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Knowledge and skill retention of emergency care attendants, EMT-As, and EMT-Ps
ORIGINAL CONTRIBUTION
Knowledge and Skill Retention of Emergency Care Attendants, EMT-As, and EMToPs Neal S. Latman, PhD Kenneth Wooley, MA Austin, Texas The retention of knowledge and skill proficiency was evaluated for emergency care attendants (ECAs), emergency medical technicians (EMT-As) and paramedics (EMT-Ps). The sample represented 4.1% of the total number of individuals trained and certified in these positions in Texas. The average loss of didactic knowledge did not exceed 10% over a two-year period. After two years the ECAs had lost approximately 55%, EMT-As 50%, and EMT-Ps 61% of their basic skills proficiency. Retention of knowledge and skill appears to be directly related to frequency of use. Participants in continuing education programs experienced an 11% better retention average for skill than did nonparticipants. The employees of privately operated ambulance services retained their basic skills better than did members of other types of services. The rate of knowledge deterioration for the sample evaluated was not correlated (R = 0.08) to the original written score. Latman NS, Wooley K: K n o w l e d g e and skill retention of e m e r g e n c y care attendants, EMT-As, and EMT-Ps. Ann Emerg Med 9:183-189, April 1980.
emergency medical services, personnel, skill retention; paramedics, skill retention INTRODUCTION The provision of p r o m p t prehospital emergency medical care appears to be t a k i n g a new direction. A change in the concept of the function of an a m b u l a n c e service occurred about 1970.1, 2 D u r i n g the p a s t 10 years a m b u l a n c e operations h a v e evolved from a basic concern for high-speed t r a n s p o r t a t i o n to an a t t e m p t to provide adequate, prompt, and efficient e m e r g e n c y medical assistance to indiv i d u a l s who suddenly become ill or injured. 3 The diagnostic accuracy and appropriateness of t r e a t m e n t provided by amb u l a n c e a t t e n d a n t s v a r y g r e a t l y . 4-7 One p r e l i m i n a r y s t u d y 3 c o m p a r e d t h e abilities of physicians, cardiac technicians (CRT), emergency medical technicians (EMTs), emergency d e p a r t m e n t nurses, and intensive care nurses to recognize t e l e m e t e r e d electrocardiogram p a t t e r n s and t r e a t patients. A n u m b e r of studies 9-13 have reported evidence t h a t a p r e h o s p i t a l emergency medical service (EMS) which functions o p t i m a l l y can salvage 8% to 25% of victims of motor vehicle accidents. There is, therefore, an a p p a r e n t discrepancy between the high promise of a system and a c h i e v e m e n t of t h a t promise. One factor t h a t m a y contribute to this lack of optimal achievement is the r a t e at which a m b u l a n c e a t t e n d a n t s lose skill proficiency and didactic knowledge. A p r e l i m i n a r y study 14 revealed the w r i t t e n e x a m i n a t i o n scores, one y e a r a f t e r t r a i n i n g , of 18 p a r a m e d i c s who p a r t i c i p a t e d in an in-service continuing From the EMS Division, Texas Department of Health, Austin, Texas. This project was supported and funded by the Emergency Medical Services Division, Texas Department of Health. Address for reprints: Neal S. Latman, PhD, Director of Research, Leo N. Levi National Arthritis HosPital, Hot Springs National Park, Arkansas 71901.
9:4 (April) 1980
Ann
Emerg Med
183/13
education program. As the original w r i t t e n score was not provided, it is not possible to determine if the scores reported represent a gain or loss in knowledge after one year. A more detailed study, published in 1977, of the cognitive a n d technical" skill deterioration of 30 paramedics, 15 concluded t h a t skills deteriorated with time and those skills r e q u i r i n g the most technical knowledge deteriorated the fastest. After 30 months, a deterioration of 7.4% on the w r i t t e n e x a m i n a t i o n was reported. A relatively comprehensive analysis of r e t e n t i o n of k n o w l e d g e , as m e a s u r e d by w r i t t e n e x a m i n a t i o n , ~ showed a loss of knowledge over time a m o n g EMT-As. I n the four years since t h e i r course completion, the EMT-As had lost approximately 18% of t h e i r knowledge. A s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n (P < 0.05) was reported between knowledge test scores and supervisory ratings. The purpose of this study was to measure retention of knowledge and skills in a controlled a n d d e t a i l e d m a n n e r . In addition, we hoped to develop a t r a i n i n g / r e t r a i n i n g and certification/recer tification program which would c o n t r i b u t e to o p t i m a l performance in the provision of prehospital emergency medical assistance. MATERIALS AND METHODS The s a m p l e t e s t e d was chosen from i n d i v i d u a l s t r a i n e d as ECAs, EMT-As, or EMT-Ps and certified by t h e T e x a s D e p a r t m e n t of H e a l t h (TDH), and was a r a n d o m l y selected 10% of this population, stratified by level of t r a i n i n g and length of time since their last course (6, 12, 18, or 24 months), and by geographic region. A letter was sent to these individuals requesting that they participate in "a project to help develop a better EMS program." All retesting was performed d u r i n g a two-month period. The subjects were i n f o r m e d of the purpose of the project, given a questionnaire, and tested. The mult i p l e choice q u e s t i o n n a i r e was designed to elicit information about the t r a i n i n g , experience, and background of each person. Each group was given the appropriate w r i t t e n test for their level of training. This was the same test used for state certification. In addition, each individual was tested on three of the five basic skills. The three skills chosen were the same as those the individual was required to perform for initial certification. The same basic criteria of skill perform-
14/184
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050' -80 N =52
N =60
N =41
N --26
Time (months) Fig. 1. Percentage change in didactic knowledge and skill proficiency for ECAs with time. (+- SE)
Table 1 PERCENTAGE OF INDIVIDUALS PROFICIENT IN SKILLS BY LEVEL OF T R A I N I N G AND MONTHS SINCE LAST COURSE 6 months %(N=)
12 months %(N=)
18 month %(N=)
ECA Vital signs Mechanical aids
60 (20) 60 (20)
50 (31) 50 (6)
42 (15)
EMT-A Vital signs Mechanical aids
86 (25) 90 (29)
81 (31) 85 (20)
81 (16)
ance were used, and a ~'pass" or ~fail" was given for each skill. Testing i n each g e o g r a p h i c r e g i o n was performed by the p e r s o n n e l who norm a l l y a d m i n i s t e r the certifying examinations. Results were reported as the percentage change in score bet w e e n the previous c e r t i f y i n g test a n d the retest. The d a t a from each q u e s t i o n n a i r e were coded a n d keypunched on s t a n d a r d 80-column p u n c h cards with one card per individual. These were t h e n used to create a system file on t h e T D H ' s U N I V A C 1106 computer. V a r i o u s s u b p r o g r a m s of the SPSSH-110 version of the Statistical Package for the Social Sciences (SPSS) were executed a g a i n s t the file to provide the computations a n d comparisons needed. The subpro-
Ann
Emerg Med
grams CONDESCRIPTIVE, FREQ U E N C I E S , SCATTERGRAM, and CROSSTABS provided all the statistical output necessary. O t h e r v a r i a b l e s considered included the following: 1) frequency of use; 2) type of work; 3) sex; 4 ) c o n t i n u i n g education; and 5) refresher t r a i n i n g . These d a t a were grouped for the entire sample, regardless of level of t r a i n i n g or l e n g t h of t i m e since last course, to simplify the report. The ECA c u r r i c u l u m consists of a m i n i m u m of 24 h r of training. At the conclusion of the course, TDH regional personnel a d m i n i s t e r a standardized w r i t t e n ECA e x a m i n a t i o n of 50 m u l t i p l e choice q u e s t i o n s . The students also are given a test of proficiency in cardiopulmonary resusci9:4 (April) 1980
ficiency in the five basic skills.
