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5 Health Professions Training Jon Krohmer, acting assistant secretary and chief medical officer of the Office of Health Affairs in the Department of Homeland Security (DHS), chaired the panel on training. He described the panel as multidisciplinary, focusing on hospital and prehospital perspectives, including those of emer- gency physicians, emergency nurses, trauma surgeons and other specialists involved in providing on-call coverage, and emergency medical services (EMS) personnel. Krohmer framed the discussion by highlighting the w Â orkforce-related recommendations from the three Institute of Medicine (IOM) reports. These recommendations called for the following: â¢ Regionalization of critical specialty on-call services â¢ commission to examine the impact of medical malpractice A lawsuits â¢ Certification in critical care medicine to physicians who complete an accredited critical care fellowship training program â¢ assessment of emergency and trauma workforce capacity, trends, An and future needs by the Department of Health and Human Services (HHS), Department of Transportation (DOT), and DHS â¢ National standards for core competencies applicable to nurses, physi- cians, and other key emergency and trauma personnel â¢ Improved linkages between rural hospitals and academic health centers 49
50 NATIONAL EMERGENCY CARE ENTERPRISE A Shortage of Emergency Physicians Leon Haley, vice chair of clinical affairs in the Department of Emer- gency Medicine at Emory University and deputy senior vice president of medical affairs for the Grady Health System, said we will not be able to produce enough trained emergency medicine board-certified physicians to match the demand in the coming years. He said emergency department (ED) visits have increased 32 percent since 1990, from 90 million to 120 million, and the U.S. population continues to increase rapidly, especially in areas such as the South and Southwest. At the same time, the number of hospitals that provide emergency care has declined. There are now approximately 485 fewer EDs and approximately 198,000 fewer hospital beds than there were in 1990. In 2002 approximately 25,000 physicians identified themselves as ED physicians, although not all practiced in the ED. Many additional physicians are employed in the ED who do not have that specialty training. Although there has been a 79 percent increase in the number of emergency medicine practitioners over the past 10 years and the resident workforce has increased 116 percent, overall supply will not be able to match the increasing demand in the coming years, especially in the areas that have experienced the most population growth. Approximately 95,000 nurses are practicing in emergency care Âcenters across the country, including about 4,000 advanced-practice nurses. Approx- imately 2,300 physician assistants (PAs) are providing care in EDs. It is criti- cally important to note, Haley said, that there is no current certification for either of those groups for specialty training in emergency medicine. A few PA programs are designed to help train PAs in emergency medicine, but there is no defined certification, nor is there defined certification for nurse practitioners. A Shortage of Trauma Surgeons J. Wayne Meredith, director of the Division of Surgical Sciences and a Richard T. Myers professor and chair of the Department of General Surgery at Wake Forest University, said the workforce in surgery is not only failing to grow, but is shrinking relative to the population. General surgery train- ing programs in the United States turn out just under a thousand general surgery training chief residents every year. They have done that every year for the past 30 years. In addition, this year 80 percent of those graduates will go on to do some sort of fellowship training on top of their general surgery training (as compared to about 20â30 percent 25 years ago). So the number of people who are available to practice general surgery is dramati- cally diminishing, he said. âHyperspecialization is creating too few people who can practice general surgery and more people who can only do highly
HEALTH PROFESSIONS TRAINING 51 specialized things,â Meredith said. âSo community hospitals all across the country are struggling or closing because they do not have access to general surgeons.â The Accreditation Council for Graduate Medical Education has said we should train more medical students. âThe problem,â Meredith said, âis we do not have any more residency slots.â There is a chokehold on the avail- ability of residency slots in the country in virtually every specialty, and even primary care, he argued. The chokehold is based on the number of slots that are provided by Centers for Medicare & Medicaid Services funding, which remains capped at 1995 levels. âIf our strategy is to have a neurosurgeon working in every emergency department in America, ultimately we will have to find a mechanism to regionalize patients, that is, to quickly identify those whose needs exceed the resources of the local community and determine the proper place to put them. This is not to centralize them and put them all in one place, but regionalize them and distribute them to where they need to be,â Meredith asserted. âThis should be part of our planning for Homeland Security and for health system reform.