PHECC Register the Sixth Statutory Healthcare Register

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2 HECC Register the Sixth Statutory Healthcare Register The re-hospital Emergency Care Council (HECC) is an independent statutory body whose functions include establishing and maintaining the sixth statutory healthcare register in Ireland. This booklet has been compiled to inform clinical and administrative staff in Emergency Departments and other relevant Health Service facilities regarding the training and education as well as the roles and responsibilities of pre-hospital emergency care practitioners: Emergency Medical Technician () The Emergency Medical Technician can provide basic life support including automated external defibrillators, oropharyngeal airways, bag-valve-mask, glucometry and basic trauma care. The may administer Aspirin, GTN, Glucagon, Epi-pen and Entonox. aramedic () The aramedic can provide intermediate life support. This includes the skills listed for and the insertion of a laryngeal mask airway & nasopharyngeal airway, 12 lead ECG, peak flow meter, cease resuscitation, and cervical injury decision. The aramedic may administer the medications permitted for an as well as Epinephrine (1:1000), Naloxone, Salbutamol and aracetamol. The aramedic may maintain intravenous infusions once commenced. Advanced aramedic (A) The Advanced aramedic can provide advanced life support. This includes the skills listed for aramedic and the use of an endotrachael tube, intravenous cannulation, manual defibrillation, thrombolysis, needle thoracocentesis, needle cricothyrotomy and urinary catheterisation. The Advanced aramedic may administer the medications permitted for a aramedic and 23 additional medications for acute emergency medical and traumatic conditions from cardiac arrest to hypovolaemia. 1

3 HECC Register the Sixth Statutory Healthcare Register The titles Emergency Medical Technician (), aramedic (), and Advanced aramedic (A) identify healthcare professionals who are registered with HECC. re-hospital emergency care practitioners are eligible to join the HECC Register once they have completed HECC s Standard of Education & Training at the relevant level and have been awarded the National Qualification in Emergency Medical Technology (NQ). Register Division (January 2009) Count Emergency Medical Technician () 257 aramedic () 2167 Advanced aramedic (A) 157 Total Registered ractitioners 2581 Emergency Medical Technician () An Emergency Medical Technician () is a registered practitioner who has completed HECC s Standard of Education & Training at level. This is the minimum clinical level that is recommended to provide care and transport of an ill or injured patient. The duration of education and training is five weeks and is designed to provide the with the knowledge and skills for working primarily in patient transport services and in supporting the prehospital response to patients accessing the 999/112 emergency medical services. The can work for the HSE National Ambulance Service; Dublin Fire Brigade; fire, rescue and auxiliary services; and voluntary or private ambulance services. Successful completion of an course at a HECC-Recognised Training Institution entails four weeks theory and one week clinical practice and assessment. The National Qualification in Emergency Medical Technology (NQ) at level is awarded to successful candidates after a written paper comprised of multiple choice questions (MCQs) and a practical objective structured clinical examination (OSCE). aramedic () A aramedic () is a registered practitioner who has completed HECC s Standard of Education & Training at aramedic level. This is the minimum clinical level that is recommended to provide care & transport of an ill or injured patient following a 999/112 call. The aramedic is principally engaged in responding to patients who access the 999/112 service for emergency medical assistance. The aramedic can work for the HSE National Ambulance Service; Dublin Fire Brigade; fire, rescue and auxiliary services; and voluntary or private ambulance services. The education and training for aramedics consists of 28 weeks theory, supervised clinical practice on emergency ambulance vehicles and healthcare service placements as well as one year Internship. The aramedic assessment comprises of two written papers; one multiple choice question (MCQ) and one short written answer (SWA) exam plus two practical, objective structured clinical examinations (OSCE). In addition, successful completion of a structured competence assessment during the one-year Internship including case study submission, completion of professional development modules and competency assessment is required prior to full registration on the aramedic division of the HECC Register. The NQ at aramedic level is awarded to successful candidates. Advanced aramedic (A) An Advanced aramedic (A) is a registered practitioner who has at least 3 years experience as a aramedic. The A standard of education and training prepares graduates for their role as clinical leaders and expert practitioners in the field of pre-hospital emergency care. Their deployment in the HSE is a matter for the National Ambulance Service and varies from region to region; nonetheless their role has been designed to contribute to a reduction in the morbidity and mortality of patients experiencing life threatening events pre-hospital. One significant advance in this area is the expected roll-out of pre-hospital thrombolysis in There is no direct entry to this course of training and candidates are experienced aramedics principally employed by the HSE National Ambulance Service and Dublin Fire Brigade. The standard builds substantially on the aramedic standard and currently requires fourteen weeks theory and clinical practice; six weeks in-hospital and a further six weeks on emergency response vehicles with supervision. A assessment includes written papers; multiple choice question (MCQ) and short written answer (SWA) exams, a practical, objective structured clinical examination (OSCE), a component of continuous assessment by submitting case studies/reviews and finally a panel exam. The NQ at A level is awarded to successful candidates. The current A standard of education and training is under review, it is expected that one year of A Internship and competence assessment will be added prior to registration in It is expected that the A role will be expanded to include the treatment and discharge of patients who access the health service through the 999/112 system but who do not need hospital admission. This initiative will be supported by HECC s Clinical ractice Guidelines. 2 3