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N =95
N =68
N =36
N =29
Time (months) Fig. 2. Percentage change in didactic knowledge and skill proficiency for EMT-As with time. ('4-SE)
Table 2 PERCENTAGE CHANGE IN SKILL PROFICIENCY BY TYPE OF WORK AND EMS OPERATION (-+SE)
% Change in Skill Proficiency
Private ambulance Volunteer ambulance Government ambulance Nonambulance fireman
tation (CPR), t r a c t i o n s p l i n t i n g , measuring v i t a l signs, u s e of mechanical a i d s to b r e a t h i n g , a n d bandaging and splinting. The skills are graded on a pass/fail basis by the examiners, who use a c h e c k l i s t of specific c r i t e r i a . C e r t i f i c a t i o n requires a m i n i m u m grade of 70% on the written e x a m i n a t i o n and a "pass" on all skills tested. A t l e a s t t h r e e skills, selected at t h e discretion of the examiner, are tested. The EMT-A curriculum, with its minimum of 120 h r of course work (80 hr classroom, 40 h r clinical experience) g e n e r a l l y follows t h e Department of T r a n s p o r t a t i o n (DOT) guidelines. Texas s t a t e certification requires passing a 100-question multiple choice t e s t (70% or better) and d e m o n s t r a t i n g p r o f i c i e n c y in t h e 9:4 (April) 1980
-25 -37 -42 -29
(---6) (---3) (-+3) (--+6)
N=
27 179 92 37
basic skills (ie, CPR, traction splinti n g , t a k i n g v i t a l signs, u s i n g mechanical aids to b r e a t h i n g , and banda g i n g a n d splinting). The s t u d e n t s a r e t e s t e d on a m i n i m u m of t h r e e skills selected by the examiner. All skills tested m u s t be performed according to w r i t t e n c r i t e r i a for certification. The EMT-P c u r r i c u l u m consists of a m i n i m u m of 400 hr. On satisfactory completion of the course, TDH regional personnel administer a t w o - p a r t w r i t t e n e x a m i n a t i o n which r e q u i r e s for certification a p a s s i n g g r a d e of 70% on each portion. The f i r s t p a r t consists of 165 m u l t i p l e choice q u e s t i o n s , w h i l e t h e second p a r t is m a d e up of 85 short answer, situation-oriented questions. The s t u d e n t s also m u s t d e m o n s t r a t e pro-
Ann Emerg Med
The percentage c h a n g e in knowledge and skill performance over t i m e for ECAs, EMT-As, a n d EMT-Ps is i l l u s t r a t e d (Figures 1, 2, and 3). All t h r e e levels showed d e t e r i o r a t i o n with time. In 24 months both the E C A s a n d EMT-As lost a m a x i m u m of 10% of t h e i r knowledge as m e a s u r e d by t h e w r i t t e n t e s t . EMT-Ps a p p e a r e d to lose knowledge at a slower rate; however, they also demonstrated the greatest average loss of basic skill proficiency (61%). T h e E C A s lost a p p r o x i m a t e l y 55% a n d the EMT-As a b o u t 50% of t h e i r b a s i c s k i l l p r o f i c i e n c y a f t e r 24 months. While the ECAs suffered t h e i r g r e a t e s t loss of skill in the first six to 12 months, t h e EMT-As maint a i n e d a r e l a t i v e l y constant r a t e of loss d u r i n g the period. The reduction in the percentage of ECAs proficient in CPR, traction splinting, and b a n d a g i n g and splinting (B and S) is shown ( F i g u r e 4). D e t e r i o r a t i o n in CPR and B a n d S proficiency is g r e a t e s t in the first six months after course completion, and t h e n t e n d s to l e v e l off. T r a c t i o n s p l i n t i n g s h o w e d t h e g r e a t e s t det e r i o r a t i o n (only 28% proficient after 24 months) and did not begin to level off until after 18 months. The percentage of EMT-As proficient in CPR, traction splinting, and B and S also changed with time (Figu r e 5). CPR proficiency showed the m o s t d e t e r i o r a t i o n w i t h o n l y 21% proficient after 24 months. Between 60% and 70% of t h e EMT-As could still perform traction splinting and B a n d S after 24 months. Reduction in t h e p e r c e n t a g e of EMT-Ps who are proficient in CPR, traction splinting, and B a n d S over t i m e is i l l u s t r a t e d ( F i g u r e 6). The decay is most severe in CPR, w i t h b e t w e e n 20% a n d 30% p r o f i c i e n t after 18 months. The most r a p i d loss o c c u r r e d in t h e f i r s t 12 moiaths. D e c a y of t r a c t i o n s p l i n t i n g proficiency was also m o s t r a p i d in t h e f i r s t 12 m o n t h s . A f t e r 18 m o n t h s only 36% of the EMT-Ps tested could perform the b a n d a g i n g and splinting s k i l l a c c o r d i n g to t h e r e q u i r e d criteria. T h e p e r c e n t a g e of E C A s a n d EMT.As proficient in v i t a l signs and m e c h a n i c a l aids to b r e a t h i n g a s a function of time is shown (Table 1). As d e m o n s t r a t e d by t h e r e l a t i v e l y s m a l l s a m p l e size, these skills were tested less frequently t h a n others.. 185/15
There was a direct r e l a t i o n s h i p b e t w e e n the frequency of knowledge a n d skill use and r e t e n t i o n (Figure 7). T h e e f f e c t is e s p e c i a l l y p r o nounced on skill retention. No meaningful difference was found for e i t h e r didactic knowledge or skill r e t e n t i o n b e t w e e n m e n and women. The effect of continuing education is i l l u s t r a t e d ( F i g u r e 8). S k i l l r e t e n t i o n was app r o x i m a t e l y 11% b e t t e r in individuals who p a r t i c i p a t e d in some form of c o n t i n u i n g education t h a n in those who did not. Some difference in r e t e n t i o n also was noted for the t y p e of work variable (Figure 9), eg, a m b u l a n c e personnel, non-ambulance but EMSrelated work (firemen, policemen, nurses), a n d work not r e l a t e d to EMS (clerks, s e c r e t a r i e s , a d m i n i s t r a t o r s , h o u s e w i v e s ) . The a m b u l a n c e category was further divided by type of operation (volunteer, government, private, hospital, and industrial). Employees of p r i v a t e l y operated ambulance companies had the b e s t retention of basic skills (Table 2). The s a m e basic p a t t e r n of d e t e r i o r a t i o n for these groups was found for didactic knowledge. A l t h o u g h t h e r e was no signific a n t difference in the percentage of d i d a c t i c k n o w l e d g e r e t e n t i o n between individuals certified by an original course and those whose l a s t course was a r e f r e s h e r course, t h e s k i l l s a p p e a r e d to d e t e r i o r a t e s l i g h t l y more ( - 39% versus -35%) for the former. The r a t e of deterior a t i o n of knowledge was not correlated (R =0.08) to the original written test score. The sample group which particip a t e d in the e v a l u a t i o n r e p r e s e n t e d 4.1% of the i n d i v i d u a l s in Texas with ECA, EMT-A, and EMT-P t r a i n i n g a n d c e r t i f i c a t i o n • D i s t r i b u t i o n according to level of t r a i n i n g was as follows: ECA, 3.6%; EMT-A, 4.4%; a n d EMT-P, 6.1%. The mean age was 35, the m e d i a n 33, with a r a n g e of 17 to 67 years. Of the 254 counties in Texas, 105 (41%) were represented. A comparison of the a v e r a g e academic performance on the original written test of the sample to t h a t of the population for each level of t r a i n i n g and each t i m e period (6, 12, 18, and 24 months) failed to r e v e a l a n y disc r e p a n c y in r e p r e s e n t a t i o n g r e a t e r t h a n 1%. DISCUSSION