â A Shortage of Emergency Nurses Patricia Kunz Howard, operations manager for Emergency and Trauma Services at the University of Kentucky Chandler Medical Center and EMS training coordinator for Lexington Fire and Emergency Medical Services, reported that the nursing shortage is alive and well. Demand for nurses is continuing to rise by 2â3 percent every year, which is significant especially given the nursing faculty shortage. A recent Journal of the American Medical Association article showed that in the current economic downturn, many nurses who planned to retire have not left, and others have returned. Others have been working additional shifts to augment their finances, particularly when family members have been laid off. From a supply and demand standpoint, âthe economy has helped us a little bit, but not to the degree that we had hoped,â Howard said. Retaining experienced emergency nurses is a huge challenge because many are choosing to leave rather than jeopardize the safety of their patients and put their license on the line by working in such overcrowded condi- tions. In many cases they are leaving to work in intensive care units (ICUs), where they will only have to take care of one or two patients at a time. With respect to training, the clearest problem is the lack of training in emergency nursing in the basic curriculum of nursing schools, Howard observed. This not only deprives undergraduate nursing students of the chance to experi- ence emergency nursing at a time when they are making career plans, it deprives them of opportunity to acquire key skills that will make them bet- ter nurses in any setting. Also, it means that nurses who go into other fields
52 NATIONAL EMERGENCY CARE ENTERPRISE have little knowledge or insight into emergency nursing. In todayâs crowded emergency departments, providing appropriate orientation and training for new nurses can be difficult, she said. Plus, orientation for a new graduate is 6â12 months. This places an extreme financial burden on a facility because orientation costs about $80,000 per nurse, Howard noted. Nurses are often pulled out of educational offerings because they are needed right away in the department. Howard said it is important to recog- nize that, as EDs have become more crowded and more challenged, nurses also have become more challenged and they need a different skill set. We have to make sure they have the time for education and training, she said. Reforming EMS Education Dan Manz, the director of emergency medical services for the Vermont Department of Health, said that 40 years ago there was no organized EMS in this country. One of the things that boosted the profession to where it is today was the establishment of the national standard curricula to train EMS personnel by the National Highway Traffic Safety Administration. However, a new approach presented in the EMS Education Agenda for the Future (shown in Figure 5-1) represents a better model, Manz asserted. Manz called the model elegant in its simplicity because it has only five components. The first is a national core content that defines the EMS domain. For example, he said, hemorrhage control is in, neurosurgery is out. The Universe of EMS National EMS Knowledge and Skills Core Content Delineation of Provider National EMS Practice Levels Scope of Practice Replaces the Current National EMS National Standard Education Standards Curricula National EMS Education National EMS Certification Program Accreditation FIGURE 5-1â The EMS Education Agenda for the Future: A systems approach. SOURCE: Manz (2009). R01559 Figure 5-1.eps vector, editable
HEALTH PROFESSIONS TRAINING 53 Second, the core content is divided into scopes of practice for four levels of EMS personnel. Third, the national EMS education standards describe the delivery and the depth and breadth of knowledge and skills that a person must have to become competent at a particular EMS level, and the programs that can deliver that education. Finally, personnel graduating from those accredited programs take a national certification exam to demonstrate their competency. This model would put EMS education parallel with other allied health professionals. The elements in it are recognized in the IOM reports and called for in Pew Commission studies. There is fairly broad consensus that this is probably a better model for how to prepare EMS professionals in this country. But moving from where we are today to where we would like to be tomorrow is proving to be a significant challenge, Manz said. New Roles for EMS Personnel Sue Prentiss, the EMS chief in New Hampshireâs Division of Fire