: (a) prompting dental hygiene students to call 9-1-1, (b) encouraging paramedic students to interact with the dental hygiene students, (c) reminding the nursing students to interact with the family and (d) prompting respiratory students to check a deflated pilot bulb. Therefore, the observer controller must be the most knowledgable, flexible and diplomatic person in each respective department.

From start to finish of the event, communications with all observer-controllers is critical. In our instance, the paramedic program supplied 6 GMRS radios (walkie talkies) that worked reasonably well. While observer-controllers could use cell phone technology, instant speak phones (i.e.: Nextel, etc) would be the ideal technology and reflect real-life scenario for paramedic students and nurses working in the ER. Lastly, a vital component to an I-Sim event is the post-exercise debriefing (Dillon, et al, 2009; Galloway, 2009). In order to foster college wide ownership and partnership, another technique was borrowed from the military, the “hot wash,” as seen on the generic template the general out briefing was done at 2 + 45 for all college disciplines. At the “hot wash” only broad or general items are covered.

There are no reasons the nursing students needs to know if the paramedics fumbled with the defibrillation nor the paramedics need to know the nurses made a bad drug calculation. The goal of the exercise is student learning, not humiliation.

There is an old saying at the Federal Emergency Management Agency (FEMA), “the best time to plan for a hurricane is an hour after the last one leaves” (Jeff Grunow, November 15, 2009, personal interview). The same is true of an I-Sim event. Our designated leaders met on Monday after the I-Sim event and dissected the good, the bad and the ugly. We were quite pleased to find there was in fact “little bad and no ugly”. If any lesson was learned it was that each discipline needed a more detailed “template” for their objectives and some adjustments in setups, particularly in Medical Laboratory Science.

The paramedic students found out the hard way that checking your response bag before a “work shift” is not a suggestion but a necessity. However, the paramedics forgetting their suction allowed a dental hygiene student to suggest using the chair suction as an alternative. There were quiet smiles on the faces of the dental hygiene faculty!

Nursing students found themselves suddenly enveloped in a role-playing event, which felt every bit as real as an active day in the ER. Receiving a patient from the ambulance who lost IV access in transfer was challenging but typical of a real life event. Receiving orders from a retired physician was a last minute, but incredible addition to our I-Sim event, which increased the reality of the situation.

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DOMAIN3 (Memo for record . . . the physician must stay on script!)

Nursing and Respiratory Therapy students communicated impressively in the highly intense situation of a patient coding without IV or ET access. Medical Laboratory Science was called once the patient was stable, but there were a few hiccups in relation to communicating physician orders for specific labs. However, when the Medical Laboratory Science department reported they found H1N1 flu, now the clouded chest x-ray made sense.

(An interesting note, although the scenario was written months earlier, Weber State lost a dedicated math professor one-week earlier to bacterial pneumonia secondary to H1N1.) In the end, Health Administration Sciences assumed the role of doing Quality Assurance on the event.

TABLE REFERENCES Table 1

What have we learned? Our students loved the event and felt it was “fun, educational, and really challenged their individual critical thinking skills and perception of teamwork”. In addition, actually being able to apply the skills they had learned in a safe environment was still intense, but very rewarding. A few students had never participated in an actual patient code in their health care setting, and felt this I-Sim event had helped prepare themselves more for the real thing.

As we move forward to the next I-Sim, the plan is to add Radiologic Sciences and add the whole “lead apron enchilada” simulating a portable shot. While our Dental Hygiene students were great actors in round one, we intend to give that role to the Health Sciences group or the theater department. When we reach that point all eight departments of the Dumke College of Health Professions will be participating.

