Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Division 1 Introduction to Advanced Prehospital Care

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 1, Part 2 EMS Systems

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Topics History of EMS Components of an EMS System National Groups and Associations NHTSA Standards

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ EMS System A comprehensive network of personnel, equipment, and resources established to deliver aid and emergency medical care to the community

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Members of the Community Communications System EMS Providers Public UtilitiesPoison Control Centers Fire Rescue Hazmat Out-of-Hospital Components of an EMS System

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Emergency Nurses Emergency and Specialty Physicians Ancillary Services Rehabilitation Services In-Hospital Components of an EMS System

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ BLS Refers to the basic life-saving procedures such as artificial ventilation and cardiopulmonary resuscitation

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ ALS Refers to advanced life-saving procedures such as intravenous therapy, drug therapy, intubation, and defibrillation

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Some systems are tiered: BLS arrives first and then, if required, ALS arrives later.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ History of EMS EMS systems have developed from the traditional and scientific beliefs of many cultures.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Ancient Times First “protocols” established in Mesopotamia –Evidence of medications, patient assessment techniques, and bandages

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 18th and 19th Centuries Napoleonic Wars –First efforts of field care developed by one of Napoleon’s surgeons. Triage, a method of sorting patients by severity, developed. U.S. Civil War –Triage and transport of wounded soldiers –Improvised hospitals in houses, barns, and churches First civilian ambulance service –Cincinnati, Ohio (1865) –New York City Health Department Ambulance Service (1869)

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 20th Century World War II –Transportation to appropriate facilities –Battlefield ambulances Vietnam and Korean conflicts –Soldiers treated in battlefield –Evacuation by helicopter

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Post-1960s Developments Mortician-operated ambulances withdrew due to costs and demand for additional services. Fire and police departments began providing EMS. Growth of volunteer and independent local EMS provider agencies.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 1966 The National Highway Safety Act established the Department of Transportation, which provided grants for EMS. Publication of Accidental Death and Disability: The Neglected Disease of Modern Society –Highlighted deficiencies in prehospital emergency care –Set guidelines for development of EMS systems, training, ambulances, equipment

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 1969 The EMT-Ambulance program was made public. The first paramedic curriculum followed in 1977.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 1971 White House issued $9 million in EMS grants for EMS demonstration projects. –Designed to be models for subsequent system development

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 1972 The Department of Health, Education, & Welfare funded initiatives to develop regional systems.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ EMS Systems Act of 1973 Provided funding for a series of trauma projects $300 million allocated to study EMS planning, operations, expansion, and research Continued funding for regional systems until 1981

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ ManpowerTraining Communications Transportation Emergency Facilities Critical Care Units Public Safety Agencies Consumer Participation Access to Care Patient Transfer Standardized Recordkeeping Public Information and Education System Review and Evaluation Disaster Management Plans Mutual Aid To be eligible for funding a system must address:

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Two Items the Legislation Omitted System finance Medical direction

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 1977 First EMT-Paramedic curriculum was developed.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 1981 The passage of the Consolidated Omnibus Budget Reconciliation Act (COBRA) wiped out federal EMS funding.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 1988 Regulation and policy Resources management Human resources/training Transportation Facilities Communications Trauma systems Public information and education Medical direction Evaluation

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ EMS Agenda for the Future Published in 1996 as a comprehensive evaluation of the history of EMS Casts a vision for the future for EMS in the United States

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Continued Development of 14 EMS Attributes Integration of health services EMS research Legislation and regulation System finance Human resources Medical direction Education systems Public education Prevention Public access Communication systems Clinical care Information systems Evaluation

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Today’s EMS System Every EMS system must develop a system that best meets its needs. State- and regional-level EMS systems are often responsible for planning, developing protocols, and establishing standards.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Medical Direction (1 of 2) A medical director is a physician who is legally responsible for all clinical aspects of the system.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Medical Direction (2 of 2) The medical director’s role in a system is to: –Educate and train personnel –Participate in personnel and equipment selection –Develop clinical protocols –Participate in quality improvement and problem resolution –Provide direct input into patient care –Interface with the EMS system –Advocate within the medical community –Serve as the “medical conscience” of the EMS system

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The medical director can provide on-line guidance to EMS personnel in the field. This is known as on-line medical direction. © Kenneth Kerr

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Off-line medical direction refers to medical policies, procedures, and practices that medical direction has set up in advance of a call, such as standard protocols or standing orders.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Protocols are the policies and procedures for all elements of an EMS system.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Protocols are designed around the four Ts of emergency care: Triage Treatment Transport Transfer

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Public Education An essential and often overlooked component of EMS is the public. EMS systems should develop plans to educate the public on recognizing an emergency. –Accessing the system –Initiating BLS procedures

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Communications A coordinated, flexible communications plan should include: – Citizen access – Single control center – Operation communication capabilities – Medical communication capabilities – Communications hardware – Communications software