Standards and Training, said that EMS personnel are beginning to take on a number of nontraditional roles, such as developing public access defi- brillation programs and being involved in injury prevention programs. In addition, many of them, typically paramedics, have been able to get jobs in hospitals or other health care facilities. They are working primarily in emer- gency departments, but also in interventional radiology, in lab settings, and as part of cardiorespiratory teams. They are taking part in conducting stress tests, backing up the respiratory care practitioners, and delivering various other treatments. In addition, they have found opportunities in freestanding facilities such as dialysis centers. EMS providers have the immediate skills and experience to work not only in the traditional roles in the field, Prentiss noted, but also within other parts of health care system that are struggling to find people to fill slots. They are not seeking to compete for health care jobs, but should be seen as part of the supportive adjunctive community that can help fill some of the various employment vacancies in health care, which is starting to h Â appen in New Hampshire and other parts of the country. âAs EMS pro- viders move into nontraditional settings, a means to credential them will be necessary,â Prentiss said. âWe will need to determine how a paramedicâs experience and training can be applied with respect to other workforce training requirements.â Audience Discussion Sandra Schneider of the University of Rochester said âthis has been a very terrifying panel. I actually am terrified. That is because at the very time that I am starting to think I might end up needing services, I understand
54 NATIONAL EMERGENCY CARE ENTERPRISE that there wonât be anybody anywhere to take care of me.â She added, âEmergency medicine is a team sport and we need our nurses.â There is a critical shortage of emergency physicians, but itâs even worse on the nursing side. The very people that are most needed, emergency surgeons, emergency physicians, emergency nurses, and EMS, are the ones who are most often treated poorly, she said. She told a story in which her aunt was hospitalized in another city and suffered an in-hospital respiratory arrest. The aunt was taken to the ED because the ICU did not have enough staff to maintain a 2:1 nursing ratio. The ED nurse told Schneider said he was taking care of three ventilated patients, three other floor patients, and four other emergency patients, but he would do his best for her aunt. This was all so one ICU nurse wouldnât have to take care of three patients, she said. Her aunt did survive, but Schneider asked, âWhat is it going to take to keep this workforce safe and encourage people to come? Is it changes in state law? Because right now, we are doing everything we can to discourage them.â Meredith said we have to recognize that this cannot be done as a home- grown, locally designed potpourri system. Otherwise weâll get the committee that builds a camel when it is trying to build a horse. Howard said the regulatory and accrediting bodies need to come up with guidelines that maintain parity across the system. The Joint Commis- sionâs current mandate is that the ED has to reach the in-patient standards of care. We canât meet that standard when we are dealing with what was just described. âThere has to be something that says if the emergency depart- ment has to have three ICU patients for every nurse, then so does the ICU,â Howard said. âThere has to be parity across the continuum. That will take accreditation agencies and regulatory bodies to accomplish.â Addressing Workforce Shortages Nick Jouriles of the American College of Emergency Physicians (ACEP) said that emergency medicine is the specialty that is available and accessible at all hours, 24/7, in all 50 states. Approximately 25,000 physicians identify themselves as emergency physicians, Jouriles said, but we need more than 30,000. Additional training is also needed to meet workforce demands. Haley agreed there is no doubt we need to expand. Although we have been doing a remarkable job of trying to catch up, âwe are still behind the curve.â Even as we try to expand our residency programs, he said, âthere is a limit to the number of training sites that we can come up with,â given how emergency medicine training is structured. âWe will reach a point where we probably wonât produce enough emergency physicians to staff every ED in the country with a board-certified emergency physician on a 24/7 basis.â Instead, he said, âweâll need to think about how to provide support with PAs, nurse practitioners, and other trainees.â
