Fire Service EMS training and evaluation

PROPOSAL

EMS Deployment and Training

By Alan Perry

October 19, 2015

Introduction:

The Fire Service can improve on its deployment of new EMS technology and skills, by improving the training and evaluation mechanisms available to its providers. To accomplish this, the following practices may be considered to produce a reliable and consistent system for delivering new information, ongoing training, and evaluation of knowledge and skills competency. This can be done in a way that does not commit new resources. It will improve the performance and consistency of EMS services and satisfy the continuing education requirements of the providers. It consist of a single change in the character of the position of the EMS supervisors on each shift and a three part mechanism for delivery, training and evaluation.

The system change:               EMS Supervisor role

Changing, or placing more emphasis on the role of the EMS supervisor as an educator, is a simple and effective way to improve the system as a whole. Directing the EMS supervisor to periodically conduct Company training using standardized lesson plans, cognitive exams, skills evaluation and a course/instructor evaluation will bring Fire Service practices in-line with accepted standards in EMS education and evaluation. This is a proven system that will provide the mechanism for delivery of the category 1 and 2 CEU’s required for providers to re-certify. Ideally, Companies would attend a 1-2 hour training once a cycle while out-of-service, in a comfortable location away from the station, but within their own district, such as a library or community center. Senior EMS providers can and should assist with the delivery of these programs.

The three-part mechanism: Initial training

Initial training programs for new skills, new devices and/or changes to existing practice should always precede the deployment of these skills and devices in the field. Providing the initial training to the supervisors and providing them with the proper training materials will allow them to quickly and effectively deliver the necessary training, evaluate and document delivery, and assess skill competency before deployment occurs.

                                               PI driven training

PI driven training can be delivered as an individual, Company, District, Shift or System tool to remedy specific PI driven concerns. It can cover one topic or multiple topics dependent on audience and needs. PI driven training should be dynamic and focus on the most critical, severe or most costly identified deficiencies first.

                                               Annual/semi-annual protocol and skills evaluation

Protocol and skills evaluations are nothing new to EMS, all providers took exams and performed practical skills as part of their initial certification. At least once a year providers should be required to pass a basic protocol test appropriate to their level of certification, as well as a random skills evaluation based on The National Registry of Emergency Medical Technicians Practical skill sheets. This is both a preventive and maintenance measure, which will assure that providers remain current in their knowledge and skills. Providers who do not perform well can immediately be retrained and re-evaluated, or the collective results used to conduct PI driven training in the future. Any critical skill deficiency must be corrected before the provider is allowed to continue practicing at his, or her level of certification.

Summary

Formal deployment, training and evaluation programs are part of most other high risk professions. Other agencies and regional systems within the Commonwealth and across the Country already use a formal training and evaluation system. The Central Shenadoah EMS Council requires quarterly skills reviews for all providers in their system. The Lord Fairfax EMS Council requires an annual skills review. Considering the Fire Service's initiative in bringing forward thinking practices to the region, codifying a proactive and aggressive training policy seems like a logical and obtainable goal. This goal can be achieved with a minimal investment of on-duty time and effort from the existing EMS supervisors. It will add to both the competence and confidence of our providers, as they deliver the best responsive and caring service possible, to our citizens and guests. It may be advisable to add an additional EMS supervisors position to allow supervisors to rotate training, while leaving at least two in service while spreading the administrative functions out, allowing for adequate preparation and follow-up in training. Ultimately the implementation of this plan will require a commitment from the Organization, the Administrative Staff, the Training Division, EMS Supervisors and the individual providers. Developing a culture of proficiency, competency and innovation starts at the top.

Criminal MCI Calvary slide presentation

Slide presentation: Who is the Cavalry in Criminal MCI's?

Your Physical and Mental Jumpbag

Your Physical and Mental Jump-bag

By Alan Perry

September 19, 2013

The jump-bag is the one item you should always take into any EMS call, it must be equipped with the basics needed to save a life and start treatment for a variety of illnesses and injury. Your brain, mental preparedness and training are a similar set of tools, equally important, requiring your daily check-off and replacement and repair of expired or damaged items. Occasionally old items are removed to make use of new tools with proven efficacy or updates. The tools in the jump-bag should be those needed to deal with true emergencies and routine patient assessment while remaining highly portable, easy to carry, and easy to navigate. We all know this is not always the case, we also know that the information and training we have accumulated is perishable and needs to be organized in our head so that we can access it quickly and reliability. The next time you are checking off your jump-bag do a little mental check off; do you have all of your protocols memorized? Is your knowledge of basic A&P sufficient to determine what illness or injury may be present and how best to treat it? Do you know the indications, contra indications and side effects of the drugs in your drug box and common prescribed medications? Do you have tools in your head that need cleaning, repair or replacement? Have you taken action to correct it through study or repair/replacement through your training division?

