Administration and Leadership, Columns, Training

Staying Proficient in Clinical Decision-making and Skills

Issue 6 and Volume 40.

Following initial credentialing, most EMS providers meet institutional requirements for maintaining their status simply by ticking the boxes off their National Registry and state requirements for continuing education. This isn’t the way other clinicians maintain their credentials. As we advance to paramedic practitioners, we must mirror the standards others have set to prove we’re continuing to advance ourselves and maintain an appropriate skill and knowledge base.

Know the Terms

Before we discuss re-credentialing, I should clarify how “credentialing” is different from “licensure” or “certification.” Certification or licensure is a status given by a state that allows you the opportunity to seek employment suitable for that level. It doesn’t allow you to perform to your level of training within an EMS practice. The ability to treat patients and perform procedures on them is granted through credentialing by the medical director, who should have a system to evaluate providers from the time they begin their training or evaluation period within the organization.

This system is similar to the way we handle physicians in most states. Upon graduation from medical school, you can’t just go out and open a medical practice. You’re issued a training license to practice medicine under the supervision of a training program and supervising physician. The newly minted physicians are credentialed for training purposes–after one year and another board examination, they can apply for an independent license, which allows them to work inside or outside a training program.

Contrary to the name, the independent license doesn’t grant them the ability to work at a particular facility. Each healthcare facility has its own governing body that grants physicians “privileges” to practice there through the process of credentialing. For clinicians, however, credentialing at an institution lasts for one year at a time. The requirements vary from institution to institution, but there are commonalities between most.

Maintaining a credential starts with continuing medical education requirements and appropriate state and federal licenses. It applies to procedural skills as well. Each institution lists each procedure separately and the physician must document they obtained a specified number of real, cadaver, animal and/or simulated procedures to obtain initial credentialing out of residency training. Then, credentialing for each procedure must be requested along with documentation and attestation you’ve maintained procedural competency.

Maintenance of credentialing is also critical for paramedics to demonstrate they stay proficient in clinical knowledge and skills. It also serves as a measure of sustainability of paramedic workforce in a particular community. The best example of this is the skill of endotracheal intubation, which has been well studied in EMS. We know from published studies that paramedics need 30 human intubations in order to obtain initial proficiency of 90% for non-difficult airways. We also have evidence that intubation success may also be related to recent intubation experience. The reality, however, is that in many services, paramedics on average intubate 1–2 times per year.

The Medical Director’s Role

Medical directors must ensure their system is able to maintain skills of the paramedics under their direction. If these minimums aren’t met in the course of normal operations, there must be serious reassessment regarding the number of ALS providers in that system. At a minimum, there must be operating room access, simulation or cadaver labs to ensure the evidence-based minimums are met to maintain the paramedic’s credentialing to perform intubations.

In addition to these skill-based standards, there must be avenues to ensure paramedics are maintaining and improving their clinical education. To address this in our organization, we created a re-credentialing exam for our senior paramedics and EMS supervisors that focused not on the protocols but on clinical decision-making. We found that after initial testing, approximately 20% of our most senior paramedics were deficient in their clinical knowledge. We also found that there were some commonalities in knowledge deficiency across the group that needed to be addressed. As a result, we developed course work for the entire group, and the lower-performing medics were placed on an action plan designed to improve their clinical decision-making and performance on the next exam as well as establish techniques to help them perform their own self-directed improvement.

One of those methods is weekly identification of self-directed learning needs. Medics, during the course of their shift, identify areas of clinical medicine that aren’t clear to them. This can be as simple as looking up unfamiliar medications to reviewing the scientific literature associated with their protocols. Another excellent method implemented for improvement and maintenance of credentialing is patient follow-up. This task involves the medic calling a select number of patients each week to check on them and find out about their diagnosis and hospital course. This is critical, along with data from health information exchanges, to help the paramedic refine their diagnostic skills.

Maintenance of credentialing is a critical step forward for our EMS subspecialty. It’s essential that EMS physicians develop comprehensive programs to ensure the clinical knowledge and skills of their physician extenders continues to improve and their critical decision-making develops over time.