HEALTH PROFESSIONS TRAINING 55 Jouriles agreed there is a limit to how many people can be trained, but said âwe are not there yet.â This country needs to maximize what we can do to train general surgeons, trauma surgeons, intensivists, emer- gency Âphysicians, and emergency nurses. When we get to that point, then we should focus on the alternatives. He said we are nowhere near that point. Meredith said most workforce planning designs pay no attention what- soever to patients with emergency conditions. They are all designed around elective chronic diseases. He said we are going to face a huge gap in the next 10 years. Haley said that in Georgia, with an expanding population of more than 9 million people, only two emergency medicine training programs serve the entire state. âWe need to expand that, but we also need to be realistic about the numbers we are going to be able to reach,â he explained. Disaster Preparedness Mike Handrigan, acting director of the Emergency Care Coordination Center in the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR), said one IOM recommendation was for the HHS, DOT, and DHS to conduct a joint assessment of the workforce. âWe have heard that emergency physicians are behind and canât catch up; the surgical work- force canât reproduce itself to keep up with population growth; the nursing workforce is trying to stop the hemorrhage by stuffing an economic crisis in the wound; and the EMS workforce might be pulled off the streets and placed in the hospital,â Handrigan said. He noted that Homeland Securityâs mission centers mainly on cata- strophic events. The folks who volunteer for the disaster medical assistance teams are drawn from the same groups described above. âSo,â he asked, âare we looking at a house of cards?â In a small, focused catastrophe, people can suck it up and do the job. But in a catastrophe that has no geographic boundary, such as a flu pandemic, he asked, how would we handle that? Manz agreed, adding that the existing disaster response model is well engineered for a relatively local, or regional, catastrophic crisis. It presumes that you can run the machine a little harder at home for short periods of time and borrow resources from surrounding areas. That idea is not crazy, but it falls flat on its face when the whole country is in crisis at the same time, he said. Solving the workforce shortages is one of the things that could make this situation more viable. If we address the threatened specialties, then we will be better prepared as a nation to handle the really big one.
56 NATIONAL EMERGENCY CARE ENTERPRISE Improving EMS Education Dia Gainor, Idahoâs EMS director, affirmed that last month her gover- nor signed a law adopting the national EMS scope of practice model. But she argued that the education agenda had fallen short in terms of advanc- ing bridge programs (e.g., RNs becoming paramedics, and vice versa). She asked Manz where he thought we had fallen the shortest in implementing the agenda, since it was supposed to have been completed by 2010. âI think the Achilles tendon in this thing is going to be the educators,â Manz replied, adding, âI have this sneaking fear that we have built a ÂFerrari in terms of the education standards . . . and we are about to put it in the hands of an adolescent who is used to riding a bicycle.â The academic- based paramedic programs are the model that we should be aspiring to, but he has concerns about some of the lower levels, including first responder, emergency medical technician (EMT), and advanced EMT. Meredith said he would not overlook the political opposition that educators might bring to this kind of change. Prentiss added that the state had talked to her about how to write objectives and lesson plans, but she wonât know what their reaction will be until the day they actually flip the switch. The education agenda is the right move to make, but it is a large move. âFor those at the academic level, it will be an easy transition,â she said. But the reality is that many instructors are still working in the back of the fire station, or at a local high school, or at the back of the ambulance station. They are doing a great job, but some definitely have more experience than others. How we prepare them and bridge them to becoming registered nurses, for example, is pretty far off. Jerry Johnson, immediate past president of the National Association of EMTs, agreed that âthe rubber is really going to hit the road with imple- mentation.â The education standards and the scope of practice model were great work, but he noted that national certification is not achievable unless the states adopt the standards. So, he asked, how do we get the states to see the benefits of adopting it? Manz said that getting the first 40 states to do it will not be a big deal. The trick will be getting the last 10. But the answer is that the first 40 will help get the last 10 because eventually those remaining states are going to find themselves standing on a shrinking island. For example, an EMT from a state that has not adopted the new model will try to transfer into the state that has and they will be told, sorry, you are not nationally certified. Thatâs going to build huge pressure on the remaining states. Workforce Integration and Collaboration Ricardo Martinez of the Schumacher Group said that among the 150 hospital EDs he represents, the integration of EMS providers into the health