Weber State University Dumke College of Health Professions Interdisciplinary Simulation (I-Sim) Exercise

Master Scenario Template “D” is event start time Timeline Event Observer Controller Briefing D - 60 Dental Hygiene and Paramedic Students in place D - 30 VitalSim® placed in Dental Chair (Sim Patient) D - 30 Nursing / CLS / Resp /HAS students in SimLab D - 15 Sim Patient feels bad in DH chair D - 00 Patient goes into cardiac arrest D + 05 Paramedic students arrive D + 10 Paramedic students load Sim Patient in ambulance D + 15 Paramedic care in ambulance – call into Sim ER D + 25 Patient delivered to Sim ER – report to nurses given D + 30 Nursing assessment, BLS care, ALS care, ventilator D + 31 ID band placed on patient Blood work ordered if not done so already D + 45 Chest x-ray requested Family (HTHS Student) interviewed by HAS D + 60 Patient “saved” – report to ICU D + 1:15 Patient doing well in ICU D + 1:45 - Portable chest x-ray - Blood gases – ventilator settings - Nurses maintain perfusion - Additional lab studies - Gather additional information - Speak to the family Patient ready to “go home” D + 2:30 D + 2:45 D + 3:00

Conclusion

“Hot-wash” full group debrief Individual department debrief

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Outcome Observer Controller Game plan distributed All Students in DH clinic – Paramedics in 417 DH / PAR Functioning with correct EKG rhythm DH / PAR Briefing completed MLS / NURS / RESP Patient history – Call 9-1-1 DH DH obtains AED and utilizes DH (PAR) DH gives PAR report DH / PAR Final report – (load family member) DH / PAR Appropriate EMS care and report PAR / NURS Appropriate transfer of care PAR / NURS / MLS Appropriate NURS, MLS, RESP procedures NURS / HTHS/ HTHS plays family – HAS does admissions RESP / MLS / HAS Appropriate MLS procedures NURS / MLS RADSCI Appropriate HAS procedure HAS Turnover to BSN nursing for care NURS / MLS / RESP NURS, MLS, HAS, RESP, HTHS, RADSCI EMT’s go to lab (hospital) to get report and transport the “saved” Sim Patient home Review of the overall event Review of specific curriculum elements

NURS / PAR ALL Each Department

DOMAIN3 Table 2

Weber State University Dumke College of Health Professions Interdisciplinary Simulation (I-Sim) Exercise

Scenario 1-P (Cardiac Arrest) Paramedic Shred-out Timeline Event Observer Controller Briefing D - 60 Dental Hygiene and Paramedic Students in place D - 30 Vital-Sim® placed in Dental Chair (Sim Patient) D - 30 Sim Patient feels bad in DH chair D - 00 Patient goes into cardiac arrest D + 05 - AED attached – three shocks given Paramedic students arrive D + 10 - Patient on floor - CPR continues (DH or PAR) - Initial airway management - DH gives report to paramedics - “Load and go” or “stay and play” decision - Shock decision AED or monitor defibrillator - DH/PAR Interacts with family - Load and transport to ambulance Paramedic students load Sim Patient in ambulance D + 15-25 - Attach monitor defibrillator - Maintain CPR and airway management - Insert IV - Give Epinephrine / Amiodarone / Lidocaine - Intubate patient - Additional shocks as required - Transport - Report to hospital Patient delivered to Sim ER – report to nurses given D + 30 - Simulated patient transfer – Medics do paperwork D + 31 -- IV is dislodged – ET is displaced -------------- Inactive time for Paramedics “Hot-wash” full group debrief D + 2:45 Individual department debrief D + 3:00 Table 3

Outcome Game plan distributed Students in DH clinic – Paramedics in 417 Functioning with correct EKG rhythm Patient history – Call 9-1-1 DH obtains AED and utilizes DH assists and gives PAR report PAR takes over ALS care (ALS algorithm may start here)

Observer Controller All DH / PAR DH / PAR DH DH (PAR) DH / PAR

Final report – (load family member) ALS care must have been started or start here

DH / PAR / NURS

Appropriate transfer of care Appropriate NURS, CLS RESP procedures HTHS plays family – HAS does admissions

PAR /NURS / CLS NURS / HTHS/ RESP / CLS / HAS

Review of the overall event Review of specific curriculum elements

ALL Each Department

Weber State University Dumke College of Health Professions Interdisciplinary Simulation (I-Sim) Exercise