The r e l a t i v e l y slow loss of didactic knowledge evident in this s t u d y is quite s i m i l a r to t h a t found in other
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F i g . 3. Percentage change in didactic knowledge and skill proficiency for EMT-Ps with time. (+. SE)
- CPR ............... Traction Splinting ........... Bandaging and Splinting
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F i g . 4. Change in the percentage of ECAs proficient in CPR, traction splinting, and bandaging and splinting with time. reports.~, 15 Although the a v e r a g e dec r e a s e of a p p r o x i m a t e l y 10% obs e r v e d ,over a 2 4 - m o n t h p e r i o d is s t a t i s t i c a l l y significant, the question of m e a n i n g f u l s i g n i f i c a n c e h a s not been answered. The p h r a s e ~meani n g f u l s i g n i f i c a n c e , " as used h e r e , d e s i g n a t e s a m e a s u r a b l e effect or i m p a c t on t h e final outcome. T h a t is, a factor m a y be s t a t i s t i c a l l y signif-
Ann Emerg Med
i c a n t w h e n m e a s u r e d in i s o l a t i o n , b u t a change in t h a t factor (all other factors r e m a i n i n g c o n s t a n t ) w o u l d n o t n e c e s s a r i l y produce a different total effect. A factor which is identified as being m e a n i n g f u l l y significant would produce a different outcome if changed. P e r h a p s t h e b e s t m e a s u r e of meaningful significance is a correla-
9:4 (April) 1980
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= 92",~'_~,N,-69
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12' Time (months)
1'8
24'
Fig. 5. Change in the percentage of EMT-As proficient in CPR, traction splint-
ing, and bandaging and splinting with time.
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............ Traction Splinting .............. Bandaging and Splinting
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Fig. 6. Change in the percentage of EMT-Ps proficient in CPR, traction splinting, and bandaging and splinting with time. tion between the level or the loss of knowledge and the actual outcome of patients. This requires a large sample size and control of m a n y variables. Although less direct, a nomihal approach might be a correlation between the c h a n g e i n d i d a c t i c knowledge and performance r a t i n g s by a supervisor. One EMT-A w r i t t e n test has reportedly been developed
9:4 (April) 1980
with a correlation of +0.68 (P <0.01) b e t w e e n the grade and supervisory r a t i n g s . 16 A n o t h e r s t u d y of 88 EMT-As found a statistically signific a n t correlation (P< 0.05) b e t w e e n knowledge test scores and supervisory r a t i n g s , b u t n o t w i t h perform a n c e scores, s Because the m a g n i t u d e of the c h a n g e s i n s k i l l p r o f i c i e n c y were
Ann
Emerg M e d
greater t h a n those of didactic knowledge, the difficulty in establishing a generally acceptable d e f n i t i o n of a " m e a n i n g f u l l y significant" loss is reduced. If r e t r a i n i n g and recertification r e q u i r e m e n t s are to be r e l e v a n t to needs, this definition must be constructed. A s a m p l e of 21 EMS a d m i n i s trators (17 of whom were certified as a n ECA, EMT-A, or EMT-P) were asked to define a " m i n i m a l loss of didactic knowledge t h a t is meaningful" a n d a ~ m i n i m a l loss of skill proficiency that is meaningful." The average definition was approximately 13% for didactic knowledge and 15% for skill proficiency. The average degree of loss at which t h e y recomm e n d e d r e t r a i n i n g to be r e q u i r e d was approximately 32% for knowledge a n d 16% for skills. A l t h o u g h this subjective definition of '~meaningful" may be of limited value, the relative level of loss at which they thought r e t r a i n i n g should begin is of i n t e r e s t . The r e s u l t s i n d i c a t e t h a t knowledge could be allowed to deteriorate at least twice the m e a n i n g ful level before r e t r a i n i n g should resume. According to the survey, however, skill d e t e r i o r a t i o n should be prevented from exceeding the meaningful level and therefore appears to be a more critical factor. The retention of skill proficiency is apparently different for each level of t r a i n i n g and each type of skill. Frequency of use affected the a m o u n t of d e t e r i o r a t i o n i n both d i d a c t i c knowledge and skills. The degree of deterioration was inversely related to the frequency of use. The one exception was those i n d i v i d u a l s who reported using their skills once per week. A n analysis of the composition of this group failed to reveal a cause. We can only assume that either the cause was due to a variable t h a t was n o t m e a s u r e d or the group was a statistical anomaly. A 1978 s t u d y 4 s u g g e s t e d t h a t simple mechanical skills do not det e r i o r a t e w i t h less f r e q u e n t .use, while more complex ones do. It is app a r e n t from t h e r e s u l t s r e p o r t e d t h a t , a l t h o u g h p r o f i c i e n c y i n all skills deteriorates with time, proficiency in specific skills is retained at different rates. W h e n t h e t o t a l s a m p l e was stratified by type of work, the private a m b u l a n c e personnel had the least skill deterioration. The government-operated service personnel experienced a greater deterioration t h a n did private, volunteer, or hospital services. The skill and knowledge
187/17
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Written
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nce Per Month
~1~ Once In 6 Months Once Per Year [~] Never
II
--40-
--50-
F i g . 7. Percentage change in didactic knowledge and skill proficiency stratified by frequency of use. (± SE)
d e t e r i o r a t i o n differences observed in various types of operations m a y not only be a function of work frequency, as could be inferred from a previous study; 4 an additional factor, ie, motivation, m a y be involved to a signific a n t degree. The study s a m p l e clearly i n d i c a t e s t h a t n o n - a m b u l a n c e firem e n experienced less knowledge and skill deterioration t h a n did governm e n t a m b u l a n c e services personnel. A p p r o x i m a t e l y 50% of t h e governm e n t a m b u l a n c e services in Texas are operated by fire d e p a r t m e n t s and some of these assign firemen to ambulance duty regardless of i n d i v i d u a l p r e f e r e n c e . A l a r g e p e r c e n t a g e of these individuals a p p a r e n t l y do not prefer the EMS assignment.
