Friday, November 14, 2014

Crew Configuration: Feet, Urine and the Value of "Been There"

A staple in all of my airway lectures is "every game in critical care transport (CCT) is an Away game", simply meaning that people seldom bring patients to you at your base. No, you have to go get them in your vehicle of choice, do things to them and then do the job they called you for in the first place, which is to cart them off to somewhere else so other folks can do things to them. Doing this in either in someone else's place (hospital or ambulance) or a small, mobile environment brings with it a constantly elevated level of stress that comes from the fact that you can only control that environment so much. Sure, once you're in the ambulance or aircraft, that place is yours, but even that place is small and cramped and  in motion and only contains the supplies you brought with you. A hospital, by contrast, practically has oxygen and IV fluid flowing from the walls; making even someone else's hospital room a tiny bit better than your own magic flying chair. 

Stress.

Three things are crucial for mitigating this kind of inherent stress that cannot be eliminated: Good training, good experience, and most of all, a good team. 




Although the original air medical service was strictly a mode of transport, using a pilot to carry unattended patient in the back or even outside the aircraft,  the use of highly skilled teams evolved rather quickly in 1960’s and 70’s. Like the early EMS ambulances, these teams often included physicians and, in many parts of the world still do.  As time passed and the services grew, physicians in the US were largely replaced by specially trained transport clinicians, mostly nurses. Later still, these teams evolved into more diverse teams comprising paramedics, respiratory therapists and other clinical specialists on an ad hoc basis. The subject of just who is a part of this team is addressed in most CCT textbooks and courses as a matter of information about the prevalence of particular team compositions, but most of these do not include a discussion about which team is best for patient outcomes.  The Commission on Accreditation of Medical Transport System includes a requirement that a critical care transport team must “consist of a specially trained physician or a registered nurse as the primary care provider”(1), but says that team may be completed by any of a list of credentialed medical providers as long as there are two people on each transport.  

A team.

So, that leaves the question: Which crew configuration is best for air medical transport? Spoiler alert: I’m not going to answer that. As a matter of fact, I’m not even going to ask it. The honest truth is that there is very little evidence to suggest one blend of credentials is better than another for patient outcomes, leaving it largely to opinion, hearsay and conjecture. But, as far as facts go, the 2000 Medical Crew Survey by William Rau (2) finds that 71% of air medical crews that use at least a two person team consist of an RN and a paramedic. The findings of my own survey are very close to that (68%) and this number has hovered around 70% for the past 20 years. The stated purpose of this blended crew configuration is summed up well in this passage from a critical care transport textbook:


                “…the most common configuration is flight nurse/paramedic, a synergistic combination that provides a great amount of experience and diversified training in the medical crew. The flight nurse is well experienced in the critical care environment, whereas the flight paramedic is well adapted to airway management and emergency scene management. Both providers are proficient in dealing with the comorbid or multitrauma patient.”(3)

On the surface, this makes perfect sense. Find people who are experienced with critical care and people who are experienced with technical skills and transport and put them together transporting critical care patients who often need the benefit of technical skills. And, in case you missed it, make sure they are well trained and experienced. I used to work with a very experienced ICU nurse who could usually divine the patient’s problem by examining their feet and their urine. It’s pretty hard to teach that sort of thing in school. Rather, you have to see lots of feet and lots of pee before you start putting that together on your own.