I know you have grabbed a jump-bag at some point in your career and found that some critical item, perhaps oxygen, or a stethoscope was either missing, empty or broken, preventing you from doing what is required for the best patient care. It happens, and we do the best we can with what we have until we find someone else with what we need or we gain access to our back-ups. In our minds, if we draw a blank, forget or are unsure of what to do our back-up is the protocol book. I am not an advocate of “cookbook” medicine, if the protocol book has become your source for patient treatment options you are doing the equivalent of leaving your jump-bag in the truck. My “take-home” message is that you need mental preparedness just as much as physical preparedness, if not more. 

Doing a mental check-off, like doing an equipment check-off, requires some type of check-off sheet to identify the required items, there condition, and status if out for repair or on order. For a provider you can look at your protocols, pharmacology, certifications and education requirements; if you had to test out again today, would you pass? I would avoid simply meeting the expectations of your employer, agency or the public, this leads to complacency. You should be prepared to deal efficiently and effectively with every possible patient and scene presentation within, and maybe slightly beyond, your scope of practice. You didn't get into this business because it was easy, so let the fun begin.

Be Safe,
Alan

Limitations of Web-Based Instruction

The Limitations of Web-Based Instruction

By Alan Perry

Online and web-based instruction have become very popular over the years due to the limitations of individuals time and resources. Many public safety organizations have discovered its benefits due to shrinking training budgets and greater personnel resource utilization. Without on-line and web-based options many individuals and organizations would have no other alternative to provide necessary and frequently required training. But where does this leave us as instructors and students? We all know the cognitive, affective & psychomotor domains of education, how can this satisfy them all? I am not alone in my concern for the outcome of this situation.

The risk is that online and web-based training options may be used to completely replace other forms of training. This presents a problem when it comes to training that requires conveying a technique or psychomotor activity. Take intubation as but one example; you can discuss the anatomy, the procedure, look at videos of it being done, and answer multiple choice questions to get your airway CE. We all know that does not work, how does this get passed-off as somehow being adequate? For some providers that is as close as they will get to performing an actual or simulated intubation. No wonder our skills are declining.

Most of us as providers recognize that the training we receive at times is more of an exercise to satisfy some administrative requirement than a true attempt to impart a meaningful and beneficial education experience. We take it upon ourselves, for our patient’s sake, to obtain and maintain the required skills and knowledge that will benefit them. I take my EMS training seriously; I do not rely on my organization to provide all the education I need to do my job and stay on top of my profession.

As an instructor and education coordinator I know how challenging it can be to find good quality training offerings, especially for large organizations. The ease and consistency of on-line programs is tempting, however the training must match the needs of the providers, especially when QI programs indicate a need for specific training such as intubation. It may be necessary to collect the necessary training equipment, find the space, and schedule hands-on training for your staff. If you know that a problem exist and you fail to effectively mitigate it you are culpable for the failure of the system and the provider when things go wrong. My advice: don’t wait till then.

For those general refresher topics, and routine procedural reviews web-based training is an excellent choice. You still need to do your homework and make sure the program you select is relevant for your service, mirrors your protocols, and is not prone to errors and omissions. Don’t assume that the flashy training website has reviewed the material for accuracy and consistency, that’s your job. Providing online training that is confusing, irrelevant or incorrect will only make things worse and sour your staff’s attitude towards it in the future.

EMS and EMS training are both changing rapidly, not all change is good so we still need to do our homework whether we are the trainer or the trainee. Always remember that your skills can and will make a big difference in the outcomes of your patients. Staying on top of developments in the practice of EMS as a profession and of training opportunities available for your staff will always be a challenge, but that’s why you got into this business in the first place, right?

Be safe, do good work

Our Western Brethren

Commonalities of the approach to EMS by our western brethren

Bend Fire & Rescue

By Alan Perry

Where I got my information

I have visited Bend, Oregon on several occasions and found it to be a beautiful community with many natural resources, a pleasant climate and breathtaking vistas. In short a community I would love to live in. I came across the Bend Fire & Rescue Deployment Plan for 2011-2013 while perusing the department’s web site. It is a comprehensive and detailed document available to the public prepared with the help of ICMA data, and the department’s historical data to determine their compliance with NFPA 1710 . It is a document used by the state government to assist departments with identifying their circumstances and creating plans to help them remain viable.

