history of ems past, present, future jeff dostalek ems instructor, nremt-p

History of EMSHistory of EMSPast, Present, FuturePast, Present, Future

Jeff Dostalek Jeff Dostalek EMS Instructor, NREMT-PEMS Instructor, NREMT-P

IntroductionIntroduction

EMS System DevelopmentEMS System Development

History of EMS History of EMS

Role of the Paramedic today versus the “ambulance Role of the Paramedic today versus the “ambulance driver” of yesterdaydriver” of yesterday

Paramedic professional responsibilities to enhance their Paramedic professional responsibilities to enhance their ability to provide quality serviceability to provide quality service

Licensure, Certification, CredentialingLicensure, Certification, Credentialing

ObjectivesObjectives

Describe benefits of continuing educationDescribe benefits of continuing education

Medical DirectionMedical Direction

List the benefits of professional association membershipList the benefits of professional association membership

IntroductionIntroduction

The public perception of you is based onThe public perception of you is based on– TV and articlesTV and articles– Your treatment of their loved onesYour treatment of their loved ones

Continuing education is a mustContinuing education is a must

Treat everyone with respect and dignityTreat everyone with respect and dignity

How far have we comeHow far have we come

EMS System DevelopmentEMS System Development

• 14851485• First use of an First use of an

ambulance.ambulance.• Transport onlyTransport only

• 1800s1800s• First use of and First use of and

ambulance/attendant to ambulance/attendant to care for injured on sitecare for injured on site

• 19261926• Service started similar to Service started similar to

present daypresent day

• 19401940• EMS turned over to fire and EMS turned over to fire and

police departmentpolice department• No set standard of careNo set standard of care

The 20The 20thth Century and Modern Century and ModernTechnologyTechnology

EMS Made major strides after WWIIEMS Made major strides after WWII

– Bringing hospital to filed gave patients a better Bringing hospital to filed gave patients a better chance for survivalchance for survival

– Korean WarKorean WarFirst use of helicopterFirst use of helicopterM*A*S*H* UnitsM*A*S*H* Units


19561956– Mouth-to-Mouth resuscitation developedMouth-to-Mouth resuscitation developed

Late 1950s/early 1960sLate 1950s/early 1960s– Focused shifted to bring hospitals to patientsFocused shifted to bring hospitals to patients– MICU developedMICU developed


1965: “The White Paper” released1965: “The White Paper” released

– Finding included:Finding included:Lack of uniform laws and standardsLack of uniform laws and standards

Poor-quality equipmentPoor-quality equipment

Lack of communicationLack of communication

Lack of trainingLack of training


““The White Paper: finding outlined 10 The White Paper: finding outlined 10 critical points for EMS Systemscritical points for EMS Systems– Led to national Highway Safety ActLed to national Highway Safety Act– Created US Department of TransportationCreated US Department of Transportation

19681968– Training Standards implementedTraining Standards implemented– 9-1-1 created9-1-1 created


19691969– First true Paramedic programFirst true Paramedic program– Standards for ambulance design and Standards for ambulance design and

equipmentequipment

19701970– NREMT beganNREMT began


1970s (cont’d)1970s (cont’d)– 1971: Emergency Care and Transportation of 1971: Emergency Care and Transportation of

the Sick and Injured published by AAOSthe Sick and Injured published by AAOS

– 1973: Emergency Medical Services Act1973: Emergency Medical Services Act

– 1977: First National Standard Curriculum for 1977: First National Standard Curriculum for Paramedics developed by US DOTParamedics developed by US DOT


1980s/1990s1980s/1990s– Number of trained personnel grewNumber of trained personnel grew– NHTA developed 10 system elements to help NHTA developed 10 system elements to help

sustain EMS Systemsustain EMS System– Responsibility for EMS transferred to the Responsibility for EMS transferred to the

statedstated– Major legislative initiativesMajor legislative initiatives

Licensure, Certification, and Licensure, Certification, and RegistrationRegistration

Certification examinationCertification examination– Ensure all health care providers have the Ensure all health care providers have the

same basic level of knowledge and skillsame basic level of knowledge and skill– Once you pass certification you can apply for Once you pass certification you can apply for

state licensurestate licensure


LicensureLicensure– How states control How states control

who practicewho practice– Also known as Also known as

certification or certification or credentialingcredentialing

– Unlawful to practice Unlawful to practice without licensewithout license

Holding a license Holding a license shows you:shows you:– Completed initial Completed initial

educationeducation– Met the requirement to Met the requirement to

achieve the licenseachieve the license


ReciprocityReciprocity– Certification granted from another Certification granted from another

State/agencyState/agency– Requirements:Requirements:

Hold a current state certificationHold a current state certification

Be in good standingBe in good standing

National Registry certificationNational Registry certification

The EMS SystemThe EMS System

Network of coordinated services that Network of coordinated services that provide care to the communityprovide care to the community