Scenario 1-N (Cardiac Arrest) Nursing Shred-out – Emergency Care Timeline Event Outcome Observer Controller Observer Controller Briefing Game plan distributed All D - 60 Dental Hygiene and Paramedic Students in place Students in DH clinic – Paramedics in 417 DH / PAR D - 30 Vital-Sim® placed in Dental Chair (Sim Patient) Functioning with correct EKG rhythm DH / PAR D - 30 Sim Patient feels bad in DH chair Patient history – Call 9-1-1 DH D - 00 - “I have chest pain” - Students find irregular pulse -------------- Inactive time for Nursing Radio report from paramedics – Code decisions Appropriate team assembly PAR / NURS D + 25 Patient delivered to Sim ER – report to nurses given Appropriate transfer of care PAR / NURS / MLS D + 30 Nursing assessment and actions: Appropriate NURS, MLS, RESP procedures NURS / HTHS/ D + 31 - Assess and delegate CPR functions HTHS plays family – HAS does admissions RESP / MLS / HAS - Recognize and fix dislodged IV - Recognize and delegate ET displacement - Perform defibrillation and give ALS drugs - Request CLS for blood studies as needed - Escort unruly family member from code room - Return of spontaneous circulation - Assessment Blood work ordered if not done so already Appropriate NURS / MLS / RESP NURS / MLS D + 45 - Continue emergency care RADSCI procedures RADSCI - Chest x-ray requested - Monitor airway status - Additional assessment and skills assessment - Nurse talks with family Family (HTHS Student) interviewed by HAS Appropriate HAS procedure HAS D + 60 Patient “saved” – report to ICU Turnover to BSN nursing for care NURS / MLS / RESP D + 1:15 -------------- Inactive time for Emergency Nurses “Hot-wash” full group debrief Review of the overall event ALL D + 2:45 Individual department debrief Review of specific curriculum elements Each Department D + 3:00 DH = Dental Hygiene NURS = Nursing

HAS =Health Administration Science PAR = Paramedic

HTHS = Health Science RADSCI = Radiation Sciences

MLS = Medical Laboratory Science RESP = Respiratory Therapy

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DOMAIN3 References

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st Century.

Washington, DC: National Academic Press.

ASHE Higher Education Report. (2009). Best practices related to interdisciplinary education: understanding interdisciplinary challenges and opportunities. ASHE Higher Education Report, 35(2), 89-99.

Nehring, W. & Lashley, F. (2009). Nursing simulation: A review of the past 40 years. Simulation and Gaming, 40(4), 528-552.

Dillon, P., Noble, K., & Kaplan, L. (2009). Simulation as a means to foster collaborative interdisciplinary education. Nursing Education Research, 30(2), 87-90.

Pecukonis, E., Doyle, O., & Leigh-Bliss, D. (2008).

Reducing barriers to interprofessional training: promoting interprofessional cultural competence.

Journal of Interprofessional Care, 22(4), 417-428.

Galloway, S. (2009). Simulation techniques to bridge the gap between novice and competent healthcare professionals. The Online Journal of Issues in Nursing, 14(2). Retrieved from http://www. nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents// Vol142009/No2May08/Sim ulation-Techniques. aspx

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DOMAIN3 EMS Education and Healthcare Reform By: Sherry Clark, MS, RN, LP

O

n the surface it may seem simple to write an article on how Healthcare Reform will affect Emergency Medical Services (EMS) Education. The problem is that EMS Education and EMS healthcare delivery are interwoven, so it is important to understand that whatever happens with EMS delivery in the future with Healthcare Reform will undoubtedly affect EMS education programs and their ability to continue providing education for future and current EMS healthcare providers. Reform is projected to significantly influence the provision of pre-hospital emergency care, specifically in regards to call volume1, reimbursement2 and, structure3. By doing so, Healthcare Reform will inadvertently modify the configuration, delivery, and curriculum of EMS education programs in both initial and continuing education if the EMS providers’ scope of practice and skill sets expand to meet new healthcare system needs. Therefore, in order to understand how Healthcare Reform might affect EMS Education, and because EMS Education and EMS healthcare delivery are so closely tied, it is important to first look at the ways in which Reform might affect EMS provision of care.

