- Email: [email protected]
Advanced Placement Paramedic Education for Health Care Professionals: A Descriptive Evaluation
RESEARCH
ADVANCED PLACEMENT PARAMEDIC EDUCATION FOR HEALTH CARE PROFESSIONALS: A DESCRIPTIVE EVALUATION Authors: William J. Leggio, EdD, NRP, Michael G. Miller, EdD, NRP, RN, and Ashish R. Panchal, MD, PhD, Omaha, NE and Columbus, OH
Contribution to Emergency Nursing Practice
The current literature on advanced placement paramedic education for health care professionals indicates a gap in understanding the outcomes of advanced placement paramedic programs for health care providers. This article contributes major findings of high rates of completion (88.9%) and national certification (99.5%) from an advanced placement paramedic education program for nonemergency medical services health care professionals. Key implications of this research are that there is an advanced paramedic program for health care professionals wanting to bridge into the delivery of prehospital emergency medical services. Abstract Introduction: The delivery of emergency medical services is primarily performed by emergency medical technicians and paramedics in the United States. More recently, nurses and physicians have become more involved in the delivery of emergency medical services. Advanced placement paramedic education William J. Leggio is Paramedic Program Coordinator, EMS Education, School of Pharmacy and Health Professions, and College of Professional Studies, Creighton University, Omaha, NE. Michael G. Miller is EMS Program Director and Assistant Professor, School of Pharmacy and Health Professions, and College of Professional Studies, Creighton University, Omaha, NE. Ashish R. Panchal is Associate Professor of Emergency Medicine and Research Director, Department of Emergency Medicine, The Ohio State University Wexner Medical Center, and National Registry of Emergency Medical Technicians, Columbus, OH. For correspondence, write: Michael G. Miller, EdD, NRP, RN, EMS Education, Creighton University, 2500 California Plaza, Omaha, NE 68178; E-mail: [email protected]. J Emerg Nurs 2019;-:1-7. 0099-1767 Copyright Ó 2019 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jen.2019.10.010
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bridging programs have been developed to prepare the workforce, but the success of these programs is unknown. This study evaluated the demographics and performance of nonemergency medical services health care professionals who attended an advanced placement paramedic education program at a Midwestern university. Methods: This was a retrospective evaluation of student data
from 2007 to 2017. Descriptive statistics were used to tabulate demographics, program performance, and individual performance in the National Paramedic Certification Examination. Results: The program admitted 305 students; registered nurses (95%) were the majority of students. Of the 305 admitted students, 271 (88.9%) fulfilled all program requirements and were eligible to take the National Registry of Emergency Medical Technicians paramedic certification examination. Of these 271 eligible students, 201 (74.2%) took the National Paramedic Certification Examination. A total of 195 (97%) obtained certification at the first test attempt, whereas 200 (99.5%) obtained certification within 3 attempts. Of the 200 who passed the test, 175 (88%) successfully demonstrated entry-level competency in paramedic-level psychomotor testing. Discussion: The advanced placement paramedic program
evaluated in this study had high rates of successful program completion, as well as high first-time and cumulative passing rates for the National Paramedic Certification Examination. Further research is needed to identify the best practices in determining student requirements and the methodologies in delivering advanced placement paramedic education bridging programs. Key words: Emergency Medical Services; Program Evaluation;
Nurses; Curriculum; Paramedic; Emergency Introduction
Emergency Medical Services (EMS) in the United States is primarily provided by professionals who function at 4 levels of practice, as defined by the EMS Scope of Practice Model.1
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These clinicians are able to function in many settings and practice situations, constituting a flexible workforce for the variable needs and challenges faced in the prehospital environment.1–5 In Europe, nurses and physicians provide direct patient care with EMS, including ground transport, specialty care, aeromedical services, and disaster response.6–8 In the Franco-German model of EMS delivery, nurses and physicians are able to provide expanded experiences and skills in the prehospital environment, which may be beneficial for the patient.7,8 Similar examples and EMS crew configurations are present and supported in the US.9–12 In the US, there is a growing need to develop bridge programs for health care personnel to transition to EMS roles.3,13–15 As the workforce of nurses and physicians in EMS increases, a clear training paradigm to prepare these care providers for the specialized EMS environment is essential.12 Paramedic programs have begun to satisfy this need by developing bridge and transitioning programs for health care personnel to transition to EMS roles. The Committee on Accreditation of Education Programs for the Emergency Medical Services Professions (CoAEMSP) in the US has reported program evaluation data collected from a compulsory CoAEMSP survey of all accredited paramedic programs in the US (Gordy Kokx, PhD, Associate Director CoAEMSP, e-mail communication, July 05, 2018). In 2015, 218 of 696 (31%) accredited paramedic programs offered advanced placement education for health care professionals, but only 124 (18%) admitted students in the last 5 years. In these programs, a range of health care professionals were admitted. Registered nurses were most frequently admitted to these programs, followed by paramedic program graduates (non-Commission on Accreditation of Allied Health Education programs) and physicians (US credentialed). Although a number of advanced placement EMS education bridging programs have been developed, the performance of these programs in entry-level credentialing examinations is not clearly known or reported. To address this substantial gap in the published literature, the current study aimed to evaluate the demographics and performance of non-EMS health care professionals who attended an advanced placement paramedic education program from 2007 to 2017 at a Midwestern university.
