Removing the Barriers That Prohibit Using Simulation in EMS

As EMS evolves, it’s becoming more complex. EMS professionals are being tasked with performing comprehensive physical assessments in addition to high-risk and low-yield procedures. Together we must be ready for these changes that will help us improve how we provide care. We can do that through simulation.

As EMS educators, simulation should be at the core of how we teach the fundamentals. Theories should be integrated into the educational methodologies we use, and as we attempt to perfect our care delivery practices, we should always consider how much value the educational methodology can have in changing behaviors.

All too often, we hear concerns that EMS systems have limited access to simulation technology. However, the 2015 SUPER study showed that access to simulation technology wasn’t the top hurdle for a system–it was the lack of knowledgeable educators and staff to support integrating simulation technology.1 While 91% of those responding to the study reported having simulation technology or having access to it, only 71% used the equipment. Although the population surveyed was limited to those programs accredited by the Commission of Accreditation of Allied Health Education Programs, it does paint a picture of the challenges we may face. How do we remove barriers that prevent the EMS community from accessing and using simulation methodology and technology?

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Common Barriers

Since there are always barriers in integrating simulation and increasing its utilization, the first step is identifying and removing those barriers. Both experience and the SUPER study have taught us that barriers are often systematically placed or personally driven. Combating these common barriers is what will result in immediate buy-in and systematic changes that improve healthcare across your community. Creating a safe learning environment, investing in simulation and collecting the data are the top three common barriers for EMS systems.

First, EMS educators must understand how to create a safe learning environment. Educational environments solely focused on critiquing a learner’s ability to manage simple and complex patients can drive a wedge between the learner and the learning experience.

A safe learning environment helps the learner feel like they’re part of the learning experience and that it’s relevant to their professional development.

Ever have an educator make you feel unwanted? Instead, have your learners be an active part of the discussion by focusing on how and why their approach may have been wrong. A safe learning environment helps the learner feel like they’re part of the learning experience and that it’s relevant to their professional development. It also allows them to understand why a task or concept was incorrect and helps them develop the new concepts in a controlled and hands-on learning environment.

Second, whether it’s low-fidelity or highfidelity simulation technology, it’s important to invest in training tools that will help learners understand the concepts and processes needed to successfully manage any type of patient. “Investing” could mean developing partnerships with organizations that have the needed technology or purchasing the technologies for the agency.

It’s also important to invest in the educators. Regardless of how your organization is structured, those tasked with providing training must be knowledgeable in the educational methodologies and simulation technology. Having a knowledgeable group of educators will not only improve the use of the technology, it will help others understand the importance of simulation and helps to improve outcomes across the organization.

Lastly, collect data to support the investment in simulation technology and demonstrate the value simulation has on improving patient outcomes and care delivery. Wake County EMS routinely collects information on call times, total number of EMS runs and even the number of intubations per year. Why not use existing data to drive the types of education delivered, and then collect data that demonstrates skill improvement after a simulation-based workshop? There are numerous data points that can strengthen the argument and the need for increasing investment in simulation technology.

This very same data can help any organization overcome investment, partnership and even learning barriers. The proof of the need is in the data you collect. Just like Wake County EMS has done, share that data with both your agency’s leadership and your care providers. It makes a difference when asking for ongoing support.

Preparing for New Guidelines & Protocols

Whether we’re preparing for the new 2015 American Heart Association (AHA) guidelines or adapting to protocol changes, it’s important as educators to provide our learners with the foundation and the science behind any new guideline or protocol. Be honest with your learners, explain why the guidelines changed and teach them about evidence-based research. Helping them understand how the science is changing will help them develop a care delivery plan when faced with enacting any new set of guidelines. Providing information about the science develops core concepts and allows providers to be a more informed clinician. After all, we’re all clinicians and we need to be trained in that manner.

As you begin to integrate simulation into education, begin by outlining what has changed. Provide a detailed review of the concepts you’ll be covering in the simulation experience and refer back to your previous discussion regarding how science has shaped the guideline and protocol changes. It’s important to refresh their memory on the topic. Consider it “just-in-time” training.

Real-Life Examples

Wake County EMS and WakeMed Health & Hospitals are separate organizations that have a strong partnership focused on improving healthcare in the community. By focusing on how care is delivered, they understand the gaps in the healthcare delivery model and focus on improving that model from the ground up. Both organizations believe in using simulation technology and embrace it as an important educational methodology in every program taught. This partnership between organizations is what has allowed simulation to be such an integral part of healthcare delivery across Wake County.

Wake County EMS

Simulation is essential to how Wake County EMS improves care delivery across the county. To ensure Wake County EMS is providing the very best care to their community, the organization changed the way they provided monthly continuing education to include a focus on simulation. Rather than offering education via a traditional lecture format each month, leaders decided to institute “mobile months.” During odd-numbered months, new topics, concepts and protocols are introduced. In even-numbered months leaders follow up with simulation-based education, which allows instructors to reinforce the topics and skills previously discussed and demonstrated.