So, what is borne out, at least anecdotally, is that training and experience matter the most. I’ve always thought one of the greatest things about transport is that we don’t hire new grads, no matter what the license. We appreciate that the autonomy of our position requires critical thinking and exposure that is not available in the classroom. A joint position paper by the Emergency Nurse’s Association (ENA) and Air and Surface Transport Nurse’s Association (ASTNA), as well as a position paper from the International Association of Flight and Critical Care Paramedics (IAFCCP, formerly IAFP), both state the importance of specialized training and copious experience in the respective areas of expertise of nurses and paramedics prior to entering transport (4,5). A cursory examination of CCT job posting on flightweb.com (6) reveals that most employers seek a minimum of 3-5 years of experience working under their credential to qualify for an interview, regardless of what that credential is. What is more prevalent, and interesting to me, is this line right here:

Almost every employer in the market for a new flight nurse or paramedic doesn’t want a new one at all. Rather, they want someone who has done the job before, and there is no question why. Of course, to be experienced flight nurses and paramedics, those same people had to be new at one time, but given the choice, employers usually prefer seasoned transport vets over rookies. So, it is implied that the job of a flight nurse or paramedic is a different job than either of those things in their native environment (a hospital or 911 EMS) and as such, an experienced flight nurse (or paramedic or RCP, etc) will know how to do the job of transport, not just the original job for which they were educated. As the book states, paramedics may be hired for their expertise with airway skills, but speaking for my program, the transport nurses intubate also and have to maintain the same competency. The same can be said for blood administration, vasopressors and central line monitoring. These things are part of almost no job description for a 911 EMS paramedic that we hire, yet they are things our paramedics are expected to learn and become proficient. All of these skills are covered on both the Flight/Transport Nursing and Flight/Transport Paramedic exams (7,8), lending more credence to the notion that transport is its own brand of healthcare and requires its own brand of healthcare provider.

This brings me to the question I am going to ask: Is there a magic number of years or transports that bestows upon a nurse the technical skills or a paramedic the theory that they move forward from his own license to something more inclusive, like “Transport Practitioner”? In other words, how much experience does a Flight __________ need before s/he knows the job so well that it doesn’t matter who their partner is? 


I have no idea, so I asked you, my readers, a few questions about the crew configurations where you work, how you feel about them, and how comfortable you feel about your teammates.


The Survey


The survey contained 18 questions that required answers as well as on optional comment box at the end. The questions and available answers were:
CLICK TO ENLARGE


The purpose of the questions was to make people think, maybe for the first time, about how their team dynamic really functions. I purposely avoided questions about equal pay or equal scopes of practice because I didn’t want it to seem adversarial. A few respondents found ways to be adversarial anyway, and I think that’s to be expected. Mostly though, the results were civil and positive and went a short distance to restoring faith in humanity.

The Results: I’m not going to list results for every question because, quite frankly, the overall results weren’t that surprising. Here are the highlights:

351 people responded in total, broken down below by credential, transport experience and total medical experience
















The most promising thing I took from the demographics was that no one reported less than three years of total medical experience, and 98% reported at least five years.  This says to me that we’re doing a passable job of keeping really new people out of transport. However, I’d wager that this same survey taken ten years ago would have had very few respondents with less than ten years of medical experience, if any at all. As flight and CCT services grow to add more resources, some employers have gotten a little less selective about the background and experience they demand of their applicants. 

Mission profiles, service types and crew configurations:
 


Again, no real surprises here, at least not to me. Most respondents do more interfacility transports than scenes, they do most of them by helicopter, and they do them as part of an RN/paramedic team.  Under services, only 12 people answered that their service provides all four modes of transport, while the most common combination was ground + rotor + 911 (81). Even so, there were more people who answered they did rotor only (95) than any of those combinations. This could reflect growth in corporate air medicine which is typically single mode.

The crew configuration data followed the reported averages for the past 20+ years when it comes to the RN/Paramedic team reported at about 69%. No other team makeup even came close. There were a fair number of “Other” responses to this question which included assorted military configurations and civilian variations that involved more than two crew members or a pool system that included multiple disciplines that were assigned per flight based on need.


Most survey respondents were involved in direct patient care and did transport as their full time job.  

The rest of the survey dealt with the opinions that transport professionals have of themselves and their teammates regarding clinical competency. One of the first things I found when sifting this data, and honestly when writing the questions in the first place, was how difficult it is to ask these questions at all. The idea is simple; find out if CCT providers believe in the value of blended crews, and to find out if they personally benefit from the expertise of a differently licensed teammate. However, finding a way to ask those questions without sounding like any team member was any less valuable than any other proved to be a little more difficult. So I asked them through a series of smaller questions. 

