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Chapter 1EMS Systems: Roles and Responsibilities
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Objectives Outline key historic events in EMS
Identify elements needed for effective EMS systemsoperations
Differentiate between the four levels of EMS providers
List benefits of professional association membership
Describe benefits of continuing education
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Objectives
Differentiate between professionalism, professionallicensure, certification, registration
Describe the paramedics role in a patient care situation
Describe the benefits of off-line and on-line medicaldirection
Outline the components of an EMS QI program
Identify key components and benefits of EMS research
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Scenario
Its early morning when the driver of a late-model SUV clutches his chest momentarilybefore losing consciousness and swerving
into a large tree while traveling at 50 milesper hour.
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Discussion
What factors will influence his survival?
What resources will he need to maximize his chance toregain a productive life?
What safeguards influence the quality of his care?
How will the care he received today differ from 50 yearsago?
What will determine which treatments are most effectivefor him?
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EMS System Development
Pre-20th century
Biblical
Edwin Smith papyrus
Code of Hammurabi Jean LarreyNapoleonic Wars
American Civil War Clara Barton, nurse
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20th Century
WWI and WWII developments
Battlefield ambulance corps developed
1950s and 1960s Urban, hospital-based systems develop into
municipal services
Rural funeral homes develop into volunteer fire
and freestanding services
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1966
National Academy of Sciences - NationalResearch Council report
Accidental Death and Disability: The Neglected
Disease of Modern Society (the White Paper) Defined 10 critical points
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1966
Highway Safety Act of 1966
Created USDOT as a cabinet-level department
Legislative authority and funds to improve EMS
More than $142 million between 1968 and 1979 Early advanced life support pilot programs
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Mortality Comparisons
WWI to Vietnam
Advances in field care emerged for traumapatients
Reduced deaths from similar trauma
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1970s
1973 Emergency Medical Service SystemsAct
Defined 15 required components
Regional approach, trauma focus
Regional system development 1974-1981
1977 paramedic educational standards
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1980s-1990s
Consolidated Omnibus Budget ReconciliationAct (COBRA) of 1981
Preventive Health and Health Services BlockGrant consolidation
NHTSA effort to sustain the DHHS effort withreduced funding and staff
NHTSA's 10 system elements
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EMS Agenda for the Future1996
Integration of healthservices
EMS research
Legislation andregulation
System finance
Human resources
Medical direction Education systems
Public education
Prevention
Public access
Communicationssystems
Clinical care
Information systems
Evaluation
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EMS Agenda for the Future1996
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EMS in the 21st Century
2000 - EMS Education Agenda for the Future
2004 - Rural & Frontier EMS Agenda for the
Future 2005 - National EMS Scope of Practice
2006 - National EMS Core Content: TheDomain of EMS Practice
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Health Care Reform
Managed care
Expanded scope of practice
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Current EMS System
Network ofcoordinated services
Work as unifiedwhole
NHTSA EMS system components
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EMS System Operation
Citizen activation
Dispatch
Prehospital care
Hospital care
Rehabilitation
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EMS Provider Levels
Dispatchers
Emergency Medical Responder First Responder
Emergency Medical Technicians EMT-Basic
Advanced EMT EMT-Intermediate
Paramedic
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Dispatcher
Receives and processes calls
Dispatches and coordinates EMS resources
Relays medical information
Coordinates with public safety agencies Various technological capabilities Some dispatchers give pre-arrival instructions
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Emergency MedicalResponder
Includes FD, police, athletic trainers, industrialresponse teams
Trained to Recognize condition and injury extent
Assess need for EMS
Give initial care for airway, breathing, circulation
Perform safely
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Emergency MedicalTechnician
Trained in all phases of BLS
Use of AED
May assist with administration of somemedications
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Advanced EMT
EMT with several additional skills
Practice varies by state: may include
Advanced airway adjuncts IV therapy
Defibrillation
ECG interpretation
Selected drug administration
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Paramedic
Provides emergency care based on
Advanced assessment skills
Formulation of a field impression
Advanced training in
ECG interpretation
Defibrillation and pacing
Drug therapyAirway management
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National EMS Groups
Local, state, national
Involved in development, education, and implementationof EMS
Help set EMS standards
Promote professional status of EMS
Unified voice for EMS issues
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Benefits of Involvement
National associations Information sharing
Promotes profession
Enhances status of the profession Unified voice on EMS issues
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National Registry of EMTs
Professional standards development
Verifies competency
Reciprocity
Reduce costs of exam development
Research in EMS profession
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EMS Standard-Setting Groups
Get input from profession and public
Ensure public interest is served in standards
development and implementation
Protect public from unqualified providers
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Initial Paramedic Education
National standard curriculum
Competencies
Pre- or co-requisites
Minimum content for standardized program Cognitive, psychomotor, affective objectives
Clinical requirements
Length of course defined
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Paramedic Continuing Education
Maintains core or minimal levels of knowledge
Maintains fundamental technical/professional skills
Expands skills and knowledge
Promotes awareness of advances in profession
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Licensure
License to practice a profession
Occupational regulation
Permission by competent authority to engage in abusiness, profession, or activity otherwise unlawful
Involves governmental activity
May be required for paramedic practice
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Certification
Authority to participate in an activity if qualificationsmet
Fulfillment of requirements for practice in a field
Usually refers to action of a nongovernmental entity
May be required for paramedic practice
