Download CALS - Central Minnesota Site Visit 2003

CALS
CENTRAL MINNESOTA SITE VISIT 2003
Purpose of Site Visit
In July 2003, three representatives from the
Minnesota Department of Health’s Office of
Rural Health and Primary Care and the program
manager of CALS (Comprehensive Advanced
Life Support) made an onsite visit to a Critical
Access Hospital to document the experiences of
hospital personnel regarding the CALS program.
The site visited facility has 24 licensed beds and
is located in central Minnesota. The primary
purpose of the visit was to obtain information
about any impacts CALS training has had in the
site visited facility on practice patterns and
training requirements and, to the extent possible,
health care outcomes. This site visit was part of
a more comprehensive, long term evaluation of
the CALS program.
Methods
Four separate group interviews were conducted.
Group I consisted of 2 physicians and 1
physician’s assistant; Group II consisted of 2
nurses and 1 physician’s assistant, and Group III
consisted of contracted ambulance personnel
assigned to the region (1 paramedic and 1
Emergency Medical Technician [EMT]).
Members of Groups I and II worked full- or
part-time in the hospital’s Emergency
Department (ED) and had received CALS
training; Group III members had not received
CALS training. The hospital’s administrator had
also not received CALS training and was
interviewed separately. In addition, two of the
nine participants are instructors in the CALS
program.
Site Visit Findings
While each group presented a unique
perspective on the impact of CALS, some
common themes emerged:
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CALS teaches a comprehensive,
realistic, team-based approach to
providing emergency medicine in rural
hospitals.
What is CALS?
CALS (Comprehensive Advanced Life
Support) is an educational course developed
by a multidisciplinary working group
supported by the Minnesota Academy of
Family Physicians. The primary focus is to
train medical personnel in a team approach
to anticipate, recognize, and treat lifethreatening emergencies. CALS is targeted
to physicians, physician assistants, nurse
practitioners, nurses, and allied health
professionals who work in an emergency
setting. It is specifically designed for rural
communities that must deal with a broad
range of medical emergencies. There are
three components to the CALS program: 1)
home study, 2) a provider course consisting
of cardiac, trauma, pediatric, obstetrical,
neonatal, and medical advanced life support,
and 3) a benchmark lab covering 50 skills
necessary for stabilization of critically ill
emergency patients.
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•
•
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The CALS lab increases the comfort
levels of rural emergency personnel by
exposing them to procedures rarely
encountered on the job.
CALS establishes a rural-based standard
for assessing the medical equipment
needs of small hospitals and clinics.
CALS teaches participants to anticipate
and prepare for a patient’s needs prior to
arrival, improving the speed and
efficiency of treatment, leading to better
patient outcomes.
CALS has improved the speed and
efficiency of transferring critical
patients to higher levels of care.
that, unlike larger urban settings (where
resources and staff are plentiful), smaller towns
have to make do with less, and CALS provides
the tools to accomplish that.
Theme #1: CALS provides a comprehensive,
realistic, team-based approach to handling
emergency medicine in rural hospitals.
For one physician, “CALS makes
everything come together. It’s the
difference between watching your 5-year
old child’s ballet recital and going to see
a Bolshoi ballet performance.”
In the hospital administrator’s judgment, many
hospital staff members seek the educational
opportunity to attend CALS training. He said,
“We don’t have to twist anyone’s arm. We have
a long list of people who want to attend. Staff
members see the benefit of having CALS
available.”
When asked to describe CALS to someone with
no knowledge of CALS, each group used the
terms comprehensive and team-based. The
physicians considered CALS the “gold standard
for rural emergency medical care.” Rather than
placing all responsibility on one lead health care
provider for a patient’s care and for direction of
emergency room staff, CALS places
responsibility on the entire team to be assembled
and prepared before patient arrival. According to
one nurse, “since the CALS training, doctors
have more confidence in the nurses; they’re
more comfortable that we’re trained. There’s a
sense of mutual respect for the job that everyone
does. CALS drives home that everyone in the
ED can be relied upon individually and
collectively for their knowledge and expertise.”
Theme #2: CALS Lab increases the comfort
levels of rural emergency personnel by
exposing them to procedures rarely
encountered on the job.
“We don’t have major traumas every
day. You may be working in Obstetrics
one day and the ED the next. I think
there’s a comfort level in knowing what
to do in a particular situation.” - Hospital
Administrator
CALS Lab augments CALS classroom training.
Although CALS Lab is optional, each group
member who had taken the CALS course had
also taken the CALS Lab. Everyone thought
that the CALS Lab provides a valuable
opportunity to learn and practice procedures.
While expected to perform emergency
procedures, group members agreed that the
CALS Lab increased their comfort level, given
the infrequent opportunity to perform many
procedures in rural hospitals.
In the CALS philosophy, every member of the
team is valued for his or her potential
contribution to achieve the best care possible.
One ED physician from Group I cited this
example: after a receptionist had observed a
certain procedure while recording during a
trauma case, in a similar situation occurring
later, she remembered their use of the procedure
in the earlier case and brought it to the team’s
attention. The other members of the ED team
appreciated her contribution. This openness in
team approach, fostered by CALS, can only
enhance patient care.
CALS Lab combines many components of the
Advanced Life Support (ALS) training courses
required of health care practioners, which is
especially attractive for family practice
physicians working in rural clinics. According
to one rural clinic physician, “I don’t have time
in a given year to stay current with other
courses. If I can take a 2-day CALS course with
a lab where I can perform procedures, I’m
getting a good review of all five ALS courses.”