“Do you believe that the team members at your current/most recent transport program with similar experience are similarly capable, regardless of credential?”

The overall answer to this was yes, to the tune of 83% of all respondents. Most of us believe that our peers are just as good as we are. If we limit the responses to those who actually work in RN/Paramedic, that figure goes up to 88%. Nurses, paramedics and nurse/paramedic professionals all agree with this statement by at least 85%. The majority of people in non-blended crews believe their teammates are as good as they are, which is not surprising at all since they all have the same license. 

“Do you believe that you are similarly capable to the team members at your current/most recent transport program, regardless of credential?”

This answer, too, was yes at 93%. When controlled for people who work in blended crews, 95% believe they are as smart as their teammates. The individual credentials (RN, Medic and RN/Medic) also believe this to be true in very high numbers, over 94%. In CCT this is perfectly understandable; a bunch of Type A personalities who absolutely believe they are at least as smart as the people they work with, and maybe a little smarter.

 “Do you believe that the members of your team with the same credential could safely and effectively complete any transport (excluding specialty care)? (Example: Two paramedics could complete a transport without a nurse, and vice versa)

What is interesting about this is, in spite of the overwhelming belief in the first two questions that everyone is as smart as everyone else, only 68% of the total respondents agree with the above question. This gives much weight to the idea that blended teams really do matter to the team members themselves. If we control for only people working on blended crews, the number remains static at 68%. Broken down by the credential of the respondent in a blended crew, 87% of paramedics believe that either they or their nurse partner could complete transports with another provider with the same license, while 57% of nurse/medics think that. Only 48% of the nurses who report working in a blended crew agreed with the idea of their paramedic partners transporting a patient with another paramedic instead of a nurse, or two nurses transporting together. Since the majority of people reported that interfacility transports were the bulk of their mission profile, then it is reasonable to think that nurses believe that a nurse should be on that type of transport, regardless of how experienced a paramedic or other team member may be. When compared to the next question, this result makes even more sense.

“The stated purpose for a blended crew configuration for non-physician transport teams (RN/Paramedic, RN/Resp, etc) is to bring different skill sets and knowledge bases to the transport team. How strongly do you agree with that statement?”

Nearly everyone who responded agrees with the statement above, with the greatest number (94%) among those who work on a blended team. Even ten out of the 12 nurses who reported working in a homogeneous (RN/RN) configuration agree that a blended team is a good idea. I can surmise from this that we as an industry truly believe in the value of bringing different skill sets to the business of transport.

“Do you believe that experienced team members benefit from the blended crew configuration? Do you believe that new team members benefit from the blended crew configuration?”

Clearly, those who believe in blended teams believe in them for everyone on every trip. A few more people thought that new people would benefit than thought experienced do, but not by much. Some of the comments recommend that nurses new to transport might benefit from orienting with a paramedic, and vice versa. Mostly, the comments were nearly direct quotes and paraphrases of the book passage cited earlier about nursing bringing critical care hospital skills to the team and paramedics being experts in scenes and airways.

 “How many years of transport experience should a team member have before they can effectively transport any kind of patient with any other team member, regardless of credential? (Excluding specialty care)”

This question was meant to determine when people thought you might go from being a “Flight_______ (nurse, paramedic, etc)” to being a “Transport Practitioner”, and the most common answer was 3-5 years. However, this question is better summed up in the comments, and these two said it best to me: 

“After 5 years, you can either do the job or you can't. It's different from ICU or EMS; it's transport medicine.” And,

“This shouldn't happen.”

