Comprehensive Advanced

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CALS

• Comprehensive Advanced
• Life Support Program
• A Team Approach to Rural
• Emergency Care

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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

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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.

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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.

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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.

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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.

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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

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The Need

• Provide better patient care
• Solve the feelings of being inadequate
• Address medical-legal concerns
• Help with professional burn-out

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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.

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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.

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CALS Mission Statement

• The primary mission of CALS is to improve
  patient care by enhancing the providers
  established scope of practice through advanced
  education.

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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.

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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.

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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.

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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.

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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

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CALS Provider Manual
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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

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CALS 2Day 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.

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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

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Airway Management Rapid Sequence Intubation
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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.

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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

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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.

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CALS Airway Cart
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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

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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

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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

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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

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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)

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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.

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Embassy Personnel Training (cont)

• Thanks again for the wonderful course. Its
  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 Ive 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.

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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.

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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.

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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.
  

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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.

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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.

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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.

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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

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To contact CALS

• www.calsprogram.org
• Kari Lappe, RN, CALS Program Manager
• kdlappe_at_umn.edu
• 612-624-5901