Methods
This study was a retrospective, descriptive evaluation of the administrative records of students who were enrolled in a Midwestern university’s advanced placement paramedic ed-
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ucation course, titled “Paramedic certification for Health care Providers” from 2007 to 2017.13 This time frame allowed for consistency in the use of an adaptive computer-based test and same psychomotor stations for the National Paramedic Certification Examination. This evaluation was granted exempt status by an Institutional Review Board, as the study involved examining normal educational practices. The advanced placement paramedic course was designed by the EMS program medical director and a faculty committee to bridge the differences between the curricula of registered nurses and paramedics. This gap analysis was completed by identifying the differences in expected skills and knowledge competencies between registered nurses and paramedics to prepare the nurse to practice within the EMS setting. For example, paramedics are expected to perform endotracheal intubations, whereas this skill is not a basic part of the educational preparation of a registered nurse. This program was monitored by an advisory board comprising the university leadership, EMS program faculty, staff, alumni, and community partners. The community partners were varying health care professionals representing local health systems and EMS agencies. The program admission requirements were as follows: a minimum of 2 years of acute or critical care experience as a credentialed health care provider, with an active emergency medical technician credential and with Basic Life Support and Advanced Cardiovascular Life Support certifications.13 A trauma certification such as a Trauma Nursing Core Course certification and an emergency pediatric certification such as Pediatric Advanced Life Support or Neonatal Resuscitation Program certification were preferred.13 The advanced placement paramedic program admitted registered nurses, nurse practitioners, physician assistants, and physicians.13 The program did not admit licensed practical nurses, respiratory therapists, chiropractors, physical therapists, and others with similar qualifications.13 Graduation from the advanced placement program involved completion of 4 key phases of training: 1) selfassessment, 2) onsite training through a didactic approach and simulation, 3) comprehensive program final examination, and 4) completion of capstone team lead experiences with an Advance Life Support (ALS) EMS agency. After enrollment, the program required students to complete a series of self-assessments to identify content areas to review before their classes. Students then attended a 2-week course at a Midwestern university. The course sessions included morning lectures and psychomotor skill or simulation stations in the afternoon. Students were scheduled approximately 10 shifts with local fire-based ALS EMS
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Total program
TABLE 1
Demographics of the student population enrolled in the advanced placement paramedic program from 2007 to 2017 (N[305)
enrollment 305 Did not complete curriculum 34 Completed program 271 Did not sit for National Certification Examination 70 Completed National Certification Examination 201
FIGURE 1 Flow diagram of program enrollment to National Paramedic Certification Examination completion.
departments. Weekday shifts were scheduled for 6 hours in the evenings, and 2 weekend shifts were scheduled for approximately 15 hours during the day and evening. Patient care during these shifts was counted toward the students’ capstone experiences. On the last class day, students completed a comprehensive written examination. The written examination was the same comprehensive program final examination taken by the traditional undergraduate paramedic students at the Midwestern university, which consisted of 180 questions with a minimum passing score of 80%. Advanced placement students were required to complete 50 out-of-hospital patient care experiences, more commonly referred to as capstone team leads, as a requisite for program completion. All students had the option of completing these capstone patient care experiences at their local ALS EMS systems or of returning to the Midwestern university to fulfil this requirement. A certificate of completion is issued only after all 4 of these requirements are completed. The program graduate was then able to proceed to seeking National Registry of Emergency Medical Technician (NREMT) paramedic certification. Data were retrospectively collected from advanced placement course information from 2007 through 2017. Data were obtained from course rosters and student files. The data collected included demographic information, level of
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Characteristic
Frequency (Median)
Age (median, IQR) (34) Female 159 Male 146 Type of provider RN 291 APRN 6 MD/DO 4 PA 3 CRNA 1 Highest level of education attained Bachelor’s degree 191 Associates degree 85 Master’s degree 16 Certificate 6 Medical degree (MD or 4 DO) Doctor of nursing practice 3 Years of clinical experience Emergency department (3) (n¼223) Intensive care unit (3) (n ¼ 139) Flight (n¼54) (3)
Percent (IQR)
(29–41) 52% 48% 95.4% 2.0% 1.3% 1.0% 0.3%
62.6% 27.9% 5.2% 2.0% 1.3% 1.0% (2–6) (2–6) (2–7)
EMS (n¼152)
(5)
(2–8.5)
Other (n¼10)
(5)
(2–16)
RN, registered nurse; APRN, advanced practice registered nurse; MD/DO, medical doctor/doctor of osteopathy; PA, physician assistant; CRNA, certified registered nurse anesthetist; EMS, emergency medical services; IQR, interquartile range.
licensure, time to completion of all program requirements, score on the comprehensive program final examination, and years of experience. These data were linked with performance data from the National Paramedic Certification Examination conducted by the NREMT.16,17 Descriptive statistics were used to analyze program demographics and performance data on the National Paramedic Certification Examination, including first-attempt, second-attempt, and cumulative third-attempt passing rates.
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FIGURE 2 State residency map of students.
Results
Over the 10-year study period, 305 students attended the course. Of them, 89% (n¼271) completed all requirements and were issued a certificate of completion (Figure 1). Approximately 52% of students were female (n¼159), with a median age of 34 years at the time of taking the course (Table 1). Registered nurses represented 95% (n¼291) of all students, and 63% (n¼191) of the students had completed a Bachelor of Science degree before attending the program. The most common clinical experiences of the students before the program were in the emergency department (73%, N¼223), EMS (50%, N¼152), and intensive care unit (46%, N¼139) settings. A total of 224 (73.4%) students
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had experiences in more than one of the reported settings. Figure 2 depicts a cumulative number of students from each state, with the highest number of students from Washington (n¼21), Colorado (n¼19), Connecticut (n¼19), and Nebraska (n¼18). For the students who completed the course (n¼271), the median days to completion of all program requirements from the first day of class was 102 days (interquartile range: 52– 177 days). After course completion, 201 (74.2%) students scheduled and completed their first attempt of the National Paramedic Certification Examination (Table 2). The overall passing rate after 3 attempts was greater than 99%. Of these individuals, 175 (88%) passed the paramedic psychomotor examination, indicating an entry-level competency.
