2. Welcome to the S-SV EMS Agency Altered Standard of Care Administrative Module 3 This is the third of three modules of the Altered Standard of Care Training. This section focuses on: Altered Field Response Protocols Family/Patient Brochure Just-In-Time Training (JITT) This module will take approximately 1 hour to complete. At the end of this module there will be a 10 question quiz. You must complete the quiz with an 80% success rate to pass. The questions will be based on the information learned during the training module. NOTE: Completion of the quiz is required to receive CE credit.

3. This training provides an example of how the current 911 system may be altered during a major disaster or pandemic outbreak. The scenario and changes shown in this module are hypothetical only and should not be taken as actual changes to the system. System changes may follow the model that is shown in this training, but could vary based on the severity and type of incident.

4. The purpose of the Altered Standard of Care Training is to provide information regarding the alteration of the EMS system in response to an increased demand for medical-aid services, beyond the capacity of the current system providers.

5. After completing this training, you should be able to: Describe the purpose and process for establishing QRV’s. List several changes that might be made to the paramedic scope of practice. Identify elements to include in a Family/Patient Brochure. List several important elements of Just-In- Time Training.

6. A pandemic outbreak has affected a large portion of the population. It is a severe variation of the annual flu virus. The EMS system has increasingly become overwhelmed, and there is no estimated time when this impact will end. We simply do not have the resources and personnel to handle the demand for more ambulances. Ahead we will discover what changes can be made to the system to handle this type of overload

7. Now that we have modified the medical dispatch system by altering dispatch protocols, developing a Scheduled Transport Center, and establishing a Public Access Number, we will now look at alterations to the EMS Field Response protocols.

8. The MHOAC and EMS Agency Medical Director must collaborate with the OA EOC to develop a plan that will allow the EMS system to expand and meet the needs of the EMS system when the demand for response exceeds the ability of the current system. www.disasterdoug.com

9. One solution may be to convert all ALS ambulances to BLS transport units, allowing us to place paramedics on Quick Response Vehicles (QRVs) This implementation will quickly expand available EMS resources. With this change, we may see paramedics responding to 911 calls in a supervisor vehicle, fire engine, fire battalion chief vehicle, public works vehicle, or any other vehicle modified to be used for 911 response. www.disasterdoug.com

10. Establishing QRVs will allow the paramedic to: Rapidly respond to 911 medical calls Provide ALS intervention as needed Transfer care to a BLS transport unit Clear the scene quickly to be able to respond to the next call www.disasterdoug.com

11. Vehicles Secured for use as must be modified and equipped with ALS equipment/supplies, communications, etc.

12. In cooperation with fire, ambulance, and OES; establishing strategic EMS staging areas throughout the county, will allow us to share resources, including: personnel, equipment, and supplies. Consolidating our resources will reduce duplication, and ensure that only the necessary resources are deployed to each call.

13. Paramedics have been taken off of the ambulance and placed in a QRV in order to respond to more calls without having to transport the patients to the hospital. Which of the following would be considered a QRV? www.disasterdoug.com

15. Now we have staffed and equipped vehicles that may be used by paramedics as QRVs and our ambulance fleet has been converted to all BLS transport.

16. Now let’s look at an altered triage process that ranks patients based upon the severity of need. This triage system will use the following categories: requires immediate medical intervention needs medical attention, however, the response can be somewhat delayed. May be assisted with self-care or system resources other than 911 medical resources. Needs non-medical community services. www.disasterdoug.com

17. IMMEDIATEDELAYEDMINORDECEASED Witnessed= Use First Round ACLS protocols Unwitnessed = refer to public access number Refer to Public Access Number Treat and Release or Refer Treat and Transport

18. Patients presenting with life threatening conditions such as Acute MI, uncontrolled hemorrhage, severe shortness of breath, ALOC, etc., will require treatment and transportation. IMMEDIATE www.disasterdoug.com

19. Patients who respond to treatment on scene and afterward present with normal mental status, normal vital signs, and blood sugar will be given a patient brochure then released or referred. DELAYED Options for referring patients may include: The Public Access Number Doctors office Self-care www.disasterdoug.com