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Certification
A certification granted by a state,
conferring a right to engage in a trade or
profession, is in fact a license
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Registration
Act of registering
Enroll name in a register or book of record
Can be licensed/certified and registered
Example: State license and NREMT registration
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Credentialing
Local process
Allows practice in a specific setting
Usually guided by local medical director
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Professionalism
Profession Existence of a specialized body of knowledge or
expertise
Practitioners generally self regulate
Maintains standards
Includes initial and continuing educationalrequirements
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Professionalism
Standards of conduct and performance forthe profession
Approved code of ethics
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Health Care Professional
Conforms to standards of profession
Provides quality patient care
Instills pride in profession
Strives for high standards
Earns respect of others
Meets professions expectations while on and off duty
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Health Care Professional
EMS personnel occupy positions of publictrust
Unprofessional conduct hurts profession
Commitment to excellence is a daily activity
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Health Care Professional
Image and behavior Personal appearance important
Establishes credibility
Instills confidence Highly visible role model
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Health Care Professional
Paramedics represent Self
EMS agency
State/ county/ city/ district EMS office Peers
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Attributes of Professionalism
Integrity
Empathy
Self-motivation
Appearance andpersonal hygiene
Self-confidence
Communications
Time management
Teamwork anddiplomacy
Respect
Patient advocacy
Careful delivery ofservice
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Primary Responsibilities
Preparation Response
Scene assessment
Patient assessment
Management Appropriate disposition
Patient transfer
Documentation
Return to service
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Additional Responsibilities
Community involvement
Supporting primary care efforts
Citizen involvement advocacy
Participation in leadership activities
Personal and professional development
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Medical Direction
Medical director serves as Medical leader
Resource
Patient advocate
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Role of Medical Direction
EMS system design/operations
Education
Personnel selection process
Equipment selection Clinical protocol development
Quality improvement
Problem resolution
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Role of Medical Direction
Patient care input
Interagency interfaces
EMS advocacy in medical community
Medical conscience of EMS system
Advocate for quality care
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Types of Medical Direction
On-line/direct
Off-line/indirect
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On-Line Medical Direction
Immediate and patient specific care
Telemetry
Continuous quality improvement (CQI)
On scene
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Off-Line Medical Direction
Prospective Protocols/standing orders
Training
Equipment, supplies, personnel selection
Retrospective
Patient care report review
CQI
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On-Scene Physician
If nonmedical direction physician Follow established protocols
On-line medical direction
Physicians may jointly decide care Legal responsibility defined
Conflict resolution
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Improving System Quality
EMS continually evaluate and improve care
CQI
Focus is on system, not individual Dynamic process
Not punitive
Identify and correct problems
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Continuous Quality Improvement
Looks at all areas of EMS
Team approach
Identifies cause of problem
Develops remedies
Designs action plan
Reevaluates
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Keys to Improving Quality
Lead by example
Use data to find facts
Strategic quality plan
Human resource development Examine entire process
Evaluate success of CQI
Measure satisfaction
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EMS Research: Benefits
Essential for future of EMS
May prove/disprove benefits of care
Can change standards, training, equipment, procedures
May affect funding
Enhances recognition and respect for EMS professionals
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Research Types
Descriptive
Experimental
Prospective
Retrospective
Cross-sectional
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EMS Research
Identify problem or question
Develop hypothesis
Decide measurement types/methods
Define population
Identify limitations
Get review board approval
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EMS Research
Obtain consent
Gather data
Analyze data
Publish
Present
Follow-up studies
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Basic Research Principles
Populationgroup
Randomization and control
Sample Systematic sampling
Alternative time sampling
Convenience sampling
Sampling error
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Basic Research Principles
Parameter Nuisance variables
Blinding Unblinded
Single blinded
Double blinded
Triple blinded
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Basic Statistics
Descriptive Qualitative
Quantitative Mean
Median
Mode
Standard deviation
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Inferential Statistics
Null hypothesis Research hypothesis
Confidence
Level of significance
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Research Ethics
Institutional review board (IRB) Risks to subjects minimized
Risks to subjects outweighed by benefit
Selection of subjects equitable
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Research Consent Types
Consent at a distance Consent by proxy
Stepped consent
Cohort consent Deferred consent
Surrogate consent
Consent jury
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Research Format
Introduction
Methods
Results
Discussion
Conclusion
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Evaluating and Interpreting Research
Was the research peer reviewed?
What was the hypothesis?
Was the study approved by an institutional reviewboard and conducted ethically?
What was the population being studied?
What were the entry/exclusion criteria for the study?
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Evaluating and Interpreting Research
What sampling method was used?
How many groups were there?
How were the groups assigned?
What data were gathered?
Did the study have enough patients enrolled?
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Evaluating and Interpreting Research
Were any potential variables not accounted for?
Were the data properly analyzed?
Is the conclusion logical based on the data?
Does the conclusion apply in local EMS systems?
Are the study patients similar to those in the localEMS system?
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ConclusionThe role of the paramedic is different fromthat of the ambulance driver of the past.
Todays paramedics work in sophisticatedEMS systems.
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Questions?