Written [ ] With Continuing Education [ ] Without Continuing Education o~ Skills c-
& 5
CONCLUSION The m e t h o d o l o g y used a p p e a r s to be a reasonable approach to t r a i n ing evaluation. One problem m a y be a potential difference in performance b e t w e e n actual p a t i e n t work and the classroom setting in which this project was conducted. The a d v a n t a g e s in cost, t i m e , a n d p e r s o n n e l , how-
18/188
N=219 N=231
N=219 N=231
F i g . 8. Percentage change in didactic knowledge and skill proficiency stratified
by participation in a continuing education program. ( ± SE) ever, c o m p e n s a t e for t h i s p o t e n t i a l discrepancy. Because of these advantages, proposed changes in a train-
Ann
Emerg Med
i n g / r e t r a i n i n g p r o g r a m m i g h t easily be p i l o t t e s t e d in a s e l e c t s a m p l e p r i o r to a m a j o r c o m m i t m e n t . The
9:4 (April) 1980
5. Pozen MW, F r i e d DD, V o i g h t GG: Studies of a m b u l a n c e p a t i e n t s with. ischemic h e a r t disease. Am J Public Health 67:532-535, 1977.
Written 0 -I-
:~
6. Czaja SJ, Drury CG: A l=egional evaluation of EMT training. Emergency Medical Services 7:77-121, 1978.
Z
-10
-20
7. McAllister P, S h u m a n LJ, Wolfe H: Computer evaluation of paramedic training programs. Emergency Medical Services 7:39-97, 1978.
Skills
o-30
8. J a r m o n RG, Yesalis CE: Provider performance in the recognition and treatm e n t of telemetered e l e c t r o c a r d i o g r a m patterns. JACEP 5:971-974, 1976.
~ -40
9. Frey CF, Huelke DF, Gikas PW: Resuscitation and survival in motor vehicle accidents. J Trauma 9:292-310, 1969.
o -50
Ambu- Non Not lance ambu- Related N =321 lance N=69 N = 65
Ambulance N =321
NonNot ambu- Related lance N =69 N = 65
Fig. 9. Percentage change in didactic knowledge and skill proficiency stratified by type of work. (+- SE) relative b e n e f i t s a n d cost e f f i c i e n c y of these e x p e r i m e n t a l c h a n g e s c o u l d then be c o m p a r e d a n d t h e m o s t desirable chosen. The design of a training/retraining program must comprise a n o p t i m a l c o m b i n a t i o n of training, cost/benefit returns, and cost efficiency. The authors t h a n k the staff of the EMS Division for their support and assistance with this evaluation. Special t h a n k s go to Charles King and James Shufield. The cooperation of the Leo N. Levi National Arthritis Hospital in the completion of this report is also appreciated.
9:4 (April) 1980
REFERENCES 1. S a d l e r AM, S a d l e r BL, Webb SB:
Emergency Medical Care: The Neglected Public Service. C a m b r i d g e , M a s s a c h u setts, Balinger Publishing Co, 1977. 2. Jelenko C, Frey CF: Emergency Medical Services: An Overview. Bowie, Maryland, Robert J. Brady Co, 1976. 3. G r a n t H, Murray R: Emergency Care. Bowie, Maryland, Robert J. Brady Co, 1975. 4. Frazier WH, C a n n o n JF: Emergency medical technicians performance evaluation. NCHSR Research Report Series. Dep a r t m e n t of Health, Education, and Welfare. PHS #78-3211, 1978.
Ann
Emerg Med
10. Baker SP: Evaluation of medical care of t h e i n j u r e d . J Trauma 11:892-894, 1971. 11. Waters JM, Wells CH: The effects of modern emergency medical care systems in reducing automobile crash deaths. J Trauma 13:645-647, 1973. 12. Waller JA: Urban-oriented methods: f a i l u r e to solve r u r a l e m e r g e n c y care problems. JAMA" 226:1441-1446, 1973. 13. Willemain TR: The status of perform a n c e measures for emergency medical services. JACEP 4:143-151, 1975. 14. McManus WF, D a v i n JL: Can t h e well t r a i n e d E M T - p a r a m e d i c m a i n t a i n skills and knowledge? JACEP 5:984-986, 1976. 15. Skelton MB, McSwain NE: A study of cognitive and technical skill deterioration a m o n g t r a i n e d p a r a m e d i c s . JACEP 6:436-438, 1977. 16. Abercrombie TT, Truelove JW: A proficiency examination for emergency medical technicians. University of Alabama in Birmingham, 1974.