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TABLE 2
Performance of students who competed the advanced placement paramedic course and undertook the comprehensive program final examination (n[305) and the National Paramedic Certification Examination (n[201) Examination
Comprehensive program final examination First attempt Second attempt National Paramedic Certification Examination First-attempt success Cumulative third-attempt success*
Frequency Percent
287/305 305/305
94.1% 100%
195/201 200/201
97.0% 99.5%
* Includes student(s) who were initially unsuccessful and did not attempt to retake the examination.
Discussion
Aiming at adequately preparing the growing workforce of non-EMS health care professionals in the EMS system, a standard educational paradigm promises to enhance the safety of patients and providers.12 In this evaluation, we demonstrated how 1 paramedic program has developed a curriculum to assure the training and preparation of health care professionals to function within the EMS setting. Only after completing all program requirements were advanced placement paramedic program graduates able to pass the National Paramedic Certification Examination, with a first-attempt passing rate of 97% and a cumulative thirdattempt passing rate of 99.5%. This study adds to the body of literature, to describe and evaluate a non-EMS health care provider bridge educational program to become a paramedic. In comparison, the advanced placement paramedic program graduates from the current study passed the National Paramedic Certification Examination at higher rates than did graduates of the traditional paramedic program at the same university. The traditional year-long paramedic program offered by the same Midwestern university from 2013 to 2017 included 117 students from 5 cohorts. This group of students in the traditional program had a firstattempt passing rate of 89.7% (n¼105) and a cumulative third-attempt passing rate of 95.7% (n¼112) for the same National Paramedic Certification Examination. To the best of our knowledge, no published studies have evaluated the transition of non-EMS professionals to
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EMS care in the US and the students’ entry-level competency rates after completing a bridge program. Per communication with CoAEMSP, in a 2015 self-reported survey of EMS programs in the US, 31% of surveyed paramedic programs (n¼696) offered advanced placement education for health care professionals, and 18% of these programs have already admitted students in the past 5 years (n¼124 programs) (Gordy Kokx, PhD, Associate Director CoAEMSP, e-mail communication, July 05, 2018). A wide range of health care professionals were admitted in these programs, including registered nurses, nonaccredited paramedic program graduates, and US credentialed physicians. Of the programs that admitted advanced placement students in the past 5 years, 70% reported greater than 80% passing rates for the National Paramedic Certification Examination or state paramedic examination.16 The passing rate reported in our study is consistent with this passing rate. Furthermore, the data from our study add to the literature by describing the curricula followed in the program and the students’ outcomes in the NREMT National Paramedic Certification Examination. As in all innovative curricula, there were challenges to the implementation and evaluation. Our 2 main challenges were incomplete capstone experiences and nonattempts of the NREMT National Paramedic Certification Examination. Thirty-four (11%) students completed the 2-week course and passed the comprehensive program final examination but were not granted a certificate of program completion owing to incomplete capstone experiences (Table 2). These incompletions can be attributed to 2 known challenges. Not all states, such as Tennessee, allow paramedic students to complete field time if they are not from an approved educational institute recognized by that state’s EMS office.18 Students from these states must return to a Midwestern university to complete their remaining capstone experiences or travel to another location that allows students of an out-of-state program. Second, because of the nationwide reach of the program, there were also challenges in obtaining affiliation agreements between the Midwestern university and EMS services that meet accreditation and legal requirements in all student residential regions. Both of these challenges created barriers to completing required capstone experiences and therefore to completing the program. After attaining a certificate of program completion, 26% (n¼70) of students did not take the NREMT National Paramedic Certification Examination. The NREMT National Paramedic Certification Examination was the main outcome measured as an external verification tool of entry-level competency. There are 2 common reasons for this issue. First, some students resided in states, such as Illinois, that have their own paramedic credentialing examinations, separate
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from the National Paramedic Certification Examination.19 Second, some states, such as Nebraska, do not require proof of entry-level competency to provide paramedic licensure to non-EMS health care professionals.20 Therefore, completion of the academic program may be sufficient to attain licensure. On the basis of our work, these 70 individuals completed the designed curriculum and passed the comprehensive final examination. However, entry-level competency could not be independently verified in our evaluation. The existence of nontraditional and bridge educational pathways to EMS paramedic provider across the US needs to be further understood and evaluated. Further research into other alternative pathway paramedic education programs to identify the best practices and entrance requirements for success is warranted. Further program evaluation and research could include other measurements of success such as student satisfaction and employer feedback surveys for this group. Limitations
This study was limited to a single Midwestern universitybased EMS educational program in Omaha, Nebraska. Each class had a maximum of 10 students, and the overall data were limited to the 305 students who attended the program within the 10-year period. Our data were obtained from a national group and not geographically segmented. Additionally, this study was limited to health care providers with at least 2 years of acute or critical care experience, and there was no formal requirement for previous EMS experience other than having an active emergency medical technician credential. The study measures were limited to the NREMT National Paramedic Certification Examination serving as evidence of attaining entry-level competency. As noted, some students who completed the program may not have had independent confirmation of entry-level competency, thus introducing measurement error. We do not know whether this group received exemptions to practice as paramedics from their states or EMS systems. Our study showed that other non-EMS health professions can transition into EMS, but it did not explore the feasibility of paramedics transitioning into other health professional roles on an advanced placement pathway.