EMS is an essential part of the healthcare system in the United States, yet it seems it is often forgotten, or at the very least, an afterthought as politicians and healthcare policy makers look at the larger scope of healthcare. Changes made in the national healthcare system will unquestionably have a major effect on EMS. With Healthcare Reform, the individual health insurance mandate portion of the Patient Protection and Affordability Care Act should dramatically reduce the number of uninsured patients which will most likely affect EMS call volume1. It has been estimated that insurance coverage will be extended to 16 million more people by 20144. It is reasonable to assume that there may be a surge in call volume as those who had previously been uninsured search out the healthcare that they had been avoiding and do so by using the quickest and most readily available means of transportation: an ambulance. This might be balanced, however, by those previously uninsured, who will seek care at primary care physician’s offices or clinics instead and take private or public transportation to get there. The first scenario is the most likely to occur, at least in urban metropolitan areas where many patients who already misuse EMS transportation are uninsured or on public insurance (Medicare/Medicaid1).

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Surges in EMS call volume will undoubtedly result in an increase in Emergency Department (ED) patients. This will not only happen at the EDs, however, which currently provide indigent care to the needy because these previously uninsured patients will now be able to choose hospitals outside the current network of facilities. Currently, many of the Medicare/Medicaid and indigent community use the EMS system for non-emergency care and transportation. Therefore, hopes aren’t high that this misuse will change. In addition, as the primary care physician (PCP) shortage increases over time4 there will most likely be a resultant increase in EMS calls for routine health questions and provision of routine care as patients use EMS as their entrance into the healthcare system. With this expected increase in call volume with Healthcare Reform, urban EMS systems may begin to utilize selective dispatch or selective transport for patients. If this change in EMS delivery occurs, EMS education programs in turn will need to have greater depth in their curriculum in regards to critical thinking and assessment.

Healthcare Reform does not provide specific funds for an increase in EMS utilization, and current federal reimbursement rates do not come close to covering the cost of providing pre-hospital ambulance services5.

EMS agencies that provide 911 services have a duty to respond to a call and are obligated to provide care regardless of the patient’s ability to pay. The national ambulance fee schedule, developed by the Centers for Medicare and Medicaid Services in 2004, has been used by private insurers as a standard for rate regulation of fees. Much like hospitals, EMS reimbursement is from public and private insurers and the patients are billed for the unpaid amount. Many municipal EMS agencies are also subsidized by property taxes. As a result, budget constraints and decreasing property values have made it extremely difficult for communities to fully support the financial needs of their EMS system. As is the case with Healthcare Reform, reimbursements for hospitals will be focused on pay for performance, linking reimbursement to quality measures and ambulance reimbursement being grouped with the other healthcare providers2. It is unclear how this will ultimately affect EMS agencies since most fire-based EMS agencies currently lack the ability to measure quality outcomes and performance in ways that can be verified3. As a result, if EMS reimbursement changes from ‘fee for service’ to ‘pay for performance’, linking reimbursement to quality of care (as it will with the hospitals), it is reasonable to consider that EMS agencies will not be prepared. The other aspect of Healthcare Reform that may possibly affect EMS reimbursement is how EMS agencies will interrelate with the Accountable Care Organizations (ACO).

DOMAIN3 The Centers for Medicare and Medicaid Services defines ACOs as groups of doctors, hospitals and other healthcare providers who come together voluntarily to give coordinated high-quality care6. Reimbursement funds are subsequently provided to the ACOs based on the quality of service and reductions in the total cost of care to a patient population. The question that needs to be asked is: Will payment for ambulance services be bundled into this coordination of care? If this is the case (and because payments will be linked to patient outcomes), EMS agencies will be working with ACOs to develop performance and patient satisfaction measures, and ensuring that their patient care is evidence based with quality measures and accountability systems7. Finally, EMS reimbursement rates are already low with ‘fee for service’ even without adding the manpower needed to work with other organizations for payment and putting these additional costs and measures in place. Will fire-based EMS agencies then choose to relinquish the provision of emergency medical services instead? Will ACOs elect to acquire private ambulance services in order to ensure quality of care, efficiency and reduce re-admission rates? Either of these scenarios could change how some EMS education programs currently recruit students and structure their programs.