The public needs to be taught how to:The public needs to be taught how to:– Recognize emergenciesRecognize emergencies– Activate the EMS SystemActivate the EMS System– Provide basic careProvide basic care


Patient outcomes are determined by:Patient outcomes are determined by:– Bystander careBystander care– DispatchDispatch– ResponseResponse– Pre-hospital carePre-hospital care– TransportationTransportation– ER CareER Care– Definitive care and RehabilitationDefinitive care and Rehabilitation


DispatcherDispatcher– Usually the publics first contactUsually the publics first contact– Training level varies from State to StateTraining level varies from State to State

Scene may differ from what dispatcher Scene may differ from what dispatcher relaysrelays


As a paramedic, you must:As a paramedic, you must:– Develop care planDevelop care plan– Decide on transportation modeDecide on transportation mode– Determine receiving facilityDetermine receiving facility– Be active in your communityBe active in your community

Levels of EducationLevels of Education

EMS System function from a federal to EMS System function from a federal to local levellocal level– Federal: National EMS Scope of Practice Federal: National EMS Scope of Practice

ModelModel

– State:State: LicensureLicensure

– Local: Medical Director decides day to day Local: Medical Director decides day to day limitslimits

Levels of EducationLevels of Education

The national guideline designed to create The national guideline designed to create more consistent delivery of EMS more consistent delivery of EMS nationally.nationally.

2009: national EMS Education Standard2009: national EMS Education Standard– NREMT provides a national standard for NREMT provides a national standard for

testing and certificationtesting and certification

The DispatcherThe Dispatcher

Plays a critical rolePlays a critical role– Receives and enters Receives and enters

informationinformation– Interprets itInterprets it– relays it to appropriate relays it to appropriate

serviceservice– Pre-arrival instructionsPre-arrival instructions

Emergency Medical ResponderEmergency Medical Responder(EMR)(EMR)

Formerly “First Formerly “First responder”responder”

Requirements vary by Requirements vary by statestate

Should be able to:Should be able to:– Recognize Recognize

seriousness of seriousness of conditioncondition

– Provide basic first aidProvide basic first aid– Relay informationRelay information

EMTEMT

Formerly EMT BasicFormerly EMT Basic

Primary provider level Primary provider level in many systemsin many systems

Most populous level Most populous level in the systemin the system

Advance EMT (AEMT)Advance EMT (AEMT)

Formerly EMT-IFormerly EMT-I

Trained in:Trained in:– More advanced PathophysiologyMore advanced Pathophysiology– Some advanced proceduresSome advanced procedures

Initially developed in 1985Initially developed in 1985– Major revision in 1999Major revision in 1999

ParamedicParamedicHighest Level to be nationally Highest Level to be nationally certifiedcertified

– 1999: Major revision to 1999: Major revision to curriculum to increase level of curriculum to increase level of training and skillstraining and skills

Even if independently licensed, Even if independently licensed, you must:you must:

– Function under the guidance Function under the guidance of physicianof physician

– Be affiliated with a paramedic Be affiliated with a paramedic level servicelevel service

Paramedic EducationParamedic Education

Initial educationInitial education

– Most states based on National EMS Most states based on National EMS Education StandardsEducation Standards

– States require varying hours of educationsStates require varying hours of educationsnational Average: 1,000-1,500 hoursnational Average: 1,000-1,500 hours

Paramedic EducationParamedic Education

Continuing EducationContinuing Education– Most states require Most states require

proof of hoursproof of hours

– Attend conferences Attend conferences and seminarsand seminars

– Read EMS journalsRead EMS journals

– Get involved in post Get involved in post run reviewrun review

Continuing EducationContinuing Education

Maintenance of core knowledge and skillsMaintenance of core knowledge and skills

Expansion of knowledge and skillsExpansion of knowledge and skills

Awareness of advances in professionAwareness of advances in profession

Forms of CEU are manyForms of CEU are many

Working With Other Working With Other ProfessionalsProfessionals

Hospital StaffHospital Staff– Become familiar with the hospital;Become familiar with the hospital;

– The best patient care occurs when emergency The best patient care occurs when emergency care providers have a close rapport with staffcare providers have a close rapport with staff

ASK QUESTIONSASK QUESTIONS

Health Care ProfessionalHealth Care Professional

Conform to professional standardsConform to professional standardsProvide quality patient careProvide quality patient careInstill pride in the professionInstill pride in the professionStrive for high standardsStrive for high standardsEarn respect of othersEarn respect of othersSocietal expectations on & off dutySocietal expectations on & off dutyPosition of public trustPosition of public trustUnprofessional conduct tarnishes the profession, the Unprofessional conduct tarnishes the profession, the service, and youservice, and youImage and BehaviorImage and Behavior