Implications for Emergency Nurses
The results of our study have implications for emergency nurses seeking to function in EMS settings, such as aeromedical transport, and for those wanting to bridge their
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clinical expertise with EMS credentialing to support local EMS. We documented a high rate of non-EMS health care professionals, primarily experienced acute and critical care nurses, who successfully attained entry-level paramedic competency after program completion. For the specialty of emergency nursing, our study has implications such as successful workforce preparation to expand the role of emergency nursing into the prehospital EMS setting as paramedics.
Conclusion
Our study evaluated the outcomes from an advanced placement paramedic program at a Midwestern university. The program had high rates of successful program completion, as well as high first-attempt and cumulative passing rates in the NREMT paramedic level computer-based examination. Future research is needed to identify the best practices in student requirements and methodologies in delivering advanced placement paramedic education bridging programs.
Author Disclosures
Conflicts of interest: none to report. REFERENCES 1. The National Highway Traffic Safety Administration. National EMS scope of practice model 2019. https://www.ems.gov/pdf/National_ EMS_Scope_of_Practice_Model_2019.pdf. Published February 2019. Accessed July 8, 2019. 2. Bentley MA, Shoben A, Levine R. The demographics and education of emergency medical services (EMS) professionals: a national longitudinal investigation. Prehosp Disaster Med. 2016;31(S1):18-29. https://doi.org/ 10.1017/S1049023X16001060. 3. Emergency Medical Services. Agenda for the future. https://www.ems.gov/ pdf/advancing-ems-systems/Provider-Resources/EMS_Agenda_For_The_ Future_2010.pdf. Published 1996. Accessed July 8, 2019. 4. Emergency Medical Service. Education agenda for the future: a systems approach. https://www.ems.gov/pdf/education/EMS-Education-for-theFuture-A-Systems-Approach/EMS_Education_Agenda.pdf. Published 2000. Accessed July 8, 2019. 5. EMS Agenda 2050 Technical Expert Panel. EMS agenda 2050: a peoplecentered vision for the future of emergency medical services. https://www. ems.gov/pdf/EMS-Agenda-2050.pdf. Published January 2019. Accessed July 8, 2019. 6. World Health Organization Europe. Emergency medical services in the european union: report of an assessment project coordinated by the World Health Organization. http://www.euro.who.int/__data/assets/
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pdf_file/0003/114564/E92039.pdf. Published 2008. Accessed July 8, 2019. 7. Al-Shaqsi S. Models of international emergency medical service (EMS) systems. Oman Med J. 2010;25(4):320-323. https://doi.org/10.5001/ omj.2010.92. 8. Fischer M, Kamp J, Garcia-Castrillo Riesgo L, et al. Comparing emergency medical service systems–a project of the European Emergency Data (EED) project. Resuscitation. 2011;82(3):285-293. https:// doi.org/10.1016/j.resuscitation.2010.11.001. 9. Green MJ. 2014 critical care transport workplace and salary survey. Air Med J. 2014;33(6):257-264. https://doi.org/10.1016/j.amj.2014.09.008. 10. Gunnarsson SI, Mitchell J, Busch MS, et al. Outcomes of physicianstaffed versus non-physician-staffed helicopter transport for STelevation myocardial infarction. J Am Heart Assoc. 2017;6(2):e004936. https://doi.org/10.1161/JAHA.116.004936. 11. Crippen DW, Bonetti MM, Hoyt JW, Martin BR. Cost and survival results of critical care regionalization for medicare patients. Crit Care Med. 1989;17(7):601-606. https://doi.org/10.1097/00003246-19890700000001. 12. Air & Surface Transport Nurses Association. Position statement: critical care transport nurse safety in the transport environment. http://www.astna.org/ resource/collection/4392B20B-D0DB-4E76-959C-6989214920E9/ ASTNA_Safety_Position_Paper_2018_FINAL.pdf. Published January 2018. Accessed July 8, 2019. 13. Creighton University. Innovative paramedic certification for health professionals. https://ems.creighton.edu/programs/ems-certificates/paramediccertification-health-care-providers. Accessed July 8, 2019.
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14. Clark State Community College. Paramedic certification for registered nurses. https://www.clarkstate.edu/academics/degrees-and-certificates/ health/paramedic-certification-for-registered-nurses. Accessed July 8, 2019. 15. Study.com. How to become a paramedic nurse: step-by-step career guide. https://study.com/articles/How_to_Become_a_Paramedic_Nurse_Stepby-Step_Career_Guide.html. Accessed July 8, 2019. 16. Fernandez AR, Studneck JR, Margolis GS. Estimating the probability of passing the national paramedic certification examination. Acad Emerg Med. 2008;15(3):258-264. https://doi.org/10.1111/j.1553-2712.2008.00062.x. 17. National Registry of Emergency Medical Technicians. Paramedic candidate handbook. https://content.nremt.org/static/documents/NREMT_ ParamedicHandbook.pdf. Published 2018. Accessed July 8, 2019. 18. The Tennessee Department of Health Bureau of Health Licensure and Regulation Division of Emergency Medical Services. Chapter 1200-1201 general rules. https://publications.tnsosfiles.com/rules/1200/120012/1200-12-01.20150401.pdf. Revised April 2015. Accessed August 23, 2019. 19. Illinois General Assembly. Health facilities and regulation. (210 ILCS 50/) Emergency Medical Services (EMS) Systems Act. http://www.ilga.gov/ legislation/ilcs/ilcs3.asp?ActID=1226&ChapterID=21. Published September 2012. Accessed August 23, 2019. 20. Nebraska Department of Health and Human Services. Chapter 12 Licensure of emergency Medical Services. https://sos.nebraska. gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_ System/Title-172/Chapter-012.pdf. Published December 15, 2012. Accessed August 23, 2019.