One physician remarked that CALS Lab applies
the team approach, as nurses and others in the
same facility are being trained alongside
physicians. Physicians noted that procedures in
infant and pediatric patients not covered in detail
CALS was described as being realistic because it
provides a multi-optional approach to treating
the critically ill or injured patient in rural
settings where resources are often limited.
CALS instructs teams of physicians, physicians’
assistants/nurse practitioners, nurses and allied
health care providers to employ existing
alternative treatments when caring for patients.
This fosters a greater comfort level among ED
staff knowing multiple options are available for
stabilizing a patient. Participants expressed
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in ATLS training are included in the CALS Lab.
One physician summarized CALS Lab as
“ATLS lab on steroids.”
The ambulance personnel group (not trained in
CALS) was asked whether a separate CALS
module for EMTs and paramedics would be
useful. One paramedic thought a single course
combining all the elements of ALS training
would be useful, but only as a refresher course.
However, involving ambulance personnel with
the CALS training of the hospital personnel may
be impractical given the large turnover and
frequent rotation of EMTs and paramedics. An
EMT added that a separate CALS module
designed specifically for EMTs would be
beneficial to working with both ambulance and
ED personnel and that it may help align EMTs
with the medics in the field.
The practice of rural emergency medicine is
markedly different from urban emergency
medicine, sometimes placing rural physicians
and hospital administrators in the position of
having to decide on the necessity of purchasing
new technologies and equipment. According to
members of Group I, the CALS manual
eliminates the guesswork in equipment
acquisition. One physician stated, “CALS helps
me to champion for equipment when going
before the administration. CALS also provides
an objective standard for all rural hospitals to
follow, greatly reducing the decision-making
burden for administrators.” When questioned
about any equipment changes in the ER related
to CALS, the hospital’s administrator
commented, “We have environmental changes
in the new facility. Our medical director and
emergency room providers as well as staff
[were] involved in the design of the emergency
room services…the kinds of beds, oxygen, and
equipment. It would be my belief that those
were all related to their background and
education as well as their CALS approach.”
Theme #3: CALS provides a rural-based
standard for assessing the medical equipment
needs of small hospitals and clinics.
According to one physician, “Before
CALS, I wouldn’t have thought about
equipment needed in my clinic. No
alternative to CALS exists that teaches a
rural clinic physician about equipment.”
Theme #4: CALS teaches everyone to
anticipate and prepare for a patient’s needs
prior to arrival, improving the speed and
efficiency of treatment, leading to better
patient outcomes.
The importance of knowing what equipment to
have and where to find it was viewed as one of
the most important features of CALS. Both
Groups I and II (physicians, physician assistants,
and nurses) thought that possessing the right
equipment to treat and stabilize patients rapidly
was directly attributable to having received
CALS training. Airway boards, trauma carts,
and Rapid Sequence Intubation (RSI) cards were
frequently mentioned in both groups as items
that had greatly changed their practice of
emergency medicine. Both Groups I and II
thought that CALS had given them a standard
for setting up and organizing the ED’s
equipment. Other comments included:
•
•
“As a nurse, when traveling to work at
other hospital facilities, I always ask to
see their airway board.”
Remarking about the improvement in the
way the emergency department
functions since the CALS training, one
nurse explained, “the equipment is set
up and ready to go, and we know where
to find equipment (e.g., the chest-tube is
ready as soon as the patient enters the
ED). Before CALS, this wasn’t the case.
We were often harried, running to obtain
equipment.”
“Trauma carts pull the necessary tools
together within visible reach.”
“The RSI card allows everyone to
observe appropriate drug dosages
simultaneously.”
CALS definitively changed the way emergency
department staff work together to address the
needs of trauma and critically ill patients. Rather
than a wait-and-see-approach to care, emergency
staff now have a structure to follow for treating
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clinical situations on our own. The philosophy is
to increase our ability to rapidly stabilize
patients, rapidly determine their conditions, and
rapidly transfer to appropriate care.”
patients before they arrive in the ED. Once an
ambulance report is received, the team
assembles itself, prepares IVs, puts trauma carts
in place, calculates drug doses based on the
anticipated patient’s weight, and has the lab and
x-ray departments ready to provide their
services. Describing CALS as a universal
method of providing emergency care, one
physician remarked, “There is no doubt in my
mind that CALS improves the care of my
patients. I’ve personally witnessed the lifesaving
benefits of the procedures taught in CALS.”
More information about CALS can be found at
the following website:
http://www.mafp.org/cals.asp
Theme #5: CALS has heightened the speed
and efficiency of transferring critical patients
to higher levels of care.
According to one physician, “Using the
skills obtained during the CALS course…
stabilizing a patient and moving to
appropriate levels of care takes only onequarter of the time and effort as
previous to the CALS training.”
Those with CALS training felt strongly that
CALS has positively affected the speed with
which they make decisions about transferring
patients to appropriate levels of care. Group
members agreed that, after having been trained
in CALS, stabilizing patients so they receive
appropriate care at the hospital and during
transport is faster and more efficient. A
comment illustrating an improvement in speed
of patient transfer came from the paramedic
from Group III who noticed a greater awareness
among ED staff in their ability to identify
patients in need of higher levels of care. Transfer
to appropriate care became faster and more
efficient. The hospital’s administrator observed,
“This is because we are better equipped to
transfer patients; our decision points are a little
more rapid, we make decisions on whatever we
need to do.”
While CALS provides alternatives to emergency
patient care with a rural focus, CALS also
provides guidance as to a rural hospital’s
limitations. According to one physician, “The
philosophy of CALS is not that we, as a rural
hospital, are going to be able to take care of all
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