“As as a transport clinician, how much responsibility do you take/should your employer take for acquiring the knowledge and skills usually attributed to your teammates with other credentials? (Example: As a paramedic, how much responsibility do you take for learning things typically perceived to be part of nursing expertise such as blood administration, advanced medication infusions, intra aortic balloon pumps, etc?)( Example: As a nurse who has never intubated before, how much responsibility should your employer assume to teach you that skill?)”

These questions are combined for simplicity since they have peripheral bearing on the subject at hand. Basically, I’m asking who should drive cross training of skills in a blended crew environment. Not surprisingly, most CCT providers take ownership and most of the responsibility for their own education and training (81%). Only two people felt they had no responsibility and I openly found myself hoping to never be paired up with either of them. 67% of people believe their employer has most of that responsibility. Many people answered both they and their employer had full responsibility, making me believe those people either do or wish to work in vigorously collaborative work environments. 

“Do you believe your leadership encourages and empowers the team at your current/most recent transport program to learn beyond their scope of practice?”

This question gets to the heart of cross training and learning beyond the reason and license for which you were hired. 84.1% of respondents believe their employers stand behind, encourage and provide the tools to learn at their job. A few comments revealed disappointment that this isn’t so, but most were positive.

Open Comments: (I offer a few with no comments of my own, and these in no way reflect my opinion)

“I'm not a proponent of our RN/Medic model. While we have good medics, the overwhelming majority take no time or responsibility to learn outside their so-called "street medicine". I'd rather have RN/RN crews with a strong background in ICU and a bit of ER. In my opinion, this is much more useful in our program, where interfacility ICU patients are far more challenging to manage than a typical scene, STEMI or trauma. Medics were brought in to appease the state board of EMS and provide a less-expensive option.”

“Flight medicine is neither nursing, nor paramedicine. We all learn from each other, and learn skills/techniques/knowledge beyond our traditional nursing or paramedicine roles.”

“I like how our team is configured. Paramedic/RN, but I don't care for the insinuation that paramedics could not do this job without and RN....frankly, I feel that paramedics bring the most relevant experience to the job. If you can't take care of the airway, none of the other "stuff" matters. Most "nursing" skills can be taught to paramedics in a week, the same is not true for teaching RN's paramedic skills. As a woman in this industry (HEMS) I hate the stereotype that I am the nurse and my male partner is the paramedic. My employer is good at providing education, I just think we should get more, and be at the leading edge of the HEMS industry.”

“Physicians should form part of the operational crew. Their depth of medical knowledge and leadership is grossly under-valued and denying them operational opportunities is NOT in the patient’s best interest. Learn from London HEMS in UK - world leaders in this field.”

“Any 24 year old with 6 months experience who's successfully challenged the FP-C can work here”

“Teamwork is encouraged, but not always practiced.”

“I believe it is harder for the medic to obtain CC nurse skills than it is for the nurse to obtain the medic skills. Nurses live in the CC world in ER and ICU 40+ hours a week with constant patient loads whereas there is alot of down time in EMS and usually not much critical care (CC)”

Discussion
I begin the discussion with these two comments from the survey:

“When a Paramedic or RN has done the job 5-10 years. There is no reason why the crew can't be RN/RN or Paramedic/Paramedic. You should know the job by this time.”

“Question 15 is a poorly written question - it assumes that I can take on the role of my colleague through experience only gained in the transport environment - a nurse will not gain expert proficiency at managing ground scene calls as a first responder if they only do a few such calls a year - similarly a medic will not gain proficient 'independent' ICU level care when they only care for a small number of complex cases every year - you become an expert at what you so every day - and it is a unique service that provides the call volume, acuity, and oversight to provide a foundation to ones partners specialty – thx”

The first comment gets to the heart of what I wanted to say, and what I wanted to know from others. Does someone who does transport for a length of time move away from their exclusive license and move toward being a transport clinician, just like the folks around them? And if that’s true, how long does that take? One year? Five years? Ten? I just don’t know. This commenter put that into better words and even gave a time line, though I’m not sure I agree with that.