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ADVANCED PLACEMENT PARAMEDIC EDUCATION FOR HEALTH CARE PROFESSIONALS: A DESCRIPTIVE EVALUATION Authors: William J. Leggio, EdD, NRP, Michael G. Miller, EdD, NRP, RN, and Ashish R. Panchal, MD, PhD, Omaha, NE and Columbus, OH
Contribution to Emergency Nursing Practice
The current literature on advanced placement paramedic education for health care professionals indicates a gap in understanding the outcomes of advanced placement paramedic programs for health care providers. This article contributes major findings of high rates of completion (88.9%) and national certification (99.5%) from an advanced placement paramedic education program for nonemergency medical services health care professionals. Key implications of this research are that there is an advanced paramedic program for health care professionals wanting to bridge into the delivery of prehospital emergency medical services. Abstract Introduction: The delivery of emergency medical services is primarily performed by emergency medical technicians and paramedics in the United States. More recently, nurses and physicians have become more involved in the delivery of emergency medical services. Advanced placement paramedic education William J. Leggio is Paramedic Program Coordinator, EMS Education, School of Pharmacy and Health Professions, and College of Professional Studies, Creighton University, Omaha, NE. Michael G. Miller is EMS Program Director and Assistant Professor, School of Pharmacy and Health Professions, and College of Professional Studies, Creighton University, Omaha, NE. Ashish R. Panchal is Associate Professor of Emergency Medicine and Research Director, Department of Emergency Medicine, The Ohio State University Wexner Medical Center, and National Registry of Emergency Medical Technicians, Columbus, OH. For correspondence, write: Michael G. Miller, EdD, NRP, RN, EMS Education, Creighton University, 2500 California Plaza, Omaha, NE 68178; E-mail: [email protected]. J Emerg Nurs 2019;-:1-7. 0099-1767 Copyright Ó 2019 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jen.2019.10.010
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bridging programs have been developed to prepare the workforce, but the success of these programs is unknown. This study evaluated the demographics and performance of nonemergency medical services health care professionals who attended an advanced placement paramedic education program at a Midwestern university. Methods: This was a retrospective evaluation of student data
from 2007 to 2017. Descriptive statistics were used to tabulate demographics, program performance, and individual performance in the National Paramedic Certification Examination. Results: The program admitted 305 students; registered nurses (95%) were the majority of students. Of the 305 admitted students, 271 (88.9%) fulfilled all program requirements and were eligible to take the National Registry of Emergency Medical Technicians paramedic certification examination. Of these 271 eligible students, 201 (74.2%) took the National Paramedic Certification Examination. A total of 195 (97%) obtained certification at the first test attempt, whereas 200 (99.5%) obtained certification within 3 attempts. Of the 200 who passed the test, 175 (88%) successfully demonstrated entry-level competency in paramedic-level psychomotor testing. Discussion: The advanced placement paramedic program
evaluated in this study had high rates of successful program completion, as well as high first-time and cumulative passing rates for the National Paramedic Certification Examination. Further research is needed to identify the best practices in determining student requirements and the methodologies in delivering advanced placement paramedic education bridging programs. Key words: Emergency Medical Services; Program Evaluation;
Nurses; Curriculum; Paramedic; Emergency Introduction
Emergency Medical Services (EMS) in the United States is primarily provided by professionals who function at 4 levels of practice, as defined by the EMS Scope of Practice Model.1
WWW.JENONLINE.ORG
1
RESEARCH/Leggio et al
These clinicians are able to function in many settings and practice situations, constituting a flexible workforce for the variable needs and challenges faced in the prehospital environment.1–5 In Europe, nurses and physicians provide direct patient care with EMS, including ground transport, specialty care, aeromedical services, and disaster response.6–8 In the Franco-German model of EMS delivery, nurses and physicians are able to provide expanded experiences and skills in the prehospital environment, which may be beneficial for the patient.7,8 Similar examples and EMS crew configurations are present and supported in the US.9–12 In the US, there is a growing need to develop bridge programs for health care personnel to transition to EMS roles.3,13–15 As the workforce of nurses and physicians in EMS increases, a clear training paradigm to prepare these care providers for the specialized EMS environment is essential.12 Paramedic programs have begun to satisfy this need by developing bridge and transitioning programs for health care personnel to transition to EMS roles. The Committee on Accreditation of Education Programs for the Emergency Medical Services Professions (CoAEMSP) in the US has reported program evaluation data collected from a compulsory CoAEMSP survey of all accredited paramedic programs in the US (Gordy Kokx, PhD, Associate Director CoAEMSP, e-mail communication, July 05, 2018). In 2015, 218 of 696 (31%) accredited paramedic programs offered advanced placement education for health care professionals, but only 124 (18%) admitted students in the last 5 years. In these programs, a range of health care professionals were admitted. Registered nurses were most frequently admitted to these programs, followed by paramedic program graduates (non-Commission on Accreditation of Allied Health Education programs) and physicians (US credentialed). Although a number of advanced placement EMS education bridging programs have been developed, the performance of these programs in entry-level credentialing examinations is not clearly known or reported. To address this substantial gap in the published literature, the current study aimed to evaluate the demographics and performance of non-EMS health care professionals who attended an advanced placement paramedic education program from 2007 to 2017 at a Midwestern university.