189/19
Knowledge and Skill Retention of Emergency Care Attendants, EMT-As, and EMToPs Neal S. Latman, PhD Kenneth Wooley, MA Austin, Texas The retention of knowledge and skill proficiency was evaluated for emergency care attendants (ECAs), emergency medical technicians (EMT-As) and paramedics (EMT-Ps). The sample represented 4.1% of the total number of individuals trained and certified in these positions in Texas. The average loss of didactic knowledge did not exceed 10% over a two-year period. After two years the ECAs had lost approximately 55%, EMT-As 50%, and EMT-Ps 61% of their basic skills proficiency. Retention of knowledge and skill appears to be directly related to frequency of use. Participants in continuing education programs experienced an 11% better retention average for skill than did nonparticipants. The employees of privately operated ambulance services retained their basic skills better than did members of other types of services. The rate of knowledge deterioration for the sample evaluated was not correlated (R = 0.08) to the original written score. Latman NS, Wooley K: K n o w l e d g e and skill retention of e m e r g e n c y care attendants, EMT-As, and EMT-Ps. Ann Emerg Med 9:183-189, April 1980.
emergency medical services, personnel, skill retention; paramedics, skill retention INTRODUCTION The provision of p r o m p t prehospital emergency medical care appears to be t a k i n g a new direction. A change in the concept of the function of an a m b u l a n c e service occurred about 1970.1, 2 D u r i n g the p a s t 10 years a m b u l a n c e operations h a v e evolved from a basic concern for high-speed t r a n s p o r t a t i o n to an a t t e m p t to provide adequate, prompt, and efficient e m e r g e n c y medical assistance to indiv i d u a l s who suddenly become ill or injured. 3 The diagnostic accuracy and appropriateness of t r e a t m e n t provided by amb u l a n c e a t t e n d a n t s v a r y g r e a t l y . 4-7 One p r e l i m i n a r y s t u d y 3 c o m p a r e d t h e abilities of physicians, cardiac technicians (CRT), emergency medical technicians (EMTs), emergency d e p a r t m e n t nurses, and intensive care nurses to recognize t e l e m e t e r e d electrocardiogram p a t t e r n s and t r e a t patients. A n u m b e r of studies 9-13 have reported evidence t h a t a p r e h o s p i t a l emergency medical service (EMS) which functions o p t i m a l l y can salvage 8% to 25% of victims of motor vehicle accidents. There is, therefore, an a p p a r e n t discrepancy between the high promise of a system and a c h i e v e m e n t of t h a t promise. One factor t h a t m a y contribute to this lack of optimal achievement is the r a t e at which a m b u l a n c e a t t e n d a n t s lose skill proficiency and didactic knowledge. A p r e l i m i n a r y study 14 revealed the w r i t t e n e x a m i n a t i o n scores, one y e a r a f t e r t r a i n i n g , of 18 p a r a m e d i c s who p a r t i c i p a t e d in an in-service continuing From the EMS Division, Texas Department of Health, Austin, Texas. This project was supported and funded by the Emergency Medical Services Division, Texas Department of Health. Address for reprints: Neal S. Latman, PhD, Director of Research, Leo N. Levi National Arthritis HosPital, Hot Springs National Park, Arkansas 71901.
9:4 (April) 1980
Ann
Emerg Med
183/13
education program. As the original w r i t t e n score was not provided, it is not possible to determine if the scores reported represent a gain or loss in knowledge after one year. A more detailed study, published in 1977, of the cognitive a n d technical" skill deterioration of 30 paramedics, 15 concluded t h a t skills deteriorated with time and those skills r e q u i r i n g the most technical knowledge deteriorated the fastest. After 30 months, a deterioration of 7.4% on the w r i t t e n e x a m i n a t i o n was reported. A relatively comprehensive analysis of r e t e n t i o n of k n o w l e d g e , as m e a s u r e d by w r i t t e n e x a m i n a t i o n , ~ showed a loss of knowledge over time a m o n g EMT-As. I n the four years since t h e i r course completion, the EMT-As had lost approximately 18% of t h e i r knowledge. A s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n (P < 0.05) was reported between knowledge test scores and supervisory ratings. The purpose of this study was to measure retention of knowledge and skills in a controlled a n d d e t a i l e d m a n n e r . In addition, we hoped to develop a t r a i n i n g / r e t r a i n i n g and certification/recer tification program which would c o n t r i b u t e to o p t i m a l performance in the provision of prehospital emergency medical assistance. MATERIALS AND METHODS The s a m p l e t e s t e d was chosen from i n d i v i d u a l s t r a i n e d as ECAs, EMT-As, or EMT-Ps and certified by t h e T e x a s D e p a r t m e n t of H e a l t h (TDH), and was a r a n d o m l y selected 10% of this population, stratified by level of t r a i n i n g and length of time since their last course (6, 12, 18, or 24 months), and by geographic region. A letter was sent to these individuals requesting that they participate in "a project to help develop a better EMS program." All retesting was performed d u r i n g a two-month period. The subjects were i n f o r m e d of the purpose of the project, given a questionnaire, and tested. The mult i p l e choice q u e s t i o n n a i r e was designed to elicit information about the t r a i n i n g , experience, and background of each person. Each group was given the appropriate w r i t t e n test for their level of training. This was the same test used for state certification. In addition, each individual was tested on three of the five basic skills. The three skills chosen were the same as those the individual was required to perform for initial certification. The same basic criteria of skill perform-
14/184
0
-
\\ \\
-10,
Written - Skill
\
\
\
----Z \
-20 -30
.~ ,40
\
\
\
\
\
\
\
\
\
\
\
\
\ \
050' -80 N =52
N =60
N =41
N --26
Time (months) Fig. 1. Percentage change in didactic knowledge and skill proficiency for ECAs with time. (+- SE)
Table 1 PERCENTAGE OF INDIVIDUALS PROFICIENT IN SKILLS BY LEVEL OF T R A I N I N G AND MONTHS SINCE LAST COURSE 6 months %(N=)
12 months %(N=)
18 month %(N=)
ECA Vital signs Mechanical aids
60 (20) 60 (20)
50 (31) 50 (6)
42 (15)
EMT-A Vital signs Mechanical aids
86 (25) 90 (29)
81 (31) 85 (20)
81 (16)
ance were used, and a ~'pass" or ~fail" was given for each skill. Testing i n each g e o g r a p h i c r e g i o n was performed by the p e r s o n n e l who norm a l l y a d m i n i s t e r the certifying examinations. Results were reported as the percentage change in score bet w e e n the previous c e r t i f y i n g test a n d the retest. The d a t a from each q u e s t i o n n a i r e were coded a n d keypunched on s t a n d a r d 80-column p u n c h cards with one card per individual. These were t h e n used to create a system file on t h e T D H ' s U N I V A C 1106 computer. V a r i o u s s u b p r o g r a m s of the SPSSH-110 version of the Statistical Package for the Social Sciences (SPSS) were executed a g a i n s t the file to provide the computations a n d comparisons needed. The subpro-
Ann
Emerg Med
grams CONDESCRIPTIVE, FREQ U E N C I E S , SCATTERGRAM, and CROSSTABS provided all the statistical output necessary. O t h e r v a r i a b l e s considered included the following: 1) frequency of use; 2) type of work; 3) sex; 4 ) c o n t i n u i n g education; and 5) refresher t r a i n i n g . These d a t a were grouped for the entire sample, regardless of level of t r a i n i n g or l e n g t h of t i m e since last course, to simplify the report. The ECA c u r r i c u l u m consists of a m i n i m u m of 24 h r of training. At the conclusion of the course, TDH regional personnel a d m i n i s t e r a standardized w r i t t e n ECA e x a m i n a t i o n of 50 m u l t i p l e choice q u e s t i o n s . The students also are given a test of proficiency in cardiopulmonary resusci9:4 (April) 1980
ficiency in the five basic skills.