The second comment pretty well opposes the first, holding that paramedics are scene experts and RN’s are ICU experts and that’s how it’s always going to be. I don’t think I believe that either. I work with quite a few 20+ year nurses who have been doing transport for at least 15 years, and I have never once looked at any of them and thought “Man, I’m sure glad she worked in an ICU in 1991”. Rather, I've thought many, many times “Wow, I’m really glad she’s done 5000 transports and she’s with me today” 

By assuming that my transport competence comes from my scene management experience, you’re giving me credit for something I haven’t done in almost 14 years instead of recognizing that I am a transport practitioner, who knows flight medicine and does it really well, regardless of the card in my pocket. Medicine is constantly changing regardless of where you practice it, but we learn to manage those changes where you are, not where you were. True, I know how to work on a scene, but the most important lessons about scenes are the lessons I learned in elementary school: Don’t play in traffic, don’t put your fingers where they don’t belong, and don’t pick a fight with someone bigger than you. The pearls of an ICU are a lot more complex and come later in life, but they are just as teachable to someone willing to learn.

Willing to learn…that’s the other side of this. A big majority of those people surveyed said they take full responsibility for their education, and almost as many said their employer shares the responsibility and empowers them to get the education. That’s huge, because transport medicine is hard. In short, take all those skills you were hired for, double them, then apply them while wearing a blanket and sitting in a metal shoe box. And oh yeah, be quick about it. So, if you want to do it, it’s work. And a lot of that work has nothing to do with the license and skills for which you were originally educated and hired. It takes drive and passion to learn the rest, and people without those two things will most likely fail.

However, if you do the work and put in your time, you get to part of a brotherhood and sisterhood of exceptional professionals, and I believe that with that membership comes the identification of something greater than and beyond your license. You might have been hired because you were a nurse, but you continue and succeed because you became a transport nurse, and there is every reason to believe that you are capable to do any (non-specialty) transport with any partner, because transport is what you do. The same goes for paramedics, or RCP’s, or physicians, or whomever I missed.

What’s the best crew configuration for patients? An experienced one.

Thanks again for reading. Feel free to comment here or on Twitter @Crit_Care_Excel, and visit the website, www.critical-care-excellence.pro.

References
1. Commission on Accreditation of Medical Transport System. Accreditation Standards. 9th Edition. October 2012. Available at: http://www.camts.org/Approved_Stds_9th_Edition_for_website_2-13. Accessed November 13, 2014.
2. Rau W. 2000 Medical Crew Survey. Air Medical Journal. 2000; 6: 11-13
3. American Academy of Orthopaedic Surgeons, American College of Emergency Physicians; lead editors, Michael Murphy. [et al.]. Critical Care Transport. Jones & Bartlett Learning; 2009.
4. Air and Surface Transport Nurses Association. Staffing of critical care transport services. 2010. Available at: http://www.astna.org/PDF/ASTNA-Staffing-PositionPaper-7-9-8. Accessed November 13, 2014.
5. International Association of Flight and Critical Care Paramedics. Critical Care Paramedic Position Statement. July 2009. Available at: http://c.ymcdn.com/sites/www.iafccp.org/resource/resmgr/docs/critical_care_paramedic_posi. Accessed November 13, 2014.
6. FlightWeb Jobs Center. Available at: http://www.flightweb.com/jobs/. Accessed November 13, 2014.
7. Board for Critical Care Transport Paramedic Certification. Candidate Handbook. August 2013. Available at: http://www.bcctpc.org/FPC/documents/BCCTPChandbook. Accessed November 13, 2014
8. Board of Certification for Emergency Nursing. CFRN Content Outline. Available at: http://www.bcencertifications.org/Get-Certified/CFRN/Study/CFRN-Content-Outline.aspx. Accessed November 13, 2014.

1 comment:

  1. Very interesting post. Just in my field of interest as PhD Cand. on the subject Medical Crew and Patient Safety in HEMS.

    ReplyDelete