Methods
This study was a retrospective, descriptive evaluation of the administrative records of students who were enrolled in a Midwestern university’s advanced placement paramedic ed-
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ucation course, titled “Paramedic certification for Health care Providers” from 2007 to 2017.13 This time frame allowed for consistency in the use of an adaptive computer-based test and same psychomotor stations for the National Paramedic Certification Examination. This evaluation was granted exempt status by an Institutional Review Board, as the study involved examining normal educational practices. The advanced placement paramedic course was designed by the EMS program medical director and a faculty committee to bridge the differences between the curricula of registered nurses and paramedics. This gap analysis was completed by identifying the differences in expected skills and knowledge competencies between registered nurses and paramedics to prepare the nurse to practice within the EMS setting. For example, paramedics are expected to perform endotracheal intubations, whereas this skill is not a basic part of the educational preparation of a registered nurse. This program was monitored by an advisory board comprising the university leadership, EMS program faculty, staff, alumni, and community partners. The community partners were varying health care professionals representing local health systems and EMS agencies. The program admission requirements were as follows: a minimum of 2 years of acute or critical care experience as a credentialed health care provider, with an active emergency medical technician credential and with Basic Life Support and Advanced Cardiovascular Life Support certifications.13 A trauma certification such as a Trauma Nursing Core Course certification and an emergency pediatric certification such as Pediatric Advanced Life Support or Neonatal Resuscitation Program certification were preferred.13 The advanced placement paramedic program admitted registered nurses, nurse practitioners, physician assistants, and physicians.13 The program did not admit licensed practical nurses, respiratory therapists, chiropractors, physical therapists, and others with similar qualifications.13 Graduation from the advanced placement program involved completion of 4 key phases of training: 1) selfassessment, 2) onsite training through a didactic approach and simulation, 3) comprehensive program final examination, and 4) completion of capstone team lead experiences with an Advance Life Support (ALS) EMS agency. After enrollment, the program required students to complete a series of self-assessments to identify content areas to review before their classes. Students then attended a 2-week course at a Midwestern university. The course sessions included morning lectures and psychomotor skill or simulation stations in the afternoon. Students were scheduled approximately 10 shifts with local fire-based ALS EMS
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Total program
TABLE 1
Demographics of the student population enrolled in the advanced placement paramedic program from 2007 to 2017 (N[305)
enrollment 305 Did not complete curriculum 34 Completed program 271 Did not sit for National Certification Examination 70 Completed National Certification Examination 201
FIGURE 1 Flow diagram of program enrollment to National Paramedic Certification Examination completion.
departments. Weekday shifts were scheduled for 6 hours in the evenings, and 2 weekend shifts were scheduled for approximately 15 hours during the day and evening. Patient care during these shifts was counted toward the students’ capstone experiences. On the last class day, students completed a comprehensive written examination. The written examination was the same comprehensive program final examination taken by the traditional undergraduate paramedic students at the Midwestern university, which consisted of 180 questions with a minimum passing score of 80%. Advanced placement students were required to complete 50 out-of-hospital patient care experiences, more commonly referred to as capstone team leads, as a requisite for program completion. All students had the option of completing these capstone patient care experiences at their local ALS EMS systems or of returning to the Midwestern university to fulfil this requirement. A certificate of completion is issued only after all 4 of these requirements are completed. The program graduate was then able to proceed to seeking National Registry of Emergency Medical Technician (NREMT) paramedic certification. Data were retrospectively collected from advanced placement course information from 2007 through 2017. Data were obtained from course rosters and student files. The data collected included demographic information, level of
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Characteristic
Frequency (Median)
Age (median, IQR) (34) Female 159 Male 146 Type of provider RN 291 APRN 6 MD/DO 4 PA 3 CRNA 1 Highest level of education attained Bachelor’s degree 191 Associates degree 85 Master’s degree 16 Certificate 6 Medical degree (MD or 4 DO) Doctor of nursing practice 3 Years of clinical experience Emergency department (3) (n¼223) Intensive care unit (3) (n ¼ 139) Flight (n¼54) (3)
Percent (IQR)
(29–41) 52% 48% 95.4% 2.0% 1.3% 1.0% 0.3%
62.6% 27.9% 5.2% 2.0% 1.3% 1.0% (2–6) (2–6) (2–7)
EMS (n¼152)
(5)
(2–8.5)
Other (n¼10)
(5)
(2–16)
RN, registered nurse; APRN, advanced practice registered nurse; MD/DO, medical doctor/doctor of osteopathy; PA, physician assistant; CRNA, certified registered nurse anesthetist; EMS, emergency medical services; IQR, interquartile range.
licensure, time to completion of all program requirements, score on the comprehensive program final examination, and years of experience. These data were linked with performance data from the National Paramedic Certification Examination conducted by the NREMT.16,17 Descriptive statistics were used to analyze program demographics and performance data on the National Paramedic Certification Examination, including first-attempt, second-attempt, and cumulative third-attempt passing rates.
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FIGURE 2 State residency map of students.
Results
Over the 10-year study period, 305 students attended the course. Of them, 89% (n¼271) completed all requirements and were issued a certificate of completion (Figure 1). Approximately 52% of students were female (n¼159), with a median age of 34 years at the time of taking the course (Table 1). Registered nurses represented 95% (n¼291) of all students, and 63% (n¼191) of the students had completed a Bachelor of Science degree before attending the program. The most common clinical experiences of the students before the program were in the emergency department (73%, N¼223), EMS (50%, N¼152), and intensive care unit (46%, N¼139) settings. A total of 224 (73.4%) students
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had experiences in more than one of the reported settings. Figure 2 depicts a cumulative number of students from each state, with the highest number of students from Washington (n¼21), Colorado (n¼19), Connecticut (n¼19), and Nebraska (n¼18). For the students who completed the course (n¼271), the median days to completion of all program requirements from the first day of class was 102 days (interquartile range: 52– 177 days). After course completion, 201 (74.2%) students scheduled and completed their first attempt of the National Paramedic Certification Examination (Table 2). The overall passing rate after 3 attempts was greater than 99%. Of these individuals, 175 (88%) passed the paramedic psychomotor examination, indicating an entry-level competency.