For example, in June the simulation scenarios focused on different causes of hypotension and appropriate treatments. These included sepsis, anaphylaxis, and neurogenic and cardiogenic shock. The scenarios reinforced the previous month’s training, where recent changes to treatment protocols and the addition of norepinephrine to the formulary were introduced.

Data collected throughout the simulation training is reviewed with the findings reported to the Wake County EMS medical director and providers during the following month’s lecture session. As a result, any remaining questions or issues can be addressed before moving on to new topics.

In 2012, Wake County EMS began using simulation as part of the hiring process for all credential levels. In addition to the standard interview and general knowledge exam, simulation is used to evaluate how the candidate takes care of a patient. Wake County EMS also uses a standardized evaluation instrument based on national standard curricula to evaluate and grade candidates. Administrators are careful not to evaluate the candidates on the EMS system’s protocol or pharmacology regimen; instead they focus on how care is delivered, how candidates interact with the patient, the completeness of the assessment and the process by which the candidate uses to decide on a treatment protocol.

Simulation is at the core of how Wake County EMS provides education, because its leaders believe it’s equally as important to introduce new concepts during fundamental knowledge and skills training as it is to consider different types of methodologies for ongoing education. Therefore, simulation technology and methodology is also utilized during Wake County’s seven-week academy, which ensures new employees learn the “Wake County way” of treating patients. Two days every week are set aside for clinical time, ride time or simulation-based scenarios. Using simulation has created an environment where educators are able to reinforce new and old skills, and teach county-specific pharmacology and protocol knowledge. It’s also allowed Wake County EMS to introduce a variety of patient complaints to the new employees.

In the EMS academy, Wake County also requires new employees to complete a cardiac arrest workshop. This two-day workshop provides the core fundamentals of cardiac arrest management in an intensive didactic and practical session, which is followed by a high-stakes simulation experience.

Wake County EMS’ single greatest hurdle is helping providers understand the value of simulation. Some seasoned providers find it hard to bridge the gap of reality to simulation, while other providers–despite being advised this is just a learning opportunity–feel like they’re being evaluated and failure will lead to punishment from the medical director.

The lack of knowledgeable educators and staff to support integrating simulation technology is usually the top hurdle for an EMS system, but can be easily fixed.

WakeMed Health & Hospitals

For the healthcare system, simulation is used to teach simple and critical concepts. Utilizing high-fidelity simulation technology, individuals are exposed to care processes during multiple sessions throughout their employment–from exposing the challenges faced during an ST elevation myocardial infarction to the classic disaster medicine scenarios.

Healthcare systems should use simulation methodology and technology in all aspects of clinical medicine and education. There are always areas where simulation is used solely for the purpose of learning new concepts and reinforcing existing practices, but how about using these concepts while reviewing real events? Could we not do a pre-brief and debrief while taking care of a real patient?

The hurdles in hospital-based clinical medicine are often the same as those in EMS. People often shy away from making changes in processes and adapting new theories, and it’s imperative that as educators we help them understand the significance of new skills, technologies, and methodologies.

On May 10, 2015, WakeMed Health & Hospitals opened a new healthcare facility in Raleigh, N.C. The first patient admitted to the facility was a human patient simulator, admitted for the sole purpose of testing processes and workflows. Although the healthcare system had been doing these simulator patient admissions since 2007, it was a foreign concept to many of the new staff members hired for the new hospital.

By using the concepts outlined in simulation methodology, educators and healthcare leaders can identify and change how communication, teamwork, and healthcare is delivered. As healthcare professionals, our goal should always be to improve the care and safety of our patients, their families and the healthcare providers.


By taking the time to consider what your biggest hurdles are to embracing the use of simulation technology, you can easily determine ways to overcome them. If the resources aren’t available locally, who can you reach out to? Who is a potential partner in improving care quality and patient safety across your community? There are always opportunities and ways to increase financial support, obtain training on simulation technology and procedures, develop a plan to use more simulations, and evaluate data. Remember that the barriers created are often human- or system-based and easily overcome with time and understanding.

In its simplest form, simulation is part of everything we do in EMS. From mentally running thorough protocols to participating in an active shooter exercise, simulation is essential as we prepare for any number of situations. It’s imperative EMS educators and leadership demonstrate the value of simulation to the EMS community. Simulation allows an agency to be proactive versus reactive. If trends are discovered, education can be offered to prevent mistakes before they’re made in the field. Educators sharing with their providers the impact education is having on care delivery will allow providers to embrace the importance of training, simulation technology and the associated educational methodologies. After all, it’s about the wellbeing of the patients and their families.

This article is sponsored by Laerdal Medical. For tools and resources to help you effectively assess, plan and implement your simulation training program visit

1. McKenna K, Carhart E, Bercher D, et al. Simulation use in paramedic education research (SUPER): A descriptive study. Prehosp Emerg Care. 2015;19(3):432—440.


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