With the increased emphasis that Healthcare Reform has placed on preventative care, another area where EMS healthcare delivery could see changes is in the scope of practice for paramedics. Community Paramedic Programs have been established in several areas of the country, providing primary care, public health and social services, and physician-driven primary care extending into the home. The paramedics become the eyes and ears of the physicians and the voice of the patient8.

They work from pre-written standards and protocols with physicians, being available by phone if needed.

Community paramedic programs have already emerged in several states in the United States to bridge the identified gaps in their communities, whether it is access to healthcare in rural areas or preventative education in the urban areas. As Healthcare Reform continues and more emphasis is placed on preventative care and decreasing patient readmissions to the hospitals, along with a continued nursing shortage and increasing PCP shortage, it may be necessary to expand the scope of practice of paramedics. This new scope will be needed to allow community paramedics to work with physicians and residents of their communities to conduct wellness checks in compliance to regimen checks, as well as other identified community needs.

So what do all of these possible changes in EMS healthcare delivery mean for EMS education programs?

First and foremost, EMS education programs will need to stay alert to and be aware of the changes that will undoubtedly occur in EMS delivery since Healthcare Reform will affect how the EMS agencies do business and manage their budgets. Traditionally, EMS education programs have trained students to assess, treat, and provide safe transportation to the hospital for every patient regardless of the nature of the illness or injury; whether emergent or non-urgent. Should EMS agencies respond to the likely increase in call volume by utilizing a selective transport model, EMS programs will need to integrate more depth in patient assessment – as well as enhanced critical thinking skills – into their curriculum. In doing so, it will create a heightened awareness of whether or not patients need to go to the hospital for further evaluation or can have their healthcare delayed.

If fire-based EMS agencies respond to the inevitable changes in reimbursement with either a reduction in the number of paramedics or an actual disbanding of their EMS, some education programs will lose a core base of students. These programs will then need to be more resourceful and creative in marketing to potential students in the private sector. Some programs may find the need to change program structure to attract students by developing distance learning curriculum or hybrid courses, along with creative scheduling of classes. In addition to program structure and education delivery modifications, there may be a need to further expand current EMS curricula should there be a demand for such non-traditional paramedic roles as community paramedic. This need is made even greater as EMS agencies search for ways to ease their increasing call volume. The paramedic curriculum would need to expand from the current emphasis on emergency evaluation, treatment, and care and move towards a more thorough foundation in primary care; public health; disease management; mental and dental health; and prevention and wellness.

Another area where EMS program curricula could evolve is in assisting the development of programs, which could bridge the paramedic curriculum into nursing and Physician Assistant programs. As Healthcare Reform produces new delivery system models and the emphasis on primary and preventative care becomes greater, there will undoubtedly be an increased need for nursing and Physician’s Assistants9. Paramedics are a very logical and reasonable source of students for these programs.

Hospitals seem to be much better prepared than EMS agencies3 when it comes to adapting to the types of changes that will come about as a result of Healthcare Reform.

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DOMAIN3 There have been very few Healthcare Reform topics brought fourth at either local or national EMS seminars/conferences, which may take some of the EMS agencies by surprise thus resulting in crisis management and reactionary behavior. EMS education programs, though, can be proactive by being prepared to make changes and planning strategically for any possible fall-out due to lack of planning by EMS agencies.

Healthcare Reform will most certainly change how we provide an education for EMS healthcare providers.

4 Cullen, E., Ranji, U., Salganicoff, A., (April 2011). Healthcare Policy Explained – Primary Care Shortage. Retrieved from http://www.kaiseredu.org/Issue-Modules/Primary-Care-Shortage/Background-Brief.aspx.

