CALS

CALS

Comprehensive Advanced

Life Support Program

A Team Approach to Rural

Emergency Care

CALS

Delivery of Rural Emergency Care

• Emergency/Critical Care in Urban settings – subspecialty trained personnel with latest equipment.

• Life or Death in rural communities depends on a small team of providers.

• Customary medical training does not prepare providers for the demands of rural practice.

• Advanced life support courses – fall short• Medical-legal expectations• Rural - lack of state-of-the-art equipment• Rural - lack backup staff

CALS

Agenda for the Future - Rural Public Access

• “The further one is from a large emergency medical facility – the more one needs a high level of local emergency capacity and the less likely it is that the emergency capability will be available”.

CALS

Rural Emergency Paradox

• On a clinical bases, a rural emergency medical paradox results because Advanced Life Support (ALS) Services are difficult to establish and maintain in systems that experience insufficient volume to enable advanced providers to be paid and to retain their skills.

CALS

Rural Emergency Care Suffers due to:

• Lack of ongoing education in advanced emergency care.

• Limited availability of appropriate RURAL ALS training.

• Lack of sufficient volume for providers to retain emergency knowledge and skills.

CALS

Rural Emergency Care Suffersdue to (cont):

• The high cost of ALS training – multiple ALS Courses.

• Inadequate patient volume to pay for emergency training based on a fee-for-service revenue system.

• Lack of appropriate equipment.

CALS

Results in Rural Communities

• Disparity between rural and urban – especially evident in trauma care

• Difficulty of recruiting medical personnel to rural communities

• Increased provider burnout• Mounting medical-legal risks

CALS

The Need

• Provide better patient care

• Solve the feelings of being inadequate

• Address medical-legal concerns

• Help with professional burn-out

CALS

What is CALS?

• Educational program or educational experience in ALS including trauma, OB, cardiac, airway management, pediatrics, etc.

• Developed for the whole emergency TEAM including nurses, midlevel providers, physicians and other paramedical personnel.

CALS

Primary Focus of CALS

• Train medical personnel in a team approach.

• Training targeted for health care professionals who provide emergency and critical care.

• Specifically designed for rural providers who must treat a broad range of medical/traumatic emergencies.

CALS

CALS Mission Statement

“The primary mission of CALS is to improve patient care by enhancing the provider’s established scope of practice through advanced education”.

CALS

CALS Vision

We envision that the quality of emergency and critical care provided in rural communities by primary care provider teams can be enhanced by the use of the resuscitation triangle consisting of:

* A systematic approach * Mastery of skills and knowledge * Utilization of essential equipment.

CALS

CALS Value Statements

• We demonstrate our commitment to improving rural medical care by providing quality education especially designed to meet the needs of Rural Health Care Providers.

• We strive to provide information that is State-of-the-art and Evidence Based.

CALS

CALS Values Statements (cont)

• We believe each member of the health care team provides a value regardless of professional status and thus we emphasize the Team Approach to patient care.

CALS

Educational Components of the CALS Program

• Home study – CALS Manual and study-focusing question guide.

• Two-day CALS Provider Course – consisting of airway, cardiac, trauma, pediatric, obstetrical, neonatal, environmental, and medical advanced life support training.

• One-day CALS Benchmark Lab – covering about 50 skills useful for stabilization of critically ill or injured patients.

CALS

CALS Educational Materials• CALS Provider Manual• 2-day CALS Scenario-based Classroom Course• Benchmark Lab Manual• 1-day Benchmark Skills Lab Training Course• CALS Instructor Manual• CALS Instructor Course• CALS Emergency Procedures CD• CALS RSI Card• CALS Rescue Airway Card• CALS Equipment List

CALS

CALS Provider Manual

CALS

CALS Provider Manual

• 3 volume - loose leaf manual *Vol 1 – “The First 30 Minutes” *Vol 2 – “Emergency Skills” *Vol 3 – “Diagnostic and Treatment Portals”• Study guide – 100 questions to help focus pre-

course studying• Pre-course questionnaire – help focus training to

the needs of the providers• Pre-test - CME

CALS

CALS 2–Day Interactive Provider Course

• Brought to the rural communities.

• Taught to teams of rural providers.

• 20 to 30 providers per course.

• Interactive scenario based.

• Conducted in the rural settings in the local hospital.

CALS

Components of the CALS Provider Course

• Didactic group sessions (interactive -- Not Lectures!)

• Small group demonstrations and hands-on practice of skills

• Case-based learning• Emphasis on a team approach• Practice a Universal Approach to Emergency Care• Opportunity for dialogue between different

disciplines and practice settings• Emphasize transfer of learning

CALS

Airway Management: Rapid Sequence Intubation

CALS

The CALS Benchmark Lab

• Intense hands-on instruction in 50 critical &/or life saving emergency procedures.

• Full eight hour day of skills training.

• Taught in teams consisting of 4 providers.