Working With OtherWorking With OtherProfessionalsProfessionals

Public safety agentsPublic safety agents– Some have EMS Some have EMS

TrainingTrainingCan better perform Can better perform certain functions than certain functions than youyou

– Interagency Interagency cooperation benefits cooperation benefits patientspatients

Working With Other Working With Other ProfessionalsProfessionals

Continuity of careContinuity of care– the community has expectation of EMSthe community has expectation of EMS

– Focus on preventionFocus on prevention

– You will interact with many professional You will interact with many professional groupsgroups

Understand your role, as well as othersUnderstand your role, as well as others

EMS Group InvolvementEMS Group Involvement

National, state, regional, and localNational, state, regional, and local

Development, education, implementation and setting Development, education, implementation and setting standards for EMSstandards for EMS

NREMT: verifies competency and reciprocityNREMT: verifies competency and reciprocity

Wisconsin: Wisconsin: – DHSDHS EMS Advisory BoardEMS Advisory Board– WEMSAWEMSA STAC / RTACSTAC / RTAC– PSOWPSOW WTCSWTCS– WPS,Inc.WPS,Inc. Others ?Others ?

Primary ResponsibilitiesPrimary Responsibilities

PreparationPreparationResponse to sceneResponse to sceneScene assessmentScene assessmentPatient assessmentPatient assessmentRecognition of injury or illnessRecognition of injury or illnessManagementManagementAppropriate dispositionAppropriate dispositionPatient transport and transfer of carePatient transport and transfer of careDocumentationDocumentationReturn to serviceReturn to service

ProfessionalismProfessionalism

Standards of conduct and performance Standards of conduct and performance established by the professionestablished by the profession

You will be measured by:You will be measured by:– Standard, competencies, and education requirmentsStandard, competencies, and education requirments– Performance parametersPerformance parameters– Adherence to a “Code of Ethics”Adherence to a “Code of Ethics”


You are in a highly visible role in your You are in a highly visible role in your communitycommunity

You must:You must:– Instill confidenceInstill confidence– Establish and maintain credibilityEstablish and maintain credibility– Show concern for your patientsShow concern for your patients


Your appearance is of utmost importance Your appearance is of utmost importance

Present a professional image and treat Present a professional image and treat colleagues with respect.colleagues with respect.– Arguing with colleagues is inappropriateArguing with colleagues is inappropriate– Raising issues at the appropriate time and Raising issues at the appropriate time and

placeplace

Professional Attributes of the ParamedicProfessional Attributes of the Paramedic

IntegrityIntegrityEmpathyEmpathySelf-motivationSelf-motivationAppearance and Personal HygieneAppearance and Personal HygieneSelf confidenceSelf confidenceExcellent communicationsExcellent communicationsTime managementTime managementTeamworkTeamworkDiplomacyDiplomacyRespectRespectPatient AdvocacyPatient AdvocacyCareful delivery of serviceCareful delivery of service

Roles and ResponsibilitiesRoles and Responsibilities

Teach the community Teach the community about injury about injury prevention and illnessprevention and illness– Appropriate use of Appropriate use of

EMSEMS– CPR TrainingCPR Training– Influenza and Influenza and

pandemic issuespandemic issues– Campaign for EMS Campaign for EMS

systemsystem


paramedic carry out advanced skillsparamedic carry out advanced skills– Must take direction from medical directorsMust take direction from medical directors

Medical Director may perform many rolesMedical Director may perform many roles– Educate and trainEducate and train– Recommend new personnel or equipmentRecommend new personnel or equipment– Develop protocols, guidelines, and QADevelop protocols, guidelines, and QA


Roles of the Medical Director (cont)Roles of the Medical Director (cont)– Provide input for patient careProvide input for patient care

– Interface between EMS and other agenciesInterface between EMS and other agencies

– Advocate for EMSAdvocate for EMS

Medical DirectionMedical Direction(Medical Control)(Medical Control)

OnlineOnline– Provides immediate Provides immediate

and specific patient and specific patient care resourcescare resources

– Allows for continues Allows for continues quality improvementquality improvement

– Can render on-scene Can render on-scene care assistancecare assistance

OfflineOffline– Allows for the Allows for the

development of:development of:Protocols or guidelinesProtocols or guidelines

Standing ordersStanding orders

ProceduresProcedures

TrainingTraining

Improving System QualityImproving System Quality

Goal: evaluating and improving patient careGoal: evaluating and improving patient care