4 Clinical skills and medication administration Care management, including the administration of medications, as per level of training and division on the HECC Register: Key SA AO Authorised under HECC CGs after completion of a HECC-approved CD module or during training courses completed after 2nd April Authorised subject to special authorisation as per CG. Authorised under HECC CGs to assist practitioners only (when applied to, to assist aramedic or higher clinical levels). URMIO Authorised under HECC CGs under registered medical practitioner s instructions only. Medications A Aspirin O Epinephrine (1:1,000) auto injector Glucagon IM Glucose Gel Buccal GTN SL Nitrous oxide & Oxygen (Entonox ) Oxygen aracetamol O Salbutamol aerosol SA Morphine IM URMIO URMIO SA Epinephrine (1:1,000) IM Ibuprofen O Naloxone IM Salbutamol nebule Dextrose 10% IV SA Hartmann s Solution IV/IO SA Sodium Chloride 0.9% IV/IO SA Amiodarone IV/IO Atropine IV/IO Benzylpenicillin IM/IV/IO Clopidogrel O Cyclizine IV Diazepam IV/R Enoxaparin IV/SC Epinephrine (1:10,000) IV/IO Furosemide IV/IM Ipratropium bromide nebule Lidocaine IV SA Lorazepam O Magnesium Sulphate IV (Table continued on next page) Clinical skills and medication administration All skills apply to adults and children unless specified. Midazolam IV/IM/Buccal/IN Morphine IV/O Naloxone IV/IO Nifedipine O Ondansetron IV aracetamol R Sodium Bicarbonate IV Syntometrine IM Tenecteplase IV Skill/Clinical rocedure A Airway & Breathing Management BVM Cricoid pressure FBAO management Head tilt chin lift Jaw thrust n-rebreather mask OA Oxygen humidification ocket mask Recovery position SpO 2 monitoring Suctioning Venturi mask Flow restricted oxygen-powered ventilation device LMA/LT adult NA eak flow End Tidal CO 2 monitoring Endotracheal intubation Laryngoscopy and Magill forceps LMA/LT child Nasogastric tube Needle cricothyrotomy Needle thoracocentesis Cardiac Medications A 2-rescuer CR (Table continued on next page) 4 5