5 Garza, Mannie. (November 17, 2008). Low Reimbursement Rates Keep EMS Pay Low. Retrieved from: http://www.jems. com/article/administration-and-leadership/low-reimbursement-rates-keep-e

References

6 Centers for Medicare and Medicaid Services. (March 22, 2013). Accountable Care Organizations. Retrieved from: https://www.cms.gov/Medicare?medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/

1 - Swanson, Peter. (February 11, 2011). Emergency Medical Services: How Health Reform Could Hurt First Responders.

National Center for Policy Analysis. Retrieved from http:// www.ncpa.org/pub/ba737

7 United States Department of Health and Human Services.

(March 31, 2011). News Release – Affordable Care Act to Improve Quality of Care for People with Medicare. http://www. hhs.gov/news/press/2011pres/03/20110331a.html

2 McCallion, Teresa. (June 13, 2011). Ambulance Billing and Reimbursement Update. Retrieved from: http://www. jems.com/article/ems-insider/ambulance-billing-reimbursement-update

8 Doyle, Jennifer. (January 15, 2010). Community Paramedics Expand Healthcare Access. Journal of Emergency Medical Services. Retrieved from http://www.jems.com/article/leadership-professionalism/community-paramedics-expand-he

3 Evans, Bruce. (April 9, 2012). What Healthcare Reform Means for Fire-Based EMS. Fire Chief. Retrieved from http://firechief.com/ems/what-healthcare-reform-means-firebased-ems.

9 Cawley, James. (October 28, 2010). Advance for NPs and PAs. Healthcare Reform is Good for NPs, PAs and patients. Retrieved from http://nurse-practitioners-and-physician-assistants. advanceweb.com/Archives/Article-Archives/Healthcare-reformis-good-for-NPs-PAs-and-patients.aspx.

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CURRICULUM: DOES IT MATTER?

Curriculum: Does Sequencing Matter? by: Patricia L. Tritt, RN, MA Paramedic education consists of a vast amount of medical and related content relevant to the assessment and management of patients in the prehospital setting. The best, or most appropriate, method to sequence that content is more complex than it might first appear. Many programs offer between 35 - 45 college credit hours for just this specific content, not including anatomy and physiology or other general education courses offered through the college. Contact hour numbers vary widely but commonly fall between 1100 – 1500 hours. In addition, paramedic programs include four primary components: classroom or didactic; skills laboratory; clinical setting; and field internship experience. The amount of time required for program completion can vary from an accelerated, full-time format of six-months to 18 – 24 months. Prerequisites vary from none (no experience as an EMT) to a minimum of one year experience as an EMT. Some programs have even developed discrete content blocks into the traditional college two, three, or four hour credit hour courses.

This approach has many advantages, including providing a mechanism for a student who has difficulties in one content area to be able to repeat just the necessary course (ie. pharmacology). The traditional college credit course approach also provides easier access to articulation of credits as the individual moves through the higher education process.

No matter what your format or prerequisites may be, programs must determine how to sequence that content to maximize the development of competent, entry-level graduates.

How do you analyze sequencing? The National Standard Curriculum provided a general road map for progression that many programs followed. The National EMS Education Standards open up the opportunities for more creative sequencing. The challenge is what content is required before other topics? This subject alone can provide both animated and heated discussion among educators. A common sense approach is required to determine what works best for your institution and the schedule you follow. For example: Does the class meet for three or four hours per session or all-day eight hour classes? And how often do classes meet each week?

Perhaps the larger question is how are the clinical (hospital, clinics, or other sources of ‘clinical’ experience) and the field internship integrated into the overall program? Unfortunately, some programs schedule clinical and field hours based on availability and convenience rather than how prepared the students are based on medical content already mastered in the classroom and skill labs. As an example, the following question can be posed: How valuable is a hospital clinical in a pediatric setting if the student has not completed the pediatric course content? The clinical rotations should provide an opportunity to perform assessments on all types of patients and to practice skills after the student has the satisfactorily completed the relevant course content.