CALS

CALS Instructor Course

• Teach “transfer of learning” theory

• Review essential components of CALS training

* Universal Approach to patient care

* Team Work

* Difficult Airway management

• Practice scenario-based interactive teaching

CALS

CALS Benchmark Emergency Skills CD

• Reviews the life saving skills taught in the Lab

• Includes the many difficult airway techniques, chest tube insertion, newborn procedures, etc.

CALS

CALS Airway Cart

CALS

Essential Aspects Unique to CALS

• Team development• CALS universal approach to ALS• Approach to the difficult airway• Rapid Sequence Intubation (RSI)• Advanced airway skills• Additional topics not covered in current ALS

courses• Instruction in the proper emergency equipment for

rural hospitals

CALS

Developmental Goals of CALS

• To be the most comprehensive ALS Course

• Cover all of the ALS needs of rural providers

• Cover the essentials of all of the other ALS courses

• Maximize the emergency skills of the rural providers (especially in airway management)

• Improve the quality of emergency care in rural communities

• Improve the outcomes of emergency care in rural areas

• Help rural hospitals be correctly equipped to handle emergencies

CALS

Most Valuable Parts of the CALS Provider Course

• Based on evaluations provided by 377 CALS Provider Course participants (2002-03)

* RSI Training

* Teamwork training

* Scenario-based interactive learning

* 12-lead ECG interpretation

CALS

Most Valuable Parts of the CALS Benchmark Lab

• Based on evaluations provided by 137 CALS Skills Lab participants (2002)

* Hands-on learning

* The learning of advanced and surgical airway management skills

* The learning of chest tube insertion skill

CALS

CALS Courses through December 2005

• First course – September of 1996• 112 courses held throughout state of MN• 2500+ participants (33% physicians, 53% nurses,

6% PA/NP, 3% allied health, 5% EMPT)• Includes the Medical Personnel that work in the

US Embassies throughout the world (US Department of State)

CALS

CALS training for State Dept. Personnel

• Trained 258 providers who staff the US Embassies throughout the world.

• Many are in very remote areas with limited resources available.

• One week CALS course in Minnesota.

CALS

Embassy Personnel Training (cont)

• “Thanks again for the wonderful course. It’s unanimous that this was among the best we have ever had.” Larry Brown MD, Medical Director – Department of State and Foreign Service.

• “CALS was the best CME I’ve ever attended (and I used to be an ACLS and ATLS instructor) and we are still raving about it.” Tom – Singapore

• “I can honestly say that I will not panic if there is a major problem at my Embassy. I could not say that a week ago.”

CALS

Obtaining Acceptance of CALS in Minnesota

• Built the case for the need for CALS type of training among the Trauma Centers, University of MN Med School, NICU, Cardiac Care Centers, etc.

• Sought and received support from the leaders of the MN ACLS and ATLS Programs.

• The observed change in rural emergency/critical care after CALS Training - spoke for itself to the urban referral centers.

CALS

Financial Support for CALS Development

• Initial development largely pro bono• Early seed money from MAFP, MN ACEP,

University of MN Dept of FP.• Lab developed by Dr Ruiz, Emergency Physician

at U of MN and HCMC Trauma Center.• Support from EMS Regulatory Board, MN

ORHPC, MAFP, MN ACEP, Trauma hospital leaders – led to state legislative funding to help off-set cost of conducting the courses and labs.

CALS

Financial Support (cont)

• MN state legislative support – grant money administered through the EMS Regulatory Board:

* Off-sets part of cost of the lab and provider course.

* Assists in the development and editing of the CALS Provider Manual.

* Helps with CALS Office expenses. * Helps with CALS Instructor training. * Helped develop the CALS Benchmark Lab CD.

CALS

Financial Support (cont)

• Support from the MN ORHPC – flex grants: * Financed much of the development of the

CALS Benchmark Lab CD. * Helped CAH providers attend CALS courses

and labs. * Financed some emergency equipment for

CAHs. * Conducted Site-Study on the value of CALS

training in a CAH.

CALS

Future Distribution of CALS

• The need for CALS type of training is universal in rural communities.

• Up until now CALS Training has only been in Minnesota.

• We believe that we have a responsibility to share the CALS Program with other states if there is interest in the CALS training.

CALS

Conclusion about Rural Emergency Care Training

• It is possible to create a Rural Emergency Team.• It is possible to prepare for the unknown.• A Rural Health Care Team can stabilize most

medical/trauma emergencies.• Rural Health Care Teams can practice state-of-the-

art emergency care with the use of basic emergency equipment, the mastery of needed skills and working in an organized fashion as a team.

CALS

Conclusions about the CALS Program

• CALS training is helping to make some order out of the chaos and nightmares of rural emergency care

• CALS is positively impacting the rural emergency care in Minnesota

• CALS MD “Physicians in Minnesota consider CALS the gold standard for rural emergency medical care”

CALS

To contact CALS

www.calsprogram.org

Kari Lappe, RN, CALS Program Manager

kdlappe@umn.edu

612-624-5901