0
RESULTS 10
\\\ \..\\
2O
•
--..
Written
-------Skill
-~
\\\ \\
~ .4C
\\
\\
~ .5C \\\\t 0
6G
N =95
N =68
N =36
N =29
Time (months) Fig. 2. Percentage change in didactic knowledge and skill proficiency for EMT-As with time. ('4-SE)
Table 2 PERCENTAGE CHANGE IN SKILL PROFICIENCY BY TYPE OF WORK AND EMS OPERATION (-+SE)
% Change in Skill Proficiency
Private ambulance Volunteer ambulance Government ambulance Nonambulance fireman
tation (CPR), t r a c t i o n s p l i n t i n g , measuring v i t a l signs, u s e of mechanical a i d s to b r e a t h i n g , a n d bandaging and splinting. The skills are graded on a pass/fail basis by the examiners, who use a c h e c k l i s t of specific c r i t e r i a . C e r t i f i c a t i o n requires a m i n i m u m grade of 70% on the written e x a m i n a t i o n and a "pass" on all skills tested. A t l e a s t t h r e e skills, selected at t h e discretion of the examiner, are tested. The EMT-A curriculum, with its minimum of 120 h r of course work (80 hr classroom, 40 h r clinical experience) g e n e r a l l y follows t h e Department of T r a n s p o r t a t i o n (DOT) guidelines. Texas s t a t e certification requires passing a 100-question multiple choice t e s t (70% or better) and d e m o n s t r a t i n g p r o f i c i e n c y in t h e 9:4 (April) 1980
-25 -37 -42 -29
(---6) (---3) (-+3) (--+6)
N=
27 179 92 37
basic skills (ie, CPR, traction splinti n g , t a k i n g v i t a l signs, u s i n g mechanical aids to b r e a t h i n g , and banda g i n g a n d splinting). The s t u d e n t s a r e t e s t e d on a m i n i m u m of t h r e e skills selected by the examiner. All skills tested m u s t be performed according to w r i t t e n c r i t e r i a for certification. The EMT-P c u r r i c u l u m consists of a m i n i m u m of 400 hr. On satisfactory completion of the course, TDH regional personnel administer a t w o - p a r t w r i t t e n e x a m i n a t i o n which r e q u i r e s for certification a p a s s i n g g r a d e of 70% on each portion. The f i r s t p a r t consists of 165 m u l t i p l e choice q u e s t i o n s , w h i l e t h e second p a r t is m a d e up of 85 short answer, situation-oriented questions. The s t u d e n t s also m u s t d e m o n s t r a t e pro-
Ann Emerg Med
The percentage c h a n g e in knowledge and skill performance over t i m e for ECAs, EMT-As, a n d EMT-Ps is i l l u s t r a t e d (Figures 1, 2, and 3). All t h r e e levels showed d e t e r i o r a t i o n with time. In 24 months both the E C A s a n d EMT-As lost a m a x i m u m of 10% of t h e i r knowledge as m e a s u r e d by t h e w r i t t e n t e s t . EMT-Ps a p p e a r e d to lose knowledge at a slower rate; however, they also demonstrated the greatest average loss of basic skill proficiency (61%). T h e E C A s lost a p p r o x i m a t e l y 55% a n d the EMT-As a b o u t 50% of t h e i r b a s i c s k i l l p r o f i c i e n c y a f t e r 24 months. While the ECAs suffered t h e i r g r e a t e s t loss of skill in the first six to 12 months, t h e EMT-As maint a i n e d a r e l a t i v e l y constant r a t e of loss d u r i n g the period. The reduction in the percentage of ECAs proficient in CPR, traction splinting, and b a n d a g i n g and splinting (B and S) is shown ( F i g u r e 4). D e t e r i o r a t i o n in CPR and B a n d S proficiency is g r e a t e s t in the first six months after course completion, and t h e n t e n d s to l e v e l off. T r a c t i o n s p l i n t i n g s h o w e d t h e g r e a t e s t det e r i o r a t i o n (only 28% proficient after 24 months) and did not begin to level off until after 18 months. The percentage of EMT-As proficient in CPR, traction splinting, and B and S also changed with time (Figu r e 5). CPR proficiency showed the m o s t d e t e r i o r a t i o n w i t h o n l y 21% proficient after 24 months. Between 60% and 70% of t h e EMT-As could still perform traction splinting and B a n d S after 24 months. Reduction in t h e p e r c e n t a g e of EMT-Ps who are proficient in CPR, traction splinting, and B a n d S over t i m e is i l l u s t r a t e d ( F i g u r e 6). The decay is most severe in CPR, w i t h b e t w e e n 20% a n d 30% p r o f i c i e n t after 18 months. The most r a p i d loss o c c u r r e d in t h e f i r s t 12 moiaths. D e c a y of t r a c t i o n s p l i n t i n g proficiency was also m o s t r a p i d in t h e f i r s t 12 m o n t h s . A f t e r 18 m o n t h s only 36% of the EMT-Ps tested could perform the b a n d a g i n g and splinting s k i l l a c c o r d i n g to t h e r e q u i r e d criteria. T h e p e r c e n t a g e of E C A s a n d EMT.As proficient in v i t a l signs and m e c h a n i c a l aids to b r e a t h i n g a s a function of time is shown (Table 1). As d e m o n s t r a t e d by t h e r e l a t i v e l y s m a l l s a m p l e size, these skills were tested less frequently t h a n others.. 185/15
There was a direct r e l a t i o n s h i p b e t w e e n the frequency of knowledge a n d skill use and r e t e n t i o n (Figure 7). T h e e f f e c t is e s p e c i a l l y p r o nounced on skill retention. No meaningful difference was found for e i t h e r didactic knowledge or skill r e t e n t i o n b e t w e e n m e n and women. The effect of continuing education is i l l u s t r a t e d ( F i g u r e 8). S k i l l r e t e n t i o n was app r o x i m a t e l y 11% b e t t e r in individuals who p a r t i c i p a t e d in some form of c o n t i n u i n g education t h a n in those who did not. Some difference in r e t e n t i o n also was noted for the t y p e of work variable (Figure 9), eg, a m b u l a n c e personnel, non-ambulance but EMSrelated work (firemen, policemen, nurses), a n d work not r e l a t e d to EMS (clerks, s e c r e t a r i e s , a d m i n i s t r a t o r s , h o u s e w i v e s ) . The a m b u l a n c e category was further divided by type of operation (volunteer, government, private, hospital, and industrial). Employees of p r i v a t e l y operated ambulance companies had the b e s t retention of basic skills (Table 2). The s a m e basic p a t t e r n of d e t