HEALTH PROFESSIONS TRAINING 57 care system as nurse practitioners or physician assistants has either gone great or incredibly badly. He said we have to find a way to work together and become more integrated. We are not going to solve the physician or nursing shortages by doing things the way they have always been done. He asked the panel whether they thought it would be possible for emergency nurses and EMS personnel to develop a common model for use by mid-level and EMS providers in an emergency setting that might solve some of these problems. He asked what they saw as the biggest barriers to that type of integration. Howard responded that there has been a lot of progression in that type of model. She said they receive a lot of queries regarding the practice of paramedics in EDs. âThat really has evolved,â she said, but there is still some hesitation because it can be seen as giving up turf. She has also seen great resistance from the EMS community about letting nurses do some of the things that paramedics do. âIt really has got to be a dual collaboration and a two-way street,â she said. This is not about turf, but rather about working together because none of us can do this alone. âThat mindset needs to be developed at a national level.â Manz said he observes more and more EDs struggling to find qualified emergency nurses. âWhen there is that acute shortage staring you in the face, it brings people to the table to say wait a minute: Is there another way we can do this?â It begs the question: What is the appropriate integration of EMS personnel that will allow the scarce resource of qualified emergency nurses to focus on the most essential parts of their jobs? One concept for promoting bridging is to develop a core knowledge that everyone should have (e.g., some anatomy and physiology, and some patient assessment skills), Manz explained. Once someone studies the core, then they can specialize and become a nurse, paramedic, respira- tory therapist, or something else. Kurt Krumperman, of the University of M Â arylandâÂBaltimore County, said physicians have a similar type of core content in their training. âI think we need to really take a serious look at that,â Krumperman said, but warned we are not going to be able to cross that bridge until EMS education requires an associate degree for paramedics. Otherwise, he said, âitâs just not going to happen. But we havenât begun to hear [the] resistance [we will when] we try to make that a requirement.â Performance Improvement Ron Anderson, chief executive officer of Parkland Hospital, said he has been involved with training paramedics since 1975. One of the things he has noticed, particularly in programs run by fire departments, is that they are somewhat afraid of learning from mistakes. The hospital has asked several
58 NATIONAL EMERGENCY CARE ENTERPRISE times whether they would like to use their quality assurance programs, which are protected by law. But the municipal government has a fear of being beaten up, and they are not in a no-fault situation. Manz replied that reticence on the part of some EMS providers to be driven by evidence may partly be due to inexperience with it. Evidence-based medicine is a huge challenge in EMS because not a lot of evidence exists. We are in our infancy in terms of integrating evidence as it comes along into scope of practice models and the delivery of education, he said. But in terms of data, the National EMS Information System is essentially going to take EMS from the stone ages to state of the art. Hopefully having a better database in place will fuel research and lead to quality improvement initia- tives that contribute to evidence-based practice. Prentiss commented that this is a cultural issue. If you give people some of the tools and provide some positive examples of how performance improvement can work, over time they will start to come around and begin to bring what theyâre learning into practice. In addition, it involves making sure you have the legal infrastructure for protection outside of performance improvement, or that the state has the language within its EMS statute to provide that same type of protection. Krohmer agreed. âIn many states there is not legislative protection for quality improvement activities in the out-of- hospital setting,â he said. âBecause of that, there is an extreme hesitance on the part of hospitals to share data on EMS patients to help us examine outcomes issues.â Improving Nurse and Medical Education Nick Jouriles of ACEP underlined the point that we do not teach injury to our nurses or physicians. He was once affiliated with a medical school where the students were taught for 4 hours about the molecular genetics of malaria and not a single minute on injury, despite the fact that no cases of malaria occurred in that locale in the past hundred years and injury is the leading cause of death in the 1â44 age group. Jane Scott, of the National Heart, Lung, and Blood Institute at the National Institutes of Health, said the entire domain of emergency medicine has grown enormously in the past 40 years. Nursing complexity, medical complexity, EMS complexity, the technologies that are in use, she said, âYou name it; itâs become vastly more complicated.â She remarked that âpeople are getting pushed to the hilt and are being put in positions that they shouldnât have to be in.â Scott asked whether people in nursing and medicine who are taking on leadership roles should take coursework to start developing their skills in management, strategic planning, and team building. Meredith replied that these types of courses are becoming more and more part of faculty develop-