5 Clinical skills and medication administration AED adult AED child CR adult, child & infant CR newly born ECG monitoring (lead II) Emotional support Mechanical assist CR device Recognise death and resuscitation not indicated 12-lead ECG Active cooling Cease resuscitation Impedance Threshold Device Manual defibrillation Haemorrhage Control Direct pressure se bleed ressure points Tourniquet use Medication Administration Buccal route Intramuscular injection al er aerosol Sublingual er nebuliser Infusion maintenance SA Infusion calculations Intraosseous injection/infusion Intravenous injection/infusion er rectum Subcutaneous injection Trauma Active re-warming Cervical collar application Cervical spine manual stabilisation Helmet stabilisation/removal Log roll Move and secure patient into a vacuum mattress Move and secure patient to a long board Move patient with a canvas sheet Move patient with an orthopaedic stretcher Rapid extraction (Table continued on next page) Clinical skills and medication administration Splinting device application to lower limb Splinting device application to upper limb Repositioning # limbs AO Secure and move a patient with an extrication device AO Traction splint application AO Move and secure patient to a paediatric board Spinal injury decision Taser gun barb removal Other Assist in the normal delivery of a baby De-escalation and breakaway skills Glucometry Broselow tape Delivery complications External massage of uterus Intraosseous cannulisation Intravenous cannulisation Urinary catheterisation atient Assessment Assess pupils Assess responsiveness AVU Blood pressure Breathing & pulse rate Capacity evaluation Capillary refill Check breathing CSM assessment FAST assessment Medical Early Warning Score aediatric Assessment Triangle atient clinical status rimary survey ulse check (cardiac arrest) Rule of Nines SAMLE history Secondary survey Temperature o C Triage sieve Chest auscultation GCS Revised Trauma Score Triage sort 6 7

6 Cardiac Chest ain - Acute Coronary Syndrome ublished 22 nd May ublished 22nd May Cardiac 2008 Chest ain Acute Coronary Syndrome Cardiac Chest ain - Acute Coronary Syndrome 5/ ublished 22 nd May / ublished 22nd May Cardiac 2008Chest ain Acute Coronary Syndrome A A Cardiac chest pain Acute Coronary Syndrome Oxygen therapy Oxygen therapy Request Apply 3 lead ECG & SO2 monitor Aspirin, 300 mg O Chest ain Indication for Thrombolysis atient conscious, coherent and understands therapy atient consent obtained < 75 years MI Symptoms 20 minutes to 6 hours ST elevation > 1 mm in two or more contiguous leads GTN 0.4 mg SL Repeat prn to max of 1.2 mg SL Request Apply 3 lead ECG & SO2 monitor Aspirin 300 mg O Chest ain Contraindications for thrombolysis Contraindications Haemorrhagic stroke or stroke of unknown origin at any time Ischemic stroke in preceding 6 months Central nervous system damage or neoplasms Recent major trauma/ surgery/ head injury (within 3 weeks) Gastro-intestinal bleeding within the last month Active peptic ulcer Known bleeding disorder al anticoagulant therapy Aortic dissection Transient ischemic attack in preceding 6 months regnancy within 1 week post partum n-compressible punctures Traumatic resuscitation Refractory hypertension (sys B > 180 mmhg) Advanced liver disease Infective endocarditis GTN, 0.4 mg SL Repeat to max of 1.2 mg SL prn Time critical commence transport to definitive care ASA ain relief effective Morphine 2 mg IV Monitor vital signs Ondansetron 4 mg IV slowly Cycilizine 50 mg IV slowly Acquire & interpret 12 lead ECG Clopidogrel 300 mg O Repeat Morphine at not < 2 min intervals if indicated. Max 10 mg STEMI Symptoms 3 hours Tenecteplase < 60 kg 30 mg kg 35 mg kg 40 mg kg 45 mg > 90 kg 50 mg rimary CI available within 60 min from 999 call Tenecteplase IV Followed by Enoxaparin 40 mg IV Max 0.5 mg/kg tify & transport to rimary CI facility 8 9