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TABLE 2
Performance of students who competed the advanced placement paramedic course and undertook the comprehensive program final examination (n[305) and the National Paramedic Certification Examination (n[201) Examination
Comprehensive program final examination First attempt Second attempt National Paramedic Certification Examination First-attempt success Cumulative third-attempt success*
Frequency Percent
287/305 305/305
94.1% 100%
195/201 200/201
97.0% 99.5%
* Includes student(s) who were initially unsuccessful and did not attempt to retake the examination.
Discussion
Aiming at adequately preparing the growing workforce of non-EMS health care professionals in the EMS system, a standard educational paradigm promises to enhance the safety of patients and providers.12 In this evaluation, we demonstrated how 1 paramedic program has developed a curriculum to assure the training and preparation of health care professionals to function within the EMS setting. Only after completing all program requirements were advanced placement paramedic program graduates able to pass the National Paramedic Certification Examination, with a first-attempt passing rate of 97% and a cumulative thirdattempt passing rate of 99.5%. This study adds to the body of literature, to describe and evaluate a non-EMS health care provider bridge educational program to become a paramedic. In comparison, the advanced placement paramedic program graduates from the current study passed the National Paramedic Certification Examination at higher rates than did graduates of the traditional paramedic program at the same university. The traditional year-long paramedic program offered by the same Midwestern university from 2013 to 2017 included 117 students from 5 cohorts. This group of students in the traditional program had a firstattempt passing rate of 89.7% (n¼105) and a cumulative third-attempt passing rate of 95.7% (n¼112) for the same National Paramedic Certification Examination. To the best of our knowledge, no published studies have evaluated the transition of non-EMS professionals to
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EMS care in the US and the students’ entry-level competency rates after completing a bridge program. Per communication with CoAEMSP, in a 2015 self-reported survey of EMS programs in the US, 31% of surveyed paramedic programs (n¼696) offered advanced placement education for health care professionals, and 18% of these programs have already admitted students in the past 5 years (n¼124 programs) (Gordy Kokx, PhD, Associate Director CoAEMSP, e-mail communication, July 05, 2018). A wide range of health care professionals were admitted in these programs, including registered nurses, nonaccredited paramedic program graduates, and US credentialed physicians. Of the programs that admitted advanced placement students in the past 5 years, 70% reported greater than 80% passing rates for the National Paramedic Certification Examination or state paramedic examination.16 The passing rate reported in our study is consistent with this passing rate. Furthermore, the data from our study add to the literature by describing the curricula followed in the program and the students’ outcomes in the NREMT National Paramedic Certification Examination. As in all innovative curricula, there were challenges to the implementation and evaluation. Our 2 main challenges were incomplete capstone experiences and nonattempts of the NREMT National Paramedic Certification Examination. Thirty-four (11%) students completed the 2-week course and passed the comprehensive program final examination but were not granted a certificate of program completion owing to incomplete capstone experiences (Table 2). These incompletions can be attributed to 2 known challenges. Not all states, such as Tennessee, allow paramedic students to complete field time if they are not from an approved educational institute recognized by that state’s EMS office.18 Students from these states must return to a Midwestern university to complete their remaining capstone experiences or travel to another location that allows students of an out-of-state program. Second, because of the nationwide reach of the program, there were also challenges in obtaining affiliation agreements between the Midwestern university and EMS services that meet accreditation and legal requirements in all student residential regions. Both of these challenges created barriers to completing required capstone experiences and therefore to completing the program. After attaining a certificate of program completion, 26% (n¼70) of students did not take the NREMT National Paramedic Certification Examination. The NREMT National Paramedic Certification Examination was the main outcome measured as an external verification tool of entry-level competency. There are 2 common reasons for this issue. First, some students resided in states, such as Illinois, that have their own paramedic credentialing examinations, separate
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from the National Paramedic Certification Examination.19 Second, some states, such as Nebraska, do not require proof of entry-level competency to provide paramedic licensure to non-EMS health care professionals.20 Therefore, completion of the academic program may be sufficient to attain licensure. On the basis of our work, these 70 individuals completed the designed curriculum and passed the comprehensive final examination. However, entry-level competency could not be independently verified in our evaluation. The existence of nontraditional and bridge educational pathways to EMS paramedic provider across the US needs to be further understood and evaluated. Further research into other alternative pathway paramedic education programs to identify the best practices and entrance requirements for success is warranted. Further program evaluation and research could include other measurements of success such as student satisfaction and employer feedback surveys for this group. Limitations
This study was limited to a single Midwestern universitybased EMS educational program in Omaha, Nebraska. Each class had a maximum of 10 students, and the overall data were limited to the 305 students who attended the program within the 10-year period. Our data were obtained from a national group and not geographically segmented. Additionally, this study was limited to health care providers with at least 2 years of acute or critical care experience, and there was no formal requirement for previous EMS experience other than having an active emergency medical technician credential. The study measures were limited to the NREMT National Paramedic Certification Examination serving as evidence of attaining entry-level competency. As noted, some students who completed the program may not have had independent confirmation of entry-level competency, thus introducing measurement error. We do not know whether this group received exemptions to practice as paramedics from their states or EMS systems. Our study showed that other non-EMS health professions can transition into EMS, but it did not explore the feasibility of paramedics transitioning into other health professional roles on an advanced placement pathway.