HEALTH PROFESSIONS TRAINING 59 ment programs and programs in nursing schools and medical schools across the country because there is recognition of these needs. Emory University has a program of team-based training, with the medi- cal and nursing students using a simulation lab to promote team-building skills, Haley said. The paramedic component has not yet been implemented. Management believes there is great opportunity in terms of training physi- cians and nurses together to think about resources from a strategic point of view. But so far they have fallen short in these efforts, Haley said. Regionalization Mike Handrigan, from ASPRâs Emergency Care Coordination Center, said a solution that has been discussed is regionalizing care delivery. âIf we create a more condensed and efficient care delivery system through region- alization, how will that affect the venues in which our residents are trained? We need to be conscious of that as we move forward,â Handrigan noted. Neurosurgeon Alex Valadka added, âI think regionalization implies that everything goes to one big hospital.â A better term might be âregional coordination,â in which you make full use of your network and the smaller stuff can stay at the smaller hospitals. Believe it or not, he said, we are start- ing to see people with the simple, linear, non-displaced skull fracture who are awake and alert and have a normal head CT, who are being sent to us because they have a skull fracture. Iâm not sure why they are doing that, he said, but part of it may be lack of education on the part of the sending docs. So to some extent there may need to be some education about what does and does not need to be sent, he said. Establishing a Critical Care Certification David Wright of Emory University asked who it was that would not allow emergency physicians to be certified in critical care. He said these people are holding us back. In reality this could be changed overnight. Valadka pointed out that neurosurgeons are experiencing a problem similar to that of emergency physicians. Although neurosurgeonsâ board certificates say they do critical care, that designation is not something that is recognized by Leapfrog. So although hospitals are saying that they donât have enough intensivists or neurointensivists, and neurosurgeons are willing to do the work, they have not been allowed to participate. Haley said certification for critical care training is really a turf issue. Sur- geons in the room probably have a different perspective, but there are critical care fellowship training programs that emergency physicians have completed, but they are still not allowed to be board certified in critical care.
60 NATIONAL EMERGENCY CARE ENTERPRISE Fildes, trauma surgeon from Las Vegas, said that emergency medicineâs conflict is not with surgery. It is with the American Board of Medical S Â pecialties (ABMS). âSurgeons get it. You guys treat critically ill patients every day. What you need is a very specialized curriculum and fellowship training program that focuses on topics like obstetrical emergencies, neo- natal, children, cardiac, and renal,â Fildes said. âYou donât get any of that in the surgical critical care program.â âWe understand that you need it, and our house is not the right place to get it,â Fildes continued. âWe would support you in approaching [ABMS]. Just be careful of one thing. It is a double-edged sword. You want to end boarding, but you want to set up critical care areas in your emergency c Â enters. You have manpower shortages, but you are trying to get boards and other specialties that create bridges out of your profession. That disÂconnect will not be viewed favorably across the board. That is the only caution that I add to it.â Finally, session chair Krohmer asked the panelists to say, in one word if possible, what is the most critical workforce issue in your discipline that we need to address right now? Their responses were as follows: â¢ Haley: âER docs, more of them.â â¢ Meredith: âResidents and training slots.â â¢ Howard: âNurses.â â¢ Manz: âPartnerships.â â¢ Prentiss: âFunding.â REFERENCE Manz, D. 2009. The EMS Education Agenda for the Future. PowerPoint slide presented at the National Emergency Care Enterprise Workshop, Washington, DC.