e r i o r a t i o n for these groups was found for didactic knowledge. A l t h o u g h t h e r e was no signific a n t difference in the percentage of d i d a c t i c k n o w l e d g e r e t e n t i o n between individuals certified by an original course and those whose l a s t course was a r e f r e s h e r course, t h e s k i l l s a p p e a r e d to d e t e r i o r a t e s l i g h t l y more ( - 39% versus -35%) for the former. The r a t e of deterior a t i o n of knowledge was not correlated (R =0.08) to the original written test score. The sample group which particip a t e d in the e v a l u a t i o n r e p r e s e n t e d 4.1% of the i n d i v i d u a l s in Texas with ECA, EMT-A, and EMT-P t r a i n i n g a n d c e r t i f i c a t i o n • D i s t r i b u t i o n according to level of t r a i n i n g was as follows: ECA, 3.6%; EMT-A, 4.4%; a n d EMT-P, 6.1%. The mean age was 35, the m e d i a n 33, with a r a n g e of 17 to 67 years. Of the 254 counties in Texas, 105 (41%) were represented. A comparison of the a v e r a g e academic performance on the original written test of the sample to t h a t of the population for each level of t r a i n i n g and each t i m e period (6, 12, 18, and 24 months) failed to r e v e a l a n y disc r e p a n c y in r e p r e s e n t a t i o n g r e a t e r t h a n 1%. DISCUSSION
The r e l a t i v e l y slow loss of didactic knowledge evident in this s t u d y is quite s i m i l a r to t h a t found in other
16/186
01
-Io4
-2o4
\\
\
• Written ---,,-7-: Skill
o~
i
\ \
\
\
\
\
\
\
\
\
\
504
\
\
\
-604 N =10
N =14 N =11 12 18 T i m e (months)
6
2'4
F i g . 3. Percentage change in didactic knowledge and skill proficiency for EMT-Ps with time. (+. SE)
- CPR ............... Traction Splinting ........... Bandaging and Splinting
N =26 \ ',5
N =38
~1•=27
N =43 N =52
N =52
......
N=-41 N =33
T-
6
T
12 Time (months)
r
18
N =25 "l~
24
F i g . 4. Change in the percentage of ECAs proficient in CPR, traction splinting, and bandaging and splinting with time. reports.~, 15 Although the a v e r a g e dec r e a s e of a p p r o x i m a t e l y 10% obs e r v e d ,over a 2 4 - m o n t h p e r i o d is s t a t i s t i c a l l y significant, the question of m e a n i n g f u l s i g n i f i c a n c e h a s not been answered. The p h r a s e ~meani n g f u l s i g n i f i c a n c e , " as used h e r e , d e s i g n a t e s a m e a s u r a b l e effect or i m p a c t on t h e final outcome. T h a t is, a factor m a y be s t a t i s t i c a l l y signif-
Ann Emerg Med
i c a n t w h e n m e a s u r e d in i s o l a t i o n , b u t a change in t h a t factor (all other factors r e m a i n i n g c o n s t a n t ) w o u l d n o t n e c e s s a r i l y produce a different total effect. A factor which is identified as being m e a n i n g f u l l y significant would produce a different outcome if changed. P e r h a p s t h e b e s t m e a s u r e of meaningful significance is a correla-
9:4 (April) 1980
- -
CPR
............. Traction Splinting ................. Bandaging and Splinting N =30
= 92",~'_~,N,-69
N
N
N= 5 ~
..... • ................ i~1=18
12' Time (months)
1'8
24'
Fig. 5. Change in the percentage of EMT-As proficient in CPR, traction splint-
ing, and bandaging and splinting with time.
- -
N=9
CPR
............ Traction Splinting .............. Bandaging and Splinting
N=9". •
""~.N
=14
""...~.
~
'...:
ll
I 1
"",,
.....N =11
""
"- N =11
~1~ =13 ~ o N T
6
N =14 ~.-~ ' - / 1 12 Time (months)
=11 "[
18
~-
2
Fig. 6. Change in the percentage of EMT-Ps proficient in CPR, traction splinting, and bandaging and splinting with time. tion between the level or the loss of knowledge and the actual outcome of patients. This requires a large sample size and control of m a n y variables. Although less direct, a nomihal approach might be a correlation between the c h a n g e i n d i d a c t i c knowledge and performance r a t i n g s by a supervisor. One EMT-A w r i t t e n test has reportedly been developed
9:4 (April) 1980
with a correlation of +0.68 (P <0.01) b e t w e e n the grade and supervisory r a t i n g s . 16 A n o t h e r s t u d y of 88 EMT-As found a statistically signific a n t correlation (P< 0.05) b e t w e e n knowledge test scores and supervisory r a t i n g s , b u t n o t w i t h perform a n c e scores, s Because the m a g n i t u d e of the c h a n g e s i n s k i l l p r o f i c i e n c y were
Ann
Emerg M e d
greater t h a n those of didactic knowledge, the difficulty in establishing a generally acceptable d e f n i t i o n of a " m e a n i n g f u l l y significant" loss is reduced. If r e t r a i n i n g and recertification r e q u i r e m e n t s are to be r e l e v a n t to needs, this definition must be constructed. A s a m p l e of 21 EMS a d m i n i s trators (17 of whom were certified as a n ECA, EMT-A, or EMT-P) were asked to define a " m i n i m a l loss of didactic knowledge t h a t is meaningful" a n d a ~ m i n i m a l loss of skill proficiency that is meaningful." The average definition was approximately 13% for didactic knowledge and 15% for skill proficiency. The average degree of loss at which t h e y recomm e n d e d r e t r a i n i n g to be r e q u i r e d was approximately 32% for knowledge a n d 16% for skills. A l t h o u g h this subjective definition of '~meaningful" may be of limited value, the relative level of loss at which they thought r e t r a i n i n g should begin is of i n t e r e s t . The r e s u l t s i n d i c a t e t h a t knowledge could be allowed to deteriorate at least twice the m e a n i n g ful level before r e t r a i n i n g should resume. According to the survey, however, skill d e t e r i o r a t i o n should be prevented from exceeding the meaningful level and therefore appears to be a more critical factor. The retention of skill proficiency is apparently different for each level of t r a i n i n g and each type of skill. Frequency of use affected the a m o u n t of d e t e r i o r a t i o n i n both d i d a c t i c knowledge and skills. The degree of deterioration was inversely related to the frequency of use. The one exception was those i n d i v i d u a