20. Upon arrival, if the patient does not present with life-threatening conditions and does not require any EMS medical intervention, the patient would be given a Patient/Family Brochure and released on scene. MINOR www.disasterdoug.com

21. Only if the patient had a witnessed cardiac arrest would the field responders intervene. The patient would be given first round ACLS care and if there is no response the patient would be determined dead in the field. Family would be given a patient brochure prior to clearing the scene. DECEASED www.disasterdoug.com

22. To relieve the impact on the emergency rooms, the MHOAC and the EMS Agency Medical Director might expand the paramedic protocols to include a Disaster Flu Cache. This cache should include indications and contraindications, along with the revised protocols for items such as: powdered Gatorade, Compazine suppositories, ibuprofen, etc. www.disasterdoug.com

23. Using the Altered Standard Field Triage, who would be considered IMMEDIATE? A.A patient with nausea and vomiting with no other symptoms. B.A patient with signs and symptoms of an MI. C.A patient bleeding from an abrasion on his knee.

25. In addition to implementing the Altered Standard of Care plan, the MHOAC and the EMS Agency Medical Director, in collaboration with the OA EOC, must develop a Patient/Family Brochure. that may be distributed by EMS field personnel to patients and family members. www.disasterdoug.com

26. This brochure is designed to be distributed by EMS field personnel to patients and family members, including: Family members of patients transported to the hospital Patients treated and released on scene Family of deceased patients Patients with non-medical emergencies www.disasterdoug.com

27. The Patient/ Family Brochure should contain: information about the current situation, explaining the significant impact of the incident on the population www.disasterdoug.com

28. The Patient/ Family Brochure should contain: health threats, including current and projected effects www.disasterdoug.com

29. The Patient/ Family Brochure should contain: impact on the hospitals, describing limited resources and alternatives www.disasterdoug.com

30. The Patient/ Family Brochure should contain: EMS system changes, including changes in 911 protocols, as well as, what to expect when EMS responders arrive. www.disasterdoug.com

31. The Patient/ Family Brochure should contain: -Information regarding the local Public Access Number for individuals with non-medical emergencies www.disasterdoug.com

32. The Patient/ Family Brochure should contain: -Information regarding Web-based health information such as the CDC website, local Public Health website, or other private sites such as WebMD, etc. www.disasterdoug.com

33. The Patient/ Family Brochure should contain: -Information regarding self-care such as at-home treatment for fever, flu symptoms, minor first- aid, etc. www.disasterdoug.com

34. The Family/Patient Brochure will be provided to: A.Family members of patients being transported to the hospital. B.Patients treated and released on scene. C.Family of deceased patients D.All of the above.

37. In the event that a major disaster takes place and overwhelms the system, field responders and dispatchers must be provided with “Just-In-Time Training” on the Altered Standards of Care. This training should include didactic as well as practical application of the revised protocols. In this section we will discuss important principles of Just-In-Time Training (JITT).

38. After establishing Altered Standard Orders, responders must be provided with training including: Rolls and responsibilities of EMS system providers, Changes made to system protocols, and Changes made to overall system design www.disasterdoug.com

39. Just-In-Time training would normally be conducted by supervisors or management at each provider agency. www.disasterdoug.com

40. Following any Just-In-Time Training, personnel should be provided an opportunity to: Practice any new skills Become familiar with any new equipment or tools Review new or revised protocols www.disasterdoug.com

41. Just-In-Time Training is a process that allows responders or dispatchers to have just the right information or skills at just the right time using just the right presentation.

42. Just the right information Just the right time Just the right presentation

44. Just-In-Time Training incorporates only the pertinent information that is needed to take care of the situation at hand. Information not pertaining to this situation could overwhelm the responder or dispatcher causing them to make mistakes or overlook important steps.

45. Research confirms that understanding (i.e., knowing)—especially in times of stress—depends on effective neural pathways that connect action (i.e., doing) and emotion (i.e., feeling). Next are examples of each:

46. Although responders need to know about their assigned tasks, they also need information beyond their role and specific duties. For example, a responder may want a better understanding of how the overall response organization operates, and who is involved in each part of the operation.