About Bend Fire & Rescue

Bend Fire and Rescue serves a population of approximately 100,000 in an area of 165 square miles much of which is sparsely populated. The City of Bend has a population of 77,000. The annual call volume is around 8000 with 82% of calls being EMS in nature. Their staffing consists of 88 career personnel, 4 part-time and 5 volunteers. The chain of command contains a Chief several Deputy Chiefs including the Deputy Chief of EMS, a Battalion Chief for each of the three shifts, a Captain for each of the five stations on each shift, 6 engineers per shift and 6 ff/medics per shift. The department uses a flexible staffing model were engines and ambulances are at each station, and staffed based on the nature of the call. All-in-all, a very lean operation.

About us

Fire Departments in Southeastern Virginia tend to follow the old school east coast fire service model. It is a well-tested institution known for a strong and rigid structure which does a good job of protecting lives and assets and the jobs of firefighters. We have enjoyed both public and political support, supporting well-staffed  and well-equipped career departments in most major cities. The approach to providing EMS service is widely variable ranging from only providing a first response to being a primary EMS transport provider. In this mix there are also widely varying degrees of support for the EMS mission ranging from treating it as a necessary evil in order to maintain public support and funding, to embracing it, making innovative changes that are needed and addressing public education in EMS.

Common threads to our approaches to EMS

The most common thread among fire departments that have taken on EMS as part of their service mix is the high percentage of our total calls that are EMS in nature. Of equal importance and contrast is that most firefighters do not enter this career with the primary desire to transport the ill and injured on an ambulance. Culturally I think this is a common thread among fire-based EMS systems, one that creates the climate for poor attitudes when making decisions and long-term plans for these systems.

Where we differ

A few highlights of the Bend Fire & Rescue program jumped out at me as being very proactive and engaged in improving the quality of their EMS system; They conduct monthly EMS case reviews with their two physician advisors to include patient outcomes. EMS protocols are updated annually, A service survey is sent out for every 15 EMS calls, They have an EMS public education program even though it is limited to senior communities only at this time. The concept of flex staffing maximizes the effectiveness of a small staff allowing a smaller group of responders to handle a variety of calls whether EMS or fire. Despite the staffing limitations the department has an average response time within the city of 7:33. They have a dedicated training staff and a training facility.

How can Fire-based EMS improve

Bend Fire & Rescue appears to be doing well with the resources they have available but are clearly pushed to the limit in their current circumstances. Like many other departments they are having difficulty with being fully forthcoming about the nature of the fire services relationship with providing EMS. The financial data conveniently lumps both fire and EMS operations costs under one heading and does the same with revenue, this approach could be considered an attempt to minimize the higher operating costs for fire services and the revenue produced from the EMS activities. Being open and honest about these circumstances will better allow the management and the public to make good decisions. Their portrayal is not unique, it is a common tactic used in the fire service. We in the fire service, as public servants, should be more honest with the public and ourselves, the lack of clarity will affect our integrity ultimately. Fire-based EMS systems must look at our perception of EMS and be certain that we are embracing it, constantly looking for ways to improve upon it, and deliver the service as effectively and efficiently as possible.

Link to Bend Fire & Rescue Deployment Plan

http://www.bendoregon.gov/Modules/ShowDocument.aspx?documentID=6919

Using a noodle instead of a stick

Discipline in the workplace;

Using a noodle instead of a stick

More often than not workplace discipline in EMS and other professions involves using intimidation and negative consequences, a practice that seems to fly in the face of the old adage that a carrot works better than a stick. Perhaps as we make the sweeping changes to our EMS systems that we need to keep up and get ahead of the changes in our industry, we can reflect on that and take this opportunity to recognize that there may be a more efficient and positive way of doing things.

Superior patient care, compliance with local protocols and professionalism are what the public demands, and our profession requires, if we are to mature into recognition as part of a respected group of healthcare professionals. The root of inconsistency and variations in application of protocol and patient care standards in my view is largely a function of education and understanding of the subject material. The most effective way to combat it is by cultivating the noodle (brain).

Those evaluating non-compliance and standard deviation problems in EMS delivery may assume that these events occur due to laziness, incompetence or indifference. I suggest that in most cases it is more likely that there is both a lack of understanding and education among providers in these cases. This is not surprising given the cost of providing adequate training programs that address critical skills and constant changes in “best practices” in our field.

We need to recognize as an industry that the minimum recertification requirements for continuing education are just that- “minimum”. EMS professionals should take it upon themselves to review trade publications, medical journals and studies affecting our practice if we truly want to stay on top of our game; likewise each agency must provide both initial and ongoing training in critical skills, local protocol and operations. Why wait until a problem is exposed to address it.

Our communities depend upon us to act appropriately and provide the best care possible. I suggest that achieving excellent and consistent patient care is more about keeping those noodles sharp than a strong disciplinary policy. Communication of the desires of your OMD, the examination of evidence based best practices, and frequent discussion of the best application of them by all of your staff and administration will go a long way toward achieving that goal. It will be much more effective and less painful than the stick.

Be safe, do good work,

Alan