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Emergency Medical Dispatcher (EMD) The activities of an EMD are crucial to the efficient operation of EMS. EMDs not only send ambulances to scenes, they also make sure that system resources are in constant readiness. EMDs must be medically and technically trained.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Education and Certification Two kinds of EMS education are initial and continuing education. –Initial education is the original training course for prehospital providers. –Continuing education programs include refresher courses for recertification and periodic in-service training sessions.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Initial Education Based on the EMT-Paramedic: National Standard Curriculum published by the U.S. DOT –Establishes the minimum content for the course –Divided into 3 specific learning domains Cognitive Affective Psychomotor

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Once the initial education is completed, the paramedic will become either certified or licensed.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Certification vs. Licensure Certification is the process by which an agency grants recognition to an individual who has met its qualifications. Licensure is the process of occupational regulation.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Four Certification Levels First Responder Emergency Medical Technician-Basic Emergency Medical Technician- Intermediate Emergency Medical Technician- Paramedic

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The First Responder is usually the first EMS-trained provider to arrive on the scene.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The EMT-Basic is trained to do all that a First Responder can do, plus other complex skills.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The EMT-I should possess all the skills of an EMT-B and be competent in advanced airway, IV therapy, and other skills.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The EMT-P is the most advanced EMS provider.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Members of EMS are filling a growing number of nontraditional roles: Critical care transport Industrial or occupational EMS Tactical EMS Primary care

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ National Registry of EMTs (NREMT) Prepares and administers standardized tests for the First Responder, EMT-Basic, EMT- Intermediate, and EMT-Paramedic Establishes the qualifications for registration and re-registration, and for establishing a minimal standard of competency

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Belonging to a professional organization is a good way to keep informed about the latest technology.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Professional organizations include: National Association of EMTs National Association of Search and Rescue National Association of State EMS Directors National Association of EMS Physicians National Flight Paramedics Association National Council of State EMS Training Coordinators

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ A variety of journals are available to keep the paramedic aware of the latest changes in this ever-changing industry.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ These professional journals include: Annals of Emergency Medicine Emergency Medical Services Prehospital Emergency Care Journal of Emergency Medical Services Journal of Emergency Medicine

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Patient Transportation Patients should be taken to the nearest facility whenever possible. Medical direction should designate the facility. Patients may be transported by ground or air.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The helicopter has become an integral part of prehospital care.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Military helicopters frequently assist civilian EMS systems.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ A Type I ambulance

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ A Type II ambulance

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ A Type III ambulance

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Not all receiving facilities are equal in emergency and support service capabilities. Local systems and regions categorize hospitals based on capabilities.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Center Levels Level I – provides the highest level of trauma care Level II – may not have specialty pediatrics or a neurosurgeon on site Level III – generally does not have immediate surgical facilities available

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Mutual Aid and Mass-Casualty Preparation A formalized mutual aid agreement ensures that help is available when needed. Agreements should be between neighboring departments, municipalities, systems, or states. Each system should also put a disaster plan in place for catastrophes that can overwhelm available resources.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ An EMS system should have a disaster plan in place that is practiced frequently.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Quality Assurance and Improvement Quality Assurance is designed to maintain continuous monitoring and measurement of the quality of clinical care. Continuous Quality Improvement (CQI) is designed to refine and improve an EMS system, emphasizing customer satisfaction.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ An EMS system must be designed to meet the needs of the patient. Therefore, the only acceptable quality of an EMS system is EXCELLENCE!

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Service Quality EMS quality can be divided into two categories: “Take-it-for-granted” quality Service quality

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Take-It-for-Granted Quality Rules of Evidence –There must be a theoretical basis for change –There must be ample research –It must be clinically important –It must be practical, affordable, and teachable

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Take-It-for-Granted Quality Peer review is the process of EMS personnel reviewing each other’s actions and interactions with patients.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Take-It-for-Granted Quality Ethics are the standards that govern the conduct of a group or profession.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Customer satisfaction can be created or destroyed with a simple word or deed. Service Quality

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Research (1 of 2) Research programs are essential for moral, educational, medical, financial, and practical reasons. Future EMS research must address the following issues: –Which interventions actually reduce morbidity and mortality? –Are the benefits of a procedure worth the risk? –What is the cost-benefit ratio?

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Research (2 of 2) Has your organization participated in research?

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The Components of a Research Program (1 of 2) Identify a problem. Identify the body of knowledge on the subject. Select the best design for the study. Begin the study and collect raw data.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ The Components of a Research Program (2 of 2) Analyze the data. Assess and evaluate the results. Write a concise, comprehensive description of the study for publication in a medical journal.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Evidence-Based Medicine (EBM) Current standards accepted by physicians and other health care providers in clinical medicine Conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients Combines clinical expertise with the best available clinical evidence from systematic research

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ System Financing EMS funding can come from a variety of sources. Fee-for-service from Medicare, Medicaid, private insurance companies, or private paying patients is common. Public Utility Models are becoming increasingly popular.

Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Summary History of EMS Components of an EMS System National Groups and Associations NHTSA Standards