Changes to Standards Help Drive New Ideas
Byline: [ Bruce Evans ]
Modern and progressive fire departments now look to achieve some level of accreditation, review or award from an outside source to benchmark their service. For many it’s a status symbol; for others it helps protect fire departments from encroachment by private ambulances. Most importantly, benchmarking serves to promote critical thinking about the organization.
When an agency has to review, record and develop new plans or procedures, it ultimately improves service both to the patient and employees. The Committee on Accreditation of Ambulance Services and other accrediting bodies help to level the playing field for fire and EMS services. This has important consequences for our profession. More and more, the science of what we do is being questioned, and the evidence is hard to create or validate because not all EMS systems are similar in function or in quality of care provided. By accrediting fire-based EMS systems, there is opportunity for multi-site scientific studies.
It’s important to keep up on the changes to the CAAS standards. Like any good accrediting or standards-developing organization, it needs to make changes or updates to meet the industry standards. CAAS has made several changes directly related to fire-based operations and several that attempt to standardize the critical-care and specialty-care transport services. These changes will drive new ideas and force agencies to define processes.
For example, CAAS has revised its mutual aid standard. Previously, an agency needed to have a written process for dealing with mutual aid needs and requests. This standard has been modified to include accreditation if an agency makes attempts to participate in mutual aid.
CAAS standard 102.02 identifies resources that could be added to a disaster response. The standard asks an agency to clarify the role of specialty-care and critical-care transport units in the disaster plan. Most incident commanders have no clue as to the nature and capability of the specialty-care transport units, which can provide a valuable service on scene in a number of disasters.
Staffing a mobile intensive-care unit on-scene allows the level of service to be increased. This could be extremely valuable when establishing a casualty collection area. This resource could house a clinic or a triage area, letting BLS or transport resources move patients. In every full-scale disaster exercise I’ve participated in, the bottleneck always comes when moving patients from the scene to tertiary care. Either more spectators come to the scene or the transportation network already has been disrupted by a natural disaster. This CAAS standard change is positive, as it forces planners to consider a valuable resource.
Another positive change is found in Standard 106, which clarifies disaster simulations. The standard now specifies a table-top or full-scale exercise to practice the disaster plan. EMS agencies don’t conduct enough disaster training. Lack of resources often makes full-scale exercises prohibitive; the use of tabletops should be encouraged, and strict documentation guidelines should be available for examination by CAAS reviewers.
CAAS requires that these drills be conducted on an annual basis. Mini casualty drills and small multi-patient scenarios are helpful in training crews to deal with disasters. Starting small and working up to a bigger incident can build success for field crews. Using a five-patient scenario and the unit from one district, agency or battalion on a quarterly basis is practical for field crews to build on triage and command skills.
A change applicable to all accredited department also is found in Standard 106: The medical director should have input and approval on the agency’s continuing medical education. The main mechanical application of this program is to link the educational program to the continuous quality improvement program. The CQI and continuing medical education must address all levels of service provided. The standard also allows for different programs for different levels of providers.
In Standard 201.06, more emphasis is placed on clinical indicators. CAAS calls for the measurement of outcome data. The application of use review for critical care or specialty services also has been added. A system needs to be in place that demonstrates the need for a specialty vehicle or even a paramedic unit to determine if the transfer is appropriate. One of the flashpoints at our department is calls from urgent-care clinics or for non-emergency situations. Often these calls are solely to get the patient seen sooner or because the clinic is approaching closing time. The standard requires tracking and measuring these types of calls.
Clarifications and upgrades have been placed in the 202.100 standard regarding safety restraints and seatbelt usage. The inclusion of specialty-care units in the seatbelt standard and a continued emphasis on belted EMS workers responds to the continued death and disability we see in EMS workers. Similar trends to employ a system to ensure scene safety also is addressed in this standard
Included in the safety standard is an addition relating to employee duty and rest cycles. A trend now being seen in fire-based EMS is to use overtime to fill vacancies, a trend we will see more and more of due to rising employee benefits cost. As EMS workers fill those overtime positions, it’s bound to negatively affect patient care. While the standard attempts to bring recognition to the issue of employee fatigue, any staffing pattern changes and details of this standard may be challenged by labor unions. It is important to consider a collaborative approach to any change in this standard with the labor unit.
CAAS has increased the details on safety issues in the 202.02 standard. Specific recommendations relate to how durable medical equipment is maintained and cleaned, exposure risks are mitigated, emergency workers are notified, or patients are triaged to reduce the risk of exposure to caregivers. This is a bold move by CAAS to signal that in some cases restricting the movement of a patient contagious to the system may save an outbreak or crippling of the health care system as seen in Toronto with the SARS epidemic.
Vehicle specifications are being addressed and modified in section 203.01. A reference to emergency vehicles not exceeding the gross vehicle weight has been added. This is an excellent reinforcement of safety standards. In some accidents, brake failure was reported in vehicles that exceeded their manufacturer’s gross vehicle weight. The standard states that compartment lighting, communication systems and biomedical equipment power systems need to have redundancy in the system. The application of these aircraft standards into emergency vehicles is a giant step to reduce the possibility of a catastrophic outcome due to equipment failure.
The 203.03 standard also specifies that administration and the medical director shall have criteria for the type of medical equipment carried on the vehicles. This standard now applies to all levels of service the agencies provide. This places the medical director oversight onto all the response vehicles, including BLS or first response vehicles.
The last of the modifications is to the facilities or the physical plant of an operation. Under Standard 203.06, the word “maintained” has been added into the agency’s facilities standard. This includes adequate sleeping and hygiene facilities. For the ambulance industry this is a real improvement. In many cases the substations are poorly kept, and often that reflects on the employee’s attitude toward his or her work environment, which in turn will affect patient care. The standard calls for a safe environment at department facilities, which should include some consideration of workplace violence. Last year saw two EMS workers gunned down in their substation in Kansas City.
Several new standards now appear in the CAAS accreditation. An area of interest important to fire-based providers is 106.09. If a subcontractor is used to provide services, the standard has to be the same for those employees as they are for the parent agency seeking CAAS accreditation. It could be argued that a fire department using a private agency as a transport contractor would need to hold the private ambulance contractor to the human resources sections within the CAAS standard. More importantly, those agencies that use civilian ambulance attendants, for example the beach cities in southern California, will now need to ensure their contract personnel have the same standard applied to them as the agency retaining the CAAS accreditation.
The new Standard 201.01 applies to the medical director and the scope of knowledge that most medical directors have. In the case of specialty services and other operations outside the scope of basic paramedic emergency medicine, a doctor with specialty knowledge may need to be consulted or retained, or a relationship defined for those patients entering the system through specialty-care units in which the scope is outside the medical director’s expertise. Patients who might need a specialty consult related to field operations may include neonatal and pediatrics transfers, disaster medical scenarios, and incidents involving weapons of mass destruction. The logic behind this new standard appears to address the inevitable problems that will not be addressed by protocols or standing orders while reducing the liability to a physician medical director without operational knowledge.
In the future the Commission on Accreditation of Ambulance Services needs to take the best practices they uncover and publish examples that show how to meet the standards. The bulk of the changes in the CAAS document involve critical- or specialty-care transport units. If you are a CAAS-accredited service, you should access the document or call CAAS for an electronic version of the changes. Although the changes are small and of a limited number, some real improvement have occurred in the standard that can generate new ideas and systems to better serve the patients and frontline EMS providers.
Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy’s EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has an associate’s degree in fire management and a master’s degree in public administration.
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