In the field of medicine, an internship follows completion of medical school. In other words, the individual has the core information necessary to apply the practical skills already gained, yet the individual is not ready for licensure.

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CURRICULUM: DOES IT MATTER? The intent of the field internship in the paramedic program is to provide the opportunity to assess and manage all types of calls and develop experience in team leadership. In other words, it is a means to pull the experiences learned in the classroom, skills lab, and clinical areas together to assess, manage, and treat all types of patients in the prehospital setting.

Per the Guideline in the Standards and Guidelines: “Enough of the field internship should occur following the completion of the didactic and clinical phases of the program to assure that the student has achieved the desired competencies of the curriculum prior to commencement of the field internship. Some didactic material may be taught concurrent with the field internship.�

Content that is concurrent with the filed internship should not be core content but may be case reviews and/or case presentations, research presentations by students, completion of standardized courses (IE PHTLS or PALS), and other supportive content such as preparing resumes, interviewing for positions, etcetera.

A further challenge is how long should the field internship be? Internship is not only about hours but must also consider the length of the shifts, the volume and types of patients encountered, and the opportunities for the student to meet all of the terminal competencies and objectives for graduate entry level competency.

Another factor that significantly impacts the quality of the field internship is the structure of the preceptor – student experience. Ideally, the student should be assigned to a single preceptor for the duration of the field internship to provide optimal opportunity to develop a relationship of trust that promotes honest, objective assessment of the student and the maximum opportunity for the student to function as team lead.

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A second preceptor is also acceptable when scheduling issues provide challenges. In the preceptor de jour approach, this climate of familiarity and trust is typically lost and the rotations lose value.

Some programs choose to schedule field shifts throughout the program. Early on, these experiences are often observational only or with some assessment and skill opportunities.

These rotations should be considered field experience and may not be included as field internship since it does not meet the definition/requirements of an internship. Carefully consider what part of your field hours actually meets the definitions/requirements of an internship.

Try taking your curriculum apart and putting it back together again. Assemble your faculty and medical director and: chunk objectives and course content into logical components; list specific clinical rotations; and identify types of field experiences. Write each one on a sticky note and arrange on a white board. Continue to move around until you have a logical progression or find another creative way to approach the process of assessing your curriculum. Whichever way you decide, always keep the goals and objectives of the four components of the program at the forefront. Try the revised format and evaluate and repeat the process until you are confident that your students are receiving the very best experience possible.

* Disclaimer: Ms. Tritt is a member of the Board for the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP) and a long time accreditation site visitor. However, the views and advice expressed here are her own and should not be interpreted as CoAEMSP policy.

CONCUSSION CONFUSION

Concussion Confusion by: Allie Grasgreen

When concussion tests have reliability and validity issues (as they do), how can a coach or athletic trainer confidently return a concussed athlete to the field?

Data on head trauma are lacking, but given what we already know -- that head trauma sustained through contact sports can cause short-term problems like Johnson’s but also long-term dementia and depression -- do we really need any more data before intervening?

As put by Lewis Margolis, an associate professor of maternal and child health at UNC: “Aren’t we engaged in a large, immoral national experiment about this problem, and when will we step back and say, ‘Stop’?”

CHAPEL HILL, N.C. -- Zoya Johnson, a former gymnast at the University of North Carolina at Chapel Hill, had her last concussion two years ago -- and six others before that. She fell on her neck from the high bars.

As an athlete and a student, being concussed kept her from studying, from falling asleep. She struggled with nausea and dizziness. Today, Johnson still takes seizure medication during the day, and other medicine to help her sleep.

“I didn’t realize I had so many until I learned what a concussion was,” she said here at the annual conference of UNC’s Collegiate Sport Research Institute -- and even after she found out, it wasn’t her last. “I didn’t realize I had five until I had [my sixth].”