7 Seizure / convulsion - Adult ublished 22 nd May ublished 22nd May 2008 Seizure / convulsion Adult Seizure / convulsion - Adult 5/ ublished 22 nd May / ublished 22nd May 2008Seizure / convulsion Adult A A other causes of seizures Meningitis Head injury Hypoglycaemia Eclampsia Fever Seizure / convulsion rotect from harm Oxygen therapy other causes of seizures Meningitis Head injury Hypoglycaemia Eclampsia Fever Seizure / convulsion rotect from harm Oxygen therapy Seizing currently Seizure status ost seizure Seizing currently Seizure status ost seizure Request Request Support head Alert Midazolam 2.5 mg IV Repeat by one prn Go to Glycaemic Emergency CG Check blood glucose Blood glucose < 4 mmol/l Recovery position Airway management Check blood glucose Diazepam, 10 mg R Repeat by one prn Midazolam 5 mg IM Midazolam 10 mg buccal Midazolam 5 mg IN Go to Glycaemic Emergency CG Diazepam 5 mg IV Repeat by one prn Check blood glucose Blood glucose < 4 or > 20 mmol/l Still seizing Transport to ED if requested by Ambulance Control Go to Glycaemic Emergency CG Blood glucose < 4 mmol/l 10 11

8 Glycaemic Emergency - Adult Glycaemic Emergency - Adult A ublished 22 nd 22nd May 2008May 2008 Glycaemic Emergency - Adult 5/ / ublished ublished 22 nd May nd May 2008 Glycaemic Emergency - Adult A Abnormal blood glucose level Abnormal blood glucose level < 4 mmol/l Blood Glucose 11 to 20 mmol/l < 4 mmol/l Blood Glucose 11 to 20 mmol/l A or V on AVU > 20 mmol/l Dextrose 10% 250 ml IV infusion > 20 mmol/l Glucose gel, 5-10 g buccal or Sweetened drink Glucagon 1 mg IM Glucagon 1 mg IM Glucose gel g buccal Sweetened drink Allow 5 minutes to elapse following administration of medication Allow 5 minutes to elapse following administration of medication Sodium Chloride 0.9% 1 L IV infusion Blood Glucose 4 mmol/l Blood Glucose 4 mmol/l Repeat if indicated Glucose gel g buccal Repeat if indicated Dextrose 10%, 250 ml IV infusion Glucose gel g buccal aramedics are authorised to continue the established infusion in the absence of an Advanced aramedic or Doctor during transportation 12 13

9 atient Care Report (CR) and electronic atient Care Report (ecr) Recording interventions and medications administered to patients pre-hospital is an essential clinical responsibility for all pre-hospital emergency care practitioners. This information is recorded on the national atient Care Report. Audit of this data by the ambulance service will continue to validate the effectiveness of patient care and prehospital emergency care education and training. The completed top copy of the CR is included as part of the patient handover from the pre-hospital emergency care practitioner to the Emergency Department staff and the second copy is stored by the ambulance service according to HECC Clinical Record Management Guidelines. In parallel, the ambulance service in the HSE rth East are using tablet Cs to record patient information on the HECC ecr system which integrates with the Computer Aided Dispatch System (CAD) in the Communication Centre located in Ambulance Headquarters in Navan and the Life ack 12 defibrillator located in the ambulance. At any time the practitioner deems appropriate, patient data can be transmitted to an etriage application which can be viewed in four Emergency Departments in the region. The departments are, Our Lady of Lourdes, Drogheda; Cavan General Hospital, Cavan; Our Lady s Hospital, Navan; and Louth County Hospital, Dundalk. The patient data, including assessment details, vital observation, clinical management and interventions and ECG tracing can be viewed by Emergency Department nurses and clinicians. The ambulance service in the HSE West counties of Mayo and Roscommon are implementing the stand-alone ecr system and currently Belmullet ambulance station are recording patient data on tablet Cs and printing the ecr report in the Emergency Department in Mayo General Hospital in Castlebar. Background work on etriage implementation has been completed and this will be soon installed Mayo General Hospital. In the future it is planned to roll out the integrated ecr system nationally. A copy of the CR content is included here. (Form continued on next page) 14 15

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