Implications for Emergency Nurses
The results of our study have implications for emergency nurses seeking to function in EMS settings, such as aeromedical transport, and for those wanting to bridge their
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clinical expertise with EMS credentialing to support local EMS. We documented a high rate of non-EMS health care professionals, primarily experienced acute and critical care nurses, who successfully attained entry-level paramedic competency after program completion. For the specialty of emergency nursing, our study has implications such as successful workforce preparation to expand the role of emergency nursing into the prehospital EMS setting as paramedics.
Conclusion
Our study evaluated the outcomes from an advanced placement paramedic program at a Midwestern university. The program had high rates of successful program completion, as well as high first-attempt and cumulative passing rates in the NREMT paramedic level computer-based examination. Future research is needed to identify the best practices in student requirements and methodologies in delivering advanced placement paramedic education bridging programs.
Author Disclosures
Conflicts of interest: none to report. REFERENCES 1. The National Highway Traffic Safety Administration. National EMS scope of practice model 2019. https://www.ems.gov/pdf/National_ EMS_Scope_of_Practice_Model_2019.pdf. Published February 2019. Accessed July 8, 2019. 2. Bentley MA, Shoben A, Levine R. The demographics and education of emergency medical services (EMS) professionals: a national longitudinal investigation. Prehosp Disaster Med. 2016;31(S1):18-29. https://doi.org/ 10.1017/S1049023X16001060. 3. Emergency Medical Services. Agenda for the future. https://www.ems.gov/ pdf/advancing-ems-systems/Provider-Resources/EMS_Agenda_For_The_ Future_2010.pdf. Published 1996. Accessed July 8, 2019. 4. Emergency Medical Service. Education agenda for the future: a systems approach. https://www.ems.gov/pdf/education/EMS-Education-for-theFuture-A-Systems-Approach/EMS_Education_Agenda.pdf. Published 2000. Accessed July 8, 2019. 5. EMS Agenda 2050 Technical Expert Panel. EMS agenda 2050: a peoplecentered vision for the future of emergency medical services. https://www. ems.gov/pdf/EMS-Agenda-2050.pdf. Published January 2019. Accessed July 8, 2019. 6. World Health Organization Europe. Emergency medical services in the european union: report of an assessment project coordinated by the World Health Organization. http://www.euro.who.int/__data/assets/
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pdf_file/0003/114564/E92039.pdf. Published 2008. Accessed July 8, 2019. 7. Al-Shaqsi S. Models of international emergency medical service (EMS) systems. Oman Med J. 2010;25(4):320-323. https://doi.org/10.5001/ omj.2010.92. 8. Fischer M, Kamp J, Garcia-Castrillo Riesgo L, et al. Comparing emergency medical service systems–a project of the European Emergency Data (EED) project. Resuscitation. 2011;82(3):285-293. https:// doi.org/10.1016/j.resuscitation.2010.11.001. 9. Green MJ. 2014 critical care transport workplace and salary survey. Air Med J. 2014;33(6):257-264. https://doi.org/10.1016/j.amj.2014.09.008. 10. Gunnarsson SI, Mitchell J, Busch MS, et al. Outcomes of physicianstaffed versus non-physician-staffed helicopter transport for STelevation myocardial infarction. J Am Heart Assoc. 2017;6(2):e004936. https://doi.org/10.1161/JAHA.116.004936. 11. Crippen DW, Bonetti MM, Hoyt JW, Martin BR. Cost and survival results of critical care regionalization for medicare patients. Crit Care Med. 1989;17(7):601-606. https://doi.org/10.1097/00003246-19890700000001. 12. Air & Surface Transport Nurses Association. Position statement: critical care transport nurse safety in the transport environment. http://www.astna.org/ resource/collection/4392B20B-D0DB-4E76-959C-6989214920E9/ ASTNA_Safety_Position_Paper_2018_FINAL.pdf. Published January 2018. Accessed July 8, 2019. 13. Creighton University. Innovative paramedic certification for health professionals. https://ems.creighton.edu/programs/ems-certificates/paramediccertification-health-care-providers. Accessed July 8, 2019.
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14. Clark State Community College. Paramedic certification for registered nurses. https://www.clarkstate.edu/academics/degrees-and-certificates/ health/paramedic-certification-for-registered-nurses. Accessed July 8, 2019. 15. Study.com. How to become a paramedic nurse: step-by-step career guide. https://study.com/articles/How_to_Become_a_Paramedic_Nurse_Stepby-Step_Career_Guide.html. Accessed July 8, 2019. 16. Fernandez AR, Studneck JR, Margolis GS. Estimating the probability of passing the national paramedic certification examination. Acad Emerg Med. 2008;15(3):258-264. https://doi.org/10.1111/j.1553-2712.2008.00062.x. 17. National Registry of Emergency Medical Technicians. Paramedic candidate handbook. https://content.nremt.org/static/documents/NREMT_ ParamedicHandbook.pdf. Published 2018. Accessed July 8, 2019. 18. The Tennessee Department of Health Bureau of Health Licensure and Regulation Division of Emergency Medical Services. Chapter 1200-1201 general rules. https://publications.tnsosfiles.com/rules/1200/120012/1200-12-01.20150401.pdf. Revised April 2015. Accessed August 23, 2019. 19. Illinois General Assembly. Health facilities and regulation. (210 ILCS 50/) Emergency Medical Services (EMS) Systems Act. http://www.ilga.gov/ legislation/ilcs/ilcs3.asp?ActID=1226&ChapterID=21. Published September 2012. Accessed August 23, 2019. 20. Nebraska Department of Health and Human Services. Chapter 12 Licensure of emergency Medical Services. https://sos.nebraska. gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_ System/Title-172/Chapter-012.pdf. Published December 15, 2012. Accessed August 23, 2019.
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