It was clear at a panel discussion here on head trauma in college athletics that despite growing attention being paid to the issue, there’s still a lot that people don’t know -- and aren’t doing -- about it.

For instance, how many concussions does it take to cause long-term cognitive problems? How much does sports culture -- which rewards toughness and fighting through adversity and pain -- have to do with the prevalence of head trauma, and what can be done to shift it?

The National Collegiate Athletic Association, facing a rising risk of litigation and following the lead of the National Football League, has taken some steps to try to prevent head trauma. In 2010 it mandated that all institutions develop concussion management plans, and it has adjusted some rules to discourage dangerous forms of contact.

(For example, it moved the kickoff line 15 yards forward, which has resulted in more touchbacks -- and thus fewer collisions on returns -- while not affecting the frequency of scoring.)

But the association is still skirting responsibility and needs to be held accountable, said Ramogi Huma, founder of the National College Players Association.

“There’s a lot the NCAA can do in policy,” Huma said. “By avoiding it, they are a cancerous part of the culture.”

The Ivy League in 2012 limited contact in practices to try to reduce head trauma, and is working with the Big Ten Conference to gather data on concussions. It will take years before any conclusions can begun to be drawn, but any steps that might help are worthwhile, said Huma, who has pushed the NCAA and other conferences to adopt similar policies but been largely ignored.

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CONCUSSION CONFUSION A good chunk of discussion focused on a factor that’s not easily addressed by tests or making athletes sit out a play when their helmet comes off during a play (which the NCAA now does): culture.

However, Mihalik noted that physicians in general don’t get a lot of training in concussions.

“I would argue that a coach that is there all the time that knows the athletes might be better equipped to identify the subtle nuances of a concussion,” he said.

“If there’s something that’s not keeping you off the field, you’re going to play through it,” Huma When people think about head trauma, football is said. “Anything less is an embarrassment.” most often the main sport (and perhaps the only Jason Mihalik, an assistant professor of exercise sport) that comes to mind. Athletes do sustain and sport science at UNC, recalled hearing some more concussions in football than in any other coaches tell concussed students to just take the sport, simply because there are more athletes playing the game. But the rate of concussions per concussion test and get back out on the field. athlete is worse in ice hockey, and head trauma can occur in any contact sport (as well as in those “The testing itself is not the answer,” he said. that wouldn’t be considered contact sports, like “There are many other things that go into it.” gymnastics).

Identifying the symptoms and knowing your athlete -- recognizing that a smart quarterback UNC -- which Mihalik said goes above and becalling the same play three times in a row is yond what’s required by the NCAA’s concussion probably a sign that something’s wrong -- are management plans -- does pre-season baseline also crucial. testing for 20 of its 29 sports. Then, when an athlete is concussed, officials can measure their test Johnson said her fellow athletes didn’t even take the tests seriously until she started speak- results against the non-concussed results. ing up about how concussions were affecting Huma, who played football at the University of her personally.

California at Los Angeles, said he doesn’t know if he’ll let his two sons play football once they’re Athletic trainers or physicians on the sidelines are charged with testing the athletes and decid- older. ing whether they’re O.K. to go back to playing.

“No, I shudder to think of all the hits I took and But when coaches hold huge power at institutions, and the institutions or even the athletics gave,” he said, comparing the risks to Russian roulette. “I don’t think anyone knows how this is department are hiring the trainers, conflicts of interest could result in pressure on the trainers going to turn out.” to give a go-ahead when they shouldn’t, Huma said.

In multiple cases last year, athletes showed obvious signs of concussions -- vomiting on the field and falling down repeatedly -- but were not removed from the game.

“I think there’s a need for independent doctors,” Huma said. “The person who at the end of the day decides whether or not the player returns should not have a conflict of interest.”

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Educator Update | www.naemse.org

Reprinted from INSIDE HIGHER ED April 19, 2013 with the permission of Inside Higher Ed, copyright 2013.

Inside Higher Ed is the free daily news Web site for people who work in higher education. Breaking news, lively commentary and thousands of job postings bring more than 800,000 people to the site each month.

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