l s who reported using their skills once per week. A n analysis of the composition of this group failed to reveal a cause. We can only assume that either the cause was due to a variable t h a t was n o t m e a s u r e d or the group was a statistical anomaly. A 1978 s t u d y 4 s u g g e s t e d t h a t simple mechanical skills do not det e r i o r a t e w i t h less f r e q u e n t .use, while more complex ones do. It is app a r e n t from t h e r e s u l t s r e p o r t e d t h a t , a l t h o u g h p r o f i c i e n c y i n all skills deteriorates with time, proficiency in specific skills is retained at different rates. W h e n t h e t o t a l s a m p l e was stratified by type of work, the private a m b u l a n c e personnel had the least skill deterioration. The government-operated service personnel experienced a greater deterioration t h a n did private, volunteer, or hospital services. The skill and knowledge
187/17
[]
Daily
[]Once
Written
Per Week
Once In 2 Weeks ]
nce Per Month
~1~ Once In 6 Months Once Per Year [~] Never
II
--40-
--50-
F i g . 7. Percentage change in didactic knowledge and skill proficiency stratified by frequency of use. (± SE)
d e t e r i o r a t i o n differences observed in various types of operations m a y not only be a function of work frequency, as could be inferred from a previous study; 4 an additional factor, ie, motivation, m a y be involved to a signific a n t degree. The study s a m p l e clearly i n d i c a t e s t h a t n o n - a m b u l a n c e firem e n experienced less knowledge and skill deterioration t h a n did governm e n t a m b u l a n c e services personnel. A p p r o x i m a t e l y 50% of t h e governm e n t a m b u l a n c e services in Texas are operated by fire d e p a r t m e n t s and some of these assign firemen to ambulance duty regardless of i n d i v i d u a l p r e f e r e n c e . A l a r g e p e r c e n t a g e of these individuals a p p a r e n t l y do not prefer the EMS assignment.
Written [ ] With Continuing Education [ ] Without Continuing Education o~ Skills c-
& 5
CONCLUSION The m e t h o d o l o g y used a p p e a r s to be a reasonable approach to t r a i n ing evaluation. One problem m a y be a potential difference in performance b e t w e e n actual p a t i e n t work and the classroom setting in which this project was conducted. The a d v a n t a g e s in cost, t i m e , a n d p e r s o n n e l , how-
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N=219 N=231
N=219 N=231
F i g . 8. Percentage change in didactic knowledge and skill proficiency stratified
by participation in a continuing education program. ( ± SE) ever, c o m p e n s a t e for t h i s p o t e n t i a l discrepancy. Because of these advantages, proposed changes in a train-
Ann
Emerg Med
i n g / r e t r a i n i n g p r o g r a m m i g h t easily be p i l o t t e s t e d in a s e l e c t s a m p l e p r i o r to a m a j o r c o m m i t m e n t . The
9:4 (April) 1980
5. Pozen MW, F r i e d DD, V o i g h t GG: Studies of a m b u l a n c e p a t i e n t s with. ischemic h e a r t disease. Am J Public Health 67:532-535, 1977.
Written 0 -I-
:~
6. Czaja SJ, Drury CG: A l=egional evaluation of EMT training. Emergency Medical Services 7:77-121, 1978.
Z
-10
-20
7. McAllister P, S h u m a n LJ, Wolfe H: Computer evaluation of paramedic training programs. Emergency Medical Services 7:39-97, 1978.
Skills
o-30
8. J a r m o n RG, Yesalis CE: Provider performance in the recognition and treatm e n t of telemetered e l e c t r o c a r d i o g r a m patterns. JACEP 5:971-974, 1976.
~ -40
9. Frey CF, Huelke DF, Gikas PW: Resuscitation and survival in motor vehicle accidents. J Trauma 9:292-310, 1969.
o -50
Ambu- Non Not lance ambu- Related N =321 lance N=69 N = 65
Ambulance N =321
NonNot ambu- Related lance N =69 N = 65
Fig. 9. Percentage change in didactic knowledge and skill proficiency stratified by type of work. (+- SE) relative b e n e f i t s a n d cost e f f i c i e n c y of these e x p e r i m e n t a l c h a n g e s c o u l d then be c o m p a r e d a n d t h e m o s t desirable chosen. The design of a training/retraining program must comprise a n o p t i m a l c o m b i n a t i o n of training, cost/benefit returns, and cost efficiency. The authors t h a n k the staff of the EMS Division for their support and assistance with this evaluation. Special t h a n k s go to Charles King and James Shufield. The cooperation of the Leo N. Levi National Arthritis Hospital in the completion of this report is also appreciated.
9:4 (April) 1980
REFERENCES 1. S a d l e r AM, S a d l e r BL, Webb SB:
Emergency Medical Care: The Neglected Public Service. C a m b r i d g e , M a s s a c h u setts, Balinger Publishing Co, 1977. 2. Jelenko C, Frey CF: Emergency Medical Services: An Overview. Bowie, Maryland, Robert J. Brady Co, 1976. 3. G r a n t H, Murray R: Emergency Care. Bowie, Maryland, Robert J. Brady Co, 1975. 4. Frazier WH, C a n n o n JF: Emergency medical technicians performance evaluation. NCHSR Research Report Series. Dep a r t m e n t of Health, Education, and Welfare. PHS #78-3211, 1978.
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Emerg Med
10. Baker SP: Evaluation of medical care of t h e i n j u r e d . J Trauma 11:892-894, 1971. 11. Waters JM, Wells CH: The effects of modern emergency medical care systems in reducing automobile crash deaths. J Trauma 13:645-647, 1973. 12. Waller JA: Urban-oriented methods: f a i l u r e to solve r u r a l e m e r g e n c y care problems. JAMA" 226:1441-1446, 1973. 13. Willemain TR: The status of perform a n c e measures for emergency medical services. JACEP 4:143-151, 1975. 14. McManus WF, D a v i n JL: Can t h e well t r a i n e d E M T - p a r a m e d i c m a i n t a i n skills and knowledge? JACEP 5:984-986, 1976. 15. Skelton MB, McSwain NE: A study of cognitive and technical skill deterioration a m o n g t r a i n e d p a r a m e d i c s . JACEP 6:436-438, 1977. 16. Abercrombie TT, Truelove JW: A proficiency examination for emergency medical technicians. University of Alabama in Birmingham, 1974.
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