47. Responders must understand how to perform their assigned task(s). Examples of how JITT encourages hands on learning include: Incident-specific scenarios Practicing administering vaccines/meds Practicing filling out forms and other documentation Practicing interviewing techniques with peers Practicing using assigned communication equipment (for example, two-way radios)

48. Responders need to feel comfortable with a given skill set and feel motivated to continue performing under pressure. Responders also need to be reassured that their contributions to a response effort are valued. Failing to provide this feedback may result in decreased job performance and affect a responder’s sense of duty— potentially compromising the overall response.

49. It is impossible to be trained prior to an incident until the circumstances are actually known. Once this information is known, the ability to be trained on when, what, where, why, and how can begin. This also gives personnel a chance to understand what is expected of them.

50. In order for personnel to make sense of what they are being trained on, the information must be presented in a logical manor according to the incident or circumstance. It must capture their interest and have a flow to it that can be easily followed.

51. There is no one-size-fits-all teaching technique. To convey the most information to the broadest audience, your program must employ all of the training techniques at your disposal: auditory, visual, and experiential. Ahead we will look at these techniques.

53. Auditory learners respond best to didactic (or instructive) lectures enhanced by skillful dialog and case studies.

54. Visual learners respond best to images, handouts, or demonstrations that reinforce the lessons.

55. Experiential learners need to practice specific tasks or procedures. For example, a responder might practice preparing an injection site or delivering a phone bank script.

56. Although JITT may be augmented by tools such as position descriptions, video training, or job action sheets, it seldom takes into account different learning styles of responders. Many JITT curricula focus on auditory and visual learners only, and do not offer responders an opportunity to practice what they have learned.

57. Due to the nature of the types of incidents that we respond to as part of EMS, it is important that if there are new skills to be implemented or administration of medications outside current protocols, there needs to be hands on training as well.

58. Practicing these skills will give the responder confidence when performing the skills. They will also be able to focus clearly on the task at hand.

59. For JITT to be successful, managers and administrators should support its concepts and guiding principles on a continuum, or at regular intervals. The JITT method is a cyclical process: feedback from responders triggers changes to the training and materials. Revised materials are used during subsequent training.

60. Preparedness leaders can support the strategy of JITT through planning, regular training of core responders, and making sure staff understand and can apply JITT principles.

61. Using JITT during an incident ensures that various learning styles of responders are considered, since the trainer determines how to best implement elements of JITT.

62. JITT doesn’t end once an emergency response does. Preparedness staff should carefully evaluate JITT using responder evaluation forms to determine the effectiveness of, and any needed improvements to the trainings and materials.

63. Example of a post-response evaluation card:

64. Before an incident, managers and trainers would have tested and refined the training principles and techniques. During an incident, evaluate operations and staff Performance to improve the content of ongoing JITT training. After an incident, responders would fill out a survey about the JITT received earlier in the day.

65. The three learning styles most effective for learners include: A.Auditory, Visual, and Olfactory B.Auditory, Visual, and Experiential C.Preparedness, Response, and Recovery

66. If you answered, A. Auditory, Visual, and Olfactory, you should know that Smelling (Olfactory) is not a proven learning style. The correct answer is, B. Auditory, Visual, and Experiential. To convey the most information to the broadest audience, your program must employ all of the training techniques at your disposal auditory, visual, and experiential.

67. In this section you’ve learned how JITT offers a more thoughtful approach to current training methods. The JITT model considers different learning styles along with the intellectual, behavioral, and emotional needs of responders. Supporting the model of JITT before an incident, implementing its principles during an incident, and evaluating it after an incident helps preparedness leaders better execute responder training, resulting in improved operational performance and effectiveness.

68. As you can see, many changes will be made to the field protocols to compensate for the increased demand on the 911 system. During an incident like this EVERYONE has a part to play to make the 911 system run as proficiently as possible. Now that we have reviewed the elements for the field using Altered Standard of Care guidelines, you will now be quizzed on what you have learned. Thank you for participating in the…