Continuous Quality ImprovementContinuous Quality Improvement

Quality AssuranceQuality Assurance


Continues quality improvement (CQI)Continues quality improvement (CQI)– Tools to continually evaluate careTools to continually evaluate care– Quality ControlQuality Control– Process of assessing current practice looking Process of assessing current practice looking

for ways to improvefor ways to improve– Dynamic ProcessDynamic Process


Review ambulance Review ambulance runs when possibleruns when possible

Focus of CQI is Focus of CQI is improving careimproving care

CQI can be peer CQI can be peer review:review:– Be professionalBe professional– Should be a Should be a

constructive processconstructive process


CQI programs helps CQI programs helps prevent problems by:prevent problems by:– Evaluating day-to-day Evaluating day-to-day

operationsoperations– Identify possible stress Identify possible stress

pointspoints

Look for ways to Look for ways to eliminate human eliminate human error:error:– Ensure adequate Ensure adequate

lightinglighting– Store medications Store medications

properlyproperly


Ways to eliminate human errorWays to eliminate human error– Be careful when handing patients offBe careful when handing patients off– Three sources of errorsThree sources of errors

Rules-based failureRules-based failure

Knowledge-based failureKnowledge-based failure

Skills-based failureSkills-based failure


Ways to eliminate human error (cont’d)Ways to eliminate human error (cont’d)– Agencies need clear protocolsAgencies need clear protocols– Be aware of your environmentBe aware of your environment– Ask yourself “Why am I doing this”Ask yourself “Why am I doing this”– Use cheat sheetUse cheat sheet– Be conscientious of protocolsBe conscientious of protocols

Patient SafetyPatient Safety

1996 Institute of Medicine1996 Institute of Medicine– Launched efforts to improve patient safety Launched efforts to improve patient safety

and quality of care.and quality of care.– At least 44,000 and may up to 98,000 people At least 44,000 and may up to 98,000 people

die in hospital each year as a result of die in hospital each year as a result of medical errorsmedical errors

Highest Risk for EMSHighest Risk for EMS

Ambulance CrashesAmbulance CrashesDropping PatientsDropping PatientsHand-offHand-offCommunication issuesCommunication issuesMedication issuesMedication issuesPoor sterile techniquePoor sterile techniqueAirway issuesAirway issuesSpinal ImmobilizationSpinal Immobilization

Preventing Medical ErrorsPreventing Medical Errors

Look-alike, Sound-alike MedicationLook-alike, Sound-alike MedicationPatient identificationPatient identificationCommunication on hand-offCommunication on hand-offPerform correct procedures Perform correct procedures Medication accuracyMedication accuracyPulling tubes and linePulling tubes and lineUsing proper technique Using proper technique Proper Hand hygieneProper Hand hygiene

Preventing Medical Error in EMSPreventing Medical Error in EMS

Environmental methodsEnvironmental methods– Clear-established protocolsClear-established protocols– Sufficient lighting for procedures and Sufficient lighting for procedures and

assessmentassessment– Performing patient care duties with minimal Performing patient care duties with minimal

interruptionsinterruptions– Organizing and packaging drugsOrganizing and packaging drugs– Securing equipment in patient care Securing equipment in patient care

compartments.compartments.

Preventing Medical Error in EMS Preventing Medical Error in EMS (cont’d)(cont’d)

Individual methodsIndividual methods– Reflection in actionsReflection in actions– Question assumptionsQuestion assumptions– Reflection biasReflection bias– Use decisions aidsUse decisions aids– Ask for helpAsk for help

SummarySummary

Ambulance corps were developed in WW Ambulance corps were developed in WW II to transport and rapidly care for soldersII to transport and rapidly care for solders

Helicopter implemented during the Korean Helicopter implemented during the Korean WarWar

SummarySummary

1966 the National Academy of Sciences 1966 the National Academy of Sciences and the National Research Council and the National Research Council released the “The White Paper”released the “The White Paper”

Paramedics must be licensed before Paramedics must be licensed before performing any functionperforming any function

SummarySummary

Standards for pre-hospital care are Standards for pre-hospital care are regulated by state law and State EMS regulated by state law and State EMS officesoffices

Four levels of trainingFour levels of training– First ResponderFirst Responder– EMTEMT– Advance EMTAdvance EMT– ParamedicParamedic

SummarySummary

Paramedics should be familiar with:Paramedics should be familiar with:– Roles of other health care providersRoles of other health care providers– Continuing education requirementsContinuing education requirements– Medical ControlMedical Control– Code of ethicsCode of ethics– Professional attributes of a health care Professional attributes of a health care

providerprovider– Quality Assurance Quality Assurance – Patient safety considerationPatient safety consideration

EMS Star of LifeEMS Star of Life

DetectionDetection

ReportingReporting

ResponseResponse

On Scene CareOn Scene Care

Care in TransitCare in Transit

Transfer to Definitive Transfer to Definitive CareCare

history of ems past, present, future jeff dostalek ems instructor, nremt-p

Documents

license slide

credentialing slide

created slide

dignity slide

modern technology ems